Q&A with Dr. Amesh Adalja
Our world today is pretty different than it was 100 years ago. We have smart phones, Bluetooth, the internet, virtual reality and 3D printers. You can change the temperature in your home from your office at the press of a button or start your car’s engine from across the parking lot. So why does one of the biggest threats to human health remain unchanged?
According to Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, the flu still poses as much of a risk to human health as it did during the major flu pandemic of 1918.
Dr. Adalja was a member of the U.S. Department of Health and Human Services’ National Disaster Medical System, with which he was deployed to Haiti after the 2010 earthquake and selected for their mobile acute care strike team. He has served on U.S. government panels tasked with developing guidelines for the treatment of botulism and anthrax in mass casualty settings and has served as an external advisor to the New York City Health and Hospital Emergency Management Highly Infectious Disease training program, as well as a FEMA working group on nuclear disaster recovery. He is an associate editor of the journal Health Security and his work has been published in journals like The New England Journal of Medicine, The Journal of Infectious Diseases, Clinical Infectious Diseases, Emerging Infectious Diseases and The Annals of Emergency Medicine.
Dr. Amesh Adalja
Nano: Dr. Adalja, on your blog, you write about infectious diseases ranging from the Bubonic plague to Malaria and Ebola. Is there an infectious disease that you think poses the greatest threat today?
Dr. Adalja: I think the disease the poses the greatest threat is the same one that has posed a threat for the last several centuries – and that’s influenza. Influenza is a virus that mutates a lot, it changes continuously, it is spread by the respiratory route and has the ability to cause severe disease. The flu has caused several pandemics over the last several centuries that have disrupted human civilization, most notably in 1918. Even though we’ve known about this threat for so long, we still have a very poor vaccine. There’s also a lot of apathy about the flu – people don’t think about it as the threat that it is. There are a lot of things that make it rank the highest on my list of threats.
Nano: Why do you think people don’t know that the flu is such a threat?
Dr. Adalja: The flu has a spectrum of illness, and many people only associate it with the cough, cold, and fevers that a lot of people experience during the winter season and then recover from. I don’t think they fully realize that seasonal influenza is not the same thing that we would see in a pandemic. The major pandemics of the 20th century were in 1918, 1957 and 1968, and many people are too young to remember what they were like. The 2009 flu outbreak was very significant, but it wasn’t as scary as ’18, ’57 or ’68, so it has kind of reinforced the common belief that the flu isn’t dangerous.
There’s also a lot of distrust of the vaccine – it might not be the best vaccine, but it’s the best vaccine that we have. Some people don’t like the antiviral drug Tamiflu and have recovered from the flu without it, so they think it’s not such a big deal. But they don’t have the full context of what the flu can really do. Right now in China, we’ve been having a bird flu outbreak with the H7N9 strain of influenza. It’s very scary and dangerous and is currently at the top of most people’s threat lists as a possible pandemic virus.
Nano: This year’s flu season was considered especially severe. Are there any key takeaways from this flu season that we should apply going forward?
Dr. Adalja: This flu season was particularly severe. In some measures, it exceeded the level of illness we saw in the 2009 pandemic. The biggest lesson to learn is that we struggled to deal with this season.
We had a high rate of pediatric deaths, we had hospitals that were inundated and had to open parking lot tents to take care of patients. And this was just a seasonal flu outbreak, not a pandemic. You can imagine, if the system was so stressed just dealing with a seasonal outbreak, what would happen during a pandemic.
There were a lot of investments made after September 11th to fortify the U.S. healthcare system against infectious disease in the wake of anthrax attacks and worries about bird flu, but a lot of that has started to recede, so I don’t think we’re well prepared today. Whatever gains have been made can quickly erode if people aren’t thinking about these threats.
Nano: Bill Gates was recently quoted as saying that he thinks the next major global pandemic could happen in our lifetimes, that we’re not prepared, and that we should prepare for these types of threats the way we prepare for war. What are your thoughts on that comment?
Dr. Adalja: It is akin to preparing for war. We know there are these pandemic threats looming out there in the world, but they aren’t thought of as existential threats the way nuclear war or chemical weapons are. I don’t think you can separate infectious disease outbreaks from national security.
We know that these outbreaks not only cause death and suffering, but they have cascading effects on economies and industries. We saw during the Ebola outbreak in 2014 how three countries teetered on the verge of becoming completely failed because of the outbreak. These things synergize and can magnify whatever fundamental problems the pandemic is causing.
Nano: How do you think we can develop better vaccines to prevent these kinds of disease outbreaks?
Dr. Adalja: We have to be much more proactive. You hear about the military working on fighter planes for wars that are decades away. In healthcare, we don’t do that. We tend to make vaccines on the fly during the pandemics. We did that during the 2009 H1N1 outbreak and the recent Zika outbreak.
There are threats out there that we know about, and we have to start working on vaccines for them before they appear. It takes about a decade for a vaccine to be developed, and we can’t make them as well on the fly. The H1N1 vaccine, for example, only became available after the peak of the epidemic. We have to be investing in these things ahead of time in anticipation that there will be a continual onslaught of new pathogens to tackle.
Nano: Why do you think we’re not being proactive about vaccine development? Is it a funding issue or a lack of awareness?
Dr. Adalja: First of all, we tend to wait for threats to materialize until we start trying to find a solution to prevent it from getting out of hand. We saw that with Ebola and with Zika. Simply, many people alive today do not understand the real power of infectious disease. The 20th and 21st centuries have been generally characterized by a recession of disease threats; we eradicated smallpox from the planet and deaths from many infectious diseases have fallen dramatically. People have the luxury of not remembering what flu pandemics were like or what it was like before penicillin. We’ve seen success after success, which is great, but it makes people think that these are easy problems that can be solved with a snap of the fingers. In a way, we’ve become a victim of our own success. If you look at the last 30 or 40 years of history with infectious disease, it’s just one small sliver of the what the whole experience of humans has been with infectious disease. And that history has not been good.
Secondly, to develop a vaccine, you need significant monetary investment. This means that a company has to see the vaccine as a good market opportunity, but if the vaccine is for an infectious disease that hasn’t materialized yet, there is no market. This makes it very hard to muster resources for vaccines against diseases that haven’t appeared yet or that have only appeared in small populations or developing countries that have no ability to pay for the vaccine. So, it’s not the same market incentive to develop a vaccine as it is to develop a drug that treats erectile dysfunction or depression or high cholesterol.
Nano: Why does it take a decade to develop a vaccine? Is there any way to shorten that timeline?
Dr. Adalja: Often there are basic scientific questions that need to be answered, which require multiple experiments to understand. There are also regulatory burdens. You need to conduct clinical trials to show that a vaccine is safe and effective, and those don’t always go smoothly. For example, one country might not accept another country’s data. There’s a lot that goes into development and it takes an enormous amount of time.
People have started to recognize that need to speed up vaccine development, especially after the 2014 Ebola outbreak, and there are some changes happening and initiatives like the Coalition for Epidemic Preparedness Innovations (CEPI) coming to the forefront. But it’s not a panacea, because some of the problems we face are just tougher than others. For example, we’ve been looking for an HIV vaccine since the virus was discovered.
Nano: Does the issue of data being kept in silos around the world instead of widely shared effect our ability to quickly and efficiently develop effective vaccines?
Dr. Adalja: The easier it is to get data that you need, whether it’s from a country or a private individual, the faster you can accomplish these things. Open access to data and having the ability to get that information rapidly would be a major boon to manufacturing vaccines, but there are some barriers to that. We have seen examples of countries who don’t want data about disease outbreaks exported – for example, during the Middle East respiratory syndrome (MERS) outbreak in Saudi Arabia, there was a lot of concern about the genomic data of the virus being exported outside of the country. We’ve also seen pushback against the U.S. government by Indonesia for looking at flu strains from Indonesian patients for vaccines. There’s a viral sovereignty issue where people want to keep viruses in their own country – either because it’s a new virus that they want to contain themselves, because they don’t want the virus to be associated with their part of the world, or they want a guarantee that their country will have access to the vaccines, drugs and diagnostics that result from their samples. There are definitely issues with data sharing like this, but there is generally a better recognition that the more people that have access to data, the more minds can work on it unimpeded.
Nano: Are there any emerging technologies you think are promising or aren’t getting enough recognition or use?
Dr. Adalja: Diagnostic tests have advanced significantly over the last several years. Rapid next-generation sequencing and multi-analysis tests looking for respiratory pathogens are huge advancements in helping to identify specific diseases. But the uptake of these tests is very slow and some hospitals don’t think the benefits outweigh the costs. In being prepared for a pandemic though, having as many diagnostic tools at hand, whether you’re in rural Africa or a New York City emergency room, it’s important to find the cause of disease quickly. So, a whole myriad of diagnostic tools available now need to have significantly increased or universal use.
Nano: Tell us a story about a recent experience you’ve had with an infectious disease.
Dr. Adalja: In addition to infectious disease, I’m also certified in emergency medicine and do a couple of shifts per month in the emergency room. Several months ago, I saw a patient who had recently traveled to Puerto Rico and had classic symptoms of Zika. It was after hours (around 8 p.m.) and I needed to get the Zika test done to confirm the diagnosis. To order the test, I had to first call the microbiologist to say I wanted the test done. I was then told I needed to call the state health department to authorize the test. It’s very difficult to call them after hours, so I left a message, which was returned a few hours later with an approval. To send the test, you also have to put the name of the person from the state health department who authorized the test on the sample. After all of that, the patient was in fact diagnosed with Zika. It was a male patient and there isn’t a treatment for Zika, so I don’t think many doctors would have jumped through all of those hoops to confirm the diagnosis.
But I don’t think that’s how you want to deal with infectious disease. It was like being at the DMV. You can’t have that kind of culture in healthcare – it should be immediate and seamless. This is where the public health world could take a lesson from Silicon Valley about how quickly we need to get things done and avoid bureaucracy and red tape. I had a similar difficult experience trying to call the health department about a case of MERS because it was Father’s Day. To me, it’s not surprising that the first case of Ebola in Dallas was missed – the incentives just aren’t there. How many times do you go to an ER and get a diagnosis of a viral illness, but no one does a test to confirm what kind of virus it is?