This month, two concerning stories about the ongoing epidemic of Ebola virus disease (Ebola for short) in Africa grabbed our attention. On Monday, several social media sites circulated posts about Congolese refugees who had crossed the border from Mexico to Texas and tested positive for Ebola. The various posts circulated widely enough that they were picked up by mainstream media outlets, and Texas health officials eventually had to issue statements to refute the claims. Then on Tuesday, health authorities in Uganda confirmed the first trans-border spread of the outbreak from its source in eastern Democratic Republic of the Congo (DRC) in the form of a five-year-old child and several family members.
Both reports were alarming: the first for its falsehood and propagation of dangerous mythology surrounding emerging infectious disease threats; and the second for its confirmation that this current Ebola outbreak, now burning for over nine months and achieving the status of the second-largest in recorded history, shows no signs of abating. As infectious disease and public health professionals, we feel there are powerful lessons to be learned from each.
Misinformation may be one of the greatest public health threats we face today. As the 21st century ages into adulthood, we run the risk of walking back the tremendous achievements made by public health in the 20th century. From 1900 through the dawn of the new millennium, public health actions such as sanitation and hygiene, vaccines, and disease surveillance and control measures virtually eliminated the worst childhood diseases from the United States, completely eradicated the scourge of smallpox, and increased American life expectancy by 30 years. Yet today we face burgeoning outbreaks of vaccine-preventable disease, such as measles, fueled by baseless speculation regarding the safety of the very vaccines that we have used effectively for a generation. Public trust in established institutions of knowledge and expertise is eroding as discourse over science becomes increasingly politicized; fertile ground for ideological or political zealots to propagate their own false narratives.
The Congolese refugee story is one such example where common myths about disease were used for political purpose, presumably to stoke fear and distrust of refugees and immigrants. While certainly not a new meme, fear of disease-carrying immigrants continues to distort our perception of infectious disease risk and distract from the most important interventions we need to take to protect ourselves. While we should increase our health screening services for undocumented persons arriving at our border, that is not where our vulnerabilities to emerging infectious diseases lie. In fiscal year 2018, Customs and Border Protection (CBP) apprehended 404,142 people crossing into the U.S. illegally, whereas in any average day, CBP processes over one million passengers and pedestrians entering the U.S. through legal points of entry. This includes over 340,000 international air travelers. The point is, if a disease outbreak occurs somewhere in the world, it is likely to eventually end up here, and not via refugees or illegal immigrants. And in our modern economy that depends on free movement of people and goods across the globe, trying to reduce this risk by limiting such traffic would mean a cure worse than the disease. By the way, the worst pandemic of the 20th century, the 1918 Influenza that killed over 50 million people worldwide, appears to have originated in Kansas. Misinformation about immigrants does not provide the protection we need against emerging disease threats.
Indeed, it is misinformation and fractures in the public’s trust of authorities that drives the current outbreak in eastern DRC. Despite lessons learned from 2014, emphasis on early detection, enhanced treatment, safe and dignified burial practices, and a new vaccine, the epidemic has claimed over 1,400 lives, with no end in sight. Among the local population, rumors about the outbreak and response abound. Some people believe the outbreak is a government ruse to control political opposition, and some believe that the Ebola treatment units are harvesting organs. The result is families that are afraid to identify ill relatives, villages that refuse to admit public health teams, and even mobs that commit violence against health workers. Now that the outbreak has spread across the border with Uganda, cases are only six hours by road from the urban capital of Kampala and the international airport in Entebbe. The risk of acceleration and spread increases. The events in DRC and Uganda should serve as a warning that infectious diseases are a continuing threat, and our global public health tools are still inadequate. As Bill Gates has said, in the fight against emerging pandemic diseases, we are “bringing a knife to a bazooka fight.”
So, what can we do to help the struggle against emerging infections? First, we can fight misinformation and promote messages from our public health and scientific experts. The Centers for Disease Control and Prevention (CDC) website is a good place to start. Second, we can adequately fund our public health infrastructure that we rely on for surveillance, detection, and containment efforts. Third, we can support international collaboration in emerging infection preparedness and response, remembering that these diseases do not respect borders and combatting them is a collective effort. Finally, we can make new investments in innovation for pandemic defense – not only in new drugs and vaccines, but also in improved systems for early detection and optimized clinical care in public health emergencies. At UNMC and Nebraska medicine, we lead the world in training, research, and clinical care for highly dangerous pathogens, and we will continue to work tirelessly to develop new tools in our constant struggle against pandemic threats. Let’s all pitch in and be part of the solution.
Original editorial posted in the Omaha World Herald on June 23, 2019. Read it here.
For more education on how we lead global education, please check out: https://netec.org/
Read a New York Times Piece on this topic here.
Content written by James V. Lawler, MD MPH FIDSA with insights from Jasmine Marcelin, MD, Kelly Cawcutt, MD MS FACP, Angela Hewlett, MD MS FIDSA
In 2017, our ID fellowship program was expanded to 2 fellows per year and both Dr. Hankins and Dr. Karnatak welcomed the opportunity to experience the program growth in live action. Since then, we have filled our fellowship, currently with four fellows (they were joined in 2018 by Drs. Lindsey Rearigh and Randy McCreery).
Dr. Hankins is staying on faculty as an Instructor of Medicine, where he will be obtaining his Masters of Clinical & Translational Science, taking on the role of Associate Medical Director of Infection Prevention & Hospital Epidemiology, and continuing teaching as an attending on the General Infectious Diseases service.
Dr. Karnatak will be transitioning to the UNMC Critical Care department, where he will be completing a third year of fellowship in Critical Care Medicine.
Pastor Joyce Miller is a Lutheran minister and chaplain at Nebraska Medicine and has been a pillar of comfort for grieving faculty, staff and patient families during illness and death. She began by acknowledging that Islam, Judaism, and Christianity share similar roots, therefore it is no surprise that there are similar customs among these faiths. Miller shared the major fasting period of Christianity – Lent – is an important 40-day period of prayer, charity and alms-giving in preparation for Easter.
Kate Tyner, an Infection Preventionist working with the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP), shared about fasting specifically within the Catholic faith. She related that before the Vatican II council decision, Catholics observed strict abstinence from meat on Fridays, but that after the decision, this strict abstinence was relaxed outside of the Lenten period. Tyner also shared a beautiful quote about what fasting means: “The willingness to deny ourselves awakens in us a capacity to give ourselves in greater love to our faith.” (Adapted from Magnificat daily devotion provided by Father Donald Haggerty).
Bryan Alexander, an ID Pharmacist working with the Antimicrobial Stewardship program, shared about fasting in the Orthodox Christian faith, which we learned is a stricter fasting regimen, including fasting from meat, wine, dairy and fish with backbones on Wednesdays and Fridays, and approximately 180-200 days of limited fasting per year. Alexander related that the purpose of the limited fasting was to “simplify your diet to focus on your day”, and that the act of fasting makes feasting more joyful, especially with the communal nature of the feasts at the end of a fast.
Dr. Raj Karnatak, a senior ID fellow, shared what fasting means in the Hindu faith. The Sanskrit word for fast is Upvaas, which means “staying near God”. He shared that in his culture, different foods carry various implications. Food is divided into three categories 1) Sattvic food: fruits, vegetables and dairy. 2) Rajsic food: Spicy food, garlic, onion (Believed to create unrest in mind). 3) Tamsic food: Meat, fish, and eggs (can serve to decrease spiritual enhancement); therefore, fasting often involves abstinence from Rajsic and Tamsic foods. People can fast in different ways in Hinduism – complete abstinence from all food/water, abstinence from only food, limiting intake to just one meal per day, or even abstinence from speaking (Maunvrat). He reminded us that fasting has been used as a political/social justice tool, as Mahatma Gandhi did fasting for human rights.
Nowairah Syed, a teacher at Noor Academy and wife of Dr. Ashraf, shared about fasting in Islam. The fasting month of Ramadan (which means dryness or scorching heat) occurs in the 9th lunar month, with daily fasts (abstaining from food and water) from sunrise to sunset. The daily breaking of fast is called Iftar. Dr. Fadul shared that in Sudan, men would sit outside in the community with food around sunset so that if someone was too weak from fasting to make it inside their homes, they could celebrate Iftar wherever they were at sunset, a testament to the strong sense of community responsibility. Because it is based on the lunar calendar, Ramadan can last for 29-30 days and is at a different time every year. Syed shared that Ramadan is a reminder for Muslims to be better people, both spiritually and physically, refraining from anger and frustration. It is a reminder to exercise patience, understand others and giving to charity. The fast is broken daily with dates and water, and at the end of Ramadan, called Eid, Muslims gather to celebrate with a big Feast.
After hearing about fasting in different faiths, there was spirted discussion and sharing as the group waited for sundown at 8:43pm on that evening, then it was time to feast. There was so much food there that everyone was filled and still had enough to take home leftovers. It was an event where after sharing this occasion with friends and colleagues, and learning about different cultures, one left feeling full both physically and spiritually, regardless of individual faith backgrounds.
Drs. Fadul and Ashraf were previously colleagues together at another institution where they created this tradition, and Dr. El-Ramahi joined them here; we are thrilled that they have shared it with us here at UNMC. We hope that in subsequent years the event is even bigger, expanding to the Department of Medicine and beyond, so that more people can share this special occasion, learn about different cultures, and recognize the impact of diversity in our lives.
The authors validated that the IDSA guideline-based criteria had a sensitivity of 97% (95% CI 84.2-99.9), specificity of 33.9% (95% CI: 30.1-37.8), negative predictive value of 99.5% (95% CI: 97.3-100.0), and a positive predictive value of 7.5% (95% CI: 5.2-10.4). They found that application of these testing criteria would have avoided testing in 32% of patients, and avoided unnecessary antibiotics) in 23% of patients.
Lt Col Schnaubelt began her military career as a Cadet at the United States Air Force Academy with hopes of flying fighter jets. Her focus quickly changed after a visit to Haiti where she realized that her true passion was a career in medicine. After the academy she attend medical school at Loyola University Chicago. Dr. Schnaubelt completed her internal medicine residency at Wright State University, and infectious diseases fellowship at San Antonio Military Medical Center. Following her medical training, she was deployed to Afghanistan, and was then assigned to Landstuhl Regional Medical Center in Germany.
Following her assignment in Germany, Dr. Schnaubelt was selected as an 
Congratulations, Dr. Schnaubelt, on a well-earned promotion, recognizing your talents and long list of accomplishments. We appreciate you and thank you for your service, as both a military officer, and an UNMC ID faculty member.
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