Category Archives: Emergency

PAHO Head Reflects on Zika, Obscurity to Crisis, during 65th ASTMH Keynote

The Following blog from the 65th American Society of Tropical Medicine and Hygiene Annual Meeting opening keynote address has been re-posted here.

20161113_174950From moving quickly to train heads of state in risk communications, to making major decisions based on limited evidence, to sitting with Zika victims whose children had just been diagnosed with microcephaly, the head of the Pan American Health Organization (PAHO) offered a detailed assessment Sunday night of her experience with the sudden explosion of the Zika virus in the Americas.

In her keynote address to a packed hall at opening of ASTMH 2016 Annual Meeting, PAHO Director Dr. Carissa F. Etienne, MBBS, MSc, described the extraordinary experience and lessons learned from encounters with a once-obscure disease that now has been documented in 48 countries and territories in the Americas—and 67 globally.

20161113_180235Dr. Etienne credited “vigilant, astute, front-line health care workers” with first noting the unusual clusters of rash disease in Brazil in late 2014 that turned out to be an early indication that Zika virus had arrived. She noted it was also front-line health workers who first noted the spike in cases of microcephaly and Guillain-Barré Syndrome and connected them to the Zika virus.

Dr. Etienne said their “astute” observations have re-enforced her conviction that, when it comes to protecting the public from infectious disease, there is no substitute for “good clinical judgment and alertness for atypical events.”

Dr. Etienne recalled how quickly the situation escalated and the challenges this presented on a day-to-day basis. For example, heads of state wanted to take charge of discussing the emergency in radio and television appearances. So PAHO moved quickly to provide technical information along with training in risk communications.

There was also the fact that Zika was first discovered while many countries in the Americas were in the middle of preparing for potential Ebola infections and responding to outbreaks of chikungunya. Yet despite this confusing swirl of activity, she said health officials had to move 20161113_180647swiftly to declare Zika an emergency, even though they lacked a complete picture of the true extent of the threat.

“Determination of causality needs to run its course, but PAHO cannot wait until the final verdict of the scientific community,” Dr. Etienne said. “We must be willing to make decisions based on incomplete evidence.”

Dr. Etienne said her experience with the Zika response has reminded her of the many ways infectious diseases take their toll on people, communities and countries. She said Zika has been particularly hard on countries in the Americas that already were suffering economically. And she said it was profoundly moving to spend time with parents whose children have been diagnosed with microcephaly linked to Zika.

“It was quite emotional,” she said. “Here are mothers and fathers loving their child and caring for their child but recognizing that this child’s life will probably be marked by disability.”

Dr. Etienne said that given limitations with diagnostic tests and disease surveillance, the current case count probably underestimates the true magnitude of Zika infections in the Americas. She also believes that “microcephaly is merely the tip of the iceberg” and it will take years to assess the full impact of Zika on children whose mothers were infected with Zika during pregnancy.

Among other things, Dr. Etienne said the experience with the Zika outbreak should prompt a re-thinking “of our approach to reproductive health services.”

“There is still a long way to go with Zika,” she said. “This is not going to be a 100 meter dash. This is a marathon in which science and public health must work hand in hand.”

Malaria, War and Death

In wars in malaria endemic areas, malaria can cause more damage than what occurs on the battlefield. The United States just observed its annual Memorial Day where those who died serving the country are remembered. Wing Beats, the journal of the Florida  Mosquito Associations reported on the status of malaria vectors in the state of Georgia and stressed the damage malaria did during the US Civil War:

  • “From 1861 to1866 malaria was the second most commonly diagnosed ailment – diarrhea/dysentery was first – among Union troops, with over 1.3 million cases. Although sold iers native to the South were much more likely to have experienced malaria growing up, they also suffered deaths and incapacitation that affected the timing and outcome of battles.”

UN PeacekeepingDuring the Korean conflict, “paragonimiasis, malaria, and amoebiasis were the most fatal parasitic diseases during the early 1950s in the Korean Peninsula,” and consequently were responsible for deaths of prisoners of war. The U.S. military received a severe damage during World War II in the Pacific where it was said that “more soldiers were lost by malaria than by battle itself.” The experience led to hundreds of units specialized in controlling malaria in Korea.

In Europe during World War II, people in concentration camps and prisoners of war were used in experiments. “In Dachau Professor Claus Schilling tested synthetic malaria drugs and injected helpless prisoners with high and sometimes lethal doses.” Malaria as a biological warfare agent was demonstrated in Italy where “The German army’s 1943 flooding of the Pontine Marshes south of Rome, which later caused a sharp rise in malaria cases among Italian civilians, has recently been described by historian Frank Snowden as a unique instance of biological warfare and bioterrorism.”

Today malaria continues to produce death in conflict zones. “The area of Walikale in North Kivu, Democratic Republic of Congo, is intensely affected by conflict and population displacement.” The most frequently reported cause of death among the local population was fever/malaria at 34.1% .

During the civil war in Côte d’Ivoire “the availability and use of protective measures against mosquito bites and accessibility to health care infrastructure deteriorated.” A study of resettlement camps of displaced families after the Angolan civil war “Malnutrition was the leading cause of death (34%), followed by fever or malaria (24%) and war or violence (18%).”

Some of the most highly malaria endemic countries in the world still experience conflicts. Malaria kills directly, it can be used as a weapon, and war disrupts efforts to control it. If we are to “end malaria for good,” we might also think about trying to end war and conflict, too.

Hurricanes and Malaria

As deadly Hurricane Sandy has traipsed across the Caribbean and heads for the US East Coast, we think about the equally dangerous aftermath of such tropical storms.  Below are excerpts from articles that examine the devastating effect hurricanes afterwards by increasing malaria and other mosquito-borne diseases.

sandy-14-20121025-203625p_sm-2.gifScientific American reports that so far, “Sandy killed at least 66 people as it made its way through the Caribbean islands, including 51 in Haiti, mostly from flash flooding and mudslides, according to authorities.” If it is like other storms it may also leave disease in its wake.

Kouadio and colleagues stress the need for risk assessment because, “Natural disasters including floods, tsunamis, earthquakes, tropical cyclones (e.g., hurricanes and typhoons) and tornadoes have been secondarily described with the following infectious diseases including diarrheal diseases, acute respiratory infections, malaria, leptospirosis, measles, dengue fever, viral hepatitis, typhoid fever, meningitis, as well as tetanus and cutaneous mucormycosis.”

Immediately after a tropical storm Anopheles species may temporarily decrease, while other disease carrying mosquitoes may increase, but public health officials need to remain on guard. In contrast two mosquito-borne Infections, malaria and West Nile, were found after Hurricane Jeanne in Haiti in 2004. Campanella referred to the challenges for infectious disease surveillance and the reliability of the results under such post-storm conditions as happened after Hurricane Mitch in Nicaragua.

Reliable surveillance and response is crucial as countries, especially in the Americas, move closer to pre-elimination. Natural disasters can not only destabilize control and surveillance operations, but may enhance disease spread.  Emergency preparedness and response should always include a focus on the diseases that storms leave behind.

Malaria in the time of cholera … and other disasters of 2010

2010 is winding up as a year of natural disasters.  The scope of some, like the floods in Pakistan, lead people to ponder the effects of global warming. When the disasters are located in malaria endemic areas, malaria itself may be a second disaster in the making.

There was much talk about the potential epidemics of malaria after the Haiti earthquake – people living unprotected in tent cities as water pooled around these as the rainy season approached and eventually Hurricane Tomas provided a knock-out punch.  CDC documented that malaria transmission was clearly going on in the early post-quake days, but, few reports were coming out during the rainy periods.

Some preventive malaria measures for Haiti, like introduction of larvivorous fish, were reported, but the headlines have been grabbed over the past couple months by a more visibly deadly disease – cholera. Some of the same problems of displacement, poor environmental conditions, including the poor housing situation, have put Haitians at risk for both cholera and malaria, and the end is not in sight.

dscn8908-sm.JPGFloods this year in the African Sahel and Pakistan have also displaced populations and created greater breeding opportunities for mosquitoes thereby, increasing the number of cases among people already adversely affected by the floods. These situations demonstrate the challenges of weak heath systems that find it hard to respond to malaria made weaker or even destroyed by natural disasters. For example IRIN reported that even prior to the floods Pakistan’s national malaria strategy implementation was lagging.

WHO makes it clear that not all disasters that lead to malaria outbreaks are ‘natural’…

Malaria epidemics kill more than 100 000 people of all ages every year and up to 30% of malaria deaths in Africa occur in the wake of war, local violence or other emergencies.

malaria-emergency-who-eng.jpgAn effective emergency response, according to WHO, involves some of the key elements needed to deliver malaria services during normal times: 1) coordination among partners, 2) accurate and timely assessment, 3) planning, 4) implementation and 5) monitoring and evaluation. The difference in an emergency is the timescale. The health systems concerns here are that if these steps have not been taken in ‘normal’ times, the impact of malaria in an emergency will be harder on the population.

Efforts to strengthen health systems therefore, should have a beneficial impact in the event of emergencies – if trained staff are in deployed, procurement and supply chains deliver commodities and feedback mechanisms are in place to enhance future planning, people may have a better chance of surviving from malaria during the next disaster

Haiti – will malaria be added to all the problems?

According to the WHO’s Weekly Epidemiological Record (2008), “Hispaniola is the only Caribbean island where malaria persists” in endemic form.  From that base, “Hispaniola has been the source of outbreaks of Plasmodium falciparum malaria in the Bahamas and Jamaica.” Current estimates from WHO are for “eliminating … malaria from
Hispaniola by 2016–2017.”

haiti-damage-un-photo.jpgWhat are the implications for malaria transmission from the horrendous earthquake that has devastated the Port au Prince area?

Randall and Tirrell report that, “SURVIVORS of the Haiti earthquake face deadly outbreaks of diarrhoea, measles and malaria after the country’s already fragile water and health systems were destroyed.” The destruction of general as well as health infrastructure and the loss of life in the health workforce will have long term consequences in the ability of the country to respond to infectious diseases now and for a long time to come.

According to the Global Fund, “The current malaria situation is not well known in the country because of the inexistence, since 1988, of a structured and operational control program at both the central and peripheral levels. Still malaria has long been documented in Haiti as a significant public health problem. Haiti is the only island in the Caribbean region (Hispaniola – Dominican Republic and Haiti) where malaria is endemic.”

In addition, The World Malaria Report 2009, states that, “As of 2008, French Guiana, Guatemala and Haiti were the only countries yet to adopt the policy of using ACT for treatment of P. falciparum malaria.” The WMR also documents that half of Haiti’s population is at high risk from malaria and the remainder at low risk.

Prior to the catastrophe Haiti’s Round 3 Global Fund project was reportedly on track in terms of malaria treatment and bednet distribution, although chloroquine is listed as the treatment drug. Health and Management Information Systems including surveillance activities were still in need of strengthening.

Researchers from the US Centers for Disease Control and Prevention have shown highly “focal and seasonal distribution of malaria in Haiti,” with rural areas and rainy season periods producing more of the disease. Sub-Urban areas are increasingly at risk. For example, “Historically, malaria transmission peaks in November, December, or January in central Haiti.”

We can conclude that those right in the densely populated (and heavily damaged) parts of Port au Prince may not be at immediate risk from malaria, but as people move out from the city center to seek shelter and services, more people will be susceptible.

Haiti has yet to receive its Round 8 Global Fund money and the Round 3 grant is basically finished. We hope that donors trying to provide aid in this emergency will not forget to bring malaria drugs and insecticide-treated nets.