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Pestilence, war, and lice
three countries. Four products containing beclomethasone are used widely in the UK but not elsewhere. We conclude that the European market shows considerable heterogeneity. The UK differs from the other three countries in not selling questionable products. Put another way, despite frequent complaints about excess expenditure for health at least 20% of the sales of the first fifty compounds in Italy and France and 12% in Germany are a waste of money. The other three countries might be interested in looking at the reasons for this difference in order to spend their own resources more wisely. Another factor is that the expenses of the UK National Health Service are among the lowest per caput and in relation to the gross national product. The differences in the most sold drugs in the four countries suggest market pressure rather than the patients’ interest. Any evaluation should ultimately rely on the relation between prescriptions and epidemiological data, but it is hard to believe, for example, that the large sales of immunomodulators or calcitonin in Italy reflect important underlying differences in the prevalence of the disease. The European Community should surely pay attention to these startling differences, especially in view of the establishment of the European Drug Agency. The need for harmonisation of prescriptions may offer the opportunity for research aimed at making doctors’ approaches to therapy more rational.
Silvio Garattini, Livio Garattini Centro di Economia Sanitaria "A Valenti", Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
Pestilence, war, and lice See page 1213
Large military forces are deployed for many reasons world wide, with various degrees of logistic support. With any lengthy campaign, especially in tropical areas, entomologists and field laundries are essential components of such support. By these means the armies are protected against pestilence, and ultimately civilian populations too. Collapse of the support infrastructure has serious consequences for civilians. There are few places where the threshold for epidemics is
lower than in Ethiopia. Tenuous public health facilities in a population with pockets of overcrowding where louseborne relapsing fever (LBRF) is endemic means that it takes little social upheaval for unbridled release of this pestilence on the local inhabitants. A lengthy civil war consequently created the ideal stimulus for spread of the spirochaete Borrelia recurrentis by the infected body louse Pediculus humanus humanus, which excretes the organism in its faeces. The irritation of the bite provokes scratching that inoculates the skin of the potential patient. The clinical manifestations of the ensuing recurrent attacks of vasculitis have been well described.1-4 Combatants in the civil war provided the nidus for the epidemic. Other than food and ordnance, there was no logistic support so that, unprotected medically, their .
permitted ready spread among themselves and to local civilians.1,2 Supervision of the return of hundreds of thousands of soldiers from the battlefields of northern Ethiopia to their areas of original recruitment was a formidable task entrusted to the International Committee
musters
1192
of the Red Cross, which organised camps on the southbound routes. That this exercise was completed successfully while treatment for LBRF was provided was praiseworthy in itself; that any numerical observations were recorded in such mayhem is truly exceptional. In this issue Sundnes and Haimanot provide unique data which confirm that control of an epidemic of LBRF can be achieved by elimination of the vector in combination with antibiotic treatment.
underscores the need for sound advice so that, when there is a large infested entomological effort is not wasted on superfluous activities. population, Although the body louse feeds on the skin, it lives and lays its eggs on the warm adjacent garments. The only action that is necessary is insufflation of pediculicidal powder such Their
account
10% dichlorodiphenyl-trichloroethane (DDT) or, better, 1% malathion or 0-5% permethrin at moderate pressure under the clothes.56 Shaving and washing the as
body and spraying belongings and tents are pointless, wasteful, and costly in terms of time, resources, and effort. Borrelia recurrentis is highly sensitive to single doses of many cheap antibiotics such as tetracycline, penicillin, and erythromycin. 1-3,7 The attendant discomfort of the JarischHerxheimer reaction, which occurs in a higher proportion (16-80%) of LBRF cases 1,5,8,9 than of other spirochaetal diseases (eg, syphilis, Lyme disease, and leptospirosis) is noteworthy and may be related to changes in cytokines8 and glucose homoeostasis.1O With treatment, LBRF is seldom fatal, but LBRF or the Jarisch-Heixheimer reaction does not guarantee immunity from reinfection, which depends on successful vector control The lesson learned by the British Army over fifty years agoll that the advice of entomologists is essential, economical, and effective must be made known to agencies such as the Red Cross. Vigilance in former Yugoslavia, with ready recourse to entomological advice, is essential if epidemic typhus, a more serious louse-borne disease, is to be prevented. M World Royal Army Medical College, London, UK
1
Borgnolo G, Denku B, Chiabrera F, Hailu B. Relapsing fever in Ethiopian children: a clinical study. Ann Trop Paediatr 1993; 13:
2
Borgnolo G, Hailu B, Ciancarelli A, et al. Louse-borne relapsing fever: a clinical and an epidemiological study of 389 patients in Asella Hospital, Ethiopia. Trop Geogr Med 1993; 45: 66-69. Daniel E, Bayene H, Tessema T. Relapsing fever in children: demographic, social and clinical features. Ethiopian Med J 1992; 30:
165-71.
3
207-14. Brown V, Larouze B, Desve G, et al. Clinical presentation of louseborne relapsing fever among Ethiopian refugees in northern Somalia. Ann Trop Med Parasitol 1988; 82: 499-502. 5 Alexander J O’D. Arthropods and human skin. Berlin: Springer Verlag, 1984: 32, 41, 45, 49. 6 Gordon RM, Lavipierre M M J. Entomology for students of medicine. Oxford: Blackwell, 1962: 230. 7 Gebrehinot T, Fiseha A. Tetracycline versus penicillin in the treatment of louse-borne relapsing fever. Ethiopian Med J 1992; 30: 175-81. 8 Negussie Y, Remick DG, Deforge LE, et al. Detection of plasma tumor necrosis factor, interleukins 6 and 8 during the JarischHerxheimer reaction of relapsing fever. J Exp Med 1992; 175: 1207-12. 9 Zein ZA. Louse-borne relapsing fever (LBRF): mortality and frequency of Jarisch-Herxheimer reaction. J R Soc Health 1987; 107: 146-47. 10 Teklu B, Habte-Michael A, White NJ, et al. Glucose and insulin homeostasis during the Jarisch-Herxheimer reaction. Trans R Soc Trop Med Hyg 1985; 79: 74-77. 11 Burgess NRH. Fifty years of military entomology. In: Prospectus of the Army Medical Services. Golspie, UK: Method Publishing
4
Company,
1992: 46-47.
Silvio Garattini, Livio Garattini Centro di Economia Sanitaria "A Valenti", Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
Pestilence, war, and lice See page 1213
Large military forces are deployed for many reasons world wide, with various degrees of logistic support. With any lengthy campaign, especially in tropical areas, entomologists and field laundries are essential components of such support. By these means the armies are protected against pestilence, and ultimately civilian populations too. Collapse of the support infrastructure has serious consequences for civilians. There are few places where the threshold for epidemics is
lower than in Ethiopia. Tenuous public health facilities in a population with pockets of overcrowding where louseborne relapsing fever (LBRF) is endemic means that it takes little social upheaval for unbridled release of this pestilence on the local inhabitants. A lengthy civil war consequently created the ideal stimulus for spread of the spirochaete Borrelia recurrentis by the infected body louse Pediculus humanus humanus, which excretes the organism in its faeces. The irritation of the bite provokes scratching that inoculates the skin of the potential patient. The clinical manifestations of the ensuing recurrent attacks of vasculitis have been well described.1-4 Combatants in the civil war provided the nidus for the epidemic. Other than food and ordnance, there was no logistic support so that, unprotected medically, their .
permitted ready spread among themselves and to local civilians.1,2 Supervision of the return of hundreds of thousands of soldiers from the battlefields of northern Ethiopia to their areas of original recruitment was a formidable task entrusted to the International Committee
musters
1192
of the Red Cross, which organised camps on the southbound routes. That this exercise was completed successfully while treatment for LBRF was provided was praiseworthy in itself; that any numerical observations were recorded in such mayhem is truly exceptional. In this issue Sundnes and Haimanot provide unique data which confirm that control of an epidemic of LBRF can be achieved by elimination of the vector in combination with antibiotic treatment.
underscores the need for sound advice so that, when there is a large infested entomological effort is not wasted on superfluous activities. population, Although the body louse feeds on the skin, it lives and lays its eggs on the warm adjacent garments. The only action that is necessary is insufflation of pediculicidal powder such Their
account
10% dichlorodiphenyl-trichloroethane (DDT) or, better, 1% malathion or 0-5% permethrin at moderate pressure under the clothes.56 Shaving and washing the as
body and spraying belongings and tents are pointless, wasteful, and costly in terms of time, resources, and effort. Borrelia recurrentis is highly sensitive to single doses of many cheap antibiotics such as tetracycline, penicillin, and erythromycin. 1-3,7 The attendant discomfort of the JarischHerxheimer reaction, which occurs in a higher proportion (16-80%) of LBRF cases 1,5,8,9 than of other spirochaetal diseases (eg, syphilis, Lyme disease, and leptospirosis) is noteworthy and may be related to changes in cytokines8 and glucose homoeostasis.1O With treatment, LBRF is seldom fatal, but LBRF or the Jarisch-Heixheimer reaction does not guarantee immunity from reinfection, which depends on successful vector control The lesson learned by the British Army over fifty years agoll that the advice of entomologists is essential, economical, and effective must be made known to agencies such as the Red Cross. Vigilance in former Yugoslavia, with ready recourse to entomological advice, is essential if epidemic typhus, a more serious louse-borne disease, is to be prevented. M World Royal Army Medical College, London, UK
1
Borgnolo G, Denku B, Chiabrera F, Hailu B. Relapsing fever in Ethiopian children: a clinical study. Ann Trop Paediatr 1993; 13:
2
Borgnolo G, Hailu B, Ciancarelli A, et al. Louse-borne relapsing fever: a clinical and an epidemiological study of 389 patients in Asella Hospital, Ethiopia. Trop Geogr Med 1993; 45: 66-69. Daniel E, Bayene H, Tessema T. Relapsing fever in children: demographic, social and clinical features. Ethiopian Med J 1992; 30:
165-71.
3
207-14. Brown V, Larouze B, Desve G, et al. Clinical presentation of louseborne relapsing fever among Ethiopian refugees in northern Somalia. Ann Trop Med Parasitol 1988; 82: 499-502. 5 Alexander J O’D. Arthropods and human skin. Berlin: Springer Verlag, 1984: 32, 41, 45, 49. 6 Gordon RM, Lavipierre M M J. Entomology for students of medicine. Oxford: Blackwell, 1962: 230. 7 Gebrehinot T, Fiseha A. Tetracycline versus penicillin in the treatment of louse-borne relapsing fever. Ethiopian Med J 1992; 30: 175-81. 8 Negussie Y, Remick DG, Deforge LE, et al. Detection of plasma tumor necrosis factor, interleukins 6 and 8 during the JarischHerxheimer reaction of relapsing fever. J Exp Med 1992; 175: 1207-12. 9 Zein ZA. Louse-borne relapsing fever (LBRF): mortality and frequency of Jarisch-Herxheimer reaction. J R Soc Health 1987; 107: 146-47. 10 Teklu B, Habte-Michael A, White NJ, et al. Glucose and insulin homeostasis during the Jarisch-Herxheimer reaction. Trans R Soc Trop Med Hyg 1985; 79: 74-77. 11 Burgess NRH. Fifty years of military entomology. In: Prospectus of the Army Medical Services. Golspie, UK: Method Publishing
4
Company,
1992: 46-47.