Prevention is better than cure for emerging infectious diseasesBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1499 (Published 21 February 2014) Cite this as: BMJ 2014;348:g1499
All rapid responses
Prevention is definitely better than cure if the prevention strategy is evidence based and effective and does not have too many loop holes in terms of false positives and false negatives in order to have optimum sensitivity and specificity of preventive strategies in terms of the ability to actually effectively curb transmission and prevent import of cases into countries which do not suffer from it at present
Ebola seems to have given us an opportunity to refine our preventive strategies in terms of screening, quarantine, and contact tracing and information technology including use of social media like twitter
Many countries seem to rely on airport screening as their sole strategy in prevention of imported infectious diseases. Evidence proves that this strategy is fraught with fallacies.
Isaac Bogoch et al have shown that screening at international points of departure in affected countries would offer greater efficiency and have also postulated that screening at entry into non-affected countries, at their international airports would be highly inefficient in certain situations (1). They also postulated that the predictive value of a positive health screening test would be extremely low and to calculate the gains in this they have considered the sensitivity and specificity to conclude that if screening from affected countries at point of exit were to be done effectively, the incremental gains from additional screening at ports of entry would be negligible.
Screening of passengers exiting from affected countries is 0•21% effective at present (2)
Gunaratnam et al (3) examined the efficiency of airport screening in New South Wales during the 2009 influenza pandemic and compared the case detection rate per 100,000 passengers screened as well as the sensitivity, positive predictive value and specificity of airport screening and compared the percentage of cases in the period detected at airport clinics with the percentage of cases detected in emergency departments and clinics and found that airport screening was ineffective in detecting cases of influenza A and recommended that its future use should be measured against potentially better interventions, such as contact tracing of people in the community
Further governments rely on self-proclamation of illness and have been admonished by courts in this regard (4).The alternative to self-proclamation that seems to have been adopted by most governments seem to be an infra-red thermometer to assess febrile states. It is perceived that travellers will not disclose their illness or their proximity to patients in the recent past and some of them may cross borders before symptoms appear, and both these factors have been identified even in literature reviews looking at effectiveness and potential use of infra-red thermometers for surveillance of airport travellers which concluded that low positive predictive value suggested limited use of such methods in early stages of an epidemic even when patients are symptomatic (5)
In order to implement more strict entry screening in the epidemic seasons of emerging infectious diseases, some authors (6) developed an infection screening system for airport quarantines using multi-parameter vital signs which can automatically detect infected individuals extremely rapidly by using a neural-network-based discriminant function which includes measured vital signs, i.e., heart rate measured by a reflective photo sensor, respiration rate calculated by a 10-GHz non-contact respiration radar, and the ear temperature measured by a thermography. They found the sensitivity of the infection screening system in detecting influenza to be 92.3%, which was significantly higher than the sensitivity of 88% as reported in their previous paper where they had used average facial skin temperature.
Most of these are based on the premise that patients will lie and hide their history and symptoms.
This prompts governments to even quarantine disease free patients for long term for months in the fear that patients may indulge in careless behaviour and subject others to risk of transmission. This in itself increases the costs, burden and further pushes fragile health systems of developing countries to the brink
But Sharangpani et al ( 7) surveyed a convenience sample of 404 departing international travellers at Detroit Metropolitan Wayne County Airport, presented them with an imaginary pandemic influenza scenario occurring in the areas to which they were travelling, and let the participants predict what protective behaviours they would take while abroad and what would be their attitudes be toward potential screening measures at US ports of entry. They found that those who understood that the pandemic influenza was serious were more likely to be comfortable with screening, and if they had influenza-like illness while abroad, they would be more readily see a physician and delay their return. Hence the authors concluded that demographic factors and perception of the severity of illness are important factors that may potentially influence the behaviours of travellers going to other countries in terms of protection, proving that educational material and advice specifically tailored for international travellers could be useful in some subsets of the traveller populations.
Thus it seems education and advice could make a huge difference and this has been further probably proven in Nigeria, (8) where twitter seems to have actually helped them fight Ebola contrary to earlier reservations, (9) which makes us realize that every sword may have two edges. And this proves that though proper information is a must, monitoring of the information is equally important.
Engagement of the people is essential and cooperation of the masses if it can be elicited will go a long way
This would prevent situations where cured seronegative patients could be potentially held in quarantine for months together (till their body fluids test negative ) (10) due to a perceived potential of such a patient to spread disease out of suspected/alleged/perceived ignorance or defiance or negligence, thus raising the opportunity costs and defeating the purpose of effective healthcare resource allocation in times of global need
1) Bogoch II, Creatore MI, Cetron MS, et al. Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak. Lancet 2014. published online Oct 21. http://dx.doi.org/10.1016/S0140-6736(14)61828-6..
2) ECDC. Infection prevention and control measures for Ebola virus disease: Entry and exit body temperature screening measures. Stockholm: European Centre for Disease Prevention and Control, 2014.
3) Gunaratnam PJ(1), Tobin S(2), Seale H(3), Marich A(4), McAnulty J(2).Airport arrivals screening during pandemic (H1N1) 2009 influenza in New SouthWales, Australia. Med J Aust. 2014 Mar 17;200(5):290-2.
5) Bitar D(1), Goubar A, Desenclos JC.International travels and fever screening during epidemics: a literature review on the effectiveness and potential use of non-contact infrared thermometers. Euro Surveill. 2009 Feb 12;14(6). pii: 19115.
6) Sun G, Abe N, Sugiyama Y, Nguyen QV, Nozaki K, Nakayama Y, Takei O, Hakozaki Y,Abe S, Matsui T.Development of an infection screening system for entry inspection at airport quarantine stations using ear temperature, heart and respiration rates. Conf Proc IEEE Eng Med Biol Soc. 2013;2013:6716-9. doi:10.1109/EMBC.2013.6611097
7) Sharangpani R(1), Boulton KE, Wells E, Kim C.Attitudes and behaviors of international air travelers toward pandemic influenza. J Travel Med. 2011 May-Jun;18(3):203-8. doi: 10.1111/j.1708-8305.2011.00500.x.
8) Carter M.How Twitter may have helped Nigeria contain Ebola. BMJ. 2014 Nov 19;349:g6946. doi: 10.1136/bmj.g6946.
9) Oyeyemi SO(1), Gabarron E(2), Wynn R. Ebola, Twitter, and misinformation: a dangerous combination? BMJ. 2014 Oct 14;349:g6178. doi: 10.1136/bmj.g6178.
Competing interests: No competing interests
It was interesting to read the recent published article in BMJ (2014; 348:g1499) entitled “Prevention is better than cure for emerging infectious diseases” by David L Heymann, Osman A Dar 1. We strongly agree with the authors about importance of health education to prevent the outbreak of newly emerged diseases. During the last two decades, the number of dengue cases has increased dramatically within the Kingdom of Saudi Arabia (KSA) especially in the cities of Jeddah and Makkah. 2-4 Moreover, there is a possibility of dengue outbreak in other surrounding countries such as Yemen. 5 Therefore, the Saudi health authorities have been aware of such incidence and proper attention was made to control the mosquito vector. It is well known that dengue virus is transmitted to human by Aedes mosquito and Aedes aegypti is known as the main vector in KSA. 6
Despite this, there is a sharp increase in the number of dengue cases reported in Saudi Arabia. In 2013, 4411 cases of dengue were reported, with 8 cases of mortality. 4 In the meantime, serious inadequacy of the procedures used to control the mosquito vector is identified as is evident by increases in the number of reported dengue cases as well as frequent outbreaks of the vector mosquito populations. 4
It would be fitting to emphasize here that health education and personal sanitation are effective steps in modern control of mosquito borne diseases. 7,8 These health strategies of controlling the dengue vector can be somewhat efficient for initial eradication of the vector mosquito as it involve elimination of possible breeding sites of larvae. Yet, such approaches are infrequently practiced in the KSA. As a result, public awareness of life cycle of the dengue vector and its favorable domestic and peri-domestic habitats is minimal or absent. Therefore, it is recommended that intensive efforts should be conducted to improve public awareness for the overall health promotion of the general public in KSA. Association between larval control strategies and health education of the public should be sustained. Thus, the public should be mindful of not only the control activities made by the special mosquito control teams but should also completely respond to the health education-related information programs scheduled by the relevant health authorities. For dengue control, public awareness and education relating to the breeding sites of the dengue vector mosquito and its physical and cultural control are important in population management of this container-breeding vector.
Unfortunately, there is severe lacking in the proper health education among the Saudi people. In the same context, very few studies have highlighted the importance of health education for reduction of dengue cases in KSA. For example, Ibrahim et al. 9 found that the knowledge, attitude and practice (KAP) on dengue disease is very low among the female students in secondary school of Jeddah. Therefore, it was recommended that school-based educational campaigns and social mobilization for raising knowledge and changing it into sound practice is urgently needed for controlling dengue epidemics in Jeddah.
The aim of this letter is to highlight the importance of the health education as an important part of dengue control process in the KSA. Health education is very essential criterion in any vector control program which implies sustaining efficient information and scientific knowledge to the society on transmitted diseases and their vectors. The knowledge on the vector life cycle and its ecology and biology should be delivered to help the people to live in a healthy conditions and destruction of vectors breeding sites.
Thus, the following recommendations are very important to improve health education on dengue and its mosquito vector in Saudi Arabia:
• Promoting the public participation and support for prevention and control the dengue fever. Additionally, the cooperation should be established between different public and private bodies for more effective control of mosquito.
• The health education programs should focus on educating the residents in how to break the vector life cycle through destruction of mosquito breeding containers such as concrete pools, water tanks, aquaria, irrigation ditches and drainages as well as air-conditioners and disposable tires.
• It is recommended that immediate cooperation between various government sectors should be activated. Proper diagnosis of the dengue infection should be conducted immediately when a dengue case arrived to the hospital.
• The health promotion would remarkably enhance the self-awareness among the individuals. Various activities should be organized including practicing the self-protection and regular workshops on the larvae and adults control strategies. The attention should be drawn to the adverse effects of the arbitrary application of insecticides without prior knowledge on dose, resistance and side effects of these chemicals.
• It is suggested that Saudi Ministry of Health as well as Ministry of Municipals should established cooperative workshops to increase the knowledge about dengue and its vector biology and ecology in the society. Regular extension programs should be carried out at different levels to highlight the importance of hygiene conditions and prevention of dengue through destroying the possible breeding sites. This is very important as both dengue vectors (Ae. aegypti and Ae. albopictus) are known for their preference to breed in man-made artificial containers in the urban areas. Thus, individual education is essential as it will develop the awareness and ultimately reduce the dengue infection in KSA.
• It is suggested that the Knowledge, Attitude and Practice (KAP) approaches on dengue fever should be applied immediately to enhance the general knowledge and practice among Saudi people.
• The residents will be aware not only to control activities conducted by the control teams but also reacting with health education arranged by the respective authorities and government bodies. The experience in application of health education programs in Malaysia and Singapore should be adopted in KSA as it showed good results as indicated by efficient reduction of dengue infection in these countries. Moreover, the role of Ministry of Culture and Information should highlight this public health issue through producing the announcements and advertisements in radio, press and television to increase the public awareness and understanding about the dengue fever and its vector control as well as how to maintain hygiene conditions inside the houses to prevent breeding and reproduction of the mosquitoes.
• On the other hand, the Destruction of Disease-Bearing Act (DDBA) should be enforced in KSA to eliminate the disease vectors. Strict regulations should be applied on anyone who violates the Act and its regulations. This will increase the awareness among the individuals and eventually reduce the dengue infection in the KSA.
Competing interests: None declared
1. Heymann, D. L., and Dar, O. A. “Prevention is better than cure for emerging infectious diseases.” BMJ: British Medical Journal 348, (2014): g1499.
2. Ministry of Health (MOH) Kingdom of Saudi Arabia. “Dengue fever epidemiology in Jeddah.” Bulletin of Ministry (2008).
3. Aziz, A. T. “Studies of Aedes aegypti and its resistance status to commonly used insecticides in control programs in Makkah city, Kingdom of Saudi Arabia.” Unpublished PhD thesis, Universiti Sains Malaysia, Malaysia. ; (2012).
4. Aziz, A., Al-Shami, S., Mahyoub, J., Hatabbi, M., Ahmad, A., and Rawi, C. An update on the incidence of dengue gaining strength in Saudi Arabia and current control approaches for its vector mosquito. Parasites & Vectors 7, no. 1 (2014): 258.
5. Amarasinghe, A. and Letson, GW. “Dengue in the Middle East: a neglected, emerging disease of importance.” Transactions of the Royal Society of Tropical Medicine and Hygiene 106, no. 1 (2012): 1-2.
6. Mahyoub, J. A. “Study of the seasonal activity and dynamic fluctuation of medically important species of mosquitoes with reference to testing the susceptibility of the dominant species to some insecticides in Jeddah.” Unpublished PhD thesis, King Abdulaziz University, Saudi Arabia. ; (2011).
7. Ong, D., Sitaram, N., Rajakulendran, M., Koh, G., Seow, A., Ong, E., and Pang, F. Y. “Knowledge and practice of household mosquito breeding control measures between a dengue hotspot and non-hotspot in Singapore.” Annals Academy of Medicine Singapore 39, (2010): 146-149.
8. Azmawati, M. N., and Aniza, I. “Evaluation of Communication for Behavioral Impact (COMBI) Program in Dengue Prevention: A Qualitative and Quantitative Study in Selangor, Malaysia.” Iranian Journal of Public Health 42 no. 5 (2013): 538.
9. Ibrahim, N. K. R., Al-Bar, A., Kordey, M., & Al-Fakeeh, A. “ Knowledge, attitudes, and practices relating to Dengue fever among females in Jeddah high schools.” Journal of Infection and Public Health, 2 no. 1: (2009): 30-40.
Authors and affiliations:
Al Thabiani Aziz, PhD
Department of Biology, Faculty of Science, University of Tabuk, Tabuk 71491, Saudi Arabia. Email: email@example.com.
Salman Abdo Al-Shami, PhD
Department of Biology, Faculty of Science, University of Tabuk, Tabuk 71491, Saudi Arabia. Email: firstname.lastname@example.org.
Competing interests: No competing interests
Thanks for this important and interesting article. Prevention is an important aspect in planning for improving health in the community. Also one of the essential parts of prevention is increasing public awareness about the importance of their role in adapting healthy habits to prevent infectious diseases and also non-infectious diseases; this needs to be organized in health education programmes for different age groups.
DR. Yousef Abdullah Al Turki
Associate Professor and Consultant family Medicine
King Saud University, college of medicine
Family and Communuty Medicine department
Riyadh, Saudi Arabia
March 6, 2014
Competing interests: No competing interests
Previously we thought that the main danger in the future is antibiotic resistance due to careless overuse of antibiotics by doctors over the years, for whatever reasons.
New and emerging infectious diseases in the past 60 years suggest that just under two thirds were transmitted from animals, with just over 70% of these from wild animals and the rest from domesticated animals.
One emerging infection, Middle East respiratory syndrome coronavirus (MERS-CoV), which was first reported in 2012, may be associated with dromedary camels. Globalisation and foreign travel is ever increasing and that has its own implications especially with new convergences of people, animals, and the environment. This research has highlighted its impact on altering the ecosystems, providing some microbes with the opportunity to breach species barriers.
Furthermore we humans behave like wild animals and disturb the animal habitats. In addition, the overall population in the underdeveloped countries like Asia and Africa doesn't help either, as it increases the demand for more meat. This study reminds us of the following list of things been caused by us:
Human encroachment, mineral extraction, deforestation, habitat fragmentation, urbanisation
Food and agriculture systems—intensified or expanded farming systems, greater livestock density, trade networks and globalisation, unregulated use of drugs and vaccines, livestock mixing patterns, biodiversity
Human behaviour—hunting and consumption practices, cultural patterns, increased travel, breakdown of governance
Environmental systems—climate change, natural disasters, periodic climate systems.
Talking of natural disasters, the UK has experienced one of the worst winter storms this year. Although the worst is hopefully over, the implication of any outbreaks of infections is being assessed by environmental and health officials. Preventive measure are being taken especially where homes are flooded and there is a possibility of water contamination. The UK, being a developed country, can possibly cope with the cost of taking such measures, but underdeveloped countries may not be able to do so. Those countries would certainly need financial assistance from the World Bank. All the nations of the world have to face this new challenge as one nation and help each other to take measures of preventing new emerging infection. This involves close cooperation and prompt notification of infections to infection reporting agencies the WHO. In addition, veterinary professionals , ecologist and forest officers can contribute significantly to overcome this new emerging infections.
Competing interests: No competing interests