Lessons Learned from Ebola

~Written by Kelly Ann Hanzlik (Contact: kelly_hanzlik@hotmail.com)

According to the World Health Organization, 28,616 people contracted Ebola and 11,310 lives were lost during the Ebola epidemic. After so many lives lost and the hopeful, but understandably tentative countdown of Ebola free days continues once again in West Africa, it is imperative that we take a moment to consider what we learned from the devastating and tragic epidemic.

I spoke with Dr. Ali S. Khan, former senior administrator for the Centers for Disease Control and Prevention, former Assistant Surgeon General, and current Dean of the University Of Nebraska College Of Public Health. He noted initially, that there is always the risk of importation of cases; that is how it started he reminds us. He elaborated further that the epidemic “changed the response from the WHO and caused a change in political focus by the nations involved that will affect future outbreaks and ensure native capabilities, as well as link them to the global response.” He also noted that new medical counter measures, such as vaccines and related therapeutics, were also the result of the Ebola impact. When asked about what we learned, he did not hesitate. “The first thing was a new vaccine that permits a novel prevention strategy using ring vaccination to prevent spread and new cases. The second is the new monoclonals and antivirals for treatment.” He also noted the better understanding of the viral progression and clinical diseases that will influence options for acute treatment and follow up of convalescents.

Ebola has provided us with a virtual plethora of opportunities to learn about the disease, its treatment and control, as well as the control of other infectious illnesses through our attempts to prevent its spread as well as through our failures, and successes. We gained valuable treatment modalities and tactics that will likely be used in future outbreaks of Ebola, as well as many other infectious diseases.

Ebola taught us other things too. It has been some time since global health has taken center stage. Ebola changed that. During the epidemic, one could not watch the news or go through a day without hearing an update on the latest development in the Ebola crisis. Although other infectious diseases like Plague, Polio, AIDS, SARS, H1N1, Cholera, and now Zika have captured the world’s attention, few diseases have made such an intense impact, nor caused the uproar and fervor that Ebola elicited. Ebola reminded us that global health is public health and affects us all, and as such, deserves to be a priority for national and international focus and funding for everything from vaccine development and research, to capacity for response locally, nationally, and internationally. Global health has teetered on the edge of public awareness, and remained a quiet player in the competition of priorities in national budgets. Today, it is abundantly clear how vital this sector is to each nation’s, as well as the world’s health, safety, success and even its survival.

Another effect from the Ebola crisis was the opportunity to educate people about public health and the transmission of infectious disease. Through education, public health officials were able to promote behaviors that ensured the safety and health of the public. It is stunning that in this day and age, we persist in so many behaviors that put us and those we interact with at risk. The discrepancy in what we say we will do, and what we are actually willing to commit to and take action on, looms large. Persisting low vaccination rates and the prevalence of infectious diseases such as sexually transmitted diseases, measles, pertussis and influenza show this. Ebola offers yet another opportunity to demonstrate the connection between our behaviors and our risks and disease.

Ebola also showed us that many nations continue to lack sufficient financing, infrastructure, facilities, support and medical staff to treat their own populations. Endemic conditions like malaria, and neglected tropical diseases like Guinea worm disease, Yaws, Leishmaniasis, Filariasis, and Helminths, as well as other conditions continue to affect millions globally.  Maternal and childhood morbidity and mortality rates remain deplorable as well. And millions of children around the world continue to suffer and die of malnutrition and disease before they reach the age of five. This is unacceptable, especially because proper treatment and cures for these conditions exist. Ebola also highlighted the need for treatments for chronic non-infectious conditions as well.

Moreover, Ebola clearly demonstrated the enormous need that remains for sufficiently trained medical professionals and healthcare staff to provide adequate care for many populations throughout the world. The loss of so many extraordinary and heroic staff that dedicated their lives to helping others in need under the most daunting and challenging of circumstances was devastating to those whom they served, and must not be in vain.

Additionally, Ebola provided us with yet another chance to relearn lessons about the role of safety in giving aid to others in need. We learned that we cannot just rush in with aid, but must recall the basics that every first responder and medical student must learn:  Ensure scene safety before giving care, and first do no harm. Ebola showed us the necessity to strategize and prepare to give care by utilizing personal protective equipment. It also reminded us very quickly that we could indeed do harm, and worsen the epidemic when we acted without first assessing the situation and ensuring proper protection and preparation.

So, it remains to be seen just how much we will learn from Ebola. Will we learn from our mistakes? Will we take the global view in the future, or the narrow one? Will we truly live by the motto of the Three Musketeers and be "one for all and all for one", or persist in "it's all about me"? Only time will tell. 

Is Measles Eradication Possible when the World is Still Trying to Eradicate Polio?

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com)

Also published on Global Contagions

Humanity has only truly conquered one human infectious disease, smallpox. Smallpox was successfully eradicated in 1977 after causing between 100 and 300 million deaths in the 20th century. Strides are being made to make polio the second eradicated infectious disease. Polio eradication efforts have been ongoing for almost 30 years, costing nearly 11 billion dollars. The World Health Organization (WHO) set a goal for polio eradication by 2000 but, 16 years later, that goal has yet to be achieved for reasons such as oral polio vaccine (OPV) effectiveness, armed conflict, and myths about vaccine dangers. The global public health community has been “burned” by the polio eradication campaign and may not have the money or energy for another global eradication campaign, especially since the polio campaign is still ongoing. Even if the global health community is burnt out on polio eradication efforts, is it time to turn our attention toward measles eradication?

Measles, along with smallpox and polio, is one of the very few diseases that meets the criteria necessary for eradication. Measles cases can be easily diagnosed due to the characteristic rash, the vaccine is incredibly effective, and there is no animal host where the virus can hide. Perhaps most importantly, measles transmission has been eliminated in large geographic areas, demonstrating that eradication may be feasible.

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Number of reported measles cases from April 2015 to September 2015 (6 months); Photo Credit: World Health Organization

Measles is a deadly disease. In 2013, measles killed an estimated 145,000 people, mostly children in Africa, while leaving countless others deaf, blind, or otherwise disabled. To prevent measles individuals need to receive two vaccinations, which are 99% effective at preventing measles. While the number of children receiving measles vaccinations has risen over the past decade, there are still a handful of countries where children aren’t receiving vaccines (Democratic Republic of Congo, Ethiopia, Nigeria, India, Pakistan). Even places like the United States and some countries in Europe, which have eliminated measles locally, are seeing outbreaks due to imported cases. Until measles is eradicated, imported cases will continue to pop-up in countries without local transmission.

While measles meets the criteria for eradication efforts, there are still challenges to achieving that goal. One major challenge is that measles is incredibly contagious; infectious droplets can linger in the air for up to two hours, infecting unsuspecting people. To interrupt measles transmission, over 95% of the population needs to be vaccinated, compared to only 80% for smallpox and polio. The measles vaccine is also harder to deliver than the OPV, which is administered via a few drops in a child’s mouth. The measles vaccine must be given via injection, thus trained staff is necessary, and the vaccine has to be reconstituted in the field (liquid added to the powder vaccine to make the complete vaccine). Once reconstituted, the vaccine is only viable for six hours, which isn’t much of an issue for large vaccination campaigns but becomes problematic when only one or two children need to be vaccinated.

As with many global public health campaigns, governments and non-governmental organizations donate money to help high-risk countries control the spread of measles. In 2009, the global recession hit and measles eradication efforts lost significant funding. Mass vaccination campaigns were canceled or reduced and routine vaccination programs suffered. Following the reduction in vaccinations the number of measles cases exploded in southern African countries, going from 170,000 in 2008 to 200,000 in 2011. Added to these challenges is the perception of measles in high-income countries. Even though measles is a deadly disease, many in high income countries view measles as a minor illness with  a rash and fever; certainly not something worth spending billions of dollars on over the course of many years.

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Source: Butler D (2015). Measles by the numbers: A race to eradication. Nature 518 (7538): 148-149. doi: 10.1038/518148a.

Measles eradication is feasible. Measles meets the criteria necessary for eradication; it is easily diagnosed, it has an effective vaccine, and humans are the only host. It has been successfully eliminated in large areas of the world (for example, all 35 countries of the Americas eliminated measles in 2002), demonstrating that it is possible to at least end local transmission. However, significant challenges do exist. While the global health world may be hesitant to embark on another “eradication” campaign after the continued struggle with eradicating polio, perhaps it’s best to start eradicating measles without labeling it an “eradication” campaign. Avoiding the “eradication” label may help prevent critics who are hesitant about taking on another potentially long and expensive eradication campaign, especially as the polio eradication campaign is still ongoing. Regardless of the use of the word “eradication” in the efforts to rid the world of measles, without measles in the world, lives will be saved. Let’s ensure measles is added to the very short list of human diseases we’ve eradicated.

Defeating Tuberculosis: A Possibility?

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

Disease has always played a part in reforming community and geographical distribution of people through the ages. The bubonic plague, the Spanish flu, cholera and tuberculosis (TB), are some of the illnesses that have altered human history. Interestingly, TB has been glorified in literature more than others. The characters, Mimi in La boheme, Fantine in Les Miserables and Satine in Moulin Rouge all met with a similar fate at the hands of this disease.

According to the Global Tuberculosis Report 2015, the year 2015 is considered a turning point for TB as the global community progressed from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs). TB mortality has decreased by 47% since 1990. Between 1990 and 2014, as a result of correct and timely diagnosis, 43 million lives were saved. We have made progress by moving from the “Stop TB Strategy” to the “End TB Strategy”. According to the latter, the targets for 2030 are to reduce the number of TB deaths by 90% and incidence by 80% (1).

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Source: TBAlert.org

These statistics give us hope for a world without TB. But, having worked in a tertiary hospital in a low middle-income country, I have my doubts. Although the statistics reported by the World Health Organization (WHO) are the best available at the moment, these are estimates with very wide confidence intervals and may not provide a precise idea of the current situation in low and low middle income countries (LIC and LMICs).

In the surgical ward where I worked, one-third of the abdominal procedures were for perforation due to abdominal TB. To my knowledge, patient records were maintained through an electronic health system on the hospital server. Hard copies of the records were kept in nurses’ offices or junior doctors; duty rooms. These were put in storage, usually available for 4 to 5 years. The conditions of the storage area were extremely shabby and damp, where paper records could hardly survive. Electronic records, however, were said to be available in perpetuity. No one knew if these records were ever shared with the WHO to help with estimates. Popular opinion was that if the world knew the actual incidence and prevalence of diseases like TB in countries like ours it would be an embarrassment. Regardless, it is essential to have as accurate as possible estimates to converge efforts towards a TB free world.

Despite the best intentions and apparently achievable goals, the situation remains grim. According to the WHO, TB still imposes a great burden on the world. In 2014, 9.6 million new cases of TB were diagnosed while 1.5 million people died as a result of TB (2). Despite the history of this disease, research for newer TB drugs has been limited (3). In 2012, a new drug for multidrug resistant TB was introduced after a drought of 50 years (4). In addition, though BCG vaccines are part of immunization programs in countries where the disease is endemic, the current vaccine was developed in 1921 and is not entirely effective (5). A systemic review and meta-analysis that included articles from 1950 to 2013 reported 19% efficacy against TB in vaccinated children compared to non-vaccinated children (6). Although current research is encouraging there are questions of affordability of newer drugs for low resource countries where TB is more prevalent. Furthermore, five percent of the global burden of TB is due to multidrug resistant strains (7). The research required for averting these cases poses additional problems of affordability, availability and accessibility in LICs and LMICs.

Children present another area of grave concern. It is estimated that 550,000 children are infected with TB each year. The condition is frequently overlooked in children, often due to delayed and inefficient diagnosis (8). Adoption of the latest recommended diagnostic tools by the WHO is a challenge in itself because accessibility, affordability and availability again come into play in LICs and LMICs. Since TB flourishes in poor living conditions, the current global refugee and migrant situation has increased concerns about TB exposure, infection and transmission (9).

It is time that LICs and LMICs focus on establishing the true burden of major diseases like TB, and work towards adopting recommended diagnostic tools and treatment for all forms of TB. Unless the state actors and international community work together, the policies and aid provided will continue to fall short and the target to end TB will remain out of reach.

References:

1. World Health Organization. Global Tuberculosis Report 2015. 2015.

2. World Health Organization. Research for Tuberculosis Elimination. 2014.

3. Frick M. 2014. Report on Tuberculosis Research Funding Trends, 2005-2013. [Internet]. Treatment Action Group. 2015. Available from: http://www.treatmentactiongroup.org/sites/tagone.drupalgardens.com/files/tbrd2012 final.pdf

4. Médecins Sans Frontières, International Union Against Tuberculosis and Lung Disease. DR-TB Drugs Under the Microscope. Sources and prices for drug-resistant tuberculosis medicines. 2nd edition. 2013.

5. World Health Organization. Tuberculosis vaccine development [Internet]. World Health Organization; 2015 [cited 2016 Mar 19]. Available from: http://www.who.int/immunization/research/development/tuberculosis/en/

6. A Roy et al. Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systemic review and meta-analysis.  BMJ 2014; 349:g4643

7. World Health Organization. Multidrug Resistant Tuberculosis (MDR-TB). 2015.

8. World Health Organization. Combating Tuberculosis in Children. 2015.

9. World Health Organization. Tuberculosis prevention and care for migrants. 2014.

The Environmental Cost that Living in this World Puts on Our Health

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

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Source: Environmental Health, World Health Organization (WHO)

As revolting as it sounds, there are places in the world where the chances of consuming one’s neighbours’ faeces are quite high if one is not vigilant regarding sanitation and hygiene. That being the condition of many areas in low and lower-middle income countries does not mean that high and higher-middle income countries are exempt from any environmental conditions that are harmful to health.

But, what is environment health? The World Health Organization (WHO) defines the term as, “All the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours”. It, however, excludes genetics and the social and cultural environment.

In low-income settings, concerns for environmental health may arise in the context of sanitation and hygiene, as well as indoor and outdoor pollution. In high-income countries, many chronic diseases like diabetes and cardiovascular disease, are associated with sedentary lifestyles. While these might be attributed to behaviour, one must consider that such behaviours can arise from changes in the environment. Over 80% of communicable and non-communicable diseases can be attributed to environmental hazards.  Overall, conservative estimates indicate that about one quarter of the total global burden of disease is owing to this cause (WHO, 2011). Furthermore, the biggest killers of children under 5 years are all environmental-related diseases, including diarrhoea, respiratory infections, and malaria.

Other diseases of concern are helminthic infections, trachoma (a bacterial eye infection), Chagas disease, leishmaniosis, onchocerciasis, and dengue fever. All of which are associated with impoverished conditions and can be mitigated by improving sanitation, hygiene, and housing. Although conflicts and natural disasters might be catastrophic for any country, struggling economies tend to suffer more because disasters worsen the poor conditions which directly affect sanitation and hygiene practices, creating conducive conditions for various infectious diseases, and ultimately feeding into the vicious cycle of poverty.

Many interventions are underway to address these conditions, including Water, Sanitation and Hygiene (WASH) initiatives, Integrated Vector Management, Programme on Household Air Pollution, International Programme on Chemical Safety, Health and Environment Linkages Initiative, and Intersun Programme for the effects of UV radiation. The acknowledgement of the effects of the environment has grown. One of the Millennium Development Goals (MDGs) was, “To ensure environmental sustainability.” The Sustainable Development Goals (SDGs) are more extensive and thorough in placing focus on the environment. Goal 1 is to end poverty, goal 6 is to make provision of clean water and sanitation possible, and goal 13 is to stop climatic change resulting in floods and drought (United Nations, 2014).

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The Sustainable Development Goals. Source: United Nations System Staff College

It is encouraging to see steps being taken to control environmental hazards; however, the journey to measuring and eradicating such conditions still remains a challenge, which will hopefully be overcome through future endeavours.

References:

United Nations (2014). Sustainable Development Goals. doi:10.1017/CBO9781107415324.004

World Health Organization (2011). WHO Public Health & Environment Global Strategy Overview

Recent Therapeutic Advancements in Combating Dengue and Glioma

~Written by Kate Lee, MPH (Contact: kate@recombine.com)

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Sanofi-Pasteur's Dengvaxia has been approved for the prevention of the four subtypes of dengue in children over 9 years old and adults under 45 years old. Photo Credit: European Pharmaceutical Review

Infectious and chronic diseases are some of the top priorities in global health. Abundant funding, both from the government and private sector, is poured into therapeutics research to help decrease morbidity and mortality from both types of diseases. For example, recent news has highlighted two promising therapies with the potential to alleviate the global burden of two diseases: dengue fever, an infectious disease, and glioblastoma, a chronic disease.

After 20 years of research, Sanofi, a French pharmaceutical company, developed Dengvaxia, a vaccine to prevent dengue. Mexico is the first country to approve the vaccine for use in children over the age of nine and adults under the age of 45. A clinical trial last year found the vaccine to have an effectiveness of 60.8% against four strains of the virus[1]. Sanofi bypassed European and US regulations and sought regulatory approval for Dengvaxia in dengue-endemic countries. According to their press release, the vaccine, “will be priced at a fair, affordable, equitable, and sustainable price... and may be distributed for free in certain countries”[2].

Dengue is a febrile viral illness that is spread via the bite of an infected mosquito, and is endemic to tropical and sub-tropical climates. According to the World Health Organization (WHO), about 400 million people globally are infected with the dengue virus each year. Prevention has been limited to effective mosquito control and appropriate medical care[3]. These measures are often either ineffectively implemented, or there are limited, or no available medical resources in the community. Dengvaxia has the potential to reduce the burden of dengue, especially in developing countries that are particularly hard-hit with the disease. Future research could be directed towards making the vaccine more effective in children, as severe forms of dengue are the leading cause of illness and death in children in Asian and Latin American countries[3].

As one tropical virus is being prevented, another virus is being used to combat brain cancer. Researchers at Harvard and Yale have teamed up to use vesicular stomatitis virus (VSV) and Lassa virus, to search for and destroy cancer cells in mice[4]. Lassa is a febrile illness, usually transmitted by rodents, and is endemic to tropical and subtropical regions of the world[5]. VSV has been studied for many years and is generally effective in killing cancer cells; it becomes deadly to the patient when it reaches the brain[4,6]. Interestingly, including Lassa virus appears to make VSV safe for cancer therapy in the brain.

Researchers created a Lassa-VSV chimera, an organism that includes the genetic codes of two different organisms, to target glioma, one of the deadliest forms of brain cancer, which accounts for more than 80% of primary malignant brain tumors[7]. Glioblastoma is the most common form of glioma and is associated with poor survival, making this chimeric treatment a potential life saver for many patients. The next step in the treatment development process is primate research to evaluate safety. This is still a long way from the initiation of human trials, and eventual market, but promising nevertheless, for the millions of people globally who are affected by brain cancer.

Dengvaxia and the Lassa-VSV chimera represent recent advancements in therapeutics with potentially significant global impact for brain cancer and dengue respectively - diseases that affect populations in many nations.

References:

1.     Sanofi's Dengvaxia, World's First Dengue Vaccine, Approved For Use In Mexico. International Business Times. http://www.ibtimes.com/sanofis-dengvaxia-worlds-first-dengue-vaccine-approved-use-mexico-2219515. Published December 10, 2015. Accessed December 20, 2015.

2.     World’s First Dengue Vaccine Approved After 20 Years of Research. Bloomberg Business. http://www.bloomberg.com/news/articles/2015-12-09/world-s-first-dengue-vaccine-approved-after-20-years-of-research. Published December 9, 2015. Accessed December 20, 2015.

3.     Dengue and severe dengue. World Health Organization. http://www.who.int/mediacentre/factsheets/fs117/en/. Updated May 2015. Accessed December 20, 2015.

4.     Using a deadly virus to kill cancer: Scientists experiment with new treatment. The Washington Post. https://www.washingtonpost.com/national/health-science/using-a-deadly-virus-to-kill-cancer-scientists-experiment-with-new-treatment/2015/12/07/7d30bc5a-9785-11e5-8917-653b65c809eb_story.html. Published December 7, 2015. Accessed December 20, 2015.

5.     Lassa fever. World Health Organization. http://www.who.int/mediacentre/factsheets/fs179/en/. Updated March 13, 2015. Accessed December 20, 2015.

6.     Viral Therapy in Treating Patient with Liver Cancer. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01628640. Updated July 2015. Accessed December 20, 2015.

7.     Schwartzbaum J A, Fisher J L, Aldape K D, Wrensch M. Epidemiology and molecular pathology of glioma. Nature Clinical Practice Neurology (2006) 2, 494-503. doi:10.1038/ncpneuro0289

Climate Change and Health, Part 3: Infectious Disease

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

This is my final post of a three part series on climate change and health. The first post looked at how climate change will influence the onset and severity of droughts in some areas. The second post examined how some regions are predicted to see an increase in droughts, which would decrease food supply; thus, increasing nutrient deficiencies in those areas. This post will briefly discuss the influence of climate change on waterborne diseases.

Change in climate, including the increases in temperature and changes in rainfall patterns may lead to an increase in waterborne diseases, where insect vectors contaminate the water (Shuman, 2010). Often, higher temperatures are needed for some insects to complete their life cycle. This is the case for mosquitoes, as they live in warm, aquatic habitats (Shuman, 2010). With an increase in temperature and more flooding, there will be an increase in mosquitoes (Shuman, 2010). Thus, there may be an increase in the transfer of dengue and malaria (Ramasamy & Surendran, 2011). These warm, aquatic habitats will also be ideal for snails, which transfer schistomiasis (Ramasamy & Surendran, 2011). Furthermore, with a rise in sea levels, there is likely to be an increase in saline levels (Ramasamy & Surendran, 2011). Certain types of mosquitoes and snails have a high tolerance for salt water and are thus able to breed in water with high salt concentrations (Ramasamy & Surendran, 2011).

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Taken from: Watts N, Adger W N, Agnolucci P, Blackstock J, Byass, P, Cai W, Costello A (2015). Health and climate change: policy responses to protect public health. The Lancet, 6736(15)

The relationship between climate change and health is complex because there are many different contributing factors and there is limited scientific evidence for many regions, several of which are under-resourced (New York Times, 2015). Furthermore, areas of high-resource have not been impacted in the same way, due to advantages as simple as air conditioning (New York Times, 2015). Thus, more scientific evidence is needed, to determine more ways in which climate change could possibly influence the health of a population. More recognition also needs to be given to this issue so that contingency plans can be made for possible outbreaks of diseases that were discussed in this blog post.

References:

Shuman, E. K. (2010). Global Climate Change and Infectious Diseases. The New England Journal of Medicine , 362 (12), 1061-1063.

Ramasamy, R., & Surendran, S. (2011). Possible impact of rising sea levels on vector-borne infectious diseases. BMC Infectious Diseases , 11 (18).

Tavernise, S. (2015, July 13). Unraveling the Relationship Between Climate Change and Health. Retrieved September 10, 2015, from http://www.nytimes.com/2015/07/14/health/unraveling-the-relationship-between-climate-change-and-health.html?_r=0

The World Hepatitis Summit 2015

~Written by Caity Jackson (Contact: caityjackson@gmail.com)

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The World Hepatitis Alliance team members. Photo Credit: Caity Jackson

Today, viral hepatitis kills more people than HIV/AIDS, tuberculosis, or malaria and has become the 7th major cause of death globally. Despite this, hepatitis has not received the same global attention as the other illnesses it shares the Top 10 global killer list with. The President of the World Hepatitis Alliance Charles Gore noted in his plenary speech ‘‘we felt honestly, neglected.” Neglected they are not today.

Walking into the Scottish Exhibition and Conference Center (SECC), one could feel the energy and urgency in the crowd. The first ever World Hepatitis Summit brought together a group of patients, NGOs, academics, and government officials that have long awaited their time in the spotlight. The Summit’s three-day meeting came in response to last year’s World Health Assembly Resolution calling for concerted action to reverse the ever-rising death toll from viral hepatitis. It serves as the beginning of a series of summits focusing on information sharing and “how we can scale up and not waste the precious resources we know are limited” said Gore. Those at the summit are passionately working towards increasing awareness about viral hepatitis, focusing on the draft WHO Global Health Sector Strategy on Viral Hepatitis which aims to reduce new cases of chronic hepatitis B and C by 90%, reduce hepatitis B and C deaths by 65%, and treat 80% of eligible persons with chronic hepatitis B and C infections by 2030.

Because viral hepatitis has been neglected for so long (viral hepatitis was not included in the Millennium Development Goals) much needs to be done rapidly to make up for lost time. In that context, the Summit, intended as an annual event, will focus on the public health approach to viral hepatitis and become the central forum for countries to share their experience and best practices in order to drive rapid advances in national responses. The inaugural World Hepatitis Summit made history; an effort everyone hopes will lead to reducing the burden on those afflicted by viral hepatitis.

For the full press release please visit the WHO Media centre

For another perspective, please visit the BioMed Central Blog

Lessons, Impact, and the 'Fearonomics' of the Ebola Outbreak in Nigeria

~Written by Sulzhan Bali, PhD (Contact: sulzhan.bali@twigh.org) 

Also published on the DGHI Diaries From the Field Blog

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Passport Sticker with Ebola Symptoms and National Helpline. Photo Credit: Sulzhan Bali, PhD

24th of July.

The day Macchu Picchu was discovered in 1911.

The day Apollo XI returned to the Earth after the first successful mission of taking humans to the moon in 1969. 

Yet, in Nigeria, that day in 2014 will always be marked as the day Patrick Sawyer—the index patient of Ebola—died and set an outbreak in motion in one of the most populated cities in Africa. Patrick Sawyer was a Liberian-American citizen and a diplomat who violated his Ebola quarantine to travel to Nigeria for an ECOWAS convention. His collapse at the airport, coupled with an ongoing strike by Nigerian doctors in public hospitals, landed him at a private hospital in Obalende, where he infected eight other people. 

Patrick Sawyer’s death marked the beginning of an Ebola epidemic in Lagos, a city of 21 million. Lagos is a major economic hub in Africa and one of its biggest cities. An uncontrolled Ebola epidemic would have a far-reaching economic impact beyond the borders of the city, its country, and even its continent.

A recent study has shown that Ebola virus remains active in a dead body for more than a week. Add to this that the body is most infectious in the hours before death, and it is a "virus bomb" waiting to happen if handled incorrectly. West Africa, especially Nigeria, has a strong funeral culture. This Ebola-infected Liberian diplomat’s body was transported and incinerated in accordance with the WHO and CDC protocol. This feat was achieved despite immense political and diplomatic pressure to return the body for funeral rites. It represents one of the many cases of collaboration and "clinical system governance" that are at the heart of the successful containment of Ebola in Nigeria. It is one of the many stories that I'm hoping to highlight in my research on the role of the private sector in Nigeria’s successful Ebola containment.

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One of Many Ebola Information Posters Around Lagos. Photo Credit: Sulzhan Bali, PhD

As part of my research, I am looking at 10 different economic sectors to understand how the Ebola outbreak impacted the private sector and how the private sector dealt with the challenges that the Ebola outbreak posed. My hope is that this research will lead to lessons for the private sector on how, in times of an epidemic, they can help the government to mitigate the disease’s economic impact. I also hope that the resulting report will help governments engage with the private sector more effectively in times of emergencies.

With many outbreaks, especially of highly fatal diseases such as Ebola, fear is the biggest demon. This fear has led to the crippling of economies of Ebola-affected countries. This fear has cost Sierra Leone, Guinea, and Liberia 12 % of their GDP in foregone income and unraveled the years of progress made by these countries. However, this fear is not just a phenomenon limited to West Africa. I had a very personal encounter with this fear recently, when I was quarantined for a few hours in the United States (despite Nigeria being declared Ebola free since October 2014). 

It has been a humbling experience so far, as I try to understand how this fear and the hysteria around Ebola can lead to significant behavioral changes—some of them necessary but some extreme. Everyone I speak to has a story to share. Some people tell of how they bought more than two bus tickets to prevent sitting next to other people. Others tell of hospitals resembling "ghost buildings" as people avoided hospitals and doctors like the plague. Many tell of the "Ebola elbow-shake" that replaced the usual handshake or hug. The reality is that although the Ebola outbreak infected 21 people in Nigeria, it actually affected the lives of 21 million people in Lagos alone, in one way or another. I have come to realize that there is a thin line between precaution and hysteria. Maintaining the equilibrium between the two is the key to controlling the disease and mitigating its economic impact.

As I wrap up my interviews, a few questions resonate with me time and time again from these sessions.

“Are we prepared for the next time?” 

“Ebola is back in Liberia. What can we do to prevent Ebola from coming back to Nigeria?” 

 For the doctors who died in Nigeria’s fight against Ebola:

“Can we truly say our country is a safer place after their sacrifice?” 

And for myself:

“How will your report help Nigeria?”

These are the questions that keep me going. Although my report may not be able to answer all of the aforementioned questions, I do hope it will at least get policy makers, students, and advocacy groups talking about how countries can be better prepared for the next big outbreak and how public-private collaboration can lead a country out of an epidemic and on a path of recovery.

To end on a positive note, 24th July, 2015 also marked one year since the last polio case in Nigeria—an achievement that clearly shows what collaboration in global health can achieve.

(To learn more about my research or to contribute/collaborate in my study, please contact me.)

World Hepatitis Day 2015 - Focusing on Prevention

~Written by Theresa Majesty (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

The World Health Organization (WHO) states that approximately 1.5 million people die each year from the various types of hepatitis caused by hepatitis viruses A, B, C, D, and E. It is estimated that half a billion people worldwide are infected with hepatitis B or C virus, the strains responsible for the majority of cases of liver cirrhosis and liver cancer.

In order to bring attention to the large global burden of disease caused by viral hepatitis, 2015’s World Hepatitis Day is July 28th. This date was chosen to honor the birthday of Nobel Laureate Professor Baruch Samuel Blumberg who discovered the hepatitis B virus and developed the first hepatitis B vaccine. This year the emphasis is on prevention, with the slogan “Prevent hepatitis. Act now.”

We can prevent hepatitis by providing safe food and water (hepatitis A and E), vaccines (hepatitis A, B, and E), screening blood donations and providing proper equipment to maintain infection control (hepatitis B and C). While hepatitis B and C can be treated, many people in low- and middle- income countries lack access to treatment due to a lack of screening and the high cost of treatment. Until screening and treatment options become more accessible and affordable, prevention messages are incredibly important.

To help people learn how to prevent hepatitis, the WHO World Hepatitis Day 2015 campaign focuses on four key prevention messages:

1. Prevent hepatitis - know the risks
2. Prevent hepatitis – demand safe injections
3. Prevent hepatitis – vaccinate children
4. Prevent hepatitis – get tested, seek treatment

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Figure 1: A poster from World Hepatitis Alliance. 

If you’d like to get involved in raising awareness about hepatitis, please visit worldhepatitisday.org. There you’ll find some ideas on how to get involved, information on what social media campaigns have been formed, and materials to share to help spread the word that hepatitis is preventable.

The future of the fight against hepatitis looks promising. WHO has been increasing its efforts to fight hepatitis by establishing the Global Hepatitis Programme in 2011, and in 2014 moved that program to the cluster of HIV/AIDS, Tuberculosis, Malaria, and Neglected Tropical Diseases to help facilitate work between HIV/AIDS and hepatitis programs (due to the high number of people around the world living with both HIV and viral hepatitis). Furthermore, WHO, in conjunction with the Scottish Government and the World Hepatitis Alliance, is organizing the first ever World Hepatitis Summit in Glasgow, Scotland over 2-4 September 2015. This invite-only summit will bring together policy makers, patients, and other key stakeholders to determine how best to make lasting progress to reduce the global burden of hepatitis.

There is still progress to be made by the global community in order to win the fight against hepatitis. Key efforts, such as establishing events to publicize the global burden of viral hepatitis and holding summits to bring together the stakeholders that can make a difference, are contributing to saving lives in the fight against viral hepatitis.

Sustaining the Fight against Malaria

~ Written by Randall Kramer, PhD, M.E. (Professor of Environmental Economics and Global Health, Duke University) & Leonard Mboera, PhD, MSc (Chief Scientist, Tanzania National Institute for Medical Research)

*Also published on the Duke Global Health Institute Website 

On World Malaria Day, April 25, there’s much to celebrate and acknowledge when it comes to the fight against malaria. Over the past 15 years, we’ve seen a huge ramp-up of international funding, and the latest statistics show impressive progress—a 46% decrease in malaria infections among children in sub-Saharan Africa and an estimated 4.3 million deaths averted globally over time.

One of the most effective malaria control measures has been the free distribution of several hundred million insecticide-treated mosquito nets that protect people from mosquitoes while sleeping. In 2004, only 3% of at-risk people in sub-Saharan Africa had an insecticide-treated mosquito net available to them, compared to 49% in 2014 after an international campaign.

The U.S. government is among the major funders of malaria control, and it’s one of the few international assistance programs that has garnered bipartisan support through the Bush and Obama terms. But despite the upsurge in spending and the laudable success of these programs, malaria remains one of the leading causes of death in poorer and tropical parts of the world.

The need for continued support is critical; it’s estimated that eliminating malaria as a major global disease threat would require double the current $3 billion invested annually in malaria control. But in the face of so many other pressing needs, why should we continue to invest in malaria?

In the last year, nearly 200 million people suffered from malaria, and its death toll—more than 500,000—was 50 times greater than that of the widely publicized outbreak of Ebola in West Africa. And malaria takes a particularly devastating toll on the young. More than 80% of the deaths from malaria are in children under five, and those who manage to survive the illness often suffer lasting effects on development, school performance and lifetime earnings.

Because malaria is such a resilient killer, we can expect to see these malaria losses continue and potentially rise in the absence of continued financial support. In fact, with temperatures steadily increasing throughout the world as a result of global warming, malaria-transmitting mosquitoes have begun to take residence in new regions, raising the specter of malaria spreading far beyond its current boundaries.

In addition to the physical suffering malaria causes, the disease stunts national economic progress.

Studies by Columbia University economist Jeffrey Sachs suggest that, if not for malaria keeping children out of school and agricultural workers out of the fields, the rate of economic development in sub-Saharan Africa would have been much higher in the past few decades.

And lastly, we can’t underestimate the goodwill generated by our investments in mosquito nets and other malaria-defeating approaches in recipient countries. As one community member told our research team in rural Tanzania, “Mosquito nets have been a great help to us. The day when mosquito nets were distributed, people were very happy, because many people in our community could not afford to buy the mosquito nets.”

The malaria parasite, a resilient and opportunistic pest, has successfully co-inhabited with humans for thousands of years, and it continues to adapt and evolve, damaging populations and economies across the globe. We now have the knowledge, technology and health systems to significantly reduce its devastating human impacts. But putting these assets into action will require renewed political will and financial commitment from rich and poor countries around the globe—including the U.S.