OUTBREAK BREAKOUTS
When an epidemic strikes--or the threat of one becomes imminent--how should health authorities, and the public react?
Outbreaks should be reported as they are: no drama, no spin.
This is one of the guidelines for media practitioners in reporting the SARS outbreak, among the many other rules posted in the health department's web page for SARS. And clearly, these guidelines may be applied to other outbreaks.
The National Epidemiology Center (NEC) of the Department of Health (DOH) is at the heart of any disease outbreaks in the country. And often, epidemiologists are at the forefront of telling people the real score, including the media.
At the NEC, they tell it as it is, according to Dr. Enrique Tayag, the newly installed chief of the center. The DOH recently had a change in leadership, and Tayag had received the new assignment two days before this interview. He had long been in the infectious-diseases area such that talking epidemiological is second nature.
"We call the spade, a spade," Tayag says about how the center handles information on outbreaks. And take care of the consequences of such a report, whatever they are, he adds.
Tayag explains that reporting outbreaks is not about consequences, but rather it is about getting people involved in controlling the situation and saving an entire community or country from getting infected.
Reporting an outbreak is a task that is at the tail end of a long tedious process. When DOH declares an outbreak, "it means it has done its job of verifying, investigating, analyzing, and installing control measures," Tayag explains.
No dilemma, nonnegotiable
There is no dilemma in announcing an outbreak, he says. Questions like "Should we announce it or not?" or "How and when should we announce it?" are nonexistent.
"It's nonnegotiable," he says, referring to the truth behind any epidemic, and the "truth shall always set you free." Tayag pointed to the SARS outbreak in China that resulted in the sacking of two government health personnel there. Concealment and not reporting outbreaks pose grave danger to everyone, he says. "We don't want that to happen here."
Tayag wants to clarify also, for the sake of jargon, that outbreak and epidemic are synonymous. "They mean the same," he says.
And seeking for the truth, Tayag says, takes time. He pointed to a case that needed seven days for the results of a particular test. The media can sometimes become impatient, he says.
The impatience is understandable, Tayag says, but it should also be understood that within the NEC, there exists a race between which to do first: announcing the outbreak or doing something about it.
"When we have to choose between telling it to those WHO need to know and doing something about it, we choose doing something about it," Tayag explains. "If we chase two rabbits, both will escape."
The NEC is very clear with its policy of controlling the outbreak first, before anything else--including talking to the media. Tayag explains that issuing an official report takes second priority, and emphasizes that when a report is out in the media, much work has already been covered.
The problem begins when the DOH report is delayed, in media standard, which is more often misconstrued as "we are hiding something, or we do not want to reveal anything." Tayag clarifies that they understand where the media are coming from. "We can't blame them," he says while underscoring the important role of the media in containing an epidemic. "The steps take long, owing to the process that a final report is arrived at," Tayag explains, adding that the media have to understand the nature of verification and investigation. He says that a faulty report is a faulty report and is hard to retract when already issued. "Ang nasabi ay nasabi na; mahirap nang bawiin yon."
Epidemic intelligence
What action does NEC take when reports, not issued by them, reach their office?
"We have an epidemic intelligence unit that logs all reports, rumors, and what have you," Tayag reveals. The rule is "this happened unless proved otherwise" and not "this did not happen unless proved otherwise." Tayag points to the sharp contrast between the two. To prove, he says, the area in question is contacted. A call is made to verify if the concerned health unit knows about the report.
"If they know about it, the implication is that they are doing something about it already. You cannot know something and not do anything about it," he explains, adding that epidemiologists do not take any single small report for granted.
On the other hand, if the answer is negative, the implication is that further verification and investigation are yet to be done.
One case in point, Tayag mentions, is the report of an alleged outbreak of typhoid somewhere in Mindanao. Upon receipt of the report, a team set out to the area to investigate, only to discover something else. A group of practitioners, Tayag relates, had installed a new laboratory in the area and that all those WHO were having fever were tested for typhoid. As the test method was not sensitive enough for typhoid, all tested positive. "We had to tell them that their test was not the standard one," he says. "It was a pseudoepidemic."
A rather funny aNECdote of a faulty reporting, he says, was the one "reported" by a group that held a medical mission in a particular area. "They reported an epidemic of pneumonia, because all their bottles of cough syrup were gone."
"We refuse to be convinced what we are convinced of already," Tayag says. Theirs is the unrelenting pursuit of answers to the questions "Why is it happening? What is causing it? What is the reason for this?" And they convince themselves that there must be a better explanation to an outbreak, despite having discovered one already.
More than the usual
The local government units through the mayor, Tayag says, can announce an outbreak. "DOH was able to transfer this capacity to detect, prevent, handle outbreaks. It is not something centralized. The mayor can say there is an outbreak in his locality, but this is based on the accepted definition of an outbreak.
Tayag defines an outbreak as "something that is more than the usual, or better yet, something unusual." For example, he says, "if there were no reported cases before of the disease, even a single case is already an outbreak."
He explains further that an outbreak is not dependent on the magnitude or the number of cases and hence is very relative. "If you have a thousand cases and the usual is 1,500, you cannot consider that an outbreak."
The story is different, he says, if you have 500 cases spread in 12 months; or five cases in two weeks. Tayag also explains that 500 cases out of 100,000 population getting sick is far less serious than having 500 cases out of 1,000.
It is another story when an illness is endemic to a community, that which is lingering, year in, year out, he adds. The thumbnail is "an outbreak is more than the usual."
Finding a middle ground
The recent meningococcemia outbreak in Baguio City drew mixed reactions from the locals. The reactions "depend on the point of view," according to Tayag.
One transient male worker at a fast-food chain in the city recalls how he and his coworkers would shy away from invitations for Friday nights out. "We would decline invitations especially because those places were crowded. We were just too paranoid to go out," he says.
He says that at the height of the outbreak, everyone was a suspect, and it sowed paranoia of the highest level. "Nobody wanted to go out of his house," he continues. And worse, he says, even a simple case of cold was misreported as a meningococcemia case.
Businessmen understandably took the outbreak declaration a pain to their business, Tayag says. The more common people were on the brink of panicking, to the extent of getting all the masks they could.
DOH declared the outbreak contained in a news report on November 24 last year.
Which action is appropriate? To inform or to not inform?
"The reaction of the people has something to do with your efforts to give the proper information," says Tayag, and explains the ineffectiveness of any information when people are too scared: "If people are too fearful, you won't be able to inform them properly because they react too much."
On the other hand, if you have a population that is indifferent, then that poses another problem, because "they also need to know how to protect themselves."
Tayag explains that the challenge in getting public cooperation is in keeping a balanced reaction and making sure that factual information is given to the public not only once, but as frequently as possible.
Doing this requires money, which he says is another story.
The NEC has a work in progress of a "quick-report" nature. According to Tayag, they are in the process of building a section in the DOH web site, much like that of the World Health Organization, where one can have quick and easy access to updates on outbreaks, if there are any.
Disease detectives
Filipinos are lucky to have epidemiologists in each territorial unit of the health department. "We consider ourselves diseases detectives, and we are scattered all over the country, we are organized, and we are networked," Tayag says.
Like in a familiar detective movie scene, they assemble themselves like police officers ready to set out to a locality with reports of distress.
No wonder that our epidemiologists saved the country from those scary days of the SARS outbreak. "Our neighbors had the sophisticated equipment, but we had the epidemiologists. That saved the day," he says of the way SARS was contained in the Philippines.
Basic epidemiology is a requirement in containing outbreaks, he says, and being a third-world country has the advantage of a "preventive stance" over sophistication. Disease detectives know the measures to prevent diseases from entering our area of responsibility, concludes Tayag.
STRICTER CONTROLS, BROADER OBLIGATIONS
GENEVA
The World Health Organization's ruling body decided to boost global measures to tackle epidemics and the growing threat of emerging infectious diseases.
At its annual meeting on May 23, the 192-country WHO assembly approved a proposal to update measures on quarantines and travel restrictions that date back to 1951. The assembly agreed to strengthen and broaden the scope of the International Health Regulations to cover country-hopping diseases such as SARS, new variants of influenza, and polio.
"This is a major step forward for international health," said Lee Jong-wook, WHO director general. "These new regulations recognize that diseases do not respect national boundaries. They are urgently needed to help limit the threats to public health."
The WHO has been urging its members for several years to update the rules, which went through their last detailed revision in 1969 and effectively only allow worldwide controls to stop cholera, plague, and yellow fever. The revised regulations, which will come into force in 2007, govern the roles of countries and the WHO in tackling outbreaks.
Countries will have much broader obligations to put in place routine preventive measures--such as stricter controls at airports, ports, and land borders in the event of an outbreak--as well as to detect and respond to health threats that could spread beyond their frontiers. Countries must also alert the WHO when a disease on the list strikes.
Early in the SARS outbreak in 2003, Chinese authorities faced criticism for allegedly acting too slowly to inform the outside world.
The updated rules also cover "natural occurrence, accidental release, or deliberate use of biological and chemical agents or radionuclear material."
"The new regulations bring disease control into the 21st century," said Anarfi Asamoa-Baah, WHO head of communicable diseases. "With this framework, we can now support the work of countries in controlling outbreaks more effectively."
WHO officials earlier noted that the updated rules would largely reflect existing--but informal--procedures that have built up in recent years. WHO country offices around the world already provide operational support to countries in identifying and responding to disease outbreaks.
"The existing regulations were written for a very different world from the one we live in today," said Guenael Rodier, the WHO head of disease surveillance. Added Rodier: "Air travel was a luxury and the movement of goods and people around the world was relatively slow. Today, travel and trade have expanded far beyond what was envisaged under the original regulations. The new rules respond to a globalized, 24-hour world in which a disease outbreak in one country can rapidly move around the world."
The regulations, which also aim to tackle as yet unidentified health threats, include a list of steps to help countries assess the global risks posed by local outbreaks. "Every country already has some of these capacities but almost no country has a perfect system," said WHO official Max Hardiman. "The new regulations set clear standards and will help countries to identify where their disease surveillance and response must improve."
WHO members also decided that the agency should help developing countries build up their ability to apply the new rules.
Smallpox vaccine
Meanwhile, the WHO approved moves to build up a reserve of smallpox vaccine but again put off a final decision to destroy remaining stocks of the virus, which is regarded as a potentially destructive biological weapon.
Smallpox was declared eradicated as a disease in 1980, and the issue of destroying the last remaining stocks of the highly contagious virus, held in two high-security laboratories in Russia and the United States, has been under discussion since the 1990s. The issue was not tackled during the WHO assembly because of a more immediate but temporary focus on finalizing research for prevention, detection, and treatment, officials said.
"The long-term aim of the WHO and the assembly is to destroy this virus, that's clear," said WHO disease expert Mike Ryan, emphasizing that a decision to do so was adopted six years ago.
The UN health agency received backing for the first time for ongoing moves to build up an international reserve of vaccines in case of an emergency. Stocks of 2.5 million doses are being built up in Geneva, and an additional 31 million doses will be donated by countries, including 20 million doses from the United States and five million from France, the agency said.
Health officials acknowledged they had to balance research needs with fears that virus samples could fall into the wrong hands and be used to make biological weapons.
"Clearly there is no question that the emergence of the biological-weapon threat has raised concern about smallpox," Ryan said, underlining long-standing suspicions that the virus might have been kept elsewhere secretly. "The question from a public-health point of view is do we know enough about the virus, do we have the correct antivirals, do we have safe and effective vaccines, and effective and rapid diagnostics," he added.
Biosafety and biosecurity issues will be a top priority in considering requests for research on smallpox, the WHO emphasized. An advisory committee of experts last November highlighted the growing threat of chemical replication in the form of a synthesized smallpox virus, the development of which may become possible with ongoing scientific advances. One WHO official estimated that scientists could be capable of reproducing the entire genetic structure of the virus synthetically within a decade.
Lee rejected advice from the panel of experts to allow genes from the smallpox virus to be implanted in other less virulent types of pox viruses for research Lee asked the advisory committee to reconsider its recommendation to allow the practice.
AFP
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