- Email: [email protected]
Human schistosomiasis: an emerging threat for Europe
Correspondence
1 2
3
4
Silver KL, Singer PA. A focus on child development. Science 2014; 345: 121. Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet 2014; published online June 17. http://dx.doi.org/10.1016/S01406736(14)60455-4. Walker SP, Chang SM, Powell CA, Grantham-McGregor SM. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. Lancet 2005; 366: 1804–07. Gertler P, Heckman J, Pinto R, et al. Labor market returns to an early childhood stimulation intervention in Jamaica. Science 2014; 344: 998–1001.
Global health and the media We commend Pamela Das and Gabriela Sotomayor for shining a light on WHO and its recent handling of communications at the 67th World Health Assembly (June 21, p 2102).1 What this article also touches on is the role of the media and global health more broadly. Health advocates already struggle to make core public health issues headline news and at the forefront of people’s minds. With a record-breaking number of agenda items, World Health Assembly briefings with the media should have been proportionate to new developments and changes being made to communicate these effectively and appropriately. The media have a responsibility to communicate with the public responsibly. And health advocates have a responsibility to communicate stories with the media. History has shown that when they do, positive change might be stimulated—as seen with HIV and enhanced access to antiretrovirals. The media is a powerful force for good and WHO needs to prioritise these relationships. Neglect the media and the issues are overlooked. A report2 by independent think tank Chatham House on governance and 1094
WHO suggests the complexity of WHO as an organisation. With reform on the agenda, media and communication necessitate a central role. Article 2 of the WHO constitution, about the functions of the organisation, emphasises the need “to provide information, counsel and assistance in the field of health”,3 which is clearly essential “to assist in developing an informed public opinion among all peoples on matters of health”3 and needs partnership with the media to achieve that goal. Systems need to be in place to respond to questions and points of clarification by those tasked with spreading new ideas and developments—otherwise an absence of clarity will lead to no dissemination. Twitter and Facebook posts cannot substitute briefings with the press. We urge WHO to respond in time for the 68th World Health Assembly. We declare no competing interests.
*Joseph R Fitchett, Lalitha Bhagavatheeswaran joseph@filminitiative.org Department of Infectious Diseases, King’s College London, London WC2R 2LS, UK (JRF); Global Health Film initiative, Royal Society of Medicine, London, UK (JRF, LB); and Department of Global Health, London, UK (LB) 1
2
3
Das P, Sotomayor G. WHO and the media: a major impediment to global health? Lancet 2014; 383: 2102–04. Clift C. What’s the World Health Organization for? Final Report from the Centre on Global Health Security Working Group on Health Governance. 2014. http://www.chathamhouse. org/sites/files/chathamhouse/field/field_docu ment/20140521WHOHealthGovernanceClift. pdf (accessed June 30, 2014). WHO. Constitution of the World Health Organization. 2005. http://apps.who.int/gb/ bd/PDF/bd47/EN/constitution-en.pdf (accessed June 30, 2014).
Human schistosomiasis: an emerging threat for Europe In their Seminar, Daniel Colley and colleagues (June 28, p 2253)1 described the epidemiology of human schistosomiasis, but it is important
to acknowledge that schistosomiasis is now becoming a European disease. The Mediterranean area is a former settlement of Bulinus and climate warming creates favourable conditions for local transmission in southern Europe. The emergence of urinary schistosomiasis in Corsica (France), with a decade of native cases around Europe, might mean that schistosomiasis is now a cause for concern in Europe.2,3 Also, many travellers (migrants or tourists) come back from endemic areas after being contaminated through contact with water. Among travellers, the European armed forces have many cases of schistosomiasis because of their deployments in Africa (especially Côte d’Ivoire, Mali, and Central African Republic).4 Clinical examination has low sensibility and specificity (one of three people are asymptomatic).1,4,5 European physicians have to manage this new situation. Medical education enhancement would improve their clinical sensibility. Nowadays, unexplained chronic urinary or digestive symptoms should evoke suspicion of schistosomiasis. Biological screening should be systematically done in these patients and in travellers with water contact in endemic countries, whatever their symptomatology. Finally, epidemiological surveillance should permit the detection of clusters around cases and monitor the spread of the local transmission. We declare no competing interests.
*Franck de Laval, Hélène Savini, Elodie Biance-Valero, Fabrice Simon [email protected] French Military Center for Epidemiology and Public Health, CESPA, Camp de Sainte Marthe, 13014 Marseille, France (FdV); Department of Infectious Diseases and Tropical Medicine, Laveran Military Teaching Hospital, Marseille, France (HS, FS); and Department of Biology, Robert Picqué Military Teaching Hospital, Bordeaux, France (EB-V) 1
2
Colley DG, Bustinduy AL, Secor WE, King CH. Human schistosomiasis. Lancet 2014; 383: 2253–64. ProMED-mail. Schistosomiasis—France: (Corsica). Archive Number 20140518.2480187. 2014. http://www.promedmail.org (accessed Sept 3, 2014).
www.thelancet.com Vol 384 September 20, 2014
Correspondence
and drugs of the previous century. We need a shift for tuberculosis: the one most important ingredient of a new paradigm is not biomedical or social, it is urgency.
Calling tuberculosis a social disease—an excuse for complacency?
[email protected]
In the June 28 issue of The Lancet, Ali Mohsin re-discussed the paradigm of tuberculosis as a social disease.1 The social element of tuberculosis is certainly important because there is strong evidence that tuberculosis does flourish in poverty, but this has several pitfalls. First, reservation of an exceptional social disease status for tuberculosis might, paradoxically, be detrimental, especially if the designation social suggests that poverty eradication is necessary to eliminate tuberculosis. Second, a paucity of studies show that social interventions have an effect on tuberculosis transmission and incidence.2 Third, associating tuberculosis with poverty is a driver of stigma in communities.3 Is HIV any less social than tuberculosis? The HIV pandemic has taught us that with political will, adequate funding, community mobilisation, and scientific resources, the huge barriers of poverty and social deprivation can be overcome. On the contrary, given the dismal success of eliminating tuberculosis, perhaps the biomedical community has used the social paradigm as an excuse to underperform. The emergence of drug-resistant tuberculosis is iatrogenic and suggests that the current biomedical and public health approaches for tuberculosis are failing. The time has come to use the successful HIV recipe (political will, money, activism, and brains) for tuberculosis. We have had enough of using the paradigms, diagnostics,
1
4
5
www.thelancet.com Vol 384 September 20, 2014
We declare no competing interests.
*Petros Isaakidis, Stella Smith, Suman Majumdar, Jennifer Furin, Tony Reid Médecins Sans Frontières, Mumbai 400 052, India (PI, SS); Burnet Institute, Melbourne, VIC, Australia (SM); Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA (JF); and Médecins Sans Frontières, Luxembourg City, Luxembourg (TR)
2
3
Ali M. Treating tuberculosis as a social disease. Lancet 2014; 383: 2195. Bhargava A, Pai M, Bhargava M, Marais BJ, Menzies D. Can social interventions prevent tuberculosis?: the Papworth experiment (1918–1943) revisited. Am J Respir Crit Care Med 2012; 186: 442–49. Kielstra P. Ancient enemy, modern imperative. A time for greater action against tuberculosis. 2014. http://www.economistinsights.com/sites/ default/files/Ancient%20enemy%20modern%20 imperative.pdf (accessed July 8, 2014).
Cardiovascular outcome trials of glucose-lowering strategies in type 2 diabetes We agree with Rury Holman and colleagues (June 07, p 2008)1 that prospective cardiovascular outcome studies of glucose-lowering drugs cannot solve the problem of how to help patients and clinicians make decisions. We support the authors’ proposal for exploitation of electronic health records to do large, low-cost, pragmatic randomised trials measuring real-world outcomes.2 These trials should be the standard for all newly licensed drugs. These trials, however, will permit assessment of only previously licensed drugs. We have published an analysis, 3 which suggests the need to rethink the criteria for approval, registration, and clinical use of new drugs. Even with optimistic assumptions, including cardiovascular benefit, we have
estimated that more than 90% of people started on such treatment will not benefit. A 1% reduction in HbA1c would add only about 10 months of quality-adjusted life for a 45 year old and 6 weeks for a 75 year old. But such gains would be completely eliminated by any treatment deemed, by the patient, to reduce the quality of life by more than 3%, a figure below that generally cited for injectable drugs. On this basis, even a drug for diabetes that improves cardiovascular outcomes might be a poor choice for many patients. These measures of likely health gains matter because such treatments, although potentially providing benefit in aggregate outcomes, are being used for individual benefit. The patient should be the one who makes choices about treatment once they are fully informed of potential benefits, burdens, and harms. When these factors are closely balanced, and when patients vary in the weight they give to different factors, good quality information that is clearly communicated becomes particularly important. Data about glucose lowering falls far short of what licensing and regulatory bodies, clinicians, and patients need from new drugs for diabetes.
A Dowsett, Public Health England/Science Photo Library
Holtfreter M, Mone H, Muller-Stover I, Mouahid G, Richter J. Schistosoma haematobium infections acquired in Corsica, France, Aug 2013. Euro Surveill 2014; 19: 208–21. Soentjens P, Clerinx J, Aerssens A, Cnops L, Van Esbroeck M, Bottieau E. Diagnosing acute schistosomiasis. Clin Infect Dis 2014; 58: 304–05. Meltzer E, Schwartz E. Schistosomiasis: current epidemiology and management in travelers. Curr Infect Dis Rep 2013; 15: 211–15.
3
We declare no competing interests.
*John S Yudkin, Sandeep Vijan, Jeremy B Sussman, Richard Lehman, Ben M Goldacre [email protected] Division of Medicine, University College, London WC1E 6BT, UK (JSY); Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA (SV, JBS); Department of Primary Health Care, University of Oxford, Oxford, UK (RL); and London School of Hygiene & Tropical Medicine, London, UK (BMG) 1
2
3
Holman RR, Sourij H, Califf RM. Cardiovascular outcome trials of glucose-lowering drugs or strategies in type 2 diabetes. Lancet 2014; 383: 2008–17. Staa TP, Goldacre B, Gulliford M, et al. Pragmatic randomised trials using routine electronic health records: putting them to the test. BMJ 2012; 344: e55. Vijan S, Sussman JB, Yudkin JS, Hayward RA. The effect of patients’ risks and preferences on health gains with glucose lowering in type 2 diabetes. JAMA Internal Med 2014; 174: 1227–34.
1095
1 2
3
4
Silver KL, Singer PA. A focus on child development. Science 2014; 345: 121. Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet 2014; published online June 17. http://dx.doi.org/10.1016/S01406736(14)60455-4. Walker SP, Chang SM, Powell CA, Grantham-McGregor SM. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. Lancet 2005; 366: 1804–07. Gertler P, Heckman J, Pinto R, et al. Labor market returns to an early childhood stimulation intervention in Jamaica. Science 2014; 344: 998–1001.
Global health and the media We commend Pamela Das and Gabriela Sotomayor for shining a light on WHO and its recent handling of communications at the 67th World Health Assembly (June 21, p 2102).1 What this article also touches on is the role of the media and global health more broadly. Health advocates already struggle to make core public health issues headline news and at the forefront of people’s minds. With a record-breaking number of agenda items, World Health Assembly briefings with the media should have been proportionate to new developments and changes being made to communicate these effectively and appropriately. The media have a responsibility to communicate with the public responsibly. And health advocates have a responsibility to communicate stories with the media. History has shown that when they do, positive change might be stimulated—as seen with HIV and enhanced access to antiretrovirals. The media is a powerful force for good and WHO needs to prioritise these relationships. Neglect the media and the issues are overlooked. A report2 by independent think tank Chatham House on governance and 1094
WHO suggests the complexity of WHO as an organisation. With reform on the agenda, media and communication necessitate a central role. Article 2 of the WHO constitution, about the functions of the organisation, emphasises the need “to provide information, counsel and assistance in the field of health”,3 which is clearly essential “to assist in developing an informed public opinion among all peoples on matters of health”3 and needs partnership with the media to achieve that goal. Systems need to be in place to respond to questions and points of clarification by those tasked with spreading new ideas and developments—otherwise an absence of clarity will lead to no dissemination. Twitter and Facebook posts cannot substitute briefings with the press. We urge WHO to respond in time for the 68th World Health Assembly. We declare no competing interests.
*Joseph R Fitchett, Lalitha Bhagavatheeswaran joseph@filminitiative.org Department of Infectious Diseases, King’s College London, London WC2R 2LS, UK (JRF); Global Health Film initiative, Royal Society of Medicine, London, UK (JRF, LB); and Department of Global Health, London, UK (LB) 1
2
3
Das P, Sotomayor G. WHO and the media: a major impediment to global health? Lancet 2014; 383: 2102–04. Clift C. What’s the World Health Organization for? Final Report from the Centre on Global Health Security Working Group on Health Governance. 2014. http://www.chathamhouse. org/sites/files/chathamhouse/field/field_docu ment/20140521WHOHealthGovernanceClift. pdf (accessed June 30, 2014). WHO. Constitution of the World Health Organization. 2005. http://apps.who.int/gb/ bd/PDF/bd47/EN/constitution-en.pdf (accessed June 30, 2014).
Human schistosomiasis: an emerging threat for Europe In their Seminar, Daniel Colley and colleagues (June 28, p 2253)1 described the epidemiology of human schistosomiasis, but it is important
to acknowledge that schistosomiasis is now becoming a European disease. The Mediterranean area is a former settlement of Bulinus and climate warming creates favourable conditions for local transmission in southern Europe. The emergence of urinary schistosomiasis in Corsica (France), with a decade of native cases around Europe, might mean that schistosomiasis is now a cause for concern in Europe.2,3 Also, many travellers (migrants or tourists) come back from endemic areas after being contaminated through contact with water. Among travellers, the European armed forces have many cases of schistosomiasis because of their deployments in Africa (especially Côte d’Ivoire, Mali, and Central African Republic).4 Clinical examination has low sensibility and specificity (one of three people are asymptomatic).1,4,5 European physicians have to manage this new situation. Medical education enhancement would improve their clinical sensibility. Nowadays, unexplained chronic urinary or digestive symptoms should evoke suspicion of schistosomiasis. Biological screening should be systematically done in these patients and in travellers with water contact in endemic countries, whatever their symptomatology. Finally, epidemiological surveillance should permit the detection of clusters around cases and monitor the spread of the local transmission. We declare no competing interests.
*Franck de Laval, Hélène Savini, Elodie Biance-Valero, Fabrice Simon [email protected] French Military Center for Epidemiology and Public Health, CESPA, Camp de Sainte Marthe, 13014 Marseille, France (FdV); Department of Infectious Diseases and Tropical Medicine, Laveran Military Teaching Hospital, Marseille, France (HS, FS); and Department of Biology, Robert Picqué Military Teaching Hospital, Bordeaux, France (EB-V) 1
2
Colley DG, Bustinduy AL, Secor WE, King CH. Human schistosomiasis. Lancet 2014; 383: 2253–64. ProMED-mail. Schistosomiasis—France: (Corsica). Archive Number 20140518.2480187. 2014. http://www.promedmail.org (accessed Sept 3, 2014).
www.thelancet.com Vol 384 September 20, 2014
Correspondence
and drugs of the previous century. We need a shift for tuberculosis: the one most important ingredient of a new paradigm is not biomedical or social, it is urgency.
Calling tuberculosis a social disease—an excuse for complacency?
[email protected]
In the June 28 issue of The Lancet, Ali Mohsin re-discussed the paradigm of tuberculosis as a social disease.1 The social element of tuberculosis is certainly important because there is strong evidence that tuberculosis does flourish in poverty, but this has several pitfalls. First, reservation of an exceptional social disease status for tuberculosis might, paradoxically, be detrimental, especially if the designation social suggests that poverty eradication is necessary to eliminate tuberculosis. Second, a paucity of studies show that social interventions have an effect on tuberculosis transmission and incidence.2 Third, associating tuberculosis with poverty is a driver of stigma in communities.3 Is HIV any less social than tuberculosis? The HIV pandemic has taught us that with political will, adequate funding, community mobilisation, and scientific resources, the huge barriers of poverty and social deprivation can be overcome. On the contrary, given the dismal success of eliminating tuberculosis, perhaps the biomedical community has used the social paradigm as an excuse to underperform. The emergence of drug-resistant tuberculosis is iatrogenic and suggests that the current biomedical and public health approaches for tuberculosis are failing. The time has come to use the successful HIV recipe (political will, money, activism, and brains) for tuberculosis. We have had enough of using the paradigms, diagnostics,
1
4
5
www.thelancet.com Vol 384 September 20, 2014
We declare no competing interests.
*Petros Isaakidis, Stella Smith, Suman Majumdar, Jennifer Furin, Tony Reid Médecins Sans Frontières, Mumbai 400 052, India (PI, SS); Burnet Institute, Melbourne, VIC, Australia (SM); Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA (JF); and Médecins Sans Frontières, Luxembourg City, Luxembourg (TR)
2
3
Ali M. Treating tuberculosis as a social disease. Lancet 2014; 383: 2195. Bhargava A, Pai M, Bhargava M, Marais BJ, Menzies D. Can social interventions prevent tuberculosis?: the Papworth experiment (1918–1943) revisited. Am J Respir Crit Care Med 2012; 186: 442–49. Kielstra P. Ancient enemy, modern imperative. A time for greater action against tuberculosis. 2014. http://www.economistinsights.com/sites/ default/files/Ancient%20enemy%20modern%20 imperative.pdf (accessed July 8, 2014).
Cardiovascular outcome trials of glucose-lowering strategies in type 2 diabetes We agree with Rury Holman and colleagues (June 07, p 2008)1 that prospective cardiovascular outcome studies of glucose-lowering drugs cannot solve the problem of how to help patients and clinicians make decisions. We support the authors’ proposal for exploitation of electronic health records to do large, low-cost, pragmatic randomised trials measuring real-world outcomes.2 These trials should be the standard for all newly licensed drugs. These trials, however, will permit assessment of only previously licensed drugs. We have published an analysis, 3 which suggests the need to rethink the criteria for approval, registration, and clinical use of new drugs. Even with optimistic assumptions, including cardiovascular benefit, we have
estimated that more than 90% of people started on such treatment will not benefit. A 1% reduction in HbA1c would add only about 10 months of quality-adjusted life for a 45 year old and 6 weeks for a 75 year old. But such gains would be completely eliminated by any treatment deemed, by the patient, to reduce the quality of life by more than 3%, a figure below that generally cited for injectable drugs. On this basis, even a drug for diabetes that improves cardiovascular outcomes might be a poor choice for many patients. These measures of likely health gains matter because such treatments, although potentially providing benefit in aggregate outcomes, are being used for individual benefit. The patient should be the one who makes choices about treatment once they are fully informed of potential benefits, burdens, and harms. When these factors are closely balanced, and when patients vary in the weight they give to different factors, good quality information that is clearly communicated becomes particularly important. Data about glucose lowering falls far short of what licensing and regulatory bodies, clinicians, and patients need from new drugs for diabetes.
A Dowsett, Public Health England/Science Photo Library
Holtfreter M, Mone H, Muller-Stover I, Mouahid G, Richter J. Schistosoma haematobium infections acquired in Corsica, France, Aug 2013. Euro Surveill 2014; 19: 208–21. Soentjens P, Clerinx J, Aerssens A, Cnops L, Van Esbroeck M, Bottieau E. Diagnosing acute schistosomiasis. Clin Infect Dis 2014; 58: 304–05. Meltzer E, Schwartz E. Schistosomiasis: current epidemiology and management in travelers. Curr Infect Dis Rep 2013; 15: 211–15.
3
We declare no competing interests.
*John S Yudkin, Sandeep Vijan, Jeremy B Sussman, Richard Lehman, Ben M Goldacre [email protected] Division of Medicine, University College, London WC1E 6BT, UK (JSY); Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA (SV, JBS); Department of Primary Health Care, University of Oxford, Oxford, UK (RL); and London School of Hygiene & Tropical Medicine, London, UK (BMG) 1
2
3
Holman RR, Sourij H, Califf RM. Cardiovascular outcome trials of glucose-lowering drugs or strategies in type 2 diabetes. Lancet 2014; 383: 2008–17. Staa TP, Goldacre B, Gulliford M, et al. Pragmatic randomised trials using routine electronic health records: putting them to the test. BMJ 2012; 344: e55. Vijan S, Sussman JB, Yudkin JS, Hayward RA. The effect of patients’ risks and preferences on health gains with glucose lowering in type 2 diabetes. JAMA Internal Med 2014; 174: 1227–34.
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