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The new plagues

By John Bland
A catastrophic convergence of many factors — all too many of them stemming from man’s inhumanity to man — has spawned a crop of malign new diseases and fostered the reappearance of older ones in regions thought to have seen the last of them. What can and is being done?

Despite the powerful arsenal of vaccines and drugs that humanity has developed since World War II, infectious diseases are not only still here to plague us but are alarmingly on the increase. They are proving to be the biggest killers of the vulnerable. The lethal nature of these diseases is being aided and abetted by the continuing erosion of health systems, the spread of antibiotic resistance, disruption caused by warfare, mass movements of people, the added threat of climate change, and above all the yoke of poverty.

Many drugs once regarded as effective and reliable are no longer curing common infections such as tuberculosis, pneumonia, gonorrhoea and otitis. But if our arsenal of drugs against infectious diseases loses its power, the future for huge numbers of sufferers — even those with a banal ear infection — could be bleak.

Consequently, the International Red Cross and Red Crescent Movement’s range of health and medical activities has had to vastly expand to confront these emerging and re-emerging diseases, which threaten rich and poor countries alike.

Health protection has always been a key element of Red Cross and Red Crescent duties and has gradually applied to an increasing number of civilians in war as well as in peace time. Today, health plays an important part in a great variety of National Societies’ activities and embraces first aid, community health care, health education, blood transfusion, nursing, HIV/AIDS prevention and treatment, support for vaccination campaigns and water and sanitation projects.

 

 

 

Back with a vengeance

Diphtheria suddenly showed a dramatic and alarming upsurge in some regions of the former Soviet Union around 1990 and, within four years, had spread to virtually all the newly independent States. At least 90 per cent of all the diphtheria cases reported worldwide during 1990-1995 were in these countries, largely because of the collapse of health services which had previously ensured universal coverage of the population. Dr Hakan Sandbladh, Head of Relief Health at the International Federation of Red Cross and Red Crescent Societies, explains that in 1994 the Movement joined with the World Health Organization (WHO) and the United Nations Children’s Fund in launching an 18-month vaccine programme in Belarus, Ukraine and the Baltic states of Estonia, Latvia and Lithuania. As a result, 38 million people received the diphtheria vaccine; in the Ukraine alone, the Federation delivered 23 million doses in 1995/1996.

The Federation was heavily committed to this effort, providing the mechanism for vaccination sessions, some 40 million doses of vaccine, syringes, the “cold chain” (which ensures that vaccines remain viable all the way from the manufacturer to the patient), and even transport vehicles. Vital health education was offered to ensure that people understood the need for such protection. The net result was that, in those five countries, cases dropped from a peak of 6,059 in 1995 to only 277 in the first five months of 1998. The Federation estimates that 400,000 cases and 10,000 deaths were prevented. Moreover, the countries are now self-sufficient in the production and administration of vaccines.

Lessons learnt from the diphtheria campaign will be crucial in developing an effective strategy for dealing with future health challenges in the former Soviet Union, including the spread of HIV/AIDS. “There was a big spin-off in all this for the National Societies in the region,” says Dr Sandbladh, “because the countries concerned realized that in the Red Cross they had found a national partner. We in turn learnt that there are certain outbreaks that we can readily deal with.”

Similarly, when a serious outbreak of meningitis threatened the Kano area of northern Nigeria in 1996, the Federation sent an emergency response unit, well equipped to provide basic health care, consisting of trained staff members with their own transport and telecommunications equipment. The team quickly trained 50 Nigerian Red Cross teams, each with three or four members. It also undertook health education to teach local residents what symptoms to watch out for and how to prevent and treat this acute bacterial disease, which affects the membranes covering the brain and spinal cord. Within nine weeks the teams vaccinated 2.1 million people and treated 1,000 patients with the medicine chloramphenicol.

Dr Sandbladh points out that, besides the sickness and death that these efforts prevented, the region now has over 150 volunteers who know how to organize such a campaign in case of further need. “We showed the National Society that in an emergency you can have a quick start with only a couple of days’ training.”

What are these diseases?

Emerging infectious diseases are those due to newly identified and previously unknown infections which cause public health problems, either locally or internationally. They include: HIV infection which causes AIDS; new variant Creutzfeldt-Jakob disease, a disease of the central nervous system suspected, though not proven, to be associated with a similar disease in cattle called bovine spongiform encephalopathy; and diseases such as Ebola haemorrhagic fever. Other examples include a new form of cholera, hepatitis C and hepatitis E, Legionnaires’ disease and Lyme disease. Many emerging diseases are thought to be due to the closer contact of man with their reservoirs in nature, triggering a “jump” of the infectious agent from animal to humans across the species barrier.

Re-emerging diseases are those whose prevalence had fallen to levels so low that they were no longer considered a public health problem, but which have now resurfaced at epidemic levels. They include: malaria, whose days appeared to be numbered back in the 1960s, until it bounced back as the parasite developed resistance to antimalarial drugs and the mosquitoes which transmit it became resistant to the insecticide DDT; diphtheria — a new scourge in areas where traditionally sound vaccination services have broken down; tuberculosis — increasing worldwide, due in part to its close association with HIV infection; and cholera, which has resurfaced in countries where it had previously disappeared, its spread encouraged by inadequate and poorly maintained water and sanitation systems.

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.



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