Civil Unrest and the Global Polio Eradication Efforts

~Written by  Kate Lee - MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

Vaccine-preventable illnesses are an ongoing global health issue. Just in the United States alone there have been outbreaks of measles and pertussis (whooping cough) from parents refusing to vaccinate their children. In 2013, California had over 9,000 people infected with pertussis. As of September 2014, the United States had almost 600 measles cases. For every 1,000 children getting infected with measles, 1 to 2 will die. There will be continuous outbreaks of diseases once thought to have been controlled or eradicated if parents do not adhere to the immunization schedule for their children. This is, however, an argument for another day.

Despite all of this, the United States no longer has ongoing transmission of one of the more debilitating illnesses that affected a lot of children in its peak during the 1950s: polio. This is, of course, due to vaccination campaigns. Since the launch of global polio eradication efforts in 1988, polio incidence has dropped to more than 99%. What can be said of these efforts in parts of the world that are not as stable economically, politically, or socially? In early 2014 India celebrated its third year without wild-type polio. In 2013, the African continent had 274 cases of polio but only 22 in 2014. Overall in 2014, there were 350 cases of polio, down from 416 in 2013 in the African continent. Ongoing poliovirus transmission occurs in three endemic countries: Nigeria, Afghanistan, and Pakistan. Although poor sanitation is a risk factor for polio, prevention of vaccination is the biggest risk one that these countries face.

Mistrust, misconceptions, and religious reasons all feed into public notions of vaccination. Political unrest may be one of the most important obstacles in the global campaign to end polio. Boko Haram insurgency has led to civil unrest in areas of northern Nigeria where ongoing polio transmission occurs. There has been a decline in polio cases in Afghanistan since the Taliban has allowed vaccination in recent years, but that has not been the case for Pakistan. The Pakistani Taliban and other Islamist groups have led killings of health care workers in an anti-immunization campaign. These militant groups threaten not only health care workers that administer the vaccines to the communities, but also the parents who offer vaccination for their children. Since the Pakistani Taliban ban on immunizations in 2012, more than 60 polio workers have been killed. The result of this has been Pakistan counting its 260th case of polio as of November 2014.

Sadly, the political unrest feeds into public mistrust, resulting in a cycle that perpetuates civil instability and polio transmission, leaving the $10 million global eradication effort hanging in the balance. Some health authorities are questioning if the polio campaign is worth it. Lives are lost, health resources are wasted, and new strategies must be reached to continue the immunization effort in Pakistan. Many individuals wonder why polio should be a priority when the country is undergoing so many more problems. There are a variety of other infectious diseases that place the population at risk due to poor sanitation and malnutrition. Outside of health, the threat of the Taliban hangs over the heads of the population. But, why would the Taliban target immunization campaigns? Part of the answer lies in negotiating leverage to stop drone strikes from the United States. The other part of the answer is rooted in a CIA campaign in 2012 to hide Osama bin Laden intelligence operations through the guise of immunization campaigns. Polio in Pakistan is not the first disease to be heavily affected by political unrest and exploited by militant groups, and it sadly may not be the last. What is extremely crucial to understand is that health and politics are not mutually exclusive.

This theme of political cooperation is constant throughout every public health issue. The global effort to erase polio is not an exception. Militant groups, however, now present an added obstacle in achieving social and political stability so that health care workers can conduct their tasks peacefully. Families and vaccinators should not have to fear that their lives are at risk for undertaking public health activities. Rethinking the immunization strategy in Pakistan is necessary. Improvement of basic health services and sanitation are starting points not just for polio, but a multitude of other infectious diseases. These campaigns are important, but take time and money to come to fruition, two resources that are becoming scarcer in a very unstable country.

References:

http://www.cdc.gov/polio/updates/

https://news.vice.com/article/afghanistan-confirms-new-polio-cases-as-pakistans-outbreak-reaches-grim-milestone

http://www.theguardian.com/society/2014/sep/07/us-nearly-600-measles-cases-this-year-cdc

http://time.com/27308/4-diseases-making-a-comeback-thanks-to-anti-vaxxers/

http://www.polioeradication.org/

http://www.washingtonpost.com/blogs/worldviews/wp/2012/10/17/taliban-polio-vaccines/

http://www.bbc.com/news/world-asia-26121732

http://www.npr.org/blogs/goatsandsoda/2014/07/28/330767266/taliban-in-pakistan-derails-world-polio-eradication

Health Issues on the African Horizon for 2015

~ Written by Mike Emmerich - Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich 

As 2014 draws to a close and we review what has happened over this past year, we also look forward to 2015 and all of it challenges. Numerous organisations and commentators have written of the challenges that lie over the horizon for 2015, as regards Global Health. From my own experience of working on the continent I have identified the following challenges for 2015 for Africa.

Some of the issues/challenges overlap and/or influence one another. They do not stand alone, the one can exacerbate the other.

Water

Water, on its own, is unlikely to bring down governments, but shortages could threaten food production and energy supply and put additional stress on governments struggling with poverty and social tensions. Water plays a crucial role in accomplishing the continent's development goals, a large number of countries on the continent still face huge challenges in attempting to achieve the United Nations water-related Millennium Development Goals (MDG)

Africa faces endemic poverty, food insecurity and pervasive underdevelopment, with almost all countries lacking the human, economic and institutional capacities to effectively develop and manage their water resources sustainably. North Africa has 92% coverageand is on track to meet its 94% target before 2015. However, Sub-Saharan Africa experiences a contrasting case with 40% of the 783 million people without access to an improved source of drinking water. This is a serious concern because of the associated massive health burden as many people who lack basic sanitation engage in unsanitary activities like open defecation, solid waste disposal and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease with children being the most vulnerable. Hence as I have previously written, this poor sanitisation causes numerous water borne disease and causes diarrhoea leading to dehydration, which is still a major cause of death in children in Sub-Saharan Africa.

“Africa is the fastest urbanizing continent on the planet and the demand for water and sanitation is outstripping supply in cities” Joan Clos, Executive Director of UN-HABITAT

Health Care Workers

Africa has faced the emergence of new pandemics and resurgence of old diseases. While Africa has 10% of the world population, it bears 25% of the global disease burden and has only 3% of the global health work force. Of the four million estimated global shortage of health workers one million are immediately required in Africa.

Community Health Workers (CHWs) deliver life-saving health care services where it’s needed most, in poor rural communities. Across the central belt of sub-Saharan Africa, 10 to 20 percent of children die before the age of 5. Maternal death rates are high. Many people suffer unnecessarily from preventable and treatable diseases, from malaria and diarrhoea to TB and HIV/AIDS. Many of the people have little or no access to the most fundamental aspects of primary healthcare. Many countries are struggling to make progress toward the health related MDGs partly because so many people are poor and live in rural areas beyond the reach of primary health care and even CHW's.

These workers are most effective when supported by a clinically skilled health workforce, and deployed within the context of an appropriately financed primary health care system. With this statement we can already see where the problems lie; as there is a huge lack of skilled medical workers and the necessary infrastructure, which is further compounded by lack of government spending. Furthermore in some regions of the continent CHW's numbers have been reduced as a result of war, poor political will and Ebola.

Ebola

The Ebola crisis, which claimed its first victim in Guinea just over a year ago, is likely to last until the end of 2015, according to the WHO and Peter Piot, a scientist who helped to discover the virus in 1976. The virus is still spreading in Sierra Leone, especially in the north and west.

The economies of West Africa have been severely damaged: people have lost their jobs as a result of Ebola, children have been unable to attend school, there are widespread food shortages, which will be further compounded by the inability to plant crops. The outbreak has done untold damage to health systems in Guinea, Liberia and Sierra Leone. Hundreds of doctors and nurses and CHW's have died on the front line, and these were countries that could ill afford to lose medical staff; they were severely under staffed to begin with.

Read Laurie Garrett's latest article: http://foreignpolicy.com/2014/12/24/pushing-ebola-to-the-brink-of-gone-in-liberia-ellen-johnson-sirleaf/

The outcome is bleak, growing political instability could cause a resurgence in Ebola, and the current government could also be weakened by how it is attempting to manage the outbreak.

Political Instability

Countries that are politically unstable, will experience problems with raising investment capital, donor organisations also battle to get a foothold in these countries. This will affect their GDP and economic growth, which will filter down to government spending where it is needed most, e.g.: with respect to CHW's.

Political instability on the continent has also lead to regional conflicts, which will have a negative impact on the incomes of a broad range of households,and led to large declines in expenditures and in consumption of necessary items, notably food. Which in turn leads to malnutrition, poor childhood development and a host of additional health and welfare related issues. Never mind the glaringly obvious problems such as, refugees, death of bread winners etc...

Studies on political instability have found that incomplete democratization, low openness to international trade, and infant mortality are the three strongest predictors of political instability. A question to then consider is how are these three predictors related to each other? And also why, or does the spread of infectious disease lead to political instability?

Poverty

Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally is rooted in political, social and economic injustices. Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health, which in turn traps communities in poverty. Mechanisms that do not allow poor people to climb out of poverty, notably; the population explosion, malnutrition, disease, and the state of education in developing countries and its inability to reduce poverty or to abet development thereof. These are then further compounded by corruption, the international economy, the influence of wealth in politics, and the causes of political instability and the emergence of dictators.

The new poverty line is defined as living on the equivalent of $1.25 a day. With that measure based on latest data available (2005), 1.4 billion people live on or below that line. Furthermore, almost half the world, over three billion people, live on less than $2.50 a day and at least 80% of humanity lives on less than $10 a day.

Big Stories in Infectious Diseases for 2014

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

Not many people probably paid much attention to public health, much less global public health, before Ebola arrived in the US and Spain. Despite the focus on Ebola, there have been other global infectious disease developments in 2014.

Antibiotic Resistance

A major threat to humans worldwide is the emergence of antibiotic resistance. According to the Infectious Diseases Society of America, the CDC, WHO, the European Union, and President Obama, the problem of antibiotic resistance has reached crisis level. This is due to the overuse of antibiotics worldwide and major pharmaceutical suppliers who have basically abandoned antibiotic development because they don’t make enough money to justify the expense. This is a major problem because we could end up going back to death rates akin to the pre-antibiotic era, where something as simple as a minor cut could be deadly. Another fact to mention is the huge use of antibiotics in agricultural animals. Agricultural use accounts for 80% of antibiotic use in the US and that continued usage gives bacteria more exposure to the antibiotics and more opportunity to develop resistance.

Hepatitis C and HIV/AIDS

In case you didn’t hear, in only a 25 year span from the discovery of hepatitis C virus (HCV), we now have a treatment that cures 95% of the people who take the pill once a day for 8-12 weeks. I want you to let that soak in a minute…….because this is huge. HCV affects something like 250 million people around the world and now we can not just suppress the virus, but can actually clear it from someone’s body. Unfortunately, right now the cost of this treatment is $74,000 or more per person, basically putting this cure out of reach of anyone in middle or low income countries. Also in 2014, the world reached the tipping point for HIV/AIDS. That means that for the first time in the 30+ year epidemic, the number of people newly infected was less than the number of HIV positive people who got access to HIV medicines. While not every individual country has reached this milestone, and we still have a ways to go to get everyone access to life-saving medication, this tipping point shows that with continued effort the end of HIV/AIDS may be nearer than we thought.

Vaccine development

Vaccines have been around for a while and humanity has tried to create vaccines for all sorts of diseases. Work is being done to create vaccine platforms that don’t involve a needle such as embedding the “stuff” of the vaccine into a microneedle array (a small disk with several microscopic points that dissolve when embedded in the skin).  There is also an effort to create a universal influenza vaccine. A universal vaccine would target viral proteins that are conserved between the different strains of influenza and don’t mutate very often, so the vaccine could be effective no matter what strains are circulating each influenza season.

Epidemics

I just want to touch on a few of the epidemics you may not have heard much about this year. There was an epidemic of enterovirus D68 this year that caused more severe disease than we had expected as enterovirus infections generally only cause mild respiratory symptoms in kids. A mosquito-borne disease, Chikungunya, has been sweeping the Caribbean and causing fever and severe joint pain. Guinea worm, affecting people living in Africa and Asia, grows inside the body and then erupts from anywhere in the body causing severe and debilitating pain. Guinea worm is on target to be the second disease eradicated in human history (after smallpox) and is being eradicated not with the use of expensive medicines but through inexpensive but challenging to implement behavioral change. 

Values and Global Health Governance: Lessons from the Ebola 2014 Outbreak

~Written by J. La Juanie Hamilton, PhD Candidate (Contact: lajuaniehamilton@gmail.com)

Twitter: @jasminogen

Values are critical in shaping the global health (GH) dialogue and landscape. Values and the actions that arise from them (virtues) underlie the policies that ensure universal access to necessary health services, adequate responses to health emergencies and resource allocation. Similarly, the values of health governing bodies can create chasms between people and their health necessities. This truth has been unfolding poignantly on an international level during the handling of the Ebola virus disease (EVD) outbreak in West Africa. 
 

What values did the actions or inaction of the international GH community endorse in handling the current EVD outbreak? Although the uniqueness of the outbreak in terms of location and challenges in diagnosis should be considered, many experts agree that the greatest force contributing to the rapid spread of EVD was inaction (1-4). In June 2014, signs that EVD was spiraling out of control throughout Guinea were flashing brightly but the response from the international community remained slow. The exception was Doctors without Borders (MSF), whose staff was already on the ground, helped to diagnose the first case and pleaded for a more robust response from international health governing bodies (3). 
 

Criticisms of health regulatory bodies grew stronger when EVD entered rich countries, which appeared to produce a marked increase in global support efforts. It is hard to say unequivocally, whether this heightened interest and commitment was inevitable or whether the cases in the US and Europe were the impetus. But it is fair to say that many mistakes were made in terms of prioritizing EVD eradication and surveillance. It may also be accurate to say that major economies responded when EVD was perceived as an immediate threat to their economy. This, I believe, is inevitable in a GH system that is built upon a market-driven approach.
 

Can a GH agenda that is framed around economics prioritize the eradication of emerging diseases and neglected diseases of poverty? Although there are compelling arguments for why high-income countries should help to combat EVD and similar diseases, it is unlikely that great achievements will be made without a values shift (5). 
 

A market driven approach inherently prioritizes the need of a few versus the need of many. This model enables the interests of major economies to outweigh the greater good of the whole, if left unchecked. The most important consequence of this approach is that it undermines international health regulatory bodies, whose actions and budgets are heavily influenced by larger economies. This is a problem which, when combined with poor health systems, harmful microbes and permeable borders will inevitably lead to threats in local communities and global security. More importantly, with the movement of people forming a major characteristic of this era, the market driven approach is an unsustainable value upon which to build GH interventions. 
 

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There are many points worth considering (schematic above). Major questions moving forward should consider creating a GH model that is more oriented toward equity, security and creativity. Resolutions that create a space in which poor nation states help to set the GH agenda without being threatened by the loss of aid from larger economies must be discussed. Additionally, addressing ways in which the GH dialogue can be re-framed to include stakeholders that currently operate based on virtues stated above should be considered. For example, is there a way to ensure a more official decision-making role for organizations like MSF?

What is next for GH governance and what will the values shift towards? EVD 2014 is a strong indicator of the limits of theoretical values, political indifference and passivity in achieving health and well-being for all. But the stories emerging from West Africa provide an opportunity for EVD 2014 to serve as a “meaning making” event in GH. It provides an impetus for changing priorities from passive verbiage of values of human dignity to a model of creativity, equity and accountability which proactively contextualizes GH policies, innovation and interventions. 

References
1. Gostin LO and Friedman EA 2014 Ebola: a crisis in global health leadership. The Lancet, 384; 1323-1324. 
2. Cohen J 2014.Ebola vaccine: Little and late. Science, 345 (6203): 1441-1442. 
3. Ebola: Massive Deployment Needed to Fight Epidemic in West Africa: http://www.doctorswithoutborders.org/news-stories/press-release/ebola-massive-deployment-needed-fight-epidemic-west-africa
4. Farrar JJ and Piot P 2014. The Ebola Emergency-Immediate Action, Ongoing Strategy N. Engl J Med 371(16):1545-1546.
5. Rid, A., & Emanuel, E. J. (2014). Why Should High-Income Countries Help Combat Ebola? JAMA, 312(13), 1297-1298.

Infectious Diseases Come from Animals? - Zoonotic Transmission

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

For those people who have been following the Ebola outbreak relatively closely or who have been doing their own research into Ebola, you may have heard that scientists think Ebola is introduced into the human population through fruit bats and/or the butchering of bush meat. 

This concept of infectious diseases passing between animals and humans is not new and is called zoonotic transmission. Now Ebola is a virus, but other disease causing agents such as bacteria, parasites and fungi can also be spread between animals and humans. While you may not have heard of zoonotic transmission before, I bet you’ve heard of some zoonotic diseases. Examples include anthrax, Lyme disease, Avian influenza, plague, malaria, dengue, West Nile virus infection, and rabies. The WHO says there are over 200 zoonotic diseases known to us thus far. I also bet you didn’t know that about 75% of recently emerging infectious diseases affecting humans are of animal origin and approximately 60% of all human pathogens are zoonotic. (I just learned these facts as well and am sufficiently surprised the numbers are that high). 

So how in the world does someone get a zoonotic disease? Well, for instance, anything transmitted by mosquitos or ticks are zoonotic diseases, so take proper precautions to prevent being bitten by all ticks and mosquitos. You can also come into contact with zoonotic diseases through petting zoos, pet stores, nature parks, farms, etc. Our beloved pets can also transmit diseases like salmonella, hookworm, and roundworm. The moral of the story is to make sure you’re washing your hands after handling animals and to be careful about petting every fluffy creature you come across. 

Now I would be missing a big part of the picture if I didn’t investigate some of the human-induced reasons why more and more of the population is in danger of being directly impacted by these “remote” zoonotic diseases. Zoonotic diseases transmitted by mosquitos for example, generally only impact people living in areas where those mosquito species are found. Climate change is allowing for some of these mosquitos to expand their territory, thereby bringing zoonotic diseases to new areas of the world. For example, two mosquito species known to carry malaria are now found at the US-Mexican border. Additionally, our expanding population and changes in how humans are migrating are causing interactions with species we’ve never encountered before through practices such as forest clear-cutting and wetland draining. 

I have no easy solutions to these problems as they stem from much larger human population growth issues. But the good news is that we, as humans, have noticed that zoonotic diseases are a growing issue and have stepped up efforts to stay on top of things. The European Union has passed legislation requiring member states to increase their monitoring of zoonotic diseases and has specific guidelines on how to do that. Self-proclaimed “Virus Hunter” Nathan Wolfe did a TED Talk on how his team and he are working on the frontlines of novel virus detection by using innovative ways to collect specimens, detect, and track previously unknown viruses in humans. (I highly recommend watching the talk even if you’re not really interested in emerging infectious diseases as it provides a practical look into the challenges of doing fieldwork in remote areas where these diseases are coming from.)

The important thing to take away from all this information is that zoonotic diseases are almost unavoidable as we humans are interacting with our world, and that world includes all sorts of known and unknown pathogens. By prioritizing innovative ways for early detection we can hopefully learn about potential diseases and create possible remedies before they become global pandemics

A Comprehensive Approach to HIV and Hepatitis C Interventions

~Written by Kathleen Lee, MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

One of the primary goals of public health, epidemiology, in particular, is estimating and examining the burden of disease. The burden in a population, however, is usually not just attributable to one illness or one causative agent. Many disease states carry with them the high likelihood of co-infections or opportunistic infections. Human immunodeficiency virus (HIV) and Hepatitis C (HCV) share at least one common route of transmission and often co-infect individuals. There are an estimated 40 million people worldwide who are infected with HIV and about 60-180 million globally are infected with HCV.1 Understanding the disease process as a whole means taking into consideration not only biological aspects of co-infection, but how this co-infection is propagated, or even mitigated, by patients’ behavior as well as their access to care. An all-inclusive and early detection approach to HIV-HCV treatment can help reduce the burden of disease in the affected population, and can help decrease transmission.

Effective interventions should focus on prevention, or at least early detection and treatment. This is not only good for the patient, but also for the health system. Between 2010 and 2019 it was estimated that HCV expenditures would be $10.7 billion.2 As disease progresses, costs increase (more medications, hospitalizations, etc.). Treatment should not only concentrate on drug therapy, but also address risk behaviors. Interventions, such as needle and syringe exchange programs (NSP) and opiate replacement therapy (ORT) are just some options that public health officials can use (and have used effectively) to curb HCV and HIV transmission in the community. Counseling is not a tool that should be overlooked as many of the co-infected population are affected with mental illness, a known risk factor for HIV acquisition. 

Both diseases separately represent a serious health concern, especially among injection drug using populations, but HIV-HCV co-infection introduces additional complications in treatment and disease progression of both conditions. Early interventions, especially during the acute phases of both diseases, can lead to better patient outcomes. Early treatment in co-infected individuals who have not yet been on antiretroviral therapy (ART) do better than those on existing ART regimens. The latter should be considered for treatment regimen changes to ensure minimal side effects and maximum adherence. Alcohol use in both HIV and HCV populations is a contributing factor to liver-related morbidity.3 Inclusion of alcohol and drug rehabilitation programs with drug therapy could decrease liver-related morbidity among co-infected patients. This is incredibly important because liver disease is the leading cause of mortality among co-infected individuals. 

Comprehensive interventions are useless if they cannot reach the population. Much has to be done to ensure that the delivery of these interventions captures as wide of an audience as possible. This includes having a well-trained staff of health workers and specialists who are able to support and motivate patients, convenient locations and times that are easily accessible for patients, and pricing should be affordable, if free is not an option.3 Many of the individuals taking advantage of such programs are often low-income, marginalized, and stigmatized by society. Giving these individuals the ability to take control of their condition and be aware of the risk behaviors and prevention strategies available for them could allow for better adherence to treatment, and consequently, better medical outcomes. Much like any other infectious disease that disproportionately affects low-income and vulnerable populations, the distribution and availability of resources are of utmost importance.

All of the above would be futile if there are no set standards to test and screen individuals who are most in need of these treatments. The lack of consensus among public health officials and the government regarding standardized screening among high-risk populations may contribute to the ongoing transmission of HIV and HCV, as well as co-infection. Ensuring sustainability of screening and treatment programs requires engagement and cooperation at all levels, from the patient to the care provider, to the community, to researchers, and even outward to national and international governing bodies.

1. Alter MJ. Epidemiology of viral hepatitis and HIV co-infection. J Hepatol. 2006;44, Supplement 1(0): S6-S9.

2. Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating future hepatitis C morbidity, mortality, and costs in the United States. Am J Public Health. 2000;90(10): 1562-

3. Viral Hepatitis: Hepatitis C Treatment. US Department of Veterans Affairs.  http://www.hepatitis.va.gov/provider/reviews/HCV-treatments.asp. Page updated December 9, 2013. Accessed October 21, 2014.

Challenges on the Frontlines of Ebola

~Written by Marilyn Perez Alemu (Contact: marilyn.perez@gmail.com) 

Healthcare workers on the frontlines of the Ebola crisis in West Africa are daily putting their lives at risk to save the lives of others. The current epidemic is the largest of its kind in history, exacerbated by a reported 70% case fatality rate. Yet Ebola is a disease that knows no mercy. Since the initial outbreak reported in March, more than 450 healthcare workers have been infected in Liberia, Sierra Leone, Guinea and Nigeria. More than 200 have died.

Despite being faced daily with this reality, as well as the looming stigmatization from their communities and families, healthcare workers continue to provide medical support to Ebola victims for the sake of those who will survive the disease. The initial international response was markedly slow and, as the outbreak intensifies, emerging challenges have severely impacted the ability of healthcare workers to respond to the growing need.

When executed properly, contact tracing is a key method for containing the outbreak spread. Ideally each contact, or person linked to a confirmed or probable case, would be identified by a healthcare worker and monitored for 21 days following exposure, allowing public health officials to track the movement of the outbreak. In theory, contact tracing is an effective method to ensure early detection of infections and immediate treatment, and stem the spread of the virus. Essentially, contact tracing has been called the key to “stop Ebola in its tracks”. And while the process seems simple enough, critical information gaps, limited databases, and an exponential increase in the number of Ebola cases have led to a breakdown in contact tracing in West Africa. With limited infrastructure and many living in remote villages, even finding patients is a challenge. Add that to the fact that people are often uncooperative with tracers, as the fear of going to a health center is something akin to a death sentence. Without the ability to do complete and proper contact tracing, rapid diagnosis and patient isolation is hindered and the outbreak will continue to spiral out of control.

While past outbreaks of Ebola were sporadic and contained within small rural areas, the current outbreak poses a serious challenge in that it has spread quickly to more crowded urban areas in West Africa. In rural areas, population density is lower, community ties are stronger, and transmission prevention measures are presumably easier to implement. Now, in vastly overpopulated urban areas, Ebola transmission has accelerated exponentially and the outbreak has gone beyond the ability to contain it. Control and prevention measures have thus intensified in both innovation and urgency, evidenced by accelerated efforts in vaccine development and experimental therapeutics.

While an Ebola outbreak is caused biologically, an Ebola epidemic is a crisis of poverty and fragile health systems. West Africa is faced with the repercussions of a weak health infrastructure, including scarcity of healthcare workers, limited resources, and poor management systems. It should be noted that these shortcomings preceded the Ebola outbreak, with just 51 doctors to serve Liberia’s 4.2 million people and 136 for Sierra Leone’s population of 6 million. To put this in context, this is fewer than many clinical units in a single hospital in the United States. Having worked its way through the cracks of a fragile health infrastructure, Ebola has effectively brought healthcare to a halt in Liberia, Sierra Leone and Guinea. An added complication is the shortage of resources, including personal protective equipment (PPE) and other control materials, and the lack of straightforward protocols and guidelines. Efforts must increase not only to ensure an ample supply of optimal PPE but also to effectively disseminate information on proper use of the equipment.

At the frontlines of the Ebola outbreak, healthcare workers face a daunting challenge. In Liberia, Emmanuel Boyah, a primary health manager with the International Rescue Committee, recounts the stress and fear of this work. Yet he and many others continue to dedicate themselves to the cause and risk their lives to care for those affected: “I feel that providing services to people during this time, when they’re in need of you, is my call.”

Vaccines and Gavi to the Rescue for Millions of Children

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

As talk continues to increase about an Ebola vaccine possibly becoming a reality in a couple months, I thought I’d offer a larger look at vaccines in general and how Gavi, the Vaccine Alliance, is helping ensure children in the poorest parts of the world can take advantage of lifesaving immunizations.

Many people have probably heard of Edward Jenner and his smallpox variolation which served to immunize people against smallpox. But this sort of variolation, taking fresh matter from a sore of someone suffering from an infectious disease and inserting that under the skin of a healthy person to cause an immune response resulting in the variolated person being immune to the disease, had been taking place in Africa, India and China long before Edward Jenner was even born.

The work done by Jenner and his predecessors were humanity’s first attempts at controlling an infectious disease through vaccination.

In the current era we have vaccinations for many of the infectious diseases that previously plagued many of the world’s richer nations, and still plague many of the poorer nations. Some may argue that we have too many vaccinations here in the West and that we are causing more harm than good through our childhood vaccinations. I’m not here to argue that particular topic with readers but if you’re interested in reading some science-based information about vaccines you can find that here, here, and here.

What I want to focus on is how vaccines have taken us from a world where millions upon millions of children died every year from infectious diseases and how the only hope for stopping an outbreak was quarantine, to a world where many of these infectious diseases are rarely seen in richer countries and are on the difficult path to being controlled in many lower income countries around the world. Now this is not to say that outbreaks of these vaccine preventable diseases such as polio, measles, and whooping cough, to name a few, are not occurring in the US, Europe, or Asia. They are, as evidenced by this interactive map from the Council on Foreign Relations.  We still have work to do that is for sure. But organizations like Gavi are focusing on eradicating these infectious diseases in middle and low income countries around the world, where these diseases exact a high toll.

So to put the effect of vaccines into perspective:

• 3 million lives are saved worldwide every year due to vaccines
• 1 child dies every 20 seconds from vaccine preventable diseases worldwide
• The United States has seen a 99-100% decrease in cases of diphtheria, measles, H. influenza, mumps, rubella, congenital rubella, polio and smallpox due to vaccinations
• Vaccines save the US $42 billion a year in medical costs and lost productivity

The incidence of many of these vaccine preventable diseases is still high in many of the poorer countries of the world; enter Gavi, the Vaccine Alliance. Gavi helps save children’s lives and protect people’s health by increasing access to immunizations in poor countries. Gavi is a public-private partnership with The Bill & Melinda Gates Foundation, WHO, UNICEF, and the World Bank. Gavi works with health ministries in 77 countries to use existing frameworks to deliver vaccines to those in need. Since 2000, Gavi has contributed to the immunization of 440 million children with another 243 million immunized between 2011 and 2015. These efforts amount to averting an estimated 3.9 million deaths from 2011 to 2015 due to vaccine preventable diseases.

Vaccines save lives; it’s as simple as that. Those vaccines we take for granted here in the US are the difference between life and death for many children in lower income countries. Gavi, the Vaccine Alliance is working to make those vaccines accessible to those who need them most. 

Politics and Medicine

~Written by Mike Emmerich, Specialist Emergency Med & ERT Africa Consultant (Contact: mike@nexusmedical.co.za) 

https://twitter.com/MikeEmmerich

"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

Politics is defined as "organised human behaviour", thus we can postulate that Medicine is micro managed organised human behaviour, at times right down to the molecular level. If we examine the Ebola outbreak/s (globally) and how it is being managed on a macro (politics) and micro scale (medicine) we can begin to see the cracks in the system, and hopefully then move to addressing these cracks, before they begin yawning chasms that are not repairable.

The region (Liberia, Sierra Leone and Guinea) has had success (we could add Nigeria and Senegal to the successes) and failures in both areas. Neither is Spain and the USA exempt from this analysis as can be noted from the various press releases (government and medical) over the past few months.

Since the first outbreaks in 1976 (Sudan and The DRC) till the current one in West Africa; care has generally been palliative and symptomatic, questions have often been asked during this period; What of a vaccine and/or other means of treating the infected patients? There was a report in the British Sunday Times (12/10/14), cited a Cambridge University zoologist as saying that “it is quite possible to design a vaccine against this disease” but reported that applications to conduct further research on Ebola were rebuffed because “nobody has been willing to spend the twenty million pounds or so needed to get vaccines through trial and production”. Globally this has been one of the failures of the pharmaceutical companies, and most probably even the WHO, for not pushing harder over the years to get this in motion.

In her 1994 book /The Coming Plague: Newly Emerging Diseases in a World Out of Balance http://lauriegarrett.com/#item=the-coming-plague, //Laurie Garrett warned that there are more than 21 million people on earth “living under conditions ideal for microbial emergence.” http://www.independent.co.uk/arts-entertainment/science-mutating-microbes-1601604.html Garrett when on to win the Pulitzer Prize in 1996 for reporting on Ebola. In 1995 Joshua Lederberg, the American molecular biologist said: "The world is just one village. Our tolerance of disease in any place is at our own peril. Are we better off today than we were a century ago? In most respects, we're worse off. We have been neglectful of the microbes, and that is a recurring theme that is coming back to haunt us."

Jump forward to the 23^rd of September 2014, US President Obama issued an unprecedented ‘Presidential Memorandum on civil society http://www.whitehouse.gov/the-press-office/2014/09/23/presidential-memorandum-civil-society’ recognising that: Through civil society, citizens come together to hold their leaders accountable and address challenges that governments cannot tackle alone. Civil society organisations…often drive innovations and develop new ideas and approaches to solve social, economic, and political problems that governments can apply on a larger scale./

If we look at the current crises in West Africa civic leaders are what is missing, hence the inability to track and trace potential infected persons, motivate communities to change risky behaviours (handing of the deceased), agitate with government to create better health care systems, this all adds fuel to the fire of the current epidemic.

Have we listened and learnt as governments, NGO's and Multinational Pharmacare companies since then?

Despite Medical Advances, Millions Are Dying, this is a banner from 1996, not 2014! from the WHO, which was "declaring a global crisis and warning that no country is safe from infectious diseases, the World Health Organization says in a new report that diseases such as AIDS, Ebola, Hanta, Mad Cow, tuberculosis, etc., killed more than 17 MILLION people worldwide last year”.

As Laurie Garrett wrote in her the closing section of her book, The Coming Plague, /“In the end, it seems that American journalist I.F. Stone was right when he said, ‘Either we learn to live together or we die together.’ While the human race battles itself, fighting over ever more crowded turf and scarcer resources, the advantage moves to the microbes’ court. They are our predators, and they will be victorious if we, Homo sapiens, do not learn how to live in a rational global village that affords the microbes few opportunities. It’s either that or we brace ourselves for the coming plague.” Time is short.

The Ebola outbreak in West Africa is “unquestionably the most severe acute public health emergency in modern times,” Dr. Margaret Chan, the director general of the World Health Organization, said Monday 20/10/2014). We do seem to be going in circles... circa 1995.. have we learnt nothing from history.

Sooner or later we learn to throw the past away History will teach us nothing ~Sting – Musician, singer-songwriter

Where have all the people gone, long time passing? Where have all the people gone, long time ago? Where have all the people gone? Gone to graveyards, everyone. Oh, when will they ever learn? Oh, when will they ever learn? ~Pete Seeger - American folk singer and activist

Global Ebola Involvement

~Written by Mike Emmerich, Specialist Emergency Med & ERT Africa Consultant (Contact: mike@nexusmedical.co.za) 

https://twitter.com/MikeEmmerich

As a passionate and committed African, having spent the past 20 years working in various countries on my continent, and having seen the effects of colonisation, globalization, war as a result of minerals and commerce (funded by big western businesses) and how Africa is marginalised via trade and commerce. Never mind the fact that all the ex-French colonies still pay tax to France, even years after independence!!

http://www.siliconafrica.com/france-colonial-tax/

It is also true that Africa’s problems are also created by many corrupt Africa politicians and greedy emerging markets in Africa.

What should our response be, in the event of disasters, war, famine or in the case of Ebola (disease outbreaks). As a human race we all live in a global village and we cannot and should not stand by when we see our fellow man/woman suffering; be it in Syria, Ukraine or in this case West Africa (Guinea, Sierra Leone and Liberia). Every effort should be made to help when and how we can, be it with manpower, resources or financial aid. This is not a regional or Africa problem, but a global one.

The entire Southern West Africa region is still emerging from a decades long conflict (partly made infamous by Blood Diamonds) and their are trails ongoing in the Hague re this conflict. One could even argue that western powers (corporate and country) were complicit in this conflict, hence they should now have at least an ethical (if not moral) motivation to get involved. Far to often we stand on the sides and wring our hands at the mess Africa is in and that it never seems to get out of this mess (that in itself is another long missive for another day/blogpost).

Now the region needs beds (hospitals) and staff to man them, there is a huge shortage of beds. The one thing that this epidemic (as most of them do) has taught us that it is gloves not vaccines that will make the difference. Good basic hygiene, clean water, bleach/chlorine and excellent palliative care in a sterile environment will make a difference. Those who have survived, have survived for these reasons.

All of the above needs to sustainable in the medium to long term and the affected countries must be encouraged through means of trade and commerce to make these changes real and lasting. I know this last paragraph sounds pie in the sky, but the rich western countries and corporates (Large Pharma) in this case must commit to push for it to happen; not for their end gains and an increase in share price (my cynical comment re what is motivating large Pharma in this case), but for the good of the region.

People in West Africa will have to alter behaviours, we won’t stop this outbreak solely by building hospitals. There will have to be a change in the way the community deals with the disease. Changing behaviour which is so closely linked to culture, tribe and religion will not happen in the short term. Meaning that the worst case scenario could come to fruition, which is over 100,000 cases by the 1st of December. (as outlined in some disease modelling programmes!)

Government ministers in the region must focus within their communities and regions on the key ways to manage this outbreak. They need to be out in the field as the voice of government, pushing for the necessary societal changes hat need to take place. The region needs beds, hospitals and basic supplies. Beds and hospitals is not being dealt with as urgently as it should be by local governments, they are waiting for outside funders to step in, they must drive the initiative on the ground and mobilise local leaders to work with their villages to manage this outbreak, otherwise the worst case scenarios that are being punted look scary. Both MSF and WHO are pushing for this, but they need local governmental support.

My closing comment is that gloves not drugs (vaccines) will save the day. Basic good clean sanitary medicine and palliative care, aligned with sound symptomatic treatment will save lives, for that we need beds, hospitals, staff and supplies, from across the globe, Cuba has stepped into the breach while others (Australia) are still wringing their hands.