British Medical Journal – 18 October 2014

British Medical Journal
18 October 2014(vol 349, issue 7979)

Editor’s Choice
Ebola: will enlightened self interest spur us to act?
BMJ 2014; 349 doi: (Published 16 October 2014) Cite this as: BMJ 2014;349:g6254
Fiona Godlee, editor in chief, The BMJ
More than 4400 people are now reported to have died in the Ebola epidemic in west Africa (doi:10.1136/bmj.g6255), and the US Centers for Disease Control has estimated that as many as 1.4 million people may be infected by the end of January. Fatality rates are reported to be around 50%. Health infrastructure in the three worst affected countries was already struggling but is now close to total collapse. The limited ranks of trained healthcare workers have been decimated by disease, exhaustion, and fear. Almost 200 healthcare workers are known to have died.

The head of the charity Médecins Sans Frontières, Joanne Liu, describes the desperate situation in an interview with The BMJ published this week: “Local doctors have been extremely brave, but we are running out of staff” (doi:10.1136/bmj.g6151). And she herself is “running out of words to convey the sense of urgency.” She acknowledges that the capacity of rich nations to respond to distant crises has been stretched like never before in recent months. This year MSF has deployed more staff in more countries than ever before.

What we now need are well trained and well equipped boots on the ground. Liu wants to see bioterrorism teams that countries set up after 9/11 to be deployed to fight Ebola. Countries with historical links to the region, mainly the United States and United Kingdom, are sending (or promising) troops to set up treatment centres. This week Andy Johnston and Mark Bailey describe Operation Gritrock, which has just sent British army medics to Sierra Leone to set up a treatment centre for health workers (doi:10.1136/bmj.g6237). But the response of other countries, Liu says, has been slower and hands off. “Everyone is looking for excuses not to deploy because they are so scared,” she says.

Perhaps the only real hope for spurring capable countries into action is enlightened self interest. So the fact that the United Nations Security Council has declared the outbreak a threat to international peace and security should help. So too should the now real threat of spread of the disease beyond west Africa. But so far screening at airports is almost the only result (doi:10.1136/bmj.g6199; doi:10.1136/bmj.g6147). This may be reassuring to travellers and citizens, but our editorialists David Mabey and colleagues say it is false reassurance and a waste of money (doi:10.1136/bmj.g6202). Previous experience from the severe acute respiratory syndrome (SARS) epidemic should have told us this, they say. Airport screening for SARS in Canada cost $C17m (£9m; €12m; $15m) and identified not a single case.

Mabey and colleagues have done the sums for Ebola. With an incubation period of 21 days—and assuming that people who want to make the journey may hide symptoms and signs—screening to prevent people boarding flights is likely to fail, and screening on entry to a country will have “no meaningful effect on the risk of importing Ebola.” Far better, they say, to provide clear information to those who may be at risk on how and where to seek care. This would be as effective as screening at a fraction of the cost. In a letter this week Sunday Oluwafemi Oyeyemi and colleagues confirm the need for clear and accurate information on how to prevent and treat Ebola infection (doi:10.1136/bmj.g6178). Their review of information shared on Twitter within affected countries shows a high prevalence of misleading information, some of which, such as the advice to drink salty water, is known to have killed people. Governments should use Twitter to spread correct information and amend misinformation, they say.

Liu and MSF have been the voice of absolute humanitarian ideals. Many health professionals and military personnel will, as individuals, rise to that same level of moral courage. For the rest, enlightened self interest is not so bad and is better than nothing. But let’s spend our resources on the right things. Not airport checks but, as Mabey and colleagues conclude, immediate scaling up of our presence in west Africa, building new treatment centres at a rate that outstrips the epidemic. This would not only help the people in affected countries but reduce the risk of the Ebola virus spreading elsewhere.

Airport screening for Ebola
BMJ 2014; 349 doi: (Published 14 October 2014) Cite this as: BMJ 2014;349:g6202
David Mabey, professor, Stefan Flasche, lecturer, W John Edmunds, professor
Author affiliations
Will it make a difference?
On 9 October the UK government announced that “enhanced screening” for Ebola virus disease will be implemented at Heathrow and Gatwick airports and Eurostar terminals. Details of how this will be done are not yet available, but the objectives presumably are to identify people arriving from Sierra Leone, Guinea, or Liberia who may have been exposed to Ebola, assess whether they have symptoms consistent with Ebola, test those who do, and isolate anyone with positive results.

Several practical difficulties will need to be overcome to achieve these objectives. As most direct flights to the UK from Sierra Leone, Guinea, and Liberia have been discontinued because of the epidemic, passengers will be arriving from various European cities, and itineraries will need to be carefully checked to identify passengers arriving from those countries. Those who are identified will be asked to complete a questionnaire stating whether they have been in contact with sick people or have attended funerals in west Africa, and whether they have symptoms such as fever, headache, diarrhoea, or vomiting. People who answer “yes” to any of these questions will presumably be referred to a health official, which is likely to lead to considerable delays; this would not be an incentive to fill in the form honestly. A thermal scanning device may also be used to check passengers’ temperature on arrival, but it is unclear what will happen to those found to have a fever. Most will not have Ebola. Even if testing facilities are on site, substantial delays to large numbers of passengers seem inevitable, and isolation of all passengers waiting for their test results may prove challenging.

The World Health Organization recommends that passengers on international flights out of Sierra Leone, Guinea, and Liberia should be screened for evidence of Ebola before boarding their flight. Those with symptoms or a raised temperature should not be allowed on the flight. Clearly, identifying people with Ebola before they board an international flight is a desirable objective. But how well does this system work in practice? Data are not available on the number of passengers denied entry to a flight during the current epidemic, but there are strong incentives for those wishing to fly to deny symptoms even if they have them and to take an antipyretic such as aspirin to bring down their temperature if they have a fever.

Lack of evidence
Is there any evidence that screening travellers arriving at international airports is an effective way of identifying those with serious infections? The data from Canada, which introduced airport screening during the SARS (severe acute respiratory syndrome) epidemic, are not encouraging. A total of 677 494 people arriving in Canada returned completed questionnaires, of whom 2478 answered “yes” to one or more question. A specially trained nurse referred each of these for in-depth questioning and temperature measurement; none of them had SARS. Thermal scanners were installed at six major airports. Of the 467 870 people screened, 95 were referred to a nurse for further assessment. None of them was confirmed to have a raised temperature. The cost of this unsuccessful programme was $CA17m (£9m; €12m; $15m).1

Why was this measure so ineffective, and could it work now? During the SARS epidemic a simple model was used to assess the fraction of cases that could be detected by entrance screening.2 Assuming that people with symptoms are not allowed to board, entrance screening can only pick up those who develop symptoms while travelling. The longer the incubation period in relation to the flight duration, the lower the chance that this will happen, and the lower the yield from entrance screening. Updating the model using data on Ebola (incubation time 9.1±7.3 days3; direct flight from Freetown to London 6.42 hours), we estimate that, if everyone with symptoms was denied boarding,about 7 out of 100 people infected with Ebola travelling to the UK would have symptoms on arrival and hence be detectable by entrance screening (95% confidence interval 3 to 13). The other 93% would enter the UK unimpeded. If passengers arriving via Paris or Brussels (journey time about 13 hours) were not screened in transit, entrance screening in the UK could detect up to 13% of infected people (95% CI 7% to 21%). The majority would still enter the UK before developing symptoms. Only if patients are allowed to fly irrespective of symptoms would entrance screening be able to detect a substantial fraction of cases (43% if there is no direct flight, 95% CI 34% to 53%).

People who know they are at risk and develop symptoms will want to seek care immediately, as they will fear for their lives. The priority should be to provide information to all those who may be at risk on how and where to seek care. This would be as effective as screening at a fraction of the cost.

Adopting the policy of “enhanced screening” gives a false sense of reassurance. Our simple calculations show that an entrance screening policy will have no meaningful effect on the risk of importing Ebola into the UK. Better use of the UK’s resources would be to immediately scale-up our presence in west Africa—building new treatment centres at a rate that outstrips the epidemic, thereby averting a looming humanitarian crisis of frightening proportions. In so doing, we would not only help the people of these affected countries but also reduce the risk of importation to the UK.
Using the infrastructure of a conditional cash transfer program to deliver a scalable integrated early child development program in Colombia: cluster randomized controlled trial
Orazio P Attanasio, Jeremy Bentham chair of economics1, Camila Fernández, senior survey researcher2, Emla O A Fitzsimons, professor of economics3, Sally M Grantham-McGregor, emerita professor of international child health4, Costas Meghir, Douglas A Warner III professor of economics5, Marta Rubio-Codina, senior research economist6
Author affiliations
BMJ 2014; 349 doi: (Published 29 September 2014) Cite this as: BMJ 2014;349:g5785
To assess the effectiveness of an integrated early child development intervention, combining stimulation and micronutrient supplementation and delivered on a large scale in Colombia, for children’s development, growth, and hemoglobin levels.
Cluster randomized controlled trial, using a 2×2 factorial design, with municipalities assigned to one of four groups: psychosocial stimulation, micronutrient supplementation, combined intervention, or control.
96 municipalities in Colombia, located across eight of its 32 departments.
Participants 1420 children aged 12-24 months and their primary carers.
Intervention Psychosocial stimulation (weekly home visits with play demonstrations), micronutrient sprinkles given daily, and both combined. All delivered by female community leaders for 18 months.
Main outcome measures
Cognitive, receptive and expressive language, and fine and gross motor scores on the Bayley scales of infant development-III; height, weight, and hemoglobin levels measured at the baseline and end of intervention.
Stimulation improved cognitive scores (adjusted for age, sex, testers, and baseline levels of outcomes) by 0.26 of a standard deviation (P=0.002). Stimulation also increased receptive language by 0.22 of a standard deviation (P=0.032). Micronutrient supplementation had no significant effect on any outcome and there was no interaction between the interventions. No intervention affected height, weight, or hemoglobin levels.
Using the infrastructure of a national welfare program we implemented the integrated early child development intervention on a large scale and showed its potential for improving children’s cognitive development. We found no effect of supplementation on developmental or health outcomes. Moreover, supplementation did not interact with stimulation. The implementation model for delivering stimulation suggests that it may serve as a promising blueprint for future policy on early childhood development.
Only the military can get the Ebola epidemic under control: MSF head
BMJ 2014;349:g6151 (Published 10 October 2014)
Operation Gritrock: first UK army medics fly to Sierra Leone
BMJ 2014;349:g6237 (Published 14 October 2014)