- Email: [email protected]
Preparation of at-risk west African countries for Ebola
Correspondence
I declare no competing interests.
www.thelancet.com Vol 385 January 24, 2015
Mahaveer Golechha [email protected] Health Economics and Financing Unit, Public Health Foundation of India, New Delhi 110070, India 1
2 3
4
5
6
Maurice J. Polio eradication effort sees progress, but problems remain. Lancet 2014; 383: 939–40. WHO. Global tuberculosis report 2013. Geneva: World Health Organization, 2013. Sachdeva KS, Kumar A, Dewan P, Satyanarayana S. New vision for Revised National Tuberculosis Control Programme (RNTCP): universal access—“Reaching the un-reached”. Indian J Med Res 2012; 135: 690–94. Sreeramareddy CT, Qin ZZ, Satyanarayana S, Subbaraman R, Pai M. Delays in diagnosis and treatment of pulmonary tuberculosis in India: a systematic review. Int J Tuberc Lung Dis 2014; 18: 255–66. Cowling K, Dandona R, Dandona L. Improving the estimation of the tuberculosis burden in India. Bull World Health Organ 2014; 92: 817–25. Small P. Why India should become a global leader in high-quality, affordable TB diagnostics. Indian J Med Res 2012; 135: 685–89.
Preparation of at-risk west African countries for Ebola The ongoing Ebola epidemic in west Africa is an unprecedented health and humanitarian crisis. So far, more than 20 000 cases have been reported1 in Guinea, Liberia, and Sierra Leone, and transmission models developed during this epidemic have predicted spread of Ebola into neighbouring west African countries.2 These predictions have already been realised in Nigeria and Senegal, but public health authorities in both countries acted swiftly to limit secondary transmission. 3,4 The experiences in Nigeria and Senegal attest to the effectiveness of conventional epi demiological methods—particularly, case isolation and contact tracing—in containing Ebola outside the three countries with widespread transmission.5 Mali became the latest west African country to report an Ebola introduction in October, 2014, followed by another independent introduction in November, 2014, and the country’s public health authorities responded efficiently such that the outbreaks have now been contained.
Improvement of Ebola preparedness and response capacity in neighbouring at-risk west African countries should therefore be prioritised so that public health responses can be rapidly initiated elsewhere if the need arises. The US Centers for Disease Control and Prevention (CDC) has more than 150 staff currently deployed to Guinea, Liberia, and Sierra Leone, and is providing in-country technical assistance to 13 of the 15 African countries identified by WHO as being at an increased risk of an Ebola introduction. 3,4,6 CDC’s activities in these countries are focused on assistance of national ministries of health, development of specimen shipment capacity, creation of incident management structures, and establishment of surveillance systems for Ebola detection and reporting. To complement available WHO guidance documents intended to help countries increase their Ebola preparedness,6,7 CDC has created a contact tracing training module so that this key measure can be quickly implemented in case of an Ebola introduction. CDC also has a liaison officer assigned with the WHO Regional Office for Africa in Brazzaville, Congo, to ensure coordination of Ebola response efforts with WHO. Finally, CDC has a rapid response team based in the USA and in west Africa that is on stand-by and ready to assist national ministries of health in the event that additional countries report their first Ebola cases. Although the arrival of only one person with Ebola is enough to cripple an unprepared country, there is ample evidence that an Ebola outbreak can be contained if conventional epidemiological measures are implemented rapidly.2,5 Therefore, a deliberate effort must be made to develop capacity to detect and respond to Ebola introductions across west Africa if further geographic spread of the epidemic is to be prevented. By fostering collaborative and transparent relations between west African countries and international partners with the primary objective
Kristin Palitza/picture-alliance/dpa/AP Images
This pathway to curative care can take weeks to months, during which patients continue to transmit the infection to others. 4 India needs to prevent the unregulated sale and inappropriate prescription of tuberculosis drugs in the private sector, a practice that has had an important role in the emergence of drug-resistant tuberculosis in the country. The government should enforce regulation for restricting tuberculosis treatment by qualified practitioners and act strictly against unqualified practitioners. Almost 1 million Indians with tuberculosis have not been diagnosed.2 India has one of the least reliable data sources for tuberculosis burden, and an improved understanding of the burden is needed to improve assessments of tuberculosis globally.5 Surveillance mechanisms need to expand across all public, private, and community-based providers, including hospitals and non-governmental organisations. Limited progress has been made in tuberculosis diagnosis and drug development. Indian pharmaceutical companies have improved access to affordable quality HIV drugs through generic production. In the same way, companies should also focus on high-quality generic diagnostics. India should develop low-cost generic versions of molecular assays to increase access to these tests both within the country and worldwide.6 India has much to learn from its previous experiences and successes. Eradication of tuberculosis in India by 2050 will not be easy—but neither was the elimination of polio. Success depends on smart planning, mobilisation of entire communities, and strong political leadership. However, in the absence of sustained financial support, strong political will and leadership, dedicated involvement of all stakeholders, stringent regulation, and community participation, attainment of a tuberculosis-free India by 2050 will remain unachievable.
329
Correspondence
of developing local capacity, there will be immediate benefits for halting this epidemic, and these countries will be better positioned to efficiently respond to future global health security threats.5 All authors are staff members of the CDC. The views expressed here are those of the authors, and they do not necessarily represent the official position of the CDC. We declare no competing interests.
*Neil M Vora, Ray R Arthur, David L Swerdlow, Frederick J Angulo [email protected] Commissioned Corps of the US Public Health Service (NMV); Center for Global Health (NMV, RRA, FJA); and National Center for Immunization and Respiratory Diseases (DLS), US Centers for Disease Control and Prevention, Atlanta, GA 30329-4027, USA 1
2
3
4
5
6
7
For the Ebola Response Anthropology Platform see http://www.heart-resources. org/ebola-responseanthropology-platform/ For the Ebola discussion board see https://groups. google.com/forum/#!forum/ ebola-anthropology-initiative For Listerv see https://lists. capalon.com/lists/listinfo/ ebola-anthropology-initiative
330
CDC. 2014 Ebola outbreak in west Africa—case counts. 2014. http://www.cdc.gov/vhf/ebola/ outbreaks/2014-west-africa/case-counts.html (accessed Jan 1, 2015). Rainisch G, Shankar M, Wellman M, Merlin T, Meltzer MI. Regional spread of Ebola virus, West Africa, 2014. Emerg Infect Dis 2015; published online Dec 23, 2014. DOI:10.3201/ eid2103.141845. Mirkovic K, Thwing J, Diack PA. Importation and containment of Ebola virus disease— Senegal, August–September 2014. MMWR 2014; 63: 873–74. Shuaib F, Gunnala R, Musa EO, et al. Ebola virus disease outbreak—Nigeria, July–September 2014. MMWR 2014; 63: 867–72. Frieden TR, Damon I, Bell BP, Kenyon T, Nichol S. Ebola 2014—new challenges, new global response and responsibility. N Engl J Med 2014; 371: 1177–80. WHO. Consolidated Ebola virus disease preparedness checklist. Oct 30, 2014. http:// apps.who.int/iris/bitstream/10665/137096/1/ WHO_EVD_Preparedness_14_eng. pdf?ua=1&ua=1 (accessed Dec 2, 2014). WHO. Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation. August, 2014. http://www.who. int/csr/disease/ebola/manual_EVD/en/ (accessed Dec 2, 2014).
Social science intelligence in the global Ebola response Sociocultural, economic, and political dimensions play a defining part in epidemics and pandemics.1 Anthropological involvement is increasingly recognised as important;2 however, integration of social sciences during global health crises remains, for the most part, delayed, inconsistent,
and distant from the centre of decision making and resource prioritisation. This problem is representative of much larger systemic barriers to academic and practitioner coordination in global health, humanitarian aid, and development practice. 3 While anthropological insights on-the-ground can and do inform extraordinary containment and education efforts during medical humanitarian emergencies, they are all too often not scaled up. This pattern is being repeated, albeit with some improvement, in the current west African Ebola response. As engaged anthropologists, we know examples of local and international colleagues being integrated into WHO and Médecins sans Frontières programmes and advising the UN Mission for Emergency Ebola Response. The governments of France, Sweden, and the UK have directly sought the consultation of regional and area experts, and mobilised support for rapid social science research. In the UK, anthropologists have been involved in the Scientific Advisory Group in Emergencies—a major advisory committee shaping the Ebola response. By contrast, in the USA social science involvement has been limited. While the US Centers for Disease Control and Prevention has established internal anthropology desks to inform the Ebola response, the US Government’s broader engagement with social scientists has been sluggish. This is alarming, in view of the substantial commitment of US military and civilian resources in west Africa. Anthropologists in Europe, Africa, and the USA have built new collaborative platforms (such as the Ebola Response Anthropology Platform) and networks (such as the Ebola Anthropology Initiative discussion board and Listerv) to support Ebola research and interventions by providing data analysis capabilities, mobilising academic institutional resources, sharing actionable recommendations, providing expertise and technical information,
and collaborating on research initiatives. This kind of initiative avoids the wasteful duplication of effort, and should be reproduced for other medical humanitarian emergencies. The Ebola response shows the need for new global mechanisms to be established that can rapidly mobilise all experts who can bring relevant local contextual, medical, epidemiological, and political information on global health emergencies. Now is the time to consider how to bring social science into the centre of future pandemic surveillance, response, community preparedness, and health system strengthening.4 This will take will, vision, and systematic engagement of our full capabilities and expertise. We declare no competing interests.
*Sharon Alane Abramowitz, Kevin Louis Bardosh, Melissa Leach, Barry Hewlett, Mark Nichter, Vinh-Kim Nguyen sabramowitz@ufl.edu Department of Anthropology, Center for African Studies, Gainesville, FL 32611, USA (SAA); Centre of African Studies and Division of Infection and Pathway Medicine, University of Edinburgh, Edinburgh, UK (KLB); Institute of Development Studies, Brighton, UK (ML); Department of Anthropology, Washington State University, Vancouver, WA, USA (BH); School of Anthropology, University of Arizona, Tucson, AZ, USA (MN); and Collège d’études mondiales, Fondation Maison des Sciences de l’Homme, Paris, France (V-KN) 1
2
3
4
Hewlett B. Ebola, culture and politics: the anthropology of an emerging disease. Belmont: Thomson Wadsworth, 2007. Janes CR, Corbett KK, Jones JH, Trostle J. Emerging infectious diseases: the role of social sciences. Lancet 2012; 380: 1884–86. Feierman S, Kleinman A, Stewart K, Farmer P, Das V. Anthropology, knowledge-flows and global health. Glob Public Health 2010; 5: 122–28. Institute of Medicine and National Research Council. Sustaining global surveillance and response to emerging zoonotic diseases. Washington, DC: The National Academies Press, 2009.
Department of Error Lasalvia A, Zoppei S, Van Bortel T, et al, and the ASPEN/INDIGO Study Group. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. Lancet 2013; 381: 55–62—In the ASPEN/INDIGO Study Group, “James Bowa” should have been “Bawo James”. This correction has been made to the online version as of Jan 23, 2015.
www.thelancet.com Vol 385 January 24, 2015
I declare no competing interests.
www.thelancet.com Vol 385 January 24, 2015
Mahaveer Golechha [email protected] Health Economics and Financing Unit, Public Health Foundation of India, New Delhi 110070, India 1
2 3
4
5
6
Maurice J. Polio eradication effort sees progress, but problems remain. Lancet 2014; 383: 939–40. WHO. Global tuberculosis report 2013. Geneva: World Health Organization, 2013. Sachdeva KS, Kumar A, Dewan P, Satyanarayana S. New vision for Revised National Tuberculosis Control Programme (RNTCP): universal access—“Reaching the un-reached”. Indian J Med Res 2012; 135: 690–94. Sreeramareddy CT, Qin ZZ, Satyanarayana S, Subbaraman R, Pai M. Delays in diagnosis and treatment of pulmonary tuberculosis in India: a systematic review. Int J Tuberc Lung Dis 2014; 18: 255–66. Cowling K, Dandona R, Dandona L. Improving the estimation of the tuberculosis burden in India. Bull World Health Organ 2014; 92: 817–25. Small P. Why India should become a global leader in high-quality, affordable TB diagnostics. Indian J Med Res 2012; 135: 685–89.
Preparation of at-risk west African countries for Ebola The ongoing Ebola epidemic in west Africa is an unprecedented health and humanitarian crisis. So far, more than 20 000 cases have been reported1 in Guinea, Liberia, and Sierra Leone, and transmission models developed during this epidemic have predicted spread of Ebola into neighbouring west African countries.2 These predictions have already been realised in Nigeria and Senegal, but public health authorities in both countries acted swiftly to limit secondary transmission. 3,4 The experiences in Nigeria and Senegal attest to the effectiveness of conventional epi demiological methods—particularly, case isolation and contact tracing—in containing Ebola outside the three countries with widespread transmission.5 Mali became the latest west African country to report an Ebola introduction in October, 2014, followed by another independent introduction in November, 2014, and the country’s public health authorities responded efficiently such that the outbreaks have now been contained.
Improvement of Ebola preparedness and response capacity in neighbouring at-risk west African countries should therefore be prioritised so that public health responses can be rapidly initiated elsewhere if the need arises. The US Centers for Disease Control and Prevention (CDC) has more than 150 staff currently deployed to Guinea, Liberia, and Sierra Leone, and is providing in-country technical assistance to 13 of the 15 African countries identified by WHO as being at an increased risk of an Ebola introduction. 3,4,6 CDC’s activities in these countries are focused on assistance of national ministries of health, development of specimen shipment capacity, creation of incident management structures, and establishment of surveillance systems for Ebola detection and reporting. To complement available WHO guidance documents intended to help countries increase their Ebola preparedness,6,7 CDC has created a contact tracing training module so that this key measure can be quickly implemented in case of an Ebola introduction. CDC also has a liaison officer assigned with the WHO Regional Office for Africa in Brazzaville, Congo, to ensure coordination of Ebola response efforts with WHO. Finally, CDC has a rapid response team based in the USA and in west Africa that is on stand-by and ready to assist national ministries of health in the event that additional countries report their first Ebola cases. Although the arrival of only one person with Ebola is enough to cripple an unprepared country, there is ample evidence that an Ebola outbreak can be contained if conventional epidemiological measures are implemented rapidly.2,5 Therefore, a deliberate effort must be made to develop capacity to detect and respond to Ebola introductions across west Africa if further geographic spread of the epidemic is to be prevented. By fostering collaborative and transparent relations between west African countries and international partners with the primary objective
Kristin Palitza/picture-alliance/dpa/AP Images
This pathway to curative care can take weeks to months, during which patients continue to transmit the infection to others. 4 India needs to prevent the unregulated sale and inappropriate prescription of tuberculosis drugs in the private sector, a practice that has had an important role in the emergence of drug-resistant tuberculosis in the country. The government should enforce regulation for restricting tuberculosis treatment by qualified practitioners and act strictly against unqualified practitioners. Almost 1 million Indians with tuberculosis have not been diagnosed.2 India has one of the least reliable data sources for tuberculosis burden, and an improved understanding of the burden is needed to improve assessments of tuberculosis globally.5 Surveillance mechanisms need to expand across all public, private, and community-based providers, including hospitals and non-governmental organisations. Limited progress has been made in tuberculosis diagnosis and drug development. Indian pharmaceutical companies have improved access to affordable quality HIV drugs through generic production. In the same way, companies should also focus on high-quality generic diagnostics. India should develop low-cost generic versions of molecular assays to increase access to these tests both within the country and worldwide.6 India has much to learn from its previous experiences and successes. Eradication of tuberculosis in India by 2050 will not be easy—but neither was the elimination of polio. Success depends on smart planning, mobilisation of entire communities, and strong political leadership. However, in the absence of sustained financial support, strong political will and leadership, dedicated involvement of all stakeholders, stringent regulation, and community participation, attainment of a tuberculosis-free India by 2050 will remain unachievable.
329
Correspondence
of developing local capacity, there will be immediate benefits for halting this epidemic, and these countries will be better positioned to efficiently respond to future global health security threats.5 All authors are staff members of the CDC. The views expressed here are those of the authors, and they do not necessarily represent the official position of the CDC. We declare no competing interests.
*Neil M Vora, Ray R Arthur, David L Swerdlow, Frederick J Angulo [email protected] Commissioned Corps of the US Public Health Service (NMV); Center for Global Health (NMV, RRA, FJA); and National Center for Immunization and Respiratory Diseases (DLS), US Centers for Disease Control and Prevention, Atlanta, GA 30329-4027, USA 1
2
3
4
5
6
7
For the Ebola Response Anthropology Platform see http://www.heart-resources. org/ebola-responseanthropology-platform/ For the Ebola discussion board see https://groups. google.com/forum/#!forum/ ebola-anthropology-initiative For Listerv see https://lists. capalon.com/lists/listinfo/ ebola-anthropology-initiative
330
CDC. 2014 Ebola outbreak in west Africa—case counts. 2014. http://www.cdc.gov/vhf/ebola/ outbreaks/2014-west-africa/case-counts.html (accessed Jan 1, 2015). Rainisch G, Shankar M, Wellman M, Merlin T, Meltzer MI. Regional spread of Ebola virus, West Africa, 2014. Emerg Infect Dis 2015; published online Dec 23, 2014. DOI:10.3201/ eid2103.141845. Mirkovic K, Thwing J, Diack PA. Importation and containment of Ebola virus disease— Senegal, August–September 2014. MMWR 2014; 63: 873–74. Shuaib F, Gunnala R, Musa EO, et al. Ebola virus disease outbreak—Nigeria, July–September 2014. MMWR 2014; 63: 867–72. Frieden TR, Damon I, Bell BP, Kenyon T, Nichol S. Ebola 2014—new challenges, new global response and responsibility. N Engl J Med 2014; 371: 1177–80. WHO. Consolidated Ebola virus disease preparedness checklist. Oct 30, 2014. http:// apps.who.int/iris/bitstream/10665/137096/1/ WHO_EVD_Preparedness_14_eng. pdf?ua=1&ua=1 (accessed Dec 2, 2014). WHO. Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation. August, 2014. http://www.who. int/csr/disease/ebola/manual_EVD/en/ (accessed Dec 2, 2014).
Social science intelligence in the global Ebola response Sociocultural, economic, and political dimensions play a defining part in epidemics and pandemics.1 Anthropological involvement is increasingly recognised as important;2 however, integration of social sciences during global health crises remains, for the most part, delayed, inconsistent,
and distant from the centre of decision making and resource prioritisation. This problem is representative of much larger systemic barriers to academic and practitioner coordination in global health, humanitarian aid, and development practice. 3 While anthropological insights on-the-ground can and do inform extraordinary containment and education efforts during medical humanitarian emergencies, they are all too often not scaled up. This pattern is being repeated, albeit with some improvement, in the current west African Ebola response. As engaged anthropologists, we know examples of local and international colleagues being integrated into WHO and Médecins sans Frontières programmes and advising the UN Mission for Emergency Ebola Response. The governments of France, Sweden, and the UK have directly sought the consultation of regional and area experts, and mobilised support for rapid social science research. In the UK, anthropologists have been involved in the Scientific Advisory Group in Emergencies—a major advisory committee shaping the Ebola response. By contrast, in the USA social science involvement has been limited. While the US Centers for Disease Control and Prevention has established internal anthropology desks to inform the Ebola response, the US Government’s broader engagement with social scientists has been sluggish. This is alarming, in view of the substantial commitment of US military and civilian resources in west Africa. Anthropologists in Europe, Africa, and the USA have built new collaborative platforms (such as the Ebola Response Anthropology Platform) and networks (such as the Ebola Anthropology Initiative discussion board and Listerv) to support Ebola research and interventions by providing data analysis capabilities, mobilising academic institutional resources, sharing actionable recommendations, providing expertise and technical information,
and collaborating on research initiatives. This kind of initiative avoids the wasteful duplication of effort, and should be reproduced for other medical humanitarian emergencies. The Ebola response shows the need for new global mechanisms to be established that can rapidly mobilise all experts who can bring relevant local contextual, medical, epidemiological, and political information on global health emergencies. Now is the time to consider how to bring social science into the centre of future pandemic surveillance, response, community preparedness, and health system strengthening.4 This will take will, vision, and systematic engagement of our full capabilities and expertise. We declare no competing interests.
*Sharon Alane Abramowitz, Kevin Louis Bardosh, Melissa Leach, Barry Hewlett, Mark Nichter, Vinh-Kim Nguyen sabramowitz@ufl.edu Department of Anthropology, Center for African Studies, Gainesville, FL 32611, USA (SAA); Centre of African Studies and Division of Infection and Pathway Medicine, University of Edinburgh, Edinburgh, UK (KLB); Institute of Development Studies, Brighton, UK (ML); Department of Anthropology, Washington State University, Vancouver, WA, USA (BH); School of Anthropology, University of Arizona, Tucson, AZ, USA (MN); and Collège d’études mondiales, Fondation Maison des Sciences de l’Homme, Paris, France (V-KN) 1
2
3
4
Hewlett B. Ebola, culture and politics: the anthropology of an emerging disease. Belmont: Thomson Wadsworth, 2007. Janes CR, Corbett KK, Jones JH, Trostle J. Emerging infectious diseases: the role of social sciences. Lancet 2012; 380: 1884–86. Feierman S, Kleinman A, Stewart K, Farmer P, Das V. Anthropology, knowledge-flows and global health. Glob Public Health 2010; 5: 122–28. Institute of Medicine and National Research Council. Sustaining global surveillance and response to emerging zoonotic diseases. Washington, DC: The National Academies Press, 2009.
Department of Error Lasalvia A, Zoppei S, Van Bortel T, et al, and the ASPEN/INDIGO Study Group. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. Lancet 2013; 381: 55–62—In the ASPEN/INDIGO Study Group, “James Bowa” should have been “Bawo James”. This correction has been made to the online version as of Jan 23, 2015.
www.thelancet.com Vol 385 January 24, 2015