- Email: [email protected]
Tackling preventable diseases in Yemen
Correspondence
Since Nepal promulgated a new Constitution in September, there has been a blockade at the India–Nepal border at transit points. The blockade is leading to another humanitarian crisis only 6 months after the massive April earthquake. The blockade has consequences on transportation, production, and distribution of medicines, and other essentials, limiting provision of basic health and emergency services, leading to decreased quality of care, and putting patients at risk of increased morbidity and mortality.1 Limited supply of fuels is directly impacting transportation and cold chain of essential vaccines and drugs, putting disease control, elimination, and eradication efforts at risk. Nepal has made substantial progress in health goals such as for maternal and child health, which is now at stake because of limitation on basic and essential services.2 This situation increases the vulnerability of the people, there is a risk of increase of maternal and child mortality, more low birthweight babies, and in the long run decreasing life expectancy. The April earthquakes have damaged many health infrastructures and while the reconstruction has just begun, this blockade is impeding health infrastructure reconstruction.1 There is also a financial cost: for the earthquakes, the loss is estimated at US$7 billion, and the blockade is estimated to cost more than $5 billion.1 Although these are immediate consequences, long-term impact could be expected for Nepal but also for other countries. First, in Nepal, this blockade could lead to catastrophic effects on the economy, putting at risk universal health coverage and health system strengthening.3 www.thelancet.com Vol 386 December 5, 2015
Second, while Nepal has made progress in controlling vaccine preventable diseases due to its immunisation coverage, any challenges on coverage and compromise on quality of vaccination are a threat to elimination of diseases such as polio and measles. 4 This increased the risk of resurgence of polio and threaten the endgame strategy at regional level and global level. This could affect health security globally (emerging and re-emerging diseases). Any haemorrhagic fevers, cholera, or any outbreaks would have catastrophic consequences, not only in Nepal. Nepal has had a number of avian influenza outbreaks in poultry, but not in humans; 5 however, the current situation could lead to an outbreak in humans putting other countries at risk because of decreased response capacity and increased vulnerability of people. Any blockade in this globalised world not only challenges the country “blocked”, but also challenges other countries. I declare no competing interests.
Jaya Lamichhane [email protected] Geneva 1290, Switzerland 1
2
3
4
5
Kathmandupost. Thapa Defends Statute, Calls Blockade Unlawful. http:// kathmandupost.ekantipur.com/ news/2015-11-05/thapa-defends-statutecalls-blockade-unlawful.html (accessed Nov 16, 2015). United Nations. Millennium Development Goals Report 2014. New York: United Nations, 2014. Bossuyt MJ. The Adverse Consequences of Economic Sanctions on the enjoyment of Human Rights. Geneva: United Nations, 2000. Bhattarai MD, Adhikari P, Bhattarai MD, Kane A, Uprety T, Wittet S. Rapid assessment of perceptions, knowledge and practices related to immunization injection safety in Nepal. http://path.org/vaccineresources/ files/Immunization_Injection%20Safety_ in_Nepal.pdf (accessed Nov 16, 2015). Centers for Disease Control and Prevention. Influenza Division International Activities. Fiscal Year 2011 Annual Report. http://www. cdc.gov/flu/international/program/ (accessed Nov 16, 2015).
Tackling preventable diseases in Yemen The health-care system in Yemen has deteriorated since the start of the war in March, 2015. Impairment exists at all levels of health services; from improper function of health-care facilities to a shortage of basic and life-saving needs, such as drugs, water, and fuel. This continuous, unresolved crisis has led to a rise in preventable diseases and other health problems, such as infectious diseases, malnutrition, diarrhoea, and unnecessary organ loss.1,2 According to WHO,3 32 hospitals and 11 polyclinics in Yemen are affected by the continuing war. Of particular importance is the shortage of fuel to run the generators needed for the storage of blood, vaccines, and drugs. According to UNICEF,4 the inability to vaccinate children has put 2·6 million children younger than 15 years at risk of measles. Furthermore, with 1·8 million children at risk of malnutrition, the risk of child death is expected to rise if the health system continues to collapse.4 It is tragic that the shortage of safe water and proper sanitation has led to the reappearance of dengue fever. By Aug 31, 2015, 6320 cases of dengue fever had been reported, with a peak in the weekly number of new cases of 421 cases recorded in the 33rd week of the war. The number of cases of pneumonia, polio, and malaria has also risen.1,3 With the increasing numbers of trauma cases and inadequate transportation for both surgeons and patients to health-care facilities, many patients do not receive the help they need on time and, as a consequence, limb amputations have become more common.2 Efforts to ameliorate the health-care crisis in Yemen should be enhanced. One step would be to establish the health priorities of different governorates (provinces) in conflict in Yemen and act accordingly. The 2014–15 Yemen Humanitarian Response Plan5 should be supported
JTB Photo/Contributor/Getty Images
Health consequences of the blockade in Nepal
See Editorial page 2228
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2251
Correspondence
and implemented to meet the goal of providing 15 million individuals with basic, life-saving needs. WHO received less than 20% of the financial support needed to deal with the crisis in Yemen, leaving a funding gap of 80%.1 Agencies such as WHO and UNICEF should work in collaboration to avoid duplication of efforts and to provide frequent, updated reports to allow for adjustment of existing plans.3,4 We declare no competing interests.
*Abdulhadi A Alamodi, Abdulaziz M Eshaq, Ahmed M Fothan, Abdulrahman M Bakather, Adam S Obad [email protected] University of Mississippi Medical Center, Jackson, MS 39216, USA (AAA); College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia (AME, AMF, AMB, ASO) 1 2
3
4
5
WHO. Health system in Yemen close to collapse. Bull World Health Organ 2015; 93: 670–71. Al-Mujahed A, Naylor H. The Washington Post, May 31, 2015. https://www.washingtonpost. com/world/middle_east/war-in-yemen-ispushing-health-care-facilities-to-the-brink-ofcollapse/2015/05/30/814d298a-0604-11e593f4-f24d4af7f97d_story.html (accessed Oct 7, 2015). WHO. Situation report number 14. Aug 31–Sept 13, 2015. Yemen conflict. http://www.emro.who.int/images/stories/ yemen/Situation_report_Issue.17.9.15.2015. pdf?ua=1&ua=1 (accessed Oct 7, 2015). UNICEF. Yemen: childhood under threat. http:// www.unicef.org/media/files/CHILD_ALERT_ YEMEN-UNICEF_AUG_2015_ENG_FINAL.pdf (accessed Oct 7, 2015). Yemen Humanitarian Country Team. 2014–15 Yemen Humanitarian Response Plan. 2015 Revision. https://www.humanitarianresponse. info/system/files/documents/files/2015%20 Revised%20YHRP_Final1_0.pdf (accessed Oct 8, 2015).
Treating snake bites—a call for partnership We welcome the Editorial (Sept 19, p 1110)1 that highlights the devastating effect of snake bites on health and the fact that Africa could soon be deprived of access to one of the most effective snake bite treatments. Likewise, we appreciate the initiative taken by the Wellcome Trust in organising an event (Sept 22–23, 2015)2 that brought 2252
together key players to identify mechanisms to “reverse the public health neglect of tropical snakebite victims”. But we do not agree with the Editors that snake bites are “largely invisible to WHO”. Antivenoms are highly effective in treating snake bite envenoming and were therefore included in the WHO Essential Medicines List in 2007.3 Also in 2007, WHO convened stakeholders to identify what should be done next; many of their recommendations are still valid. In 2009, WHO published Rabies and envenomings: a neglected public health issue 4 and launched a global database with up-to-date information on venomous snake distribution and species risk categories, available antivenoms, and antivenom producers.5 In 2010, a WHO guideline to support production, control, and regulation of antivenoms (adopted by the WHO Expert Committee on Biological Standardization) was published.6 In brief, WHO developed— consensually—a clear vision on how to move this area of public health forward. An obvious next step would be to include antivenoms in the products invited for WHO prequalification. As shown with fixed-dose combination drugs for HIV/AIDS, WHO prequalification facilitates market penetration and increases the availability of quality-assured health products where they are needed most. The WHO Prequalification Team has considerable experience in working with manufacturers and regulators to get needed products onto the market and maintain supply. The team has worked closely with African regulators to help with assessment of complex products. In the longer term, more advanced products—for example, based on monoclonal antibodies—should be developed, but this will need investment and time. Unfortunately, despite all efforts, we have failed to attract the attention of the donor community and support
for the antivenoms area of work. Nevertheless, we are committed to starting prequalification of priority antivenoms from Dec 1, 2015. We are also ready to partner with all interested organisations to address this public health issue before existing technical capacity is lost and yet more lives are needlessly impaired or lost. We declare no competing interests. © 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Lembit Rägo, Ana M Padilla Marroquin, C Micha Nübling, *Jacqueline Sawyer [email protected] Department of Essential Medicines and Health Products, WHO, CH-1211 Geneva 27, Switzerland (LR, CMN, JS). AMPM is retired. 1 2
3
4
5
6
The Lancet. Snake bite—the neglected tropical disease. Lancet 2015; 386: 1110. Mechanisms to reverse the public health neglect of snakebite victims; Wellcome Trust Genome Campus, Hinxton, Cambridge, UK; Sept 22–23, 2015. WHO. WHO model list of essential medicines. 15th list, March 2007. http://www.who.int/ medicines/publications/essentialmedicines/ en/ (accessed Nov 10, 2015). WHO. Rabies and envonomings: a neglected public health issue. Report of a consultative meeting. Jan 10, 2007. http://www.who.int/ bloodproducts/animal_sera/Rabies.pdf (accessed Sept 20, 2015). WHO. Venomous snakes distribution and species risk categories. http://apps.who.int/ bloodproducts/snakeantivenoms/database/ (accessed Sept 20, 2015). WHO. WHO guidelines for the production, control and regulation of snake antivenom immunoglobulins. http://www.who.int/ bloodproducts/snake_antivenoms/ snakeantivenomguideline.pdf (accessed Sept 20, 2015).
Snake bites and antivenom shortage in Africa The press campaign launched by Doctors Without Borders suggested that discontinuation of Fav-Afrique (Sanofi-Pasteur, Lyon, France), one of the few effective antivenoms used in Africa, would result in countless deaths. 1 The campaign has caused panic in sub-Saharan countries by suggesting that the www.thelancet.com Vol 386 December 5, 2015
Since Nepal promulgated a new Constitution in September, there has been a blockade at the India–Nepal border at transit points. The blockade is leading to another humanitarian crisis only 6 months after the massive April earthquake. The blockade has consequences on transportation, production, and distribution of medicines, and other essentials, limiting provision of basic health and emergency services, leading to decreased quality of care, and putting patients at risk of increased morbidity and mortality.1 Limited supply of fuels is directly impacting transportation and cold chain of essential vaccines and drugs, putting disease control, elimination, and eradication efforts at risk. Nepal has made substantial progress in health goals such as for maternal and child health, which is now at stake because of limitation on basic and essential services.2 This situation increases the vulnerability of the people, there is a risk of increase of maternal and child mortality, more low birthweight babies, and in the long run decreasing life expectancy. The April earthquakes have damaged many health infrastructures and while the reconstruction has just begun, this blockade is impeding health infrastructure reconstruction.1 There is also a financial cost: for the earthquakes, the loss is estimated at US$7 billion, and the blockade is estimated to cost more than $5 billion.1 Although these are immediate consequences, long-term impact could be expected for Nepal but also for other countries. First, in Nepal, this blockade could lead to catastrophic effects on the economy, putting at risk universal health coverage and health system strengthening.3 www.thelancet.com Vol 386 December 5, 2015
Second, while Nepal has made progress in controlling vaccine preventable diseases due to its immunisation coverage, any challenges on coverage and compromise on quality of vaccination are a threat to elimination of diseases such as polio and measles. 4 This increased the risk of resurgence of polio and threaten the endgame strategy at regional level and global level. This could affect health security globally (emerging and re-emerging diseases). Any haemorrhagic fevers, cholera, or any outbreaks would have catastrophic consequences, not only in Nepal. Nepal has had a number of avian influenza outbreaks in poultry, but not in humans; 5 however, the current situation could lead to an outbreak in humans putting other countries at risk because of decreased response capacity and increased vulnerability of people. Any blockade in this globalised world not only challenges the country “blocked”, but also challenges other countries. I declare no competing interests.
Jaya Lamichhane [email protected] Geneva 1290, Switzerland 1
2
3
4
5
Kathmandupost. Thapa Defends Statute, Calls Blockade Unlawful. http:// kathmandupost.ekantipur.com/ news/2015-11-05/thapa-defends-statutecalls-blockade-unlawful.html (accessed Nov 16, 2015). United Nations. Millennium Development Goals Report 2014. New York: United Nations, 2014. Bossuyt MJ. The Adverse Consequences of Economic Sanctions on the enjoyment of Human Rights. Geneva: United Nations, 2000. Bhattarai MD, Adhikari P, Bhattarai MD, Kane A, Uprety T, Wittet S. Rapid assessment of perceptions, knowledge and practices related to immunization injection safety in Nepal. http://path.org/vaccineresources/ files/Immunization_Injection%20Safety_ in_Nepal.pdf (accessed Nov 16, 2015). Centers for Disease Control and Prevention. Influenza Division International Activities. Fiscal Year 2011 Annual Report. http://www. cdc.gov/flu/international/program/ (accessed Nov 16, 2015).
Tackling preventable diseases in Yemen The health-care system in Yemen has deteriorated since the start of the war in March, 2015. Impairment exists at all levels of health services; from improper function of health-care facilities to a shortage of basic and life-saving needs, such as drugs, water, and fuel. This continuous, unresolved crisis has led to a rise in preventable diseases and other health problems, such as infectious diseases, malnutrition, diarrhoea, and unnecessary organ loss.1,2 According to WHO,3 32 hospitals and 11 polyclinics in Yemen are affected by the continuing war. Of particular importance is the shortage of fuel to run the generators needed for the storage of blood, vaccines, and drugs. According to UNICEF,4 the inability to vaccinate children has put 2·6 million children younger than 15 years at risk of measles. Furthermore, with 1·8 million children at risk of malnutrition, the risk of child death is expected to rise if the health system continues to collapse.4 It is tragic that the shortage of safe water and proper sanitation has led to the reappearance of dengue fever. By Aug 31, 2015, 6320 cases of dengue fever had been reported, with a peak in the weekly number of new cases of 421 cases recorded in the 33rd week of the war. The number of cases of pneumonia, polio, and malaria has also risen.1,3 With the increasing numbers of trauma cases and inadequate transportation for both surgeons and patients to health-care facilities, many patients do not receive the help they need on time and, as a consequence, limb amputations have become more common.2 Efforts to ameliorate the health-care crisis in Yemen should be enhanced. One step would be to establish the health priorities of different governorates (provinces) in conflict in Yemen and act accordingly. The 2014–15 Yemen Humanitarian Response Plan5 should be supported
JTB Photo/Contributor/Getty Images
Health consequences of the blockade in Nepal
See Editorial page 2228
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2251
Correspondence
and implemented to meet the goal of providing 15 million individuals with basic, life-saving needs. WHO received less than 20% of the financial support needed to deal with the crisis in Yemen, leaving a funding gap of 80%.1 Agencies such as WHO and UNICEF should work in collaboration to avoid duplication of efforts and to provide frequent, updated reports to allow for adjustment of existing plans.3,4 We declare no competing interests.
*Abdulhadi A Alamodi, Abdulaziz M Eshaq, Ahmed M Fothan, Abdulrahman M Bakather, Adam S Obad [email protected] University of Mississippi Medical Center, Jackson, MS 39216, USA (AAA); College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia (AME, AMF, AMB, ASO) 1 2
3
4
5
WHO. Health system in Yemen close to collapse. Bull World Health Organ 2015; 93: 670–71. Al-Mujahed A, Naylor H. The Washington Post, May 31, 2015. https://www.washingtonpost. com/world/middle_east/war-in-yemen-ispushing-health-care-facilities-to-the-brink-ofcollapse/2015/05/30/814d298a-0604-11e593f4-f24d4af7f97d_story.html (accessed Oct 7, 2015). WHO. Situation report number 14. Aug 31–Sept 13, 2015. Yemen conflict. http://www.emro.who.int/images/stories/ yemen/Situation_report_Issue.17.9.15.2015. pdf?ua=1&ua=1 (accessed Oct 7, 2015). UNICEF. Yemen: childhood under threat. http:// www.unicef.org/media/files/CHILD_ALERT_ YEMEN-UNICEF_AUG_2015_ENG_FINAL.pdf (accessed Oct 7, 2015). Yemen Humanitarian Country Team. 2014–15 Yemen Humanitarian Response Plan. 2015 Revision. https://www.humanitarianresponse. info/system/files/documents/files/2015%20 Revised%20YHRP_Final1_0.pdf (accessed Oct 8, 2015).
Treating snake bites—a call for partnership We welcome the Editorial (Sept 19, p 1110)1 that highlights the devastating effect of snake bites on health and the fact that Africa could soon be deprived of access to one of the most effective snake bite treatments. Likewise, we appreciate the initiative taken by the Wellcome Trust in organising an event (Sept 22–23, 2015)2 that brought 2252
together key players to identify mechanisms to “reverse the public health neglect of tropical snakebite victims”. But we do not agree with the Editors that snake bites are “largely invisible to WHO”. Antivenoms are highly effective in treating snake bite envenoming and were therefore included in the WHO Essential Medicines List in 2007.3 Also in 2007, WHO convened stakeholders to identify what should be done next; many of their recommendations are still valid. In 2009, WHO published Rabies and envenomings: a neglected public health issue 4 and launched a global database with up-to-date information on venomous snake distribution and species risk categories, available antivenoms, and antivenom producers.5 In 2010, a WHO guideline to support production, control, and regulation of antivenoms (adopted by the WHO Expert Committee on Biological Standardization) was published.6 In brief, WHO developed— consensually—a clear vision on how to move this area of public health forward. An obvious next step would be to include antivenoms in the products invited for WHO prequalification. As shown with fixed-dose combination drugs for HIV/AIDS, WHO prequalification facilitates market penetration and increases the availability of quality-assured health products where they are needed most. The WHO Prequalification Team has considerable experience in working with manufacturers and regulators to get needed products onto the market and maintain supply. The team has worked closely with African regulators to help with assessment of complex products. In the longer term, more advanced products—for example, based on monoclonal antibodies—should be developed, but this will need investment and time. Unfortunately, despite all efforts, we have failed to attract the attention of the donor community and support
for the antivenoms area of work. Nevertheless, we are committed to starting prequalification of priority antivenoms from Dec 1, 2015. We are also ready to partner with all interested organisations to address this public health issue before existing technical capacity is lost and yet more lives are needlessly impaired or lost. We declare no competing interests. © 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Lembit Rägo, Ana M Padilla Marroquin, C Micha Nübling, *Jacqueline Sawyer [email protected] Department of Essential Medicines and Health Products, WHO, CH-1211 Geneva 27, Switzerland (LR, CMN, JS). AMPM is retired. 1 2
3
4
5
6
The Lancet. Snake bite—the neglected tropical disease. Lancet 2015; 386: 1110. Mechanisms to reverse the public health neglect of snakebite victims; Wellcome Trust Genome Campus, Hinxton, Cambridge, UK; Sept 22–23, 2015. WHO. WHO model list of essential medicines. 15th list, March 2007. http://www.who.int/ medicines/publications/essentialmedicines/ en/ (accessed Nov 10, 2015). WHO. Rabies and envonomings: a neglected public health issue. Report of a consultative meeting. Jan 10, 2007. http://www.who.int/ bloodproducts/animal_sera/Rabies.pdf (accessed Sept 20, 2015). WHO. Venomous snakes distribution and species risk categories. http://apps.who.int/ bloodproducts/snakeantivenoms/database/ (accessed Sept 20, 2015). WHO. WHO guidelines for the production, control and regulation of snake antivenom immunoglobulins. http://www.who.int/ bloodproducts/snake_antivenoms/ snakeantivenomguideline.pdf (accessed Sept 20, 2015).
Snake bites and antivenom shortage in Africa The press campaign launched by Doctors Without Borders suggested that discontinuation of Fav-Afrique (Sanofi-Pasteur, Lyon, France), one of the few effective antivenoms used in Africa, would result in countless deaths. 1 The campaign has caused panic in sub-Saharan countries by suggesting that the www.thelancet.com Vol 386 December 5, 2015