- Email: [email protected]
Measles in Europe—there is room for improvement
Comment
the global-health agenda and its priorities. The G8 is one of the few bodies that can tackle the interaction between economic development, foreign policy, security, and health. Japan argued that the G8 should move from summitry to accountability. It could provide the necessary monitoring mechanisms to review donor delivery on global-health commitments. The G8 can ensure that donor promises are kept. Italy occupies the G8 chair in 2009 and could do a great deal to reposition the G8 to act as a barometer of global wellbeing. What can be done to mitigate the impact of the financial crisis? The advice from the World Bank to countries is pointed. Countries should focus on financing specific essential services for vulnerable populations. The emphasis should be on access to defined services, not on an overall figure for governmental health expenditure. Governments should identify those key services, the people they are targeting, and the means (eg, conditional cash transfers) by which services can be matched to individuals. But to make this rational planning work requires better science, better data, and better monitoring. Civil society has a vital part to play by providing an additional accountability mechanism for governments. Civil society can provide the pressure to make health a national entitlement. It can also foster solidarity between donors and recipient countries, between government and the people, and among citizens. Meanwhile, donors must keep their aid promises. The G8 could be one means to keep donors honest.
What can WHO do? The high-level consultation held in Geneva last week signalled great support from countries for WHO’s strengthened role in advocacy, analysis, and monitoring. WHO can also accelerate its work to realise the vision of universal primary health care. It can use the financial crisis as an opportunity to review and restructure its resource allocations to better respond to global priorities in health. It can insist on stronger and more effective health representation in economically influential institutions, such as the World Trade Organization. Health and health systems reflect and evolve from the economic, political, and social conditions within countries. The deep connections between health and economics, and the chronic neglect that the health community has so far paid to economics, means that if we do not now respond candidly and creatively to these threatening financial conditions, we will be failing the very people we claim to represent. We can do better than that. Richard Horton The Lancet, London NW1 7Y, UK 1 2
3
Leach B. City workers seek psychic help for financial future. Sunday Telegraph Jan 18, 2009: 5. International Health Partnership. High Level Taskforce on Innovative International Financing for Health Systems. Sept 25, 2008. http://www.internationalhealthpartnership.net/taskforce.html (accessed Jan 21, 2009). Reich MR, Takemi K. G8 and strengthening of health systems: follow up to the Toyako Summit. Lancet 2009; published online Jan 15. DOI:10.1016/ S0140-6736(08)61899-1.
Measles in Europe—there is room for improvement Published Online January 7, 2009 DOI:10.1016/S01406736(08)61850-4 See Articles page 383
356
In The Lancet today, the EUVAC.NET group1 have compiled measles data for 2006–07 from 32 European countries, in the context of eliminating measles in the WHO-European Region (WHO-EURO) by 2010. It seems good news that only half as many (3909) measles cases occurred in 2007 as in 2006 (8223). However, preliminary data suggest that measles incidence was about three times higher during the first half of 2008 than in the same period in 2007.2,3 The relatively low incidence found by EUVAC.NET in 2007 might therefore mostly reflect the periodicity of measles outbreaks, rather than sudden progress in vaccination. It is encouraging that most of the cases from 2006–07 (77–87%) have occurred in
unvaccinated individuals, confirming that the vaccine is highly effective even in the diverse socioeconomic settings of the participating countries and despite different vaccination schedules. Although this finding is not new, it is reassuring to learn that the same applies when increasingly large proportions of populations are protected by vaccine-induced rather than wild-type virus-induced immunity. The situation in vaccinated individuals in the EUVAC.NET study, however, seems more complex. 10–17% of cases occurred in people vaccinated with one dose, and 3–5% in those who had received two doses. But these rates are difficult to interpret unless coverage of two-dose vaccine is known. 9–15% of cases www.thelancet.com Vol 373 January 31, 2009
occurred in infants who were infected before they could be vaccinated. Such infants can only be protected by high population immunity, which normally cannot be reached without the opportunity for a second vaccine dose. Although the disproportionate 2006–07 reduction in incidence of measles in infants is encouraging, particular attention must be paid to adults who were vaccinated during childhood and lose their immunity,4 especially in the absence of wild-type virus circulation. In the EUVAC.NET report, however, 2006–07 differences in cumulated age distribution indicate differences in susceptible age-groups in the countries where the cases occurred. Also, differences in hospitalisation rates were largely due to mandatory admission of people with measles in Romania. The strength of the data is that they confirm that we are on track, but their weakness is that they do not tell us enough about how to improve. Countries must identify and monitor specific obstacles to measles elimination and design appropriate responses. The UK is only slowly recovering from its unsubstantiated scare that the measles, mumps, and rubella vaccination was linked to increased risk of autism.5 Also, the suspension of the National Measles and Rubella Vaccination Campaign in the Ukraine6 shows how vulnerable vaccination is to unfounded reports of side-effects. Whereas Germany has its anthroposophic communities and measles parties, the Netherlands struggles with religious objectors in the bible belt, which, after the last outbreak in 1999–2000,7 is again moving towards critical numbers of susceptible individuals, sufficient to sustain a larger outbreak. Disruption of vaccine supplies after the disintegration of the Soviet Union and political unrest in the Balkans has also caused problems with control of measles. More than 50 000 cases were recorded in 2005–06, during a large and persistent outbreak in the Ukraine, which is not part of EUVAC.NET. The high incidence in 15–29-year-olds was partly attributed to suboptimum vaccine effectiveness and possibly falsified vaccination records.8 2006 was dominated by a large outbreak in Romania, which had started in 2004 and continued in highly mobile and unvaccinated Sinti and Roma communities. Molecular epidemiology, led by the WHO Measles and Rubella Laboratory Network, retraced the spread of this virus throughout Europe.9 Similar investigations showed the spread of a genotype D4 virus in Jewish orthodox communities throughout Europe www.thelancet.com Vol 373 January 31, 2009
Science Photo Library
Comment
and to the Americas in 2007–08. Thus hard-to-reach populations need special attention at this stage of measles elimination. As long as measles is endemic on other continents, the risk of virus importation into susceptible communities remains, even after elimination of indigenous measles from WHO-EURO. Many of the strains imported into Europe in 2006–07 originated from regions with high measles lethality (also confirmed by molecular epidemiology9) but in Europe fatality rates remained low, which confirmed that, for example, local host factors and the quality of health care, rather than unusual virus virulence, are to blame.10 Although the EUVAC.NET group discuss importations into and between EUVAC.NET participating countries, the more pressing question is how much measles does Europe export to countries with poor health systems and high fatality rates.9 Importations of measles virus from Europe have already triggered several outbreaks in South America, both before and after indigenous measles was eliminated in the Americas.11 Global measles deaths fell by 60% between 1999 and 2005, mainly because of 357
Comment
progress in measles control in developing countries.12 To see large outbreaks and high measles mortality in these regions after a reintroduction of measles virus from Europe would be embarrassing. Rich countries need to be responsible for avoiding cases by implementation of high vaccination coverage, to make it the privilege of resource-poor countries not to worry about reintroductions from Europe. Therefore identification of final hurdles to measles elimination—each hurdle individually and together—is essential.
3
4 5
6
7
8
*Jacques R Kremer, Claude P Muller Institute of Immunology, WHO Regional Reference Laboratory for Measles and Rubella, Laboratoire National de Santé/CRP-Santé, Luxembourg L-1950 [email protected]
9
10 11
We declare that we have no conflict of interest. 1
2
Muscat M, Bang H, Wohlfahrt J, Glismann S, Mølbak K, for the EUVAC.NET group. Measles in Europe: an epidemiological assessment. Lancet 2009; published online Jan 7. DOI:10.1016/S0140-6736(08)61849-8. EUVAC.NET. Measles surveillance first quarterly report 2008. September, 2008. http://www.euvac.net/graphics/euvac/pdf/2008_first.pdf (accessed Nov 12, 2008).
12
EUVAC.NET. Measles surveillance second quarterly report 2008. September, 2008. http://www.euvac.net/graphics/euvac/pdf/2008_ second.pdf (accessed Nov 12, 2008). Kremer JR, Schneider F, Muller CP. Waning antibodies in measles and rubella vaccinees—a longitudinal study. Vaccine 2006; 24: 2594–601. Friederichs V, Cameron JC, Robertson C. Impact of adverse publicity on MMR vaccine uptake: a population based analysis of vaccine uptake records for one million children, born 1987–2004. Arch Dis Child 2006; 91: 465–68. WHO. WHO, UNICEF and CDC regret the Government of Ukraine’s decision to suspend the National Measles and Rubella Vaccination Campaign. May 20, 2008. http://www.euro.who.int/mediacentre/ PR/2008/20080521_1 (accessed Nov 12, 2008). van den Hof S, Conyn-van Spaendonck MA, van Steenbergen JE. Measles epidemic in the Netherlands, 1999–2000. J Infect Dis 2002; 186: 1483–86. Velicko I, Muller LL, Pebody R, et al. Nationwide measles epidemic in Ukraine: the effect of low vaccine effectiveness. Vaccine 2008; 26: 6980–85. Kremer JR, Brown KE, Jin L, et al. High genetic diversity of measles virus, World Health Organization European Region, 2005–2006. Emerg Infect Dis 2008; 14: 107–14. Grais RF, Dubray C, Gerstl S, et al. Unacceptably high mortality related to measles epidemics in Niger, Nigeria, and Chad. PLoS Med 2007; 4: e16. de Quadros CA, Izurieta H, Venczel L, Carrasco P. Measles eradication in the Americas: progress to date. J Infect Dis 2004; 189 (suppl 1): S227–35. Wolfson LJ, Strebel PM, Gacic-Dobo M, Hoekstra EJ, McFarland JW, Hersh BS. Has the 2005 measles mortality reduction goal been achieved? A natural history modelling study. Lancet 2007; 369: 191–200.
Laparoscopic versus open pyloromyotomy Published Online January 17, 2009 DOI:10.1016/S01406736(09)60007-6 See Articles page 390
358
Since the initial report of laparoscopic pyloromyotomy in 1991,1 several studies have compared outcomes after open and laparoscopic operations,2–4 including two randomised trials.5,6 These studies concluded that there was no significant difference in the complication rates and that both techniques were equally safe in experienced hands. Most of these studies are models for the various situations paediatric surgeons must consider. The subtleties are often lost in the style and flamboyance of study results. Furthermore, the biases of the advocates of both techniques are expressed with the same data used to turn results in reverse directions. Randomised trials are recognised as the best design to evaluate health-care interventions, yet they remain rare in surgery. One such trial, reported in The Lancet today by Nigel Hall and colleagues,7 addresses an important issue and fills the gap not only in laparoscopic interventions but also in paediatric surgery. Hall and colleagues present the 3-year results of a multicentre international comparison of laparoscopic versus open pyloromyotomy in 180 infants. The primary outcome measures were time to achieve full enteral
feeds and duration of postoperative hospital stay. The infants who had laparoscopic pyloromyotomy achieved full enteral feeds significantly more quickly and were discharged significantly earlier than infants who had open pyloromyotomy, with no increase in intraoperative and postoperative complications. Their parents or carers also stated a significantly higher satisfaction score with the cosmetic appearance of the surgical wounds. In fact, the trial was stopped early (200 infants was the targeted sample size) on the recommendations of the data monitoring and ethics committee in view of the statistically significant advantages of laparoscopic pyloromyotomy. Today’s report is the first randomised trial that shows an earlier postoperative recovery period for laparoscopic pyloromyotomy. Leclair and colleagues6 suggested that length of stay is not a reliable measure of postoperative recovery after pyloromyotomy because in neonates and infants the elements leading to the decision of discharge from hospital are vague and subjective. But Hall and colleagues used standardised postoperative management protocols to reduce potential bias between treatment groups. www.thelancet.com Vol 373 January 31, 2009
the global-health agenda and its priorities. The G8 is one of the few bodies that can tackle the interaction between economic development, foreign policy, security, and health. Japan argued that the G8 should move from summitry to accountability. It could provide the necessary monitoring mechanisms to review donor delivery on global-health commitments. The G8 can ensure that donor promises are kept. Italy occupies the G8 chair in 2009 and could do a great deal to reposition the G8 to act as a barometer of global wellbeing. What can be done to mitigate the impact of the financial crisis? The advice from the World Bank to countries is pointed. Countries should focus on financing specific essential services for vulnerable populations. The emphasis should be on access to defined services, not on an overall figure for governmental health expenditure. Governments should identify those key services, the people they are targeting, and the means (eg, conditional cash transfers) by which services can be matched to individuals. But to make this rational planning work requires better science, better data, and better monitoring. Civil society has a vital part to play by providing an additional accountability mechanism for governments. Civil society can provide the pressure to make health a national entitlement. It can also foster solidarity between donors and recipient countries, between government and the people, and among citizens. Meanwhile, donors must keep their aid promises. The G8 could be one means to keep donors honest.
What can WHO do? The high-level consultation held in Geneva last week signalled great support from countries for WHO’s strengthened role in advocacy, analysis, and monitoring. WHO can also accelerate its work to realise the vision of universal primary health care. It can use the financial crisis as an opportunity to review and restructure its resource allocations to better respond to global priorities in health. It can insist on stronger and more effective health representation in economically influential institutions, such as the World Trade Organization. Health and health systems reflect and evolve from the economic, political, and social conditions within countries. The deep connections between health and economics, and the chronic neglect that the health community has so far paid to economics, means that if we do not now respond candidly and creatively to these threatening financial conditions, we will be failing the very people we claim to represent. We can do better than that. Richard Horton The Lancet, London NW1 7Y, UK 1 2
3
Leach B. City workers seek psychic help for financial future. Sunday Telegraph Jan 18, 2009: 5. International Health Partnership. High Level Taskforce on Innovative International Financing for Health Systems. Sept 25, 2008. http://www.internationalhealthpartnership.net/taskforce.html (accessed Jan 21, 2009). Reich MR, Takemi K. G8 and strengthening of health systems: follow up to the Toyako Summit. Lancet 2009; published online Jan 15. DOI:10.1016/ S0140-6736(08)61899-1.
Measles in Europe—there is room for improvement Published Online January 7, 2009 DOI:10.1016/S01406736(08)61850-4 See Articles page 383
356
In The Lancet today, the EUVAC.NET group1 have compiled measles data for 2006–07 from 32 European countries, in the context of eliminating measles in the WHO-European Region (WHO-EURO) by 2010. It seems good news that only half as many (3909) measles cases occurred in 2007 as in 2006 (8223). However, preliminary data suggest that measles incidence was about three times higher during the first half of 2008 than in the same period in 2007.2,3 The relatively low incidence found by EUVAC.NET in 2007 might therefore mostly reflect the periodicity of measles outbreaks, rather than sudden progress in vaccination. It is encouraging that most of the cases from 2006–07 (77–87%) have occurred in
unvaccinated individuals, confirming that the vaccine is highly effective even in the diverse socioeconomic settings of the participating countries and despite different vaccination schedules. Although this finding is not new, it is reassuring to learn that the same applies when increasingly large proportions of populations are protected by vaccine-induced rather than wild-type virus-induced immunity. The situation in vaccinated individuals in the EUVAC.NET study, however, seems more complex. 10–17% of cases occurred in people vaccinated with one dose, and 3–5% in those who had received two doses. But these rates are difficult to interpret unless coverage of two-dose vaccine is known. 9–15% of cases www.thelancet.com Vol 373 January 31, 2009
occurred in infants who were infected before they could be vaccinated. Such infants can only be protected by high population immunity, which normally cannot be reached without the opportunity for a second vaccine dose. Although the disproportionate 2006–07 reduction in incidence of measles in infants is encouraging, particular attention must be paid to adults who were vaccinated during childhood and lose their immunity,4 especially in the absence of wild-type virus circulation. In the EUVAC.NET report, however, 2006–07 differences in cumulated age distribution indicate differences in susceptible age-groups in the countries where the cases occurred. Also, differences in hospitalisation rates were largely due to mandatory admission of people with measles in Romania. The strength of the data is that they confirm that we are on track, but their weakness is that they do not tell us enough about how to improve. Countries must identify and monitor specific obstacles to measles elimination and design appropriate responses. The UK is only slowly recovering from its unsubstantiated scare that the measles, mumps, and rubella vaccination was linked to increased risk of autism.5 Also, the suspension of the National Measles and Rubella Vaccination Campaign in the Ukraine6 shows how vulnerable vaccination is to unfounded reports of side-effects. Whereas Germany has its anthroposophic communities and measles parties, the Netherlands struggles with religious objectors in the bible belt, which, after the last outbreak in 1999–2000,7 is again moving towards critical numbers of susceptible individuals, sufficient to sustain a larger outbreak. Disruption of vaccine supplies after the disintegration of the Soviet Union and political unrest in the Balkans has also caused problems with control of measles. More than 50 000 cases were recorded in 2005–06, during a large and persistent outbreak in the Ukraine, which is not part of EUVAC.NET. The high incidence in 15–29-year-olds was partly attributed to suboptimum vaccine effectiveness and possibly falsified vaccination records.8 2006 was dominated by a large outbreak in Romania, which had started in 2004 and continued in highly mobile and unvaccinated Sinti and Roma communities. Molecular epidemiology, led by the WHO Measles and Rubella Laboratory Network, retraced the spread of this virus throughout Europe.9 Similar investigations showed the spread of a genotype D4 virus in Jewish orthodox communities throughout Europe www.thelancet.com Vol 373 January 31, 2009
Science Photo Library
Comment
and to the Americas in 2007–08. Thus hard-to-reach populations need special attention at this stage of measles elimination. As long as measles is endemic on other continents, the risk of virus importation into susceptible communities remains, even after elimination of indigenous measles from WHO-EURO. Many of the strains imported into Europe in 2006–07 originated from regions with high measles lethality (also confirmed by molecular epidemiology9) but in Europe fatality rates remained low, which confirmed that, for example, local host factors and the quality of health care, rather than unusual virus virulence, are to blame.10 Although the EUVAC.NET group discuss importations into and between EUVAC.NET participating countries, the more pressing question is how much measles does Europe export to countries with poor health systems and high fatality rates.9 Importations of measles virus from Europe have already triggered several outbreaks in South America, both before and after indigenous measles was eliminated in the Americas.11 Global measles deaths fell by 60% between 1999 and 2005, mainly because of 357
Comment
progress in measles control in developing countries.12 To see large outbreaks and high measles mortality in these regions after a reintroduction of measles virus from Europe would be embarrassing. Rich countries need to be responsible for avoiding cases by implementation of high vaccination coverage, to make it the privilege of resource-poor countries not to worry about reintroductions from Europe. Therefore identification of final hurdles to measles elimination—each hurdle individually and together—is essential.
3
4 5
6
7
8
*Jacques R Kremer, Claude P Muller Institute of Immunology, WHO Regional Reference Laboratory for Measles and Rubella, Laboratoire National de Santé/CRP-Santé, Luxembourg L-1950 [email protected]
9
10 11
We declare that we have no conflict of interest. 1
2
Muscat M, Bang H, Wohlfahrt J, Glismann S, Mølbak K, for the EUVAC.NET group. Measles in Europe: an epidemiological assessment. Lancet 2009; published online Jan 7. DOI:10.1016/S0140-6736(08)61849-8. EUVAC.NET. Measles surveillance first quarterly report 2008. September, 2008. http://www.euvac.net/graphics/euvac/pdf/2008_first.pdf (accessed Nov 12, 2008).
12
EUVAC.NET. Measles surveillance second quarterly report 2008. September, 2008. http://www.euvac.net/graphics/euvac/pdf/2008_ second.pdf (accessed Nov 12, 2008). Kremer JR, Schneider F, Muller CP. Waning antibodies in measles and rubella vaccinees—a longitudinal study. Vaccine 2006; 24: 2594–601. Friederichs V, Cameron JC, Robertson C. Impact of adverse publicity on MMR vaccine uptake: a population based analysis of vaccine uptake records for one million children, born 1987–2004. Arch Dis Child 2006; 91: 465–68. WHO. WHO, UNICEF and CDC regret the Government of Ukraine’s decision to suspend the National Measles and Rubella Vaccination Campaign. May 20, 2008. http://www.euro.who.int/mediacentre/ PR/2008/20080521_1 (accessed Nov 12, 2008). van den Hof S, Conyn-van Spaendonck MA, van Steenbergen JE. Measles epidemic in the Netherlands, 1999–2000. J Infect Dis 2002; 186: 1483–86. Velicko I, Muller LL, Pebody R, et al. Nationwide measles epidemic in Ukraine: the effect of low vaccine effectiveness. Vaccine 2008; 26: 6980–85. Kremer JR, Brown KE, Jin L, et al. High genetic diversity of measles virus, World Health Organization European Region, 2005–2006. Emerg Infect Dis 2008; 14: 107–14. Grais RF, Dubray C, Gerstl S, et al. Unacceptably high mortality related to measles epidemics in Niger, Nigeria, and Chad. PLoS Med 2007; 4: e16. de Quadros CA, Izurieta H, Venczel L, Carrasco P. Measles eradication in the Americas: progress to date. J Infect Dis 2004; 189 (suppl 1): S227–35. Wolfson LJ, Strebel PM, Gacic-Dobo M, Hoekstra EJ, McFarland JW, Hersh BS. Has the 2005 measles mortality reduction goal been achieved? A natural history modelling study. Lancet 2007; 369: 191–200.
Laparoscopic versus open pyloromyotomy Published Online January 17, 2009 DOI:10.1016/S01406736(09)60007-6 See Articles page 390
358
Since the initial report of laparoscopic pyloromyotomy in 1991,1 several studies have compared outcomes after open and laparoscopic operations,2–4 including two randomised trials.5,6 These studies concluded that there was no significant difference in the complication rates and that both techniques were equally safe in experienced hands. Most of these studies are models for the various situations paediatric surgeons must consider. The subtleties are often lost in the style and flamboyance of study results. Furthermore, the biases of the advocates of both techniques are expressed with the same data used to turn results in reverse directions. Randomised trials are recognised as the best design to evaluate health-care interventions, yet they remain rare in surgery. One such trial, reported in The Lancet today by Nigel Hall and colleagues,7 addresses an important issue and fills the gap not only in laparoscopic interventions but also in paediatric surgery. Hall and colleagues present the 3-year results of a multicentre international comparison of laparoscopic versus open pyloromyotomy in 180 infants. The primary outcome measures were time to achieve full enteral
feeds and duration of postoperative hospital stay. The infants who had laparoscopic pyloromyotomy achieved full enteral feeds significantly more quickly and were discharged significantly earlier than infants who had open pyloromyotomy, with no increase in intraoperative and postoperative complications. Their parents or carers also stated a significantly higher satisfaction score with the cosmetic appearance of the surgical wounds. In fact, the trial was stopped early (200 infants was the targeted sample size) on the recommendations of the data monitoring and ethics committee in view of the statistically significant advantages of laparoscopic pyloromyotomy. Today’s report is the first randomised trial that shows an earlier postoperative recovery period for laparoscopic pyloromyotomy. Leclair and colleagues6 suggested that length of stay is not a reliable measure of postoperative recovery after pyloromyotomy because in neonates and infants the elements leading to the decision of discharge from hospital are vague and subjective. But Hall and colleagues used standardised postoperative management protocols to reduce potential bias between treatment groups. www.thelancet.com Vol 373 January 31, 2009