PATH­WAY TO PERIL

USA TODAY International Edition - - FRONT PAGE - Mark John­son and Devi Shastri

NAIROBI, Kenyan reKENYA searcher James Miser Akoko stood at the edge of Nairobi’s vast Dan­dora dump in the late af­ter­noon heat, star­ing down into a recipe for the next pan­demic.

Dozens of men and women scoured a 30- acre garbage pit in a grim ver­sion of re­cy­cling, gath­er­ing soiled plas­tic toys, filthy cloth­ing and blan­kets, even aban­doned air­line food. Large marabou storks watched over them. Free- rang­ing pigs, goats and other live­stock grazed on refuse, mark­ing time un­til the day they be­come food them­selves — hu­man food.

In the neigh­bor­ing Koro­go­cho slum, which shel­ters 150,000 of Nairobi’s poor­est peo­ple, Akoko en­coun­tered a mid­dle- aged woman la­bor­ing over a large, un­cov­ered pot of sim­mer­ing chicken in­testines. Th­ese she would sell to passersby. Dozens of marabou storks ap­peared, cir­cling over­head.

Sci­en­tists worry the next dev­as­tat­ing dis­ease could be born where an­i­mals and hu­mans mix in a Third World slum — then cross the globe. Zika may have been a pre­view.

“One task that is still un­done for us,” said Akoko, of the In­ter­na­tional Live­stock Re­search In­sti­tute, “is to go into the dump sites and catch the marabou storks to see what they are car­ry­ing ... we don’t know what they are spread­ing in Nairobi in terms of dis­ease.”

When sci­en­tists worry about the next big out­break, it is places like this they men­tion: sprawl­ing Third World ci­ties, with large pop­u­la­tions of hu­mans and an­i­mals liv­ing to­gether amid the squalor of dirty wa­ter and poor san­i­ta­tion. Of Nairobi’s 3.4 mil­lion peo­ple, about 60% live in densely packed slums, shar­ing muddy roads with goats, pigs, chick­ens, cows and ro­dents.

Imag­ine a melt­ing pot into which live­stock, birds, flies and peo­ple all con­trib­ute bac­te­ria and other mi­crobes — a Petri dish for the cre­ation of new threats to hu­man health. Pigs, for ex­am­ple, act as mix­ing ves­sels for in­fluenza. They can be in­fected by both bird and hu­man flu, al­low­ing ge­netic ma­te­rial from each to com­bine and form new strains.

A few years ago, re­searchers at King’s Col­lege Lon­don imag­ined how this bi­ol­ogy might play out in a slum.

They de­vised a hy­po­thet­i­cal sce­nario that be­gins with im­pov­er­ished res­i­dents watch­ing their pigs and poul­try fall ill with high fevers and bleed­ing. Within a day, an­i­mals be­gin to die. Within weeks, the new in­fluenza spreads from an­i­mals to the hu­mans who han­dle them. And be­cause the res­i­dents have lives out­side the slum, work­ing in ho­tels and fac­to­ries, rid­ing on buses, the in­fluenza ad­vances be­yond the slum.

Within a month and a half, the au­thors wrote, “the virus has spread to nearly 80 mil­lion peo­ple world­wide. Car­ried abroad by in­ter­na­tional long- dis­tance com­mer­cial flights, the ill­ness leapfrogged out of Asia and ap­peared in Hong Kong, Lon­don, Paris, Mar­seilles, North Africa, New York, Bei­jing, Cal­cutta and Dubai al­most si­mul­ta­ne­ously.”

All told, the in­fluenza kills 140 mil­lion peo­ple.

It is only hy­po­thet­i­cal, of course, though “a plau­si­ble sit­u­a­tion,” said Kris­ten Bernard, pro­fes­sor of vi­rol­ogy at the Univer­sity of Wis­con­sin- Madi­son’s School of Ve­teri­nary Medicine.

The au­thors set their sce­nario in the poverty- stricken fave­las of São Paulo, Brazil, be­cause th­ese ar­eas have a high den­sity of hu­mans and an­i­mals liv­ing in close quar­ters, shar­ing poor wa­ter and san­i­ta­tion.

Much like Nairobi. Or Mum­bai. Or Mex­ico City. Or dozens of sim­i­lar ci­ties, all ex­pand­ing, as the world’s pop­u­la­tion shifts from ru­ral to ur­ban ar­eas.

—— “A mi­crobe orig­i­nat­ing in Africa or South­east Asia can ar­rive on North Amer­i­can shores within 24 hours,” ac­cord­ing to a 2014 re­port by the U. S. Cen­ters for Dis­ease Con­trol and Preven­tion. We al­ready see the re­sults. Stud­ies say a ma­jor­ity of U. S. cases of dif­fi­cult- to- treat, drug- re­sis­tant ty­phoid fever can be traced to six de­vel­op­ing coun­tries.

The ad­vance of drug- re­sis­tant ty­phoid in the U. S. has drawn lit­tle at­ten­tion, es­pe­cially when com­pared with the dis­ease that ar­rived by plane in Septem­ber 2014.

“The first case of Ebola di­ag­nosed in the U. S. had ma­jor cas­cad­ing ef­fects that rip­pled through sev­eral in­dus­tries,” said Amesh Adalja, a se­nior as­so­ciate at Johns Hop­kins Cen­ter for Health Se­cu­rity. “Ev­ery hos­pi­tal had to aug­ment their pre­pared­ness, pub­lic health agen­cies were tasked with mon­i­tor­ing large num­bers of those re­turn­ing from West Africa, air­port screen­ing tools had to be de­vel­oped, and gen­eral panic from the pub­lic and politi­cians en­sued.”

Our Ebola scare has since passed, but a longer- term prob­lem ar­rived last July.

A lit­tle more than a year af­ter the Zika virus be­gan storm­ing through Brazil and most of Cen­tral and South Amer­ica, the virus ar­rived in South Florida. The mos­qui­toes that carry Zika were wait­ing. They needed only in­fected peo­ple to bite, and they would find them soon enough.

“There is a huge vi­ral reser­voir in the Amer­i­cas,” said José Sza­poc­znik, a Zika ex­pert at the Univer­sity of Mi­ami. “And we have peo­ple com­ing from that vi­ral reser­voir to Mi­ami on an on­go­ing ba­sis.” —— Zika ar­rived last July at the peak of a hu­mid Mi­ami sum­mer. For Yes­sica Flores, it was a joy- ous time. She was preg­nant.

Flores, 38, was nearly three months into her preg­nancy. An im­mi­grant from Hon­duras, she lives in a col­or­ful one- story home in Mi­ami’s Wyn­wood neigh­bor­hood with her hus­band, her mother and her 14- year- old daugh­ter, An­drea.

“I heard about Zika from the time it started in Mi­ami,” Flores said through an in­ter­preter. “But I didn’t bother with it.”

Watch­ing Zika more closely than Flores was Chalmers Vasquez, the op­er­a­tions man­ager of Mi­ami- Dade County’s mos­quito con­trol team. He be­lieved the re­gion was ready to com­bat the mos­quito that car­ried the virus, Aedes ae­gypti.

The county had faced the same mos­quito dur­ing out­breaks of dengue fever in 2010 and 2014, and chikun­gunya, also in 2014.

On July 15, 2016, Vasquez and some co- work­ers stopped for lunch in Fort My­ers when his phone rang. Zika had reached Mi­ami. That night, he and his team set their first round of mos­quito traps and be­gan mon­i­tor­ing the pop­u­la­tion. ——

In the days af­ter Zika ar­rived in Mi­ami, Vasquez’s team walked through neigh­bor­hoods spray­ing in­sec­ti­cides from their back­packs and search­ing for any­thing that could col­lect wa­ter for the mos­qui­toes to breed in — no bot­tle cap was too small.

But in some re­spects the re­sponse to Zika was trial and er­ror.

“We found out that the in­sec­ti­cide that we were us­ing in the spray trucks was no good,” said Vasquez. The mos­qui­tos had de­vel­oped a re­sis­tance to it.

Af­ter test­ing var­i­ous com­pounds, they switched to naled, a po­tent in­sec­ti­cide sprayed from air­planes. Aerial treat­ments cut the num­ber of mos­qui­toes they caught to less than half in a week.

On Jan. 27, 2017, Flores went to the school where she worked to re­quest her ma­ter­nity leave. As she was leav­ing, she felt an abrupt pain. A co- worker told her to go to the hos­pi­tal.

That evening, af­ter the baby had been tested, the doc­tor urged Flores and her hus­band to re­lax. At seven pounds, Baby Daniella El­iz­a­beth Yac was healthy and fit.

At Univer­sity of Mi­ami, Sza­poc­znik said peo­ple have the power to stop the spread of Zika by fol­low­ing sim­ple steps: emp­ty­ing sources of stand­ing wa­ter, avoid­ing ex­ces­sive skin ex­po­sure and us­ing in­sect re­pel­lent.

Still, the CDC and oth­ers con­tinue to preach mos­quito con­trol.

“So that wasn’t a small out­break be­cause it just fiz­zled out,” said Dan Strick­man, se­nior pro­gram of­fi­cer at the Bill & Melinda Gates Foun­da­tion. “It was a small out­break be­cause we did some­thing about it.”

By Au­gust, Flores was about five months into her preg­nancy. One day, the lab pro­cess­ing her Zika test called. The voice on the other end asked ques­tions un­til Flores posed one of her own. “Does this mean I have Zika?” The an­swer she fi­nally got was not the one she wanted.

As of mid- June of this year, Flores was one of 351 preg­nant women in Florida to show lab ev­i­dence of the Zika in­fec­tion.

It is still early in our un­der­stand­ing of Zika’s link to the birth de­fect mi­cro­cephaly. Doc­tors could only mon­i­tor the baby’s de­vel­op­ment ev­ery week.

Flores be­gan to pray.

PHO­TOS BY MARK HOFF­MAN, MILWAUKEE JOUR­NAL SEN­TINEL

Res­i­dents work­ing with bare hands and with­out face masks search for food and items they can re­sell as trash is be­ing dumped at Dan­dora, a mas­sive, smol­der­ing pile of garbage in Nairobi’s Koro­go­cho slum.

A marabou stork soars over a dump in Nairobi, Kenya. The birds eat car­rion, rot­ting garbage and small mam­mals. They can weigh as much as 20 pounds.

PHO­TOS BY MARK HOFF­MAN, MILWAUKEE JOUR­NAL SEN­TINEL

A woman sells a mix­ture of chicken in­testines and in­nards and eggs wrapped in sheets of used of­fice pa­per for about 10 cents out­side her home in the Koro­go­cho slum. She has been mak­ing and selling the mix­ture for 30 years and was able to help pay for a son to at­tend a univer­sity.

James Miser Akoko, In­ter­na­tional Live­stock Re­search In­sti­tute field co­or­di­na­tor for the Ur­ban Zoo project, right, talks with Jane Waigwa, as­sis­tant chief of the Vi­wan­dani slum in Nairobi, Kenya. To make their stud­ies work, In­ter­na­tional Live­stock re­searchers have needed to gain the trust of neigh­bor­hood lead­ers and res­i­dents.

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