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Emerging diseases and the role of epidemiologists

There have been many threats of a new global epidemic of a disease with a high case fatality. Avian flu is the most recent threat. HIV became much more than a threat and reminded us of the value of a rapid and international research response, openness in reporting and use of mass media to inform the public. The problems associated with getting an infectious epidemic under control grows exponentially with the prevalence of infected and fast action is essential. This action must often involve more than the local region involved since many diseases have no border, whether they are transmitted via birds or humans.

Epidemiologists play a significant role in producing data needed to plan prevention and treatment. It is important the epidemiologists are free to publish these data and share them with others.. Epidemiologist should from their side be willing to share their data with other researchers. The scientific achievements that can be reached by sharing data with others by far overrule any user’s right or ownership principles of data.

Epidemiologists should review the infectious disease epidemiology content in their teaching programs. The 20th century focus upon cancer and cardiovascular epidemiology has perhaps made our skills in 21st century infectious disease epidemiology a bit rusty. In any case it is wise to think about how we may be able to make better predictions and to be better prepared for a possible new pandemic. Use of modern technologies, for example in genetics, and rapid survey of phenotype data may be essential and we need to develop the means of fostering these practical links. Increasingly, collaborations between veterinarian epidemiologists, human epidemiologist, microbiologists, bio-informatics experts and statisticians are essential to both the large and very complex data sources and the new biologically-driven public health policies needed.

Epidemiologists may also need to improve their skills in communication of estimated scenarios. On one hand they should be as honest and well founded as possible and they should avoid causing ungrounded alarm.  Note the difference in content of the headlines reported from the Chief Medical Officer of England’s announcements on 17 October and on 31 October – the first is a “health scare” with 50,000 excess deaths, and the second is a much more measured positive message emphasising the steps that will be taken (see Box).  Inevitably, it is possible that some epidemiologists will see colluding with a health scare as a means of increasing funding for their own research area.  This is unacceptable and does not follow good epidemiological practice. External agencies, such as the IEA and WHO, are in a good position to determine what is necessary to provide support for the facilities and manpower needed to deal with the possible national health problems.

Epidemiologists in some countries may well find themselves in the position of being the only public health personnel to fight an epidemic. They may find themselves having to tell the public that shortages of treatment, diagnostic tools or vaccines will result in rationing to those in greatest need at the start of an epidemic. In such cases, epidemiologists need to draw strength from each other and not work in isolation.  Clearly, it is unacceptable if resources to combat a global pandemic of flu are not available because wealthy countries have stockpiled supplies of vaccines and anti-viral drugs for their own protection. Our individualized rights, advocated by ethics committees over the years, must in these cases of mass diseases, rest for the principles of the common good.

The IEA will continue to develop a set of Good Epidemiology Guidelines to support our colleagues over the world that will attempt to provide consensus advice on how to act when under the political pressures of rationing scarce resources, and unwillingness of governments to disclose findings of public health importance but of adverse political consequence.  If you have views on the comments raised by IEA council, please add them to this web discussion.  The discourse will be of great value to us all.

Box: What is reported in the media about avian flu

Medical Officers on the Avian flu problem

So the estimate we are working to in the number of deaths is around 50,000 excess deaths from flu. But it could be a lot higher than that – it very much depends whether this mutated strain is a mild one or more serious.” Chief Medical Officer, England, 17 Oct 2005, http://news.scotsman.com/index.cfm?id=2099572005

“Planning to combat pandemic flu is our number one priority. We regard pandemic flu as public health enemy number one and we are on the march against it. With good planning and preparation we can reduce the impact of pandemic flu on the health of our population.” Chief Medical Officer, England, 29 Oct 2005, http://www.medicalnewstoday.com/medicalnews.php?newsid=32534

“One in four could get sick with pandemic influenza,” said Huston. “It’s something we haven’t seen before and we have no antibodies (to fight it). It’s a very daunting challenge.” Ottawa’s Chief Medical Officer of Health http://ottsun.canoe.ca/News/OttawaAndRegion/2005/10/29/1283452-sun.html

“Australia’s chief medical officer has estimated that the chance of the H5N1 virus becoming a pandemic is one in ten in any one year,” Australian Foreign Minister, 31 Oct 2005, http://www9.sbs.com.au/theworldnews/region.php?id=124241&region=7

The pharmaceutical industry on drug treatments

The stakes of an avian flu outbreak are enormous but so are the potential rewards for some hitherto-obscure drug companies.   “BioCryst expects to ask the Food & Drug Administration sometime in November for permission to start human trials of peramivir. Bennett claims that a single injection of peramivir is equal to five days of twice-daily doses of Tamiflu.” Claude Bennett, BioCryst’s president, chief operating officer and medical director http://www.forbes.com/home/free_forbes/2005/1114/214.html

We have temporarily suspended shipment of Tamiflu there,” said Roche spokesman Alexander Klauser. He stressed that the suspension would not affect the U.S. government’s order for the drug. “We have agreed orders with governments and we will fulfill them,” Klauser said. “It is important that this is seen separately from the pandemic offers.” 27 Oct 2005 http://www.cnn.com/2005/HEALTH/conditions/10/27/roche.tamiflu.ap/?eref=yahoo

MILLENNIUM DEVELOPMENT GOALS

ERADICATE EXTREME POVERTY AND HUNGER
TARGET FOR 2015: Halve the proportion of people living on less that a dollar a day and those who suffer from hunger.
ACHIEVE UNIVERSAL PRIMARY EDUCATION
TARGET FOR 2015: Ensure that all boys and girls complete primary school.
PROMOTE GENDER EQUALITY AND EMPOWER WOMEN
TARGET FOR 2005 AND 2015: Eliminate gender disparities in primary and secondary education preferably by 2005 and at all levels by 2015.
REDUCE CHILD MORTALITY
TARGET FOR 2015: Reduce by two thirds the mortality rate among children under five.
IMPROVE MATERNAL HEALTH
TARGET FOR 2015: Reduce by three quarters the ratio of women dying in childbirth.
COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES
TARGET FOR 2015: Halt and begin to reverse the spread of HIV/AIDS and the incidence of malaria and other major diseases.
ENSURE ENVIRONMENTAL SUSTAINABILITY
Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources.By 2015, reduce by half the proportion of people without access to safe drinking water.By 2020, achieve significant Improvement in the lives of at least 100 million slum dwellers.
DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENT
Develop further an open trading and financial system that includes a commitment to good governance, development and poverty reduction – nationally and internationally.Address the least developed countries’ special needs, and the special needs of landlocked and small island developing states.Deal comprehensively with developing countries’ debt problemsDevelop decent and productive work for youth.In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.In cooperation with the private sector, make available the benefits of new technologies – especially information and communications technologies. 

Jorn Olsen, Shah Ebrahim, Chitr Sitthi-amorn

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