Topic: COMMUNITY INTEREST
By Tammy Duffy
How Can Global Epidemics Get Started?
Of the roughly 400 emerging infectious diseases that have been identified since 1940, more than 60% are zoonotic, ie they came from animals. Throughout history this has been common. HIV originated in monkeys, ebola in bats, influenza in pigs and birds. The rate at which new pathogens are emerging is on the rise, even taking into account the increase in awareness and surveillance. Which pathogens will cross the species barrier next, and which one is the greatest potential public health concern, is a subject of intense interest. A modern outbreak, caused by a previously unknown virus, could travel at jet-speed around the world, spreading across the continents in just a few days, causing illness, panic and death.
Pathogens have transferred from animals to people for as long as we have had contact. The ancient domestication of livestock led to the emergence of measles, and further intensification of farming in recent decades has caused problems such as the brain-wasting Creutzfeldt-Jakob disease, the human form of BSE. Expanding trade routes in the 14th century spread the rat-borne Black Death across Europe and smallpox to the Americas in the 16th century. Today's tightly connected world has seen the spread of swine flu, Sars, West Nile virus and H5N1 bird flu.
The biggest pandemic on record was the 1918 Spanish influenza, which killed 50 million people at a time when the fastest way to travel the globe was by ship. In 2009 swine flu was the most recent pandemic that got public health officials concerned; first detected in April of that year in Mexico, it turned up in London within a week.
The 2014-2015 Ebola outbreak that killed over 11,000 people was an unprecedented epidemic tragedy. As countries pick up the pieces, a central truth emerges -- that external solutions did not match local needs. A virus does not strike in an organized, top-down fashion -- the health response cannot function this way either. As UNICEF said, “the battle against Ebola ...will be won at the heart of the community”. Epidemics strike the community first. And the community must be the first to stop them.
Treating the health system like building blocks we can place at will is a mistake. In real life, and in real time, people are what make up the health system. Effective epidemic preparedness and response must include community members in both planning and action.
Outbreak interventions came largely from external leaders with one-directional ideas. As these initiatives disseminated, they failed at the community level. Why did this happen?
Ebola spread because responders treated communities like objects. Official interventions were tainted with disregard for traditional culture and lack of empathy. Locals were not treated as the free agents they are, with individual values and behaviours.
Over the last 60 years international tourist arrivals increased from 25.3million in 1950 to 1,035 million in 2012. Changes in travel patterns include a continuing trend for visiting remote destinations and for longer stays.
Many people are unaware that exotic destinations include potential exposure to infections that are rare in their home environment and other infections such as malaria that they have never encountered previously. The resurgence of malaria in many parts of the world, with an increasing pattern of drug resistance, has led to an increase in the number of cases presenting in non-endemic areas/endemic areas. The emergence of new infections such as SARS, pandemic influenza H1N1 and the spread of dengue fever, chikungunya and West Nile Virus place an increasing responsibility on doctors to remain up-to-date with current practice.
Responsibilities that traveler's need to accept before travel include:
Regulations regarding entry requirements such as the need for yellow fever certificates can be obtained from organizations such as WHO. All travelers (domestic and international) should be up to date with routine vaccinations. A pre-travel consultation should address what vaccines are recommended, their potential side-effects and their suitability for each traveler. Knowledge of relative risks in particular destinations is essential, as is an assessment of the patient’s overall medical health and current medications. Advice for those with pre-existing chronic illness should be included. Patients who are very young, those who are pregnant and the elderly warrant special consideration.
During the planning of my recent trip to Africa, I went to the CDC website to see what vaccines I needed for traveling. I also went to my family doctor to get a consultation and the vaccines. The Yellow fever vaccine had to be administered by an infectious disease specialist.
South Africa states that they strictly enforce entry and exit requirements and other immigration laws. Failure to observe these requirements may result in the traveler being denied entry, detained, deported, and/or deemed inadmissible to enter South Africa in the future.
United States citizen visitors to South Africa for stays of up to 90 days for tourism, short business meetings, or in transit do not require visas in advance. A visitor visas will be issued at the port of entry in South Africa. If you travel to South Africa for any other purpose (e.g. employment or study) you must obtain a visa in advance. According to the CDC in order to obtain this visa, at the airport (which US citizens must pay $100 cash, circa 2003 bill issue), visitors must show proof of all vaccinations.
Travelers entering South Africa from WHO-designated countries with risk of yellow fever virus (YFV) transmission must present their current and valid International Certificate of Vaccination as approved by the World Health Organization (WHO) ( “yellow card”). No exceptions.
Here is the reality. During my trip to Africa this past week to climb Mt Kilimanjaro, it was clear the "strict enforcement" of proof of vaccination is not being followed. An entire plane of people were not asked for their proof of vaccination to obtain a Visa to enter the country. We all got a Visa, no questions asked. This is exactly how global epidemics can happen.
In July, there was a vicious attack at the Ataturk, Istanbul airport. For my trip I had to fly through Turkey to get to Kilimanjaro. Upon landing we were sent down a open hallway filled with people. People were stepping over the barriers to get to where they needed. In order to get on my next flight I just walked to the next plane. There was no passport check. Nothing. I thought this was crazy. We were all sent down this crowded hall where people were coming and going. No one was questioned about anything, no paperwork or passports checked.
My next stop would be Kilimanjaro airport. It was there I purchased my Visa for $100 USD, with a newer bill stamped 2003 or greater. Evidently from what I learned from locals about the importance of the 2003 date, is because the government views older bills as less valuable. If you give someone a tip in USD in these countries with a bill that is older than 2003, when they go to cash it in, it's value will be decreased by half.
The line at Killimonjaro airport was very long for the visa purchase. The Visa's were given out and not one person was asked to show proof of any vaccines. Not one. I found this very odd. I had all my vaccines and paperwork, but clearly this goes against the "strict enforcement" of the African government. I left the airport to commence my holiday.
The second part of my holiday included a trip to Zanzibar. When you enter the airport there is a huge sign warning visitors about yellow fever. Yet, again my vaccine paperwork was never asked for. There was a long line to get a Visa at this airport as well. Being I already had my Visa a asked a random policeman what was my next step. She asked to see my Visa. I showed it to her. Again, no asking for my proof of vaccines. She told me to go to baggage claim.
My 5 return legs of flight to the USA also found no check as it pertained to my vaccines. Everyone is assuming that the "other guy" checked it because I had a visa. They were handing out Visa's like candy at Halloween.
For epidemic prevention to succeed, communities must be actively engaged, not just issue orders. Humanitarian response means working with people, not handing our Visa's like $100 candy bars. Everyone is responsible for global health.
We had better learn from history before the next outbreak hits. Countries must be more vigilant in the strict enforcement of document reviews within countries.
