[Editorial] No health workforce, no global health security

Since the recent epidemics of Ebola, MERS, and Zika viruses, the ever-present threat of pandemic influenza, and now the menace of a yellow fever crisis, the notion of global health security has risen to the top of concerns facing the 194 member states attending next week’s 69th World Health Assembly (WHA) in Geneva, Switzerland. Without global health security, the common goal of a more sustainable and resilient society for human health and wellbeing will be unattainable.

Ebola crisis: the world must do better

The reputation of the global system for preventing and responding to infectious disease outbreaks has taken a battering in the wake of the west African Ebola epidemic.

Yet a prestigious Independent Panel believes it is possible to rebuild confidence and prevent future disasters, releasing a roadmap of 10 interrelated recommendations for national governments, the World Health Organisation, non-government organisations and researchers.

The Independent Panel on the Global Response to Ebola, launched jointly by the Harvard Global Health Institute and the London School of Hygiene and Tropical Medicine, spent months reviewing the worldwide response to the outbreak that began in 2013.

“The west African Ebola epidemic … was a human tragedy that exposed a global community altogether unprepared to help some of the world’s poorest countries control a lethal outbreak of infectious disease,” the Panel wrote in The Lancet.

“The outbreak continues … It has infected more than 28,000 people and claimed more than 11,000 lives, brought national health systems to a halt, rolled back hard-won social and economic gains in a region recovering from civil wars, sparked worldwide panic, and cost several billion dollars in short-term control efforts and economic losses.”

The Panel said its goal was to convince high-level political leaders worldwide to make necessary and enduring changes to better prepare for future outbreaks while memories of the human costs of inaction remained vivid and fresh.

It identified four key phases of inaction:

December 2013 to March 2014, when Guinea’s lack of capacity to detect the virus allowed it to spread to neighbouring Liberia and Sierra Leone;
April to July 2014, when intergovernmental and non-government organisations started to respond, health workers struggled to diagnose patients and provide effective care, national authorities played down the scope of the outbreak, and WHO and the US CDC sent expert teams but withdrew them prematurely;
August to October 2014, when global attention and responses grew, but so did panic and misinformation, leading to unnecessary and harmful trade and travel bans; and
October 2014 to September 2015, when cases began to decline, and large-scale global assistance started to arrive, albeit with weak coordination and a lack of accountability for the use of funds.

“This Panel’s overarching conclusion is that the long-delayed and problematic international response to the outbreak resulted in needless suffering and death, social and economic havoc, and a loss of confidence in national and global institutions,” the Panel said.

“Failures of leadership, solidarity and systems came to light in each of the four phases. Recognition of many of these has since spurred proposals for change. We focus on the areas that the Panel identified as needing priority attention and action.”

The Panel made 10 recommendations:

develop a global strategy to invest in, monitor, and sustain national core capacities;
strengthen incentives for early reporting of outbreaks and science-based justifications for trade and travel restrictions;
create a unified WHO Centre for Emergency Preparedness and Response with clear responsibility, adequate capacity, and strong lines of accountability;
broaden responsibility for emergency declarations to a transparent, politically protected Standing Emergency Committee;
institutionalise accountability by creating an independent Accountability Commission for Disease Outbreak Prevention and Response;
develop a framework of rules to enable, govern and ensure access to the benefits of research;
establish a global facility to finance, accelerate, and prioritise research and development;
sustain high-level political attention through a Global Health Committee of the Security Council;
a new deal for a more focused, appropriately financed WHO; and
good governance of WHO through decisive, time-bound reform, and assertive leadership.

“The human catastrophe of the Ebola epidemic that began in 2013 shocked the world’s conscience and created an unprecedented crisis,” the Panel concluded.

“The reputation of WHO has suffered a particularly fierce blow. Ebola brought to the forefront a central question: is major reform of international institutions feasible to restore confidence and prevent future catastrophes? Or should leaders conclude the system is beyond repair and take ad hoc measures when the next major outbreak strikes?

“After difficult and lengthy deliberation, our Panel concluded major reforms are warranted and feasible.”

Maria Hawthorne

Hospitals, doctors in gun sights

The AMA has joined international calls for combatants to respect the neutrality of health workers and medical facilities amid widespread outrage at an attack on a Syrian hospital that has reportedly left at least 55 dead and 60 injured.

AMA Vice President Dr Stephen Parnis said it was “unacceptable” that health professionals and facilities were being targeted in armed conflicts in many parts of the world, most recently in Syria.

“It is unacceptable that health personnel and facilities are ever regarded as legitimate targets,” Dr Parnis said. “It is the duty of the international health community to speak out and protect the non-discriminatory provision of health care to all those in need.”

The AMA Vice President was commenting following a recent spate of deadly attacks on hospitals and clinics in strife-torn parts of the world, including Syria and Afghanistan, in which hundreds of patients, doctors, nurses and other health workers have been killed and injured.

In one of the most recent incidents, Syrian Government forces were blamed for killing at least 55 people and injuring 60 late last month after launching an air strike on the al-Quds Hospital in Aleppo.

Several doctors and nurses were among those killed in the attack on the hospital, including one of the city’s few remaining paediatricians, Dr Mohammed Wassim Maaz.

A spokeswoman for Medicins Sans Frontieres (MSF) which, along with the International Committee of the Red Cross (ICRC), has been supporting the hospital, told The Guardian that 95 per cent of doctors from opposition-held parts of Aleppo had fled or been killed, leaving fewer than 80 doctors to care for around 250,000 still living in the war-torn city.

The al-Quds Hospital is the latest in a string of attacks on medical facilities. According to media reports at least seven MSF-supported hospitals and clinics have been bombed since the beginning of the year, and the US Government has punished 16 military officers over a deadly airstrike on a MSF hospital in the Afghan city of Kunduz last year in which 42 people, including 13 doctors, nurses and other health workers, were killed.

In a report on the incident released late last month, the Pentagon blamed a chain of human errors and failures of procedures and equipment for the attack, but rejected accusations from MSF that it amounted to a war crime.

MSF is furious that the hospital was bombed despite the fact all combatants had been notified of its location, and that the attack continued despite repeated calls from the medical charity to the US military alerting it to the fact it was bombing a medical facility.

The military personnel involved, including a general, will not face criminal charges and will instead receive a range of “administrative actions” including suspension, letters of reprimand and removal from command.

The ICRC, the World Health Organisation and the World Medical Association have in recent years been sounding increasingly loud warnings about the incidence of attacks on health workers and medical facilities.

Late last year they issued a joint call for governments and non-state combatants to adhere to international laws regarding the neutrality of medical staff and health facilities, and ensuring this commitment is reflected in armed forces training and rules of engagement.

The ICRC, through its Health Care in Danger project, recorded 2398 attacks on health workers, facilities and ambulances in just 11 countries between January 2012 and the end of 2014.

Disturbingly, while many incidents involved health workers and facilities caught in cross-fire or being hit in indiscriminate attacks, the ICRC has also identified numerous incidents where they have been deliberately targeted.

Governments attending the 32^nd International Conference of the Red Cross and Red Crescent last December reaffirmed their commitment to international humanitarian law and a prohibition on attacks on the wounded and sick as well as health care workers, hospitals and ambulances, and the ICRC is also working with non-state combatant groups to raise awareness of laws and conventions around the protection of patients, health workers and medical facilities.

Adrian Rollins

Diabetes affects almost one in 10

Diabetes is rapidly emerging as one of the world’s most serious public health problems, affecting almost 500 million adults and contributing to the deaths of close to four million people a year.

An alarming report from the World Health Organization has found that incidence of diabetes, once mainly confined to high income countries, is rapidly spreading, and by 2014 422 million adults were living with the disease – almost one in every 10 adults worldwide. In 1980, its prevalence among adults was less than 5 per cent.

WHO Director-General Dr Margaret Chan said the disease’s emergence in low- and middle-income countries was particularly problematic because they often lacked the resources to adequately diagnose and manage the disease, resulting in needless complications and premature deaths.

According to the WHO’s Global Report on Diabetes, the condition was directly responsible for 1.5 million deaths in 2012 and contributed to a further 2.2 million fatalities by increasing the risk of cardiovascular and other diseases.

Diabetes takes a relatively heavy toll of younger people, particularly in less wealthy countries. Of the 3.7 million deaths linked to diabetes in 2012, 43 per cent occurred in people younger than 70 years of age, and the proportion was even higher in low- and middle-income countries.

The rise in diabetes has coincided with an increase in associated risk factors, most particularly a jump in global rates of overweight and obesity. Currently, 10.8 per cent of men and 14.9 per cent of women worldwide are considered to be obese, and on current trends that will increase to 18 per cent of men and 21 per cent of women by 2025.

While rates of obesity and diabetes are continuing to climb in rich countries, the WHO said this is being outstripped in other parts of the world, particularly middle-income nations.

The relative lack of resources to prevent, diagnose and manage diabetes in less wealthy countries is exacerbating its spread and impact.

Programs and policies to encourage physical activity, promote health diets, avoid smoking and controlling blood pressure and lipids are generally better funded in rich countries, where GPs and other frontline health services are better equipped to detect diabetes early and patients generally have good access to insulin and other treatments.

The WHO said that even though most countries have national diabetes policies in place, often they lack for funding and implementation.

“In general, primary health care practitioners in low-income countries do not have access to the basic technologies needed to help people with diabetes properly manage their disease,” the agency said. “Only one in three low- and middle-income countries report that the most basic technologies for diabetes diagnosis and management are generally available in primary health care facilities.”

In particular, it highlighted serious problems with access to treatments.

“The lack of access to affordable insulin remains a key impediment to successful treatment and results in needless complications and premature deaths,” the WHO report said. “Insulin and oral hypoglycaemic agents are reported as generally available in only a minority of low-income countries. Moreover, essential medicines critical to gaining control of diabetes, such as agents to lower blood pressure and lipid levels, are frequently unavailable in low- and middle-income countries.”

Diabetes has been identified as one of four priority non communicable diseases targeted under the 2030 Agenda for Sustainable Development, but Dr Chan said the WHO report showed there was “an enormous task at hand”.

“From the analysis it is clear we need stronger responses not only from different sectors of government, but also from civil society and people with diabetes themselves, and also producers of food and manufacturers of medicines and medical technologies,” the WHO leader said.

Adrian Rollins

Ebola outbreak in West Africa: considerations for strengthening Australia’s international health emergency response

It is time for a common vision and strategy for deploying Australian expertise to international public health emergencies

An effective response to health emergencies such as the Ebola virus disease outbreak in West Africa relies on global capacity to rapidly surge the supply of skilled workers, particularly when they are limited in affected countries and increasingly depleted during the emergency. Before the Ebola outbreak, health professionals in West Africa were already scarce; for example, in Liberia the doctor-to-population ratio was 1:70 000, compared with 1:300 in Australia.1,2 In addition to clinicians, an effective response to a large outbreak of Ebola virus disease in resource-limited settings requires international technical support across a range of public health and other disciplines, including infection prevention and control, epidemiology, laboratory diagnostics, communication, mental health, anthropology, social mobilisation, logistics, security and coordination.

Early in the Ebola virus disease outbreak in West Africa, many international non-government organisations (NGOs) and several governments established treatment centres and sent public health professionals to provide clinical care and augment control efforts. Timely public health interventions in Ebola-affected rural communities achieved crucial reductions (about 94%) in Ebola transmission.3 The Centers for Disease Control and Prevention (CDC) in the United States is a case study in how governments can deploy significant public health staff to countries affected by health emergencies. At time of writing, the CDC had effected 2206 staff deployments since July 2014 to support the public health response in Ebola-affected countries across a wide range of areas including surveillance, contact tracing, database management, laboratory testing, logistics, communication and health education.4 Most CDC public health staff were deployed into roles with a low risk of Ebola virus infection (ie, non-patient care roles) and none have become infected. In assessing the CDC’s exemplary response, it is important to note its pre-existing Global Health Strategy that clearly articulates the CDC’s vision, rationale, role, strategy, funding, partnerships, staff and areas of expertise for working in international public health, including in health emergencies such as Ebola virus disease.5

In contrast, nearly 6 months into the outbreak — when almost 5000 deaths had already been recorded — the Australian Government was being criticised by public health experts for its lack of substantive assistance to Ebola-affected countries.6 The Public Health Association of Australia called on the government to help strengthen the medical and public health capacity in the region by deploying an Australian Medical Assistance Team (AUSMAT), and by supporting Australians who wanted to volunteer their services through the World Health Organization or international NGOs by encouraging their employers to provide special leave and continuation of entitlements.6 Ultimately, the Australian Government declined to deploy AUSMAT resources, stating it would not consider sending people to Ebola-affected countries until it could get assurances from developed countries closer to West Africa that Australians would be able to be evacuated for treatment in the event they became infected.7 Instead, the Australian Government chose to fund a private contractor to staff a single treatment centre built by British army engineers in Sierra Leone. To date, anecdotal reports suggest no public health professionals have been deployed to Ebola-affected countries by the Australian Government, although the risk of infection is low.

The current and all previous Australian governments have not clearly articulated a vision for providing public health support during an international health emergency. AUSMATs are multidisciplinary health teams of doctors, nurses, paramedics, firefighters (logisticians) and allied health staff such as environmental health workers, radiographers and pharmacists8 who provide timely acute medical relief immediately after disasters in Australia and overseas. Staff of state and territory governments can be members of AUSMATs, and these agencies are reimbursed by the federal government for the salaries of staff who deploy through this mechanism. AUSMATs have a relatively small number of public health professionals on a roster largely drawn from staff of state and territory health authorities, but this list includes only a limited number with relevant outbreak response skills. While AUSMATs have a proven track record in providing emergency medical care in post-disaster settings, they are not currently designed to support the public health response required for a large outbreak.

The decision not to use AUSMAT assets and the lack of federal support for other Australian health professionals who wanted to volunteer to help contain the Ebola outbreak transferred the pressure to institute human resource policies (ie, special leave and continuation of entitlements) to state and territory health authorities. Without the type of financial arrangements that the AUSMATs afford state and territory health authorities, and with a general lack of jurisdiction-funded strategies for their staff engaging in emergency responses overseas, the environment for staff deploying independently was not always supportive.

Despite the challenges, many public health professionals from state and territory health authorities and academic institutions in Australia deployed as volunteers for NGOs or United Nations agencies, including about 15% of the Australian National University Master of Applied Epidemiology (MAE) program’s alumni since 1991 (Martyn Kirk, MAE Program Director, Australian National University, personal communication). Still, only one current Australian MAE participant was deployed, with Médecins Sans Frontières (as of January 2015), compared with 97 from a similar program in the US (the CDC’s Epidemic Intelligence Service), highlighting the missed opportunity for Australia’s next generation of outbreak control experts to get invaluable field experience while providing much needed support.

Now that the Ebola virus disease outbreak is over, Australia needs to examine how well it performed in assisting the WHO to respond to this significant threat to global health, as it was declared by the International Health Regulations Emergency Committee in August 2014.9 We believe it is time for the Australian Government, in consultation with state and territory health authorities and public health training institutions, to establish a common vision and strategy for deploying Australian expertise to international public health emergencies, including Ebola virus disease outbreaks. If AUSMATs (currently the only funded mechanism) are Australia’s preferred approach to responding to international health emergencies, their capacity to support a major public health response should be expanded by including more professionals in relevant disciplines. To maximise the impact of public health professionals deployed through AUSMAT arrangements, personnel should be made available at the beginning of future health emergencies. In addition, formalising support arrangements with members of the Australian Response MAE (ARM) Network10 (created by academic institutions in response to gaps in the coordination of Australia’s public health surge capacity) may be a way for the government to effectively mobilise skilled public health professionals for deployment overseas in response to disease outbreaks. Consideration should also be given to expanding the AUSMAT roster of public health professionals and integrating structures like the ARM Network into the response framework.

The Australian Government missed an important opportunity to contribute timely, valuable technical assistance to Ebola-affected countries; support that was essential to stopping the outbreak at its source at a time when it was needed most. In the end, many Australians stepped up as volunteers in the fight to extinguish this global threat to public health. Australian federal authorities should reflect on this experience and consider it an opportunity to strengthen Australia’s response to future health emergencies and demonstrate leadership on the global stage.

Multidrug-resistant tuberculosis in Australia and our region

MDR-TB threatens TB control programs in Australia’s region and will not diminish without concerted efforts

Tuberculosis (TB) is one of the world’s great killers, but Australia has been relatively protected because of its strong public health system. Of 1300 cases reported in Australia each year, almost 90% occur in the overseas born, although Indigenous Australians are also disproportionately affected. Most cases arise in the large immigrant communities from India, Vietnam, the Philippines, China and Nepal, but high rates are also reported from Papua New Guinea (PNG), Ethiopia, Somalia and Myanmar. These cases occur primarily in permanent residents and students, rather than in refugees or those on humanitarian visas.1

Many countries are now reporting significant rates of drug-resistant tuberculosis, with at least 480 000 cases worldwide now attributable to multidrug-resistant TB (MDR-TB; defined as resistance to the two most effective first-line agents, isoniazid and rifampicin).2 However, countries with the highest rates of drug resistance often have the poorest quality data, largely due to the lack of resistance testing. Globally, MDR-TB was estimated to constitute 3.3% of new and 20% of retreatment cases in 2014. Although the deployment of molecular diagnostics to detect resistance is progressing, only a quarter of these cases were correctly identified. For example, in PNG, MDR-TB rates are similar to those described globally, but a nationwide drug-resistance survey has not been undertaken and other data sources suggest that the rates could be underestimates.3 Extensively drug-resistant TB (XDR-TB; resistant to isoniazid, rifampicin and the most effective second-line agents, quinolones and injectables) has also been sporadically reported in Australia from PNG.4 For Australian clinicians, for whom diagnostics are widely available, the rise of MDR-TB makes definitive strain identification through culture even more important.

Traditional second-line agents to treat the handful of MDR-TB cases in Australia are generally available, but prolonged courses of toxic and expensive drug combinations are required. The agents used to treat MDR-TB depend on the remaining susceptibilities, but ototoxicity (aminogylcosides), nausea (p-aminosalicylic acid) and neuropsychiatric reactions (cycloserine) are among many common side effects. It is therefore unsurprising that globally, treatment outcomes are poor, with only about half of identified patients completing the 2-year treatment course, such that only around 10% of all incident cases complete treatment worldwide.2 Meta-analyses demonstrate that the chance of treatment success diminishes as the number of drugs to which a strain is resistant increases.5 Alarmingly, there are now data on outcomes for patients with “beyond XDR”-TB, with treatment success rates comparable to the pre-antibiotic era natural history of TB.6

There is a resurgence of interest in new treatments for TB, with the first new drugs in 40 years now proceeding through development, including bedaquiline, delamanid and pretomanid. As important as individual agents is the development of new regimens that can be deployed programmatically, such as the 9-month Bangladesh regimen (comprising gatifloxacin, clofazimine, ethambutol and pyrazinamide, with prothionamide, kanamycin and high-dose isoniazid added for the intensive phase).7 There is also interest in off-label use of existing antibiotics with anti-TB activity, such as linezolid and meropenem–clavulanate, and new strategies to minimise toxicity, such as therapeutic drug monitoring. However, even if new regimens become established, significant barriers exist to providing treatment for MDR-TB in the countries that need them most. MDR-TB is both a cause and symptom of poor communicable disease control programs, with MDR-TB regimens costing around tenfold that of drug-susceptible cases.8

MDR-TB is not a problem that will just go away. Policy makers may prefer to treat the problem they can address — focusing on improving programs for drug-susceptible TB to prevent resistance amplification. However, modelling has consistently demonstrated that cases of MDR-TB predominantly arise from community transmission rather than from resistance amplification in previously susceptible strains,9 such that only targeted control programs will achieve reduction in the disease burden attributable to MDR-TB.10

As global TB rates slowly decline, the contribution of late reactivation of latent infection to incidence is likely to increase. While this makes treatment for latent MDR-TB a key consideration, evidence for effective treatments remains scarce and clinical trials are ongoing.

The ambitious post-2015 targets for TB control, which replace the relatively modest Millennium Development Goals, present an opportunity for Australian leadership. In our setting, with most TB imported and the emergence of MDR-TB so dependent on the strength of health systems, Australia has a critical role to play in supporting developing countries of our region to improve TB control programs and their health systems generally. A vision for an expanded international response, coordinated with global partners, governments, multinational organisations, affected individuals and communities is provided by the United States National Action Plan for Combating MDR-TB.11 Given that 57% of MDR-TB cases occur in the Asia–Pacific region,2 a similar response to improve clinical diagnostics and management in our region would help keep MDR-TB from our shores.

Zika preparedness in Australia

Our comprehensive national response encompasses prevention and surveillance, as well as monitoring and controlling Aedes aegypti in Australia

The spectrum of clinical illness for Zika virus infection is generally not severe — about 80% of cases are asymptomatic1 — and the infection was not previously thought to be cause for serious public health concern. There is no specific treatment for, nor a vaccine against, a Zika infection.

Recent disquiet has been raised by emerging evidence of possible vertical transmission of Zika, the development of severe congenital abnormalities, including microcephaly,2,3 and of a possible link to fetal deaths.4 In addition, a possible link to Guillain–Barré syndrome has been reported.5,6 The World Health Organization declared the clusters of microcephaly and neurological disorders a Public Health Emergency of International Concern on 1 February 2016.7 Knowledge about any causal link between Zika virus and effects in utero is still evolving; however, given the serious implications, should there be one, Australian guidance for managing pregnant women returning from Zika-affected areas and for preventing the spread of the disease has been prepared.

In almost all cases, the Zika flavivirus is transmitted by mosquitoes (particularly by Aedes aegypti). The Zika virus was first isolated from a monkey in Uganda in 1947,8 and serological evidence of past infections in humans has been reported since 1952 in Africa and since 1981 in South-East Asia.9,10 Outbreaks in the Pacific Islands were first reported in Yap State, Micronesia, in 20071 and in French Polynesia from 2013,11 with spread to many Pacific islands between 2013 and 2016.12,13 Zika has spread rapidly across the Americas since late 2015, after being first confirmed in Brazil in 2015.14 In November 2015 the international community was alerted to the possibility of severe congenital malformations, with an International Health Regulations notification about an increase in cases of microcephaly in Brazil with geographical and temporal links to Zika.15 At that time, further information was also provided by health authorities in French Polynesia about congenital malformations, also with geographical and temporal links to Zika.15

In Australia, sporadic cases of Zika have been detected since 2012 in 35 returning travellers (to 29 February 2016), and there is a continuing risk of imported Zika infections from overseas. With the number of affected overseas areas increasing, as is greater awareness among the public and health professionals, an increase in the detection of imported cases could be expected.

The low risk of local transmission of Zika in Australia is restricted to areas of Queensland where the most suitable vector, A. aegypti, is continually present. Queensland has well developed and practised plans and resources for controlling dengue (also carried by the A. aegypti mosquito) that are also applicable to Zika. Through routine vector monitoring and control activities, and the deployment of Dengue Action Response Teams (DARTs), the Queensland government has prevented dengue from becoming endemic, despite regular importations. The Queensland government recently announced a package of measures to strengthen preparedness, including enhanced laboratory capacity in Townsville. Queensland Health remains on the alert for imported cases and subsequent local transmission.

A program of mosquito surveillance and control, coordinated by the federal Department of Agriculture and Water Resources, is in place at Australia’s air and sea ports to prevent incursions of exotic mosquitoes from overseas. While foreign mosquitoes are detected during the summer months, well established programs prevent their establishing breeding populations. There is also a specific program conducted by Queensland Health in the Torres Strait for controlling A. albopictus (a potential alternative vector for the Zika virus16), active in this area since 2005. The program has been successful in preventing its spread to the mainland and in reducing the numbers of A. albopictus and, at the same time, of A. aegypti in the transport hubs of the Torres Strait.

In February 2016, the Australian Health Protection Principal Committee issued advice on the management of pregnant women returning from Zika-affected countries and on preventing sexual transmission of Zika. A public health guideline on Zika is being finalised, and advice for travellers was issued in January 2016.17 Until more is known about the link between the virus and microcephaly, Australia recommends that women who are pregnant or planning to become pregnant should consider postponing travel to areas with ongoing transmission of Zika. If they do decide to travel, they should consistently adhere to mosquito avoidance measures. This recommendation is in line with major public health agencies around the world.

The Interim recommendations for assessment of pregnant women returning from Zika virus-affected areas18 encourage health care providers to ask all pregnant women about their recent travel history. Those who have travelled to a Zika-affected country during their pregnancy should be evaluated and tested. Any woman who tests positive for Zika virus should be referred for specialist obstetric care. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has issued guidance on the care of women with confirmed Zika virus infection during pregnancy in Australia.19

Further concerns for pregnant women and their unborn babies have been triggered by the possibility of sexual transmission of Zika virus. Initially, two instances of likely sexual transmission were reported internationally, one in 2008 and the other in 2016,20,21 and two instances of Zika virus being detected by polymerase chain reaction in semen — including one 62 days after the onset of symptoms — although virus isolation was not performed, so that it was not determined whether viable virus was present.22,23 There is evidence from the United States that sexual transmission of Zika may be more common than previously reported.23 To date, all reports of suspected or confirmed sexual transmission of Zika have involved a symptomatic man transmitting the virus to a woman. It is still unknown how long the virus can persist in semen, or how infectious this may be. Mosquitoes remain the overwhelmingly predominant mode of transmission. The Australian advice, Interim recommendations for reducing the risk of sexual transmission of Zika virus,25 recommends that men with a confirmed Zika virus infection and whose partner is pregnant should abstain from sex or consistently use a condom during sex for the duration of the pregnancy. Men with a confirmed Zika infection who do not have a pregnant partner should abstain from sex or consistently use a condom during sex for 3 months after leaving a Zika-affected country.

All recommendations about travel, testing and management require definition of the countries that have current local transmission. The list of affected countries is assessed daily by the Department of Health, based on agreed criteria. This, however, is not straightforward, and differences between overseas surveillance systems mean that a variety of sources must be checked to assess whether local transmission of Zika virus is happening in a particular country.

While unease about Zika is high, there remains a lack of high quality evidence for a causative link between infection and the development of microcephaly, and there is a general lack of data on the pathogenesis and epidemiology of the disease. Further studies are urgently required, and are underway. The need to formulate recommendations despite a paucity of data and evidence is not new in public health. However, it does pose particular challenges and risks, in that we may have to modify recommendations frequently. Expert consultations and the experiences and recommendations of other agencies internationally are important in the development of such recommendations. A key component of preparedness for communicable disease outbreaks in Australia is developing nationally consistent advice across the states and territories, and harnessing the expertise that is present throughout our country.

Australia has robust systems in place that can be adapted as required to enable a rapid response to communicable diseases such as Zika, with excellent laboratory capacity, public health response capability and communicable disease surveillance systems, as well as established vector surveillance and control programs. As the situation evolves, ongoing monitoring will continue, with information and recommendations updated as necessary. Zika is the latest communicable disease threat to challenge us. Each new threat offers an opportunity for enhancing core elements of communicable disease control and for ensuring readiness for the next emerging infectious disease.

It’s official: Zika causes birth defects

The United States’ Centers for Disease Control and Prevention has declared that the Zika virus is a cause of microcephaly and other severe foetal brain defects, confirming long-held suspicions about the infection’s link to serious neurological disorders.

As the US gears up for outbreaks of the potentially deadly virus, the CDC has reported that an accumulation of evidence proves Zika can cause birth defects and pregnant women living in or travelling to areas of where it is prevalent should strictly follow steps to avoid mosquito bites and prevent sexual transmission of the virus.

“This study marks a turning point,” CDC Director Dr Tom Frieden said. “It is now clear that the virus causes microcephaly. We’ve now confirmed what mounting evidence has suggested, affirming our early guidance to pregnant women and their partners to take steps to avoid Zika infection.”

The CDC report, published in the New England Journal of Medicine, said its conclusion was not based on any one discovery but rather an accumulation of evidence from a number of recently published studies and a careful evaluation using established scientific criteria.

The CDC announcement came as the Australasian Society for Infectious Diseases reminded GPs to be on heightened alert for tropical diseases in patients with febrile illnesses – particularly those who have recently travelled overseas.

Society President Professor Cheryl Jones said serious tropical diseases including Zika, multi-drug resistant malaria and dengue were endemic in many overseas destinations popular with Australians, including Thailand, Vietnam, Myanmar, Laos and Cambodia, and there was also a local outbreak of dengue in northern Queensland.

“There has never been a more critical time for Australian health professionals to get up to speed with developments in tropical medicine,” Professor Jones said. “With malaria resistance growing and no antiviral treatment available for dengue, Zika and other mosquito-borne viruses, it is imperative that Australian doctors are able to identify these diseases and refer patients swiftly.”

Her warning came as a senior US public health official, Dr Anne Schuchat, told a White House briefing that the virus “seems to be a bit scarier than we initially thought”.

Dr Schuchat, who is a deputy director of the US Centers for Disease Control and Prevention, said that initially it was thought the species of mosquito primarily associated with carrying the disease was only present in about 12 states, but that had now been revised up to 30 states.

Authorities are particularly concerned about the US territory of Puerto Rico, where they fear there may be hundreds of thousands of infections, but the speed of the disease’s spread has them concerned it may soon appear in continental US as temperatures rise.

“While we absolutely hope we don’t see widespread local transmission in the continental US, we need the states to be ready for that,” Dr Schuchat said.

While the Zika virus has been documented in 61 countries since 2007, the World Health Organization said its transmission has really taken off since it was first detected in Brazil in May last year, and it is now confirmed in 33 countries in Central and South America, as well as 17 countries and territories in the Western Pacific, including New Zealand (one case of sexual transmission), Fiji, Samoa, Tonga, American Samoa, Micronesia and the Marshall Islands.

Its appearance has been linked to a big jump in cases of microcephaly, Guillian-Barre syndrome (GBS) and other birth defects and neurological disorders, and the WHO said that there was now “a strong scientific consensus” that the virus was the cause.

In Brazil, there were 6776 cases of microcephaly or central nervous system malformation (including 208 deaths) reported between October last year and the end of March. Before this, an average of just 163 cases of microcephaly were reported in the country each year.

The WHO reported 13 countries or territories where there has been an increased incidence of GBS linked to the Zika virus. French Polynesia experienced its first-ever Zika outbreak in late 2013, during which 42 patients were admitted to hospital with GBS – a 20-fold increase compared with the previous four years. All 42 cases were confirmed for Zika virus infection.

Similar increases in the incidence of GBS cases have been recorded in other countries where there is Zika transmission, including Brazil, Colombia, El Salvador, Venezuela, Suriname and the Dominican Republic.

Scientists have also detected potential links between the infection and other neurological disorders. In Guadeloupe, a 15-year-old girl infected with Zika developed acute myelitis, while an elderly man with the virus developed meningoencephalitis. Meanwhile, Brazilian scientists believe Zika is associated with an autoimmune syndrome, acute disseminated encephalomyelitis.

Scientists worldwide are working to develop a vaccine for the virus, and an official with the US National Institute of Allergy and Infectious Diseases said initial clinical trials of a vaccine might begin as soon as September.

Meanwhile, research on other aspects of Zika, including its link with neurological disorders, sexual transmission and ways to control the mosquitos that spread the disease is being coordinated internationally.

So far, the only confirmed cases of Zika in Australia have involved people who were infected while travelling overseas, and authorities are advising any women who are pregnant or seeking to get pregnant to defer travelling to any country where there is ongoing transmission of the virus.

Adrian Rollins

US gears up for ‘scary’ Zika

The United States is gearing up for outbreaks of the potentially deadly Zika virus amid concerns the mosquito-borne infection can also be sexually transmitted and may cause neurological disorders in adults as well as children.

As Australian health authorities monitor the appearance of the disease, particularly in areas of the country where mosquito vectors are present, a senior US public health official, Dr Anne Schuchat, told a White House briefing that the virus “seems to be a bit scarier than we initially thought”, and health authorities are ramping up efforts to research the disease and raise public awareness of the threat.

“While we absolutely hope we don’t see widespread local transmission in the continental US, we need the states to be ready for that,” Dr Schuchat said.

Adrian Rollins

Latest news:

[Comment] Trends in diabetes: sounding the alarm

Diabetes is a major cause of death and disability worldwide. In 2012 it caused as many deaths as HIV/AIDS (1·5 million).1 Disability resulting from diabetes has grown substantially since 1990, with particularly large increases among people aged 15–69 years.2 People with all types of diabetes are at risk of developing a range of complications that can endanger their health and survival, and the high costs of care increase the risk of catastrophic medical expenditure.3 Diabetes is the theme of this year’s World Health Day on April 7, and WHO has published the Global Report on Diabetes to raise awareness and spark momentum for action at the necessary scale.