Confronting Emerging Infections Diseases Now
With the recent public heath crises around SARS and influenza, scientists and doctors convened at the Academy to discuss the best way for navigating these and other infectious diseases.
Published May 1, 2007
By Marilynn Larkin
Academy Contributor
On May 17, 2003, The New York Academy of Sciences’ (the Academy’s) Emerging Infectious Diseases discussion group (EID) began in a most dramatic way. The world was in the throes of a public health crisis that was also a scientific conundrum: severe acute respiratory syndrome (SARS) seemed to have appeared out of nowhere, and although it was linked to a coronavirus—the same family of viruses that causes the common cold—it could also be lethal.
In response to the threat, the Academy convened a conference, SARS in the Context of Emerging Infectious Diseases, which brought together scientists, physicians, public health officers, and pharmaceutical representatives from around the world. At that point, SARS had infected 7761 people worldwide and claimed 623 lives.
Setting the Standard
The event not only marked the formation of EID; it also set the standard for future EID events. “The conference brought together in real time some of the top names in virology, microbiology, and public health to address an emerging threat. Since then the group has continued with the mission of educating a broad range of infectious diseases professionals, basic scientists, and clinicians about existing, re-emerging, and new pathogens,” observes Jeremy Paul, director of the Academy’s Frontiers of Science program, the umbrella for the Academy’s discussion group events in the life sciences. “Its programs deal with critical problems and are helping to establish the Academy as a watering hole for scientific discussions in this area.”
“It was marvelous how we were able to raise funds and pull together key people to launch a series of very important symposia. It shows that when a threat emerges and you really want to target it, you can do so very quickly,” adds Vincent Fischetti, co-head of the Laboratory of Bacterial Pathogenesis and Immunology at The Rockefeller University. Fischetti is a member of the steering committee of EID and chairman of the Microbiology section. The two groups have covered some of the same issues and will collaborate even more in the future, according to Paul.
From Epidemic to Pandemic
“What we’ve tried to do in these discussion groups is to say, ‘here are diseases that are having significant effects on the population, and so we’re trying to understand the pathogen, the epidemiology and transmission, and potential treatments and/or vaccines,’” explains David Perlin, scientific director and professor, Public Health Research Institute at New Jersey Medical School-UMDNJ in Newark.
“For me, the events that work best combine top quality basic science and then transition all the way through to clinical outcomes. The reason we’re studying most pathogens, whether viral, bacterial, or fungal, is because they cause disease. As with SARS, there’s a clinical manifestation that draws our attention, and in order to critically address it, we first have to understand the disease in a patient.”
Sometimes, even as investigations are undertaken at the genomic and molecular levels, and work on developing novel approaches to diagnosis and treatment is under way, an epidemic ends up being curtailed by some very basic approaches. “In the case of SARS, it was sobering for the scientific community to realize that although we focused our efforts on very sophisticated techniques and technologies, what worked in the end were isolation and quarantine—interventions that are thousands of years old,” observes Perlin, a member of the EID steering committee.
Flu Preparedness
Indeed, a similar message emerged from a well-attended and energetic EID meeting, “Flu Preparedness,” which addressed the threat of an influenza pandemic. Held on October 26, 2006, this event, like the SARS conference, brought together an international, interdisciplinary panel of experts to report on strategies to avert a global health disaster.
Peter Palese of Mount Sinai School of Medicine presented an overview of influenza viruses; Adolfo Garcia-Sastre, also of Mount Sinai, followed with a look at potential vaccines; Stephen Morseof Columbia University discussed non-pharmaceutical interventions that successfully curbed the spread of the influenza virus in some parts of the United States during the 1918 epidemic; Isaac Weisfuse of the New York City Department of Health summarized the steps—again, mostly non-pharmaceutical—that the city is taking to prepare for a potential pandemic; the UN’s David Nabarro described strategies being pursued in affected and non-affected countries globally; and Menno de Jongof Oxford University’s Clinical Research Unit in Vietnam offered a vivid perspective on patients infected with the avian influenza A(H5N1) virus.
In the event of a pandemic, tried and true approaches that include closing schools, discouraging large gatherings, and establishing quarantines and travel restrictions will probably dominate the disease-containment efforts, the experts acknowledge, along with encouraging people to stay home or indoors, and promoting the practice of “respiratory etiquette” (covering coughs and sneezes).
Fighting Fungi
Some infections defy these established approaches, and EID also explores more focused threats, grappling with diseases whose rapid diagnosis depends on the latest technologies, and whose eradication will be accomplished—for now, at least—only with complex, targeted treatments. An example is invasive aspergillosis, the subject of an EID event held on December 14, 2006.
Invasive aspergillosis is the most common filamentous fungal infection seen in immunocompromised patients and is a leading cause of fungal mortality. These infections are a critical health concern for clinicians with high-risk, hospitalized patients. In keeping with the group’s interdisciplinary approach, presenters gave an overview of the three most common types of Aspergillus infection—invasive, chronic, and allergic—as well as emerging subtypes, such as severe asthma with fungal sensitivity (SAFS).
A common theme was the need for early intervention to limit morbidity and mortality. However, as Kieren A. Marrof the Fred Hutchinson Cancer Research Center and University of Washington in Seattle stressed, culture-based assays are an “imperfect gold standard”; yet non-culture-based assays have low sensitivities for detecting the causative fungus, necessitating the use of multiple adjunctive tests whose utility is controversial. Similar difficulties and controversies also surround aspergillosis therapies—what should be used when, and in which populations?
In an effort to better understand the body’s response in invasive aspergillosis and ultimately better target treatment, two immunologists, Jean-Paul Latgéof the Pasteur Institut in Paris and Gordon Brownof the University of Cape Town, offered perspectives on the interaction of aspergillus with the immune system.
Better Research Means Better Science
“To me, these are the types of programs that resonate,” comments Perlin. “When I go to these meetings, I generally know something about the pathogens or diseases, but I don’t have a good sense of the breadth of the problem or the state of the art in terms of our knowledge.
:In the aspergillosis session, some of the people who came for clinical information left when the basic science presentations began; others came in at that time and missed the clinical information. Nevertheless, we need to continue to have this kind of crossover. If we can get basic scientists to better understand the clinical disease, they will do better-quality basic science. At the same time, we want clinicians to understand what some of the challenges are on the basic science side.”
Although topical presentations tend to draw the greatest number of participants, meetings that revisit pathogens responsible for the world’s major public health problems, such as tuberculosis are also well attended. And EID members continue to find biosecurity and the effects of increasing regulation on scientific research compelling topics. The latter are areas of particular interest to EID steering committee member Nancy Connell, professor and vice-chair for research in the Department of Medicine at UMDNJ, New Jersey Medical School, and director of the Bio-safety Level Three Facility of UMDNJ’s Center for the Study of Emerging and Re-emerging Pathogens.
Connell was instrumental in organizing a half-day symposium in which eight speakers, including Connell, debated the changing relationships between science and law enforcement, and discussed major initiatives to preserve scientific integrity while maintaining security interests (“National Security and Biological Research”). “We had representation from the FBI, along with key scientific and policy players involved in ‘dual use’ dilemmas, and the excitement was palpable,” recalls Connell.
No Easy Answers
More recently, Connell organized an innovative interactive EID meeting around similar issues (“No Easy Answers”). Brian Rappertof the University of Exeter and Malcolm Dando, University of Bradford, both in the United Kingdom, included the meeting as part of an international project, funded by a grant from the Alfred P. Sloan Foundation. The project engaged researchers and students in discussions about the threats posed by biological weapons, the relationship between current biomedical and bioscientific research and new weapon possibilities, and the range of national and international measures currently being implemented or considered.
Instead of making presentations, Rappert and Dando posed questions to the audience based on a number of scenarios. The first scenario involved the unintended discovery in 2001 of a way of boosting smallpox lethality. Australian researchers were using mousepox to immunize mice against egg protein and inserted the IL-4 gene to boost the antibody response. The resulting recombinant virus killed mice genetically resistant to smallpox as well as all immunized mice. The question: Should this research have been published?
In this instance, the work appeared first in a popular scientific magazine, New Scientist, under an attention-grabbing headline, “Disaster in the Making.” Rappert and Dando presented alternative ways to get the word out (or not) without sounding an alarm—by “burying” the finding in a peer-reviewed journal article, for example, or by informing government officials and not publishing at all.
Audience members weighed in on the topic, most noting that scientists should not seek publicity; however, if the press learns of findings from a published study, and the scientists make themselves available for interviews, they should realize that they cannot control the results. The responses to this and other scenarios were aggregated in reports that would serve to inform future public policy.
Local Public Health Problems
Local public health problems are also part of the EID agenda. On February 8, 2007, “Community Acquired Diseases in New York City” focused on methicillin-resistant Staphylococcus aureus (MRSA) and persistent hepatitis B and C infection and compared rates and risk factors among men and women living in New York City and in Newark, New Jersey. The presenters also addressed meningococcal disease in New York City, highlighting a vaccination campaign in underserved communities that helped curb transmission. “It’s important to strike a balance between global concerns and issues that affect us locally,” stresses Perlin. “Participants need to know that many of the diseases we address are right here at home, not just in Africa and Asia.”
Looking ahead, the steering committee will continue to expand the breadth and scope of the EID and Microbiology groups while striving to include clinical considerations, basic science, and public health. Hemorrhagic viruses, XDR strains of tuberculosis, coinfection of HIV/tuberculosis, emerging noroviruses, as well as the “new generation of molecular diagnostics, which are being used not just for pathogen detection and treatment, but also for personalized medicine,” are among the topics Perlin envisions the groups addressing.
Barry Kreiswirth, director of the Tuberculosis Center of the Public Health Research Institute, wants to explore the “fascinating area of food safety and animal health.” “This would cover diverse safety topics including the E. coli contamination of produce, the farming of catfish in Mississippi, and the remarkable co-farming of chicken and shrimp in China,” he says.
Biosecurity
Connell notes that recent legislation related to DSL-3 labs and other policy issues related to biosecurity are increasingly affecting laboratories in the United States and abroad. She sees the group investigating what the various subcommittees of the National Science Advisory Board for Biosecurity (NSABB) are doing and possibly taking “people through what happens if there’s an accident in the lab or a disaster of some sort,” using scenarios that could be run in an interactive format. “The Biological Weapons Convention of 1972 has as one of its pillars the transparency of relevant activities carried out by the parties to the convention. The transparency of the U.S. Biodefense program is an important issue in contemporary science policy,” Connell says.
All programming will be planned with a view toward getting heavy participation by students and postdoctoral fellows, EID steering committee member Garcia-Sastre stresses. To accomplish this, “we’ll need to rotate the timing so that more people can attend. Once people start coming regularly, they’ll feel as though they’re part of a group—that they go to the Academy to find their peers and make new friendships in a spirit of conviviality.” Developing and maintaining a “critical mass” of participants will be achieved with programs that combine big-name researchers with postdocs from different disciplines and different local institutions, he promises.
In a Good Position
Fischetti observes that the group is in a good position to draw participants in 2007-08 because a major concern—that the Academy’s move downtown would hamper attendance—was not realized. “Our meetings have been as well or better attended than before. The new facility is a great environment, there are many more scientific events being presented, and everyone has a lot more to look forward to,” he enthuses.
“People need to associate high-quality, innovative science with the Academy,” adds Perlin. “They should know that if there’s a topic of interest that’s getting media attention, the Academy is going to step forward and be a key source of information.”
Also read: A Public Good: Accelerating AIDS Vaccine Development
About the Author
Marilynn Larkin is a medical editor, journalist, and videographer based in New York City. Her work has frequently appeared in, among others, Th e Lancet, Th e Lancet Infectious Diseases, and Reuters Health’s professional newswire.
