Learning from previous outbreaks of infectious diseases

As the world grapples with the debates and uncertainties of the Covid-19 pandemic, it is useful to go back to two previous outbreaks of infectious diseases in which a virus moved from animal to human beings, which was then followed by human-to-human transmission. These outbreaks were of the Ebola virus in West Africa in 2014-16 and the spread of the H1N1 Swine Flu in a large part of the world in 2009-10.

A very important aspect of the situation in West Africa was that as the health system became exceedingly centred around tackling Ebola, so the mortality rates of other diseases, which could not receive the same attention as before, increased rapidly. This higher mortality from non-Ebola diseases turned out to be more than caused by the Ebola virus.

Hence this entire effort of making the health system too concentrated on Ebola turned out to be highly questionable. This is a lesson worth remembering as many countries are trying to make their already weak health system too highly centred on tackling Covid-19.

Summing up the Ebola experience, the World Health Organization has said in a statement dated 30 March that, “Previous outbreaks have demonstrated that when health systems are overwhelmed, mortality from vaccine-preventable and other treatable conditions can also increase dramatically. During the 2014-15 Ebola outbreak, the increased number of deaths caused by measles, malaria, HIV-AIDS and tuberculosis attributable to health system failures exceeded deaths from Ebola.”

The studies which the WHO has cited to support this view include one authored by JW Elston, C Cartwright, P Ndumbi and J Wright. This 2017 study, titled The Health impact of the 2014-15 Ebola outbreak states, “The impact of the Ebola outbreak was profound and multifaceted. The health system was severely compromised due to overwhelming demand, healthcare workers’ death,resource diversion and closure of health facilities.”

There was an 80% reduction in maternal delivery care in Ebola affected areas. Institutional care for malaria for small children declined by 40%. Reduction in coverage of vaccination was substantial. There was reduction in child protection. Increased morbidity and mortality and reduced life expectancy were reported.

This study also stated that international support was required to rebuild the health system to meet urgent health needs of people.

Another cited study was authored by AS Parpia, ML Ndeffo-Mbah, NS Wenzel and AP Galvani. This study (published in 2016) was called the Effects of Response to 2014-15 Ebola Outbreak on Deaths from Malaria, HIV-AIDS and Tuberculosis, W. Africa. It says, “Response to the 2014-15 Ebola outbreak in West Africa overwhelmed the healthcare systems of Guinea, Liberia and Sierra Leone, reduced access to health services for diagnosis and treatment for the major diseases that are endemic to the region: malaria, HIV/AIDS and tuberculosis.”

This study found that a 50% reduction in access to health care services during the Ebola outbreak exacerbated malaria, HIV-AIDS and tuberculosis mortality rates in significant ways in these three countries.

In another study published in Lancet Infectious Diseases, Mathew Waxman and colleagues reported an overall high mortality (8.1%) in patients without Ebola Virus Disease admitted to three Ebola Treatment Units.

In a comment on this study Robert Colebunders and his colleagues responded that their research also revealed a high mortality (6.4%) in non Ebola patients in an Ebola Treatment Unit in Guinea. They pointed out that several bottlenecks were responsible for high mortality associated with non-Ebola patients within Ebola treatment units. A lot of time was taken here before their non-Ebola status was confirmed by tests and they had to remain here for longer than appropriate time without receiving the required treatment for their actual disease or ailment. At the same time due to the overwhelming of the overall health system during the Ebola outbreak several non-Ebola health facilities where non-Ebola patients could be transferred had closed down.

Colebunders and colleagues recommended, (writing in Lancet Infectious Diseases), “As part of outbreak preparedness, measures are required to ensure that non-Ebola referral hospitals maintain capacity to appropriately manage seriously ill patients , including non-Ebola Virus Disease patients requiring transfer from an Ebola Treatment Unit.”

Thus what these studies have brought out is that during the Ebola outbreak on the one hand many people suffering from non-Ebola serious diseases had much higher mortality rates than before because they did not get access to modern or formal health systems. On the other hand even among non-Ebola patients, who had somehow managed to access the modern/formal health system, those who got sent to Ebola Treatment Units also had a high mortality rate due to a number of factors.

There are important lessons in this for the present times, when it is becoming increasingly evident in many countries that those suffering from serious diseases such as tuberculosis, cancer and heart disease, or those who need emergency treatment for other diseases, injuries, mental health problems and maternity complications are unable to access medical care, or in any case their access to treatments have reduced considerably. Lack of access to medicines which need to be taken regularly is another serious problem which is increasing. It is important to take urgent steps to meet this challenge.

Coming now to the H1N1 swine flu outbreak in 2009-10. An important lesson from this was that many avoidable problems are likely to arise when there is lack of adequate transparency. The Social Health and Family Affairs Committee of the Parliamentary Assembly, Council of Europe, published an important report on the Handling of the H1N1 Pandemic—More Transparency Needed. This report says, “The Parliament Assembly is alarmed about the way in which the H1N1 influenza pandemic has been handled, not only by the World Health Organization (WHO), but also by the competent health authorities at the level of the European Union and at the national level. It is particularly troubled by some of the consequences of decisions taken and advice given , leading to distortion of priorities of public health services across Europe, waste of large sums of public money and also unjustified scares and fears about health risks faced by the European public at large.”

Further, this important note on lack of transparency regarding an infectious disease related crisis says, “The Assembly notes that grave shortcomings have been identified regarding the transparency of decision making processes relating to the pandemic which have generated concerns about the possible influences of the pharmaceutical industry on some of the major decisions relating to the pandemic. The Assembly fears that that this lack of transparency and accountability will result in a plummet in confidence on the advice given by major health institutions. This may prove disastrous in the case of the next disease of pandemic scope which may turn out to be much more serious than the H1N1 Pandemic.”

The text of a resolution passed in this context in the Council of Europe Parliament said, “In order to promote their patented drugs and vaccines against flu pharmaceutical companies influenced scientists and official agencies responsible for public health standards, to alarm governments worldwide and make them squander tight health resources for inefficient vaccine strategies and needlessly expose millions of healthy people to the risks of an unknown amount of side-effects of inefficiently tested vaccine.”

It was widely felt that exaggeration of the threat had led to problems and some countries were left saddled with millions of vaccines they did not need. As Statnews reported, the early formal declaration of a pandemic by the WHO automatically activated pre-negotiated pandemic vaccine contracts that several countries had with vaccine manufacturers, but as the threat proved to be much less, Germany, Spain and other countries started complaining that they did not really need all these vaccines. France said that it will not take possession of about half the 94 million doses that it was supposed to buy.

In fact, to their credit, some top officials of the WHO came at least half-way towards acknowledging these problems and tried to make amends. On 12 April, 2010 Reuters released a report written by Stephanie Nebehay, WHO admits shortcomings in handling flu pandemic, which quotes Keiji Fakuda, then the WHO’s top influenza expert, stating that the UN agency’s six-phase system for declaring a pandemic had shown confusion about the flu bug which was ultimately not as deadly as was earlier feared. He said, “The reality is there is a huge amount of uncertainty (in a pandemic). I think we did not convey the uncertainty. That was interpreted by many as a non-transparent process.”

The prestigious BMJ or the British Medical journal joined hands with an organisation of investigative journalists to publish an expose of the conflict of interest of key scientists who were advising the WHO on influenza pandemic but also doing paid work for the pharmaceutical firms that stood to gain from this guidance. Later the BMJ editor claimed that the expose had led to the WHO making some badly-needed reforms. He wrote, “In fact the WHO endorsed the article’s central argument which was that its handling of conflict of interest needs to be improved…”

One hopes that important lessons from these two previous infectious disease outbreaks will be well learnt and included in how we counter Covid-19. Enough room is necessary for attending to other serious diseases and health problems while at the same time maintaining essential transparency.

First published in NewsClick.