The new plagues

Containing an outbreak

Ebola haemorrhagic fever made itself all too evident in 1995 in Kikwit, in the Democratic Republic of the Congo, formerly Zaire, and there were 276 deaths before this highly contagious infection was brought under control. The Federation reacted promptly, sending a team of expert doctors down to the area, where they joined forces with teams from the local Red Cross. The U.S. Center for Disease Control and Prevention, WHO, Médecins Sans Frontières and many others were involved. Later, two doctors from the National Society were sent to another African country, Gabon, to advise its government on how to react quickly to contain such an outbreak. In such operations, the Movement does not regard itself as being “on standby” to prevent potential epidemics; its role is rather to create a “module” of essential control actions to take, thus creating a pattern for a given country’s health and other services to follow and adapt to circumstances.

Last December, when a mysterious illness broke out in north-eastern Kenya and southern Somalia, causing large numbers of unexplained deaths, a Red Cross team moved quickly to investigate. People living in a wide area which had been badly hit by flooding were falling ill with acute fever and headache, followed by bleeding and vomiting — similar symptoms in fact to Ebola fever. At the same time, local health authorities reported high cases of spontaneous abortion and deaths from haemorrhaging among domestic animals. Diagnostic testing proved it to be Rift Valley fever (RVF), caused by a virus identified in Kenya in 1930.

Samples taken from humans, farm animals and insects led an international team of scientists to conclude that contact with livestock, including herding, milking, slaughtering and sheltering animals in the home, was statistically associated with acute RVF infection. The floods had encouraged the rapid breeding of certain mosquito species which harbour and transmit the virus to both animals and humans. By early February this year, the outbreak had claimed some 400 lives in Kenya and 80 in Somalia. Livestock owners lost as many as 70 per cent of their herds — a financial catastrophe for poor farmers.

Dr Ray Arthur, of WHO’s Division of Emerging and other Communicable Diseases Surveillance and Control (EMC), comments: “The Movement was among the first on the scene. They took responsibility for collecting samples and for providing care for patients, and then they created a database listing all known cases.” The massive international effort succeeded in containing this ugly disease, which had shown every potential for spreading out of control.

Another member of WHO’s EMC unit, Dr Michel Thuriaux, points out that the Kenyan Red Cross provided the international investigative teams with valuable logistical and technical assistance and with essential local contacts and knowledge.

He describes the Movement as a whole as “a strong ally of WHO, both through its international and trans-border role and through the activities of National Societies at the country level.”

Prevention at the source

Malaria is a scourge whose days had appeared to be numbered back in the 1960s. But it bounced back as the parasite developed resistance to antimalarial drugs and the mosquitoes which transmit it became resistant to the insecticide DDT. It is still steadily advancing in areas from which it had long vanished and, with climate change, is menacing upland districts which had previously been too cold for mosquitoes.

Dr Gro Harlem Brundtland, the new Director-General of WHO, said on being elected at the World Health Assembly in May: “Malaria is the single largest disease in Africa and a primary cause of poverty. Every day 3,000 children die from malaria. Every year there are 500 million cases among children and adults. Who said that infectious diseases were becoming yesterday’s problem? The time has come to respond with a new approach. The time has come to Roll Back Malaria.”

No effective vaccine has yet been developed against a human parasite, so the challenge to find a solution to malaria is formidable. The aim is to develop a vaccine that can be used alongside other malaria control activities, such as early diagnosis and antimalaria drug therapy, use of drugs to prevent malaria, and personal protection measures such as insecticide impregnated bednets. As with HIV/AIDS, scientists are still trying to work out which immune responses in humans are a measure of protection against the malaria parasite.

The Movement is particularly active in promoting environmental measures to curb mosquito populations and persuading people to sleep under bednets. To give only one example: in Azerbaijan, the Southern Camps are home to 34,000 displaced people, who fled the fighting in the Nagorny Karabakh region. The Federation’s water and sanitation teams worked round the clock to drain stagnant water and spray insecticides. Health teams doorstepped in search of undetected cases of malaria. To raise awareness about the disease and how to prevent its spread, Azeri Red Crescent nurses and volunteers distributed thousands of leaflets and colour posters.

Biggest killer of all

“The most ruthless killer of all is poverty,” declares Mr Alireza Mahallati, Director of Community Health and Social Welfare at the Federation. He speaks urgently of the 1.3 billion people living below the poverty line, and of 830 million suffering from chronic malnutrition — two-thirds of them women and children. “Great numbers of people have no amenities at all, no water or sanitation facilities, poor housing, inadequate nutrition. Little wonder that new diseases afflict them and old ones come back to haunt them. So our role in the community is to educate and inform people about how the diseases may attack and how they may be prevented. The Movement is often the whistleblower, giving advance warning of impending epidemics, since early recognition is vital.”

Conditions of poverty and uncontrolled urbanization are particularly conducive to cholera, which figures as both an emerging and a re-emerging disease because it is afflicting regions hitherto free from it as well as returning to areas from which it seemed to have been banished. Its return is also fostered by the breakdown of routine health and hygiene services following conflict or economic collapse.

As part of its operational response in the field of relief, the ICRC repairs war-damaged water installations so as to prevent the spread of epidemics such as cholera. Last year ICRC water and sanitation programmes amounted to 21 million Swiss francs — most of them in Afghanistan, Bosnia and Herzegovina, the Great Lakes region, Iraq and Somalia.

The Federation is a member of the Global Task Force on cholera, and the National Societies play an essential role in training local health workers to follow the standards and treatment protocols developed by WHO. In such countries as Iraq, Rwanda, Tanzania and Uganda, Federation teams of sanitary engineers and technicians are working to prevent its spread among communities which lack good nutrition, basic hygiene and safe drinking water. At the outbreak’s peak in Uganda, the slums of Kampala saw the most rapid spread, with between 100 and 150 new cases each day. The Uganda Red Cross recruited and trained 100 new volunteers and reached an estimated 600,000 people with its public awareness campaigns.

Social upheaval, rapid urbanization, poverty and ignorance contribute to the HIV/AIDS pandemic. Here, educating is a vital means of preventing. Says Mr Mahallati: “There are many developments in the treatment of AIDS, but we don’t have the financial and human resources to enter that field. Instead we concentrate on youth education. In some of the hardest hit areas of the world, such as sub-Saharan Africa, we initiate and advocate ways of improving training techniques to enable the community itself to undertake care of people with AIDS. We are at present expanding this in the direction of community and home care for terminally ill patients.”

TB in prisons: a Petri dish for infection

Tuberculosis is re-emerging worldwide as a lethal pandemic. WHO reports that in 1997 there were over 7 million new cases, and around 3 million individuals died of it, making it the leading infectious killer of adults. It is also the single biggest cause of death in young women, over 900 million of whom are infected; this year, one million will die and 2.5 million new cases will occur among women and girls, mainly between the ages of 15 and 44. The ICRC has, perhaps surprisingly, chosen to tackle this plague in the context of TB in prisons.

The ICRC’s specific experience gathered in prisons and other places of detention while visiting prisoners of war and security detainees give it the expertise vital to the success of this type of programme.

Dr Hernan Reyes, medical coordinator for detention-related activities, explains that prisons — particularly in countries where health services have become dilapidated — are breeding grounds for this infection. “In prisons, risky behaviour might get you AIDS. But to get TB you only need to breathe. Cells are badly ventilated, full of tobacco smoke, and people spend every day in close contact with each other.” Comparing the realities of prison life to the shallow dish used in laboratories for cultivating micro-organisms, he said:

“A prison becomes a Petri dish for catching TB.” The warders themselves are at risk, and in turn may infect their own families outside the jail. There is an added threat if drug-resistant bacilli emerge in the prison environment.

In some countries, TB amounts to an added punishment for prisoners, even a death sentence. The ICRC has therefore been working with National Societies in several parts of the former Soviet Union, including Armenia, Azerbaijan and Georgia, but also in Ethiopia and Peru, to undertake sputum tests and to ensure that treatment drugs for TB reach the prisons — and the prisoners! For there are special problems here. Any drug in prison is an asset for barter; prisoners use tricks and diversions to avoid swallowing the drugs, since they can trade them for other goods, especially since one drug of choice, rifampicin, is also used to treat gonorrhoea. There may even be a traffic in sputum, to get prisoners out of their cells and into a hospital bed.

Here more than anywhere else the WHO-recommended DOTS strategy (directly observed treatment short course) is essential, and can achieve high cure rates in any country that is determined to make it succeed. “But the treatment and cure only work when there are no defaulters,” says Dr Reyes. ”We work hand-in-hand with national TB programmes. We believe you must not start a TB programme without a lab to check sputum samples. In some cases we had to bring in our own lab technicians as the nationals working in prisons were put under pressure from some prisoners — I mean threatened — to find bacilli where there were none.” He added: “Another of our rules is: if you can’t do a programme properly, don’t start it; unfinished cures mean more drug-resistant bacilli going into the community.” In Ethiopia the Red Cross stopped its programme, as it proved impossible to observe prisoners for the whole period of treatment, which should last a minimum of six months.

His colleague, Dr Rudi Coninx, medical coordinator for training, said that in Azerbaijan there were 50 to 100 times more deaths from TB in prison than outside; one in four prisoners had been dying from it because treatment and care had become chaotic over the years. Some countries do not even report TB cases in jail in the national statistics, so nobody knows the real scale of the problem. He commented: “If you don’t deal with the problem of TB in prisons, it becomes a national problem.” As a result of the knowledge and experience it has gained in different countries, the ICRC is currently writing a manual on the treatment of TB in prisons, in collaboration with WHO.

What of the future?

Since the eradication of smallpox in 1980, the list of diseases that can be eliminated is short: polio, guinea-worm, leprosy, neonatal tetanus, measles, onchocerciasis (river blindness), lymphatic filariasis and Chagas disease. Those diseases which continue to plague humanity, whether they are “old” or “new,” will certainly challenge the ingenuity of medical science far into the 21st century. Perhaps the best that can be hoped for is to keep the worst of these epidemic diseases in check.

The new plagues pose challenges to medicine and the pharmaceutical industry. The development of viable vaccines is a long, slow process but research is eagerly seeking solutions. The e-coli bacteria (ETEC), for instance, is blamed for anything between 300,000 and 700,000 deaths a year among children under five, and is the most common cause of diarrhoea in developing countries. A promising vaccine is now under development in Sweden — an oral recombinant vaccine based on antigens that prevent the bacteria from attaching to the intestines. Trials are under way in Bangladesh, Egypt and Peru.

Even more urgent is the quest for a vaccine against HIV/AIDS, but the ability of the virus to disable the human immune system has so far confounded efforts to develop an effective drug or vaccine. Another drawback is that no one has yet established which immune responses, if any, are a measure of protection against HIV. According to WHO, “Without this crucial information, clinical studies of candidate vaccines could take years.”

On a more positive note, new vaccines are currently being developed against more than 60 different diseases. Until recently, only the most visionary researcher would have considered some of these diseases to be vaccine-preventable.

Dr Joshua Lederberg, who was awarded the Nobel Prize in physiology and medicine in 1958, once presciently warned: “The microbe that felled one child in a distant continent yesterday can reach yours today and seed a global pandemic tomorrow.” His warning has never been more appropriate than at the end of the present millennium.

John Bland
John Bland was formerly Editor-in-Chief of WHO’s World Health magazine and is now a consultant with WHO’s Action Programme for the Elimination of Leprosy.