p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 7 6 9 e7 7 0
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Editorial
The rising tide of Ebola
The Ebola virus outbreak originating in West Africa in March this year hit the lay media a few months ago. In 2014 Ebola has competed for space in international newspapers and other mass media with terrible conflicts in several regions. However, as the number of deaths from the disease rose, the outbreak became a regular news item, perhaps as much due to the fears among people outside Africa of an imported case, as to the result of international concern for the well-being of people in a far off land. On 8th August 2014, after the outbreak had spread from three African countries to a fourth, Nigeria, the World Health Organization announced the outbreak an international public health emergency. To date Ebola infection has no effective treatment and no vaccine, although the WHO tells us that both are in development.1 Ebola is, for the lay media, the archetypal incurable, fatal, infectious disease, relentlessly causing the deaths of innocent victims of all ages who had unknowingly contracted the virus. Outbreaks of Ebola and other viral haemorrhagic fevers occur in endemic areas from time to time, but (at the time of writing) this Ebola outbreak is widespread, having affected people in four African countries, Guinea, Liberia, Sierra Leone, and Nigeria, and has had a very high mortality rate, estimated at between 50 and 90% at different stages of the outbreak. Perhaps one of the most emotive elements of this outbreak, especially among the mass media, is the risk of infection among health workers caring for infected patients. Sadly, it is the case that in poor communities most affected by the outbreak, there has been completely inadequate access to protective clothing and equipment, which has contributed to the transmission of infection to healthcare workers, amongst whom there has been a startling risk of mortality not normally associated with the caring professions in the 21st Century. At least two suspected infected healthcare workers have been repatriated to the US for treatment in specialist isolation facilities. Unlike medical staff, other groups of staff who may encounter someone with Ebola have not received targeted advice by national agencies. In the UK, airport staff have threatened industrial action due to fear over the perceived risk of infection from incoming travellers. Physicians working in other countries to date unaffected by the outbreak directly, including the UK2 and USA3 have been issued with advice about how to react if they are confronted with a scenario in which they believe a patient may have contracted Ebola virus.
As well as healthcare workers, those people who handle the bodies of the deceased are known to be at increased risk of contracting the virus, which appears to remain infective for several days after the victim's death. Centuries old cultural practices are difficult to influence, leaving those people who practise them at ongoing risk. In Liberia the president blamed poverty and ignorance and entrenched cultural and religious practices for exacerbating the spread of the disease. But while both Sierre Leone and Liberia have declared states of emergency over Ebola, the government of Guinea was less active and has been criticized internationally for its observed lack of serious response to the outbreak.4 Ebola requires solid conventional health protection action. This was put cogently by CDC director, Tom Frieden, who said: ‘The bottom line with Ebola is we know how to stop it: traditional public health. Find patients, isolate and care for them; find their contacts; educate people; and strictly follow infection control in hospitals. Do those things with meticulous care and Ebola goes away.’5 The role of WHO has been interesting to observe and should be considered in light of the insightful viewpoints shared in the special issue of Public Health in February 2014:6 the declaration of an international health emergency on 8th August; and the declaration on 12th August to endorse the use of unproven interventions in the treatment of people infected with Ebola. Notably, the first few patients to be treated in this way, prior to the WHO statement, were foreign staff, who were repatriated to the US and Spain, respectively, for treatment. The WHO had convened a panel of experts on 11th August to consider the ethical implications ‘for clinical decision-making of the potential use of unregistered interventions’. The consensus they reached the following day was that, in the circumstances of this outbreak, use of such unproven interventions for either treatment or prevention was ethical.7 Given the very small supplies of these drugs, to whom they should be administered is a major ethical consideration. In addition to the ethical decision regarding use of unregistered and unproven treatments, it is clear that the global supply of such drugs is very limited. Unsurprisingly in this scenario, the WHO panel identified other areas requiring further consideration, including the need for criteria to prioritize the use of this scarce supply and to distribute it fairly; to gather and make best possible use of data with the
770
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 7 6 9 e7 7 0
relatively small numbers concerned, to ascertain, as far as possible, the extent to which any improvement or deterioration in a given patient can be attributed to the intervention, of whom 10e50% of patients would recover with no active treatment. It is unclear whether WHO will reconvene its expert panel to address these critical issues: but they do need to be addressed for this outbreak and for the next and subsequent outbreaks of new or re-emerging diseases. A postscript for anyone needing a reminder of the juxtaposition of conflict and infectious disease: something public health trainees are taught very early in their careers is that the Great War e World War One, 1914e18 e killed thousands of people; but the influenza epidemic that followed it killed far more.
references
1. WHO. Ebola virus disease. WHO. Available online at: http:// www.who.int/mediacentre/factsheets/fs103/en/; 2014 (last accessed 14 August 2014). 2. Public Health England. Ebola virus disease: clinical management and guidance. Health protection - collection, Public Health England, 2014. Available online at: http://www. gov.uk/government/collections/ebola-virus-disease-clinicalmanagement-and-guidance (last accessed 14 August 2014).
3. Centers for Disease Control and Prevention. Ebola (Ebola Virus Disease): information for healthcare workers. CDC, 2014. Available online at: http://www.cdc.gov/vhf/ebola/hcp/index. html (last accessed 14 August 2014). 4. Accessed at: http://www.csmonitor.com/World/Africa/2014/ 0807/West-Africa-steps-up-response-to-Ebola-as-press-callsfor-more. 5. CDC. CDC's surge response to West Africa Ebola outbreak. CDC. Available online at: http://www.cdc.gov/media/releases/2014/ p0806-ebola.html; 2014 (last accessed 14 August 2014). 6. Public Health. Special Issue on World Health Organization. Public Health February 2014;128(2). 7. WHO. WHO statement 12 August 2014. WHO. Available online at: http://www.who.int/en/; 2014 (last accessed 14 August 2014).
F. Sim P. Mackie The Royal Society for Public Health, John Snow House, 59 Mansell Street, London E1 8AN, UK E-mail address: [email protected]
http://dx.doi.org/10.1016/j.puhe.2014.08.015 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
In this issue Our Editors' Choice this month explores the impact of hospital care on the environment, a topic seldom considered amongst the many competing priorities of acute healthcare provision, but one which has clear public health relevance. Indeed, the healthcare public health arena is ripe both for further development and quality research and evaluation, which we look forward to including in future issues. Amongst communicable diseases, we have papers on the perhaps less well known subjects of prions (CWD) and Lyme Disease. Obesity and weight management provide a constant stream of papers: in this issue one paper examines the cost-effectiveness of postnatal weight management programmes and another at gender differences in intentional weight loss. So all in all, this issue of Public Health includes content well beyond the typical boundaries of public health publications, while, for many of our readers, being highly relevant to our everyday practice and promoting creative thinking around future research agendas.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Editorial
The rising tide of Ebola
The Ebola virus outbreak originating in West Africa in March this year hit the lay media a few months ago. In 2014 Ebola has competed for space in international newspapers and other mass media with terrible conflicts in several regions. However, as the number of deaths from the disease rose, the outbreak became a regular news item, perhaps as much due to the fears among people outside Africa of an imported case, as to the result of international concern for the well-being of people in a far off land. On 8th August 2014, after the outbreak had spread from three African countries to a fourth, Nigeria, the World Health Organization announced the outbreak an international public health emergency. To date Ebola infection has no effective treatment and no vaccine, although the WHO tells us that both are in development.1 Ebola is, for the lay media, the archetypal incurable, fatal, infectious disease, relentlessly causing the deaths of innocent victims of all ages who had unknowingly contracted the virus. Outbreaks of Ebola and other viral haemorrhagic fevers occur in endemic areas from time to time, but (at the time of writing) this Ebola outbreak is widespread, having affected people in four African countries, Guinea, Liberia, Sierra Leone, and Nigeria, and has had a very high mortality rate, estimated at between 50 and 90% at different stages of the outbreak. Perhaps one of the most emotive elements of this outbreak, especially among the mass media, is the risk of infection among health workers caring for infected patients. Sadly, it is the case that in poor communities most affected by the outbreak, there has been completely inadequate access to protective clothing and equipment, which has contributed to the transmission of infection to healthcare workers, amongst whom there has been a startling risk of mortality not normally associated with the caring professions in the 21st Century. At least two suspected infected healthcare workers have been repatriated to the US for treatment in specialist isolation facilities. Unlike medical staff, other groups of staff who may encounter someone with Ebola have not received targeted advice by national agencies. In the UK, airport staff have threatened industrial action due to fear over the perceived risk of infection from incoming travellers. Physicians working in other countries to date unaffected by the outbreak directly, including the UK2 and USA3 have been issued with advice about how to react if they are confronted with a scenario in which they believe a patient may have contracted Ebola virus.
As well as healthcare workers, those people who handle the bodies of the deceased are known to be at increased risk of contracting the virus, which appears to remain infective for several days after the victim's death. Centuries old cultural practices are difficult to influence, leaving those people who practise them at ongoing risk. In Liberia the president blamed poverty and ignorance and entrenched cultural and religious practices for exacerbating the spread of the disease. But while both Sierre Leone and Liberia have declared states of emergency over Ebola, the government of Guinea was less active and has been criticized internationally for its observed lack of serious response to the outbreak.4 Ebola requires solid conventional health protection action. This was put cogently by CDC director, Tom Frieden, who said: ‘The bottom line with Ebola is we know how to stop it: traditional public health. Find patients, isolate and care for them; find their contacts; educate people; and strictly follow infection control in hospitals. Do those things with meticulous care and Ebola goes away.’5 The role of WHO has been interesting to observe and should be considered in light of the insightful viewpoints shared in the special issue of Public Health in February 2014:6 the declaration of an international health emergency on 8th August; and the declaration on 12th August to endorse the use of unproven interventions in the treatment of people infected with Ebola. Notably, the first few patients to be treated in this way, prior to the WHO statement, were foreign staff, who were repatriated to the US and Spain, respectively, for treatment. The WHO had convened a panel of experts on 11th August to consider the ethical implications ‘for clinical decision-making of the potential use of unregistered interventions’. The consensus they reached the following day was that, in the circumstances of this outbreak, use of such unproven interventions for either treatment or prevention was ethical.7 Given the very small supplies of these drugs, to whom they should be administered is a major ethical consideration. In addition to the ethical decision regarding use of unregistered and unproven treatments, it is clear that the global supply of such drugs is very limited. Unsurprisingly in this scenario, the WHO panel identified other areas requiring further consideration, including the need for criteria to prioritize the use of this scarce supply and to distribute it fairly; to gather and make best possible use of data with the
770
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 7 6 9 e7 7 0
relatively small numbers concerned, to ascertain, as far as possible, the extent to which any improvement or deterioration in a given patient can be attributed to the intervention, of whom 10e50% of patients would recover with no active treatment. It is unclear whether WHO will reconvene its expert panel to address these critical issues: but they do need to be addressed for this outbreak and for the next and subsequent outbreaks of new or re-emerging diseases. A postscript for anyone needing a reminder of the juxtaposition of conflict and infectious disease: something public health trainees are taught very early in their careers is that the Great War e World War One, 1914e18 e killed thousands of people; but the influenza epidemic that followed it killed far more.
references
1. WHO. Ebola virus disease. WHO. Available online at: http:// www.who.int/mediacentre/factsheets/fs103/en/; 2014 (last accessed 14 August 2014). 2. Public Health England. Ebola virus disease: clinical management and guidance. Health protection - collection, Public Health England, 2014. Available online at: http://www. gov.uk/government/collections/ebola-virus-disease-clinicalmanagement-and-guidance (last accessed 14 August 2014).
3. Centers for Disease Control and Prevention. Ebola (Ebola Virus Disease): information for healthcare workers. CDC, 2014. Available online at: http://www.cdc.gov/vhf/ebola/hcp/index. html (last accessed 14 August 2014). 4. Accessed at: http://www.csmonitor.com/World/Africa/2014/ 0807/West-Africa-steps-up-response-to-Ebola-as-press-callsfor-more. 5. CDC. CDC's surge response to West Africa Ebola outbreak. CDC. Available online at: http://www.cdc.gov/media/releases/2014/ p0806-ebola.html; 2014 (last accessed 14 August 2014). 6. Public Health. Special Issue on World Health Organization. Public Health February 2014;128(2). 7. WHO. WHO statement 12 August 2014. WHO. Available online at: http://www.who.int/en/; 2014 (last accessed 14 August 2014).
F. Sim P. Mackie The Royal Society for Public Health, John Snow House, 59 Mansell Street, London E1 8AN, UK E-mail address: [email protected]
http://dx.doi.org/10.1016/j.puhe.2014.08.015 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
In this issue Our Editors' Choice this month explores the impact of hospital care on the environment, a topic seldom considered amongst the many competing priorities of acute healthcare provision, but one which has clear public health relevance. Indeed, the healthcare public health arena is ripe both for further development and quality research and evaluation, which we look forward to including in future issues. Amongst communicable diseases, we have papers on the perhaps less well known subjects of prions (CWD) and Lyme Disease. Obesity and weight management provide a constant stream of papers: in this issue one paper examines the cost-effectiveness of postnatal weight management programmes and another at gender differences in intentional weight loss. So all in all, this issue of Public Health includes content well beyond the typical boundaries of public health publications, while, for many of our readers, being highly relevant to our everyday practice and promoting creative thinking around future research agendas.
