Are we living in an age of outbreaks?
With Warm Easter Greetings & Prioritising Oral Health in Public Health
Dear Friend of Global Health Conversations,
Happy Easter! ❤️ I hope that you and yours have had a wonderful Easter weekend. And if you were just about to reach for another ovoid shaped piece of chocolate, this fortnight’s podcast episode’s insights from Dr Ema Prohić on the relationship between nutrition and oral health might be just for you. No shame, just some Easter nuggets of knowledge and a really great chat.
This fortnight I thought a little about if we are indeed living in an age of outbreaks and jotted these down below. No official Fortnight in Resources for the first time in a long time, but if you’d like to catch up on the latest on the Pandemic Accord, I recommend checking out Geneva Health Files that has been breaking down the updates on the negotiations.
I’m excited about the end of winter and the start of spring. I find myself worrying more about climate change at certain times of the year. Over the years I have come to love the sunshine and cloudless skies just as much as frosty, snowy, cozy winter days. Reading and Listening: I rediscovered Florence & the Machine this fortnight. An old favourite. As well as this Angie Stone banger that I found myself humming out of the blue. I finished The List of Suspicious Things - it was absolutely beautiful and touching. I also finished an old Nancy Mitford novel which I’m sorry to say was solidly cute enough but frankly far too frivolous and poorly aged to genuinely recommend in any forum.
One last thing. If you listen to the podcast from time to time and read this newsletter, I would appreciate if you left me a cheeky little 5-star rating wherever you listen. It helps other people find it and it means a lot to me. 🙂
Until next fortnight, Friend. Have a great one.
With love
C
Latest Episode:
Dental Dialogue: Prioritising Oral Health in Public Health (ft. Ema Prohić) - Part 1
Ema and I discuss oral health as a public health issue. Discussing system challenges, incentivisation and disincentivasation, dental caries as the most common infectious disease, bacteria and the use of antibiotics. We also discuss a public health project that I led back in 2020 with the Ministry of Health Qatar and PHCC wherein she focussed on integrating oral health into a primary care program. Ema is a doctor of dental medicine from Croatia, currently undertaking her specialization in orthodontics and facial orthopedics in Barcelona, Spain. She started her professional career as a dentist in the UK after completing her MSc in International Health Management at Imperial College Business School and has continued working in the UK in several dental practices as an NHS and private practitioner.
Are we living in an age of infectious disease outbreaks?
Yes. And no. There are many causal reasons for outbreaks of infectious diseases and why we might be seeing a higher incidence of infectious disease outbreaks in general. That said, there may be numerous, intersecting world trends that lend themselves to provoke outbreaks of infectious diseases making them more likely and more common.
Already controlled infectious diseases
Measles is a deadly disease and one of the most contagious viral diseases in the world. It was declared controlled in the United States through vaccination efforts in the year 2000. This is relatively recent and underlines how important it is not to undermine or take for granted the routine childhood immunisation efforts that have provided so many public health gains and saved so many lives. Measles vaccination was introduced in 1961 and was found to be 100% effective.
World Health Organization (WHO) reported a significant rise in measles cases and deaths for 2022, with over nine million cases and 136,000 fatalities globally. You might recall that in the late 2000s and 2010s, the MMR (mumps, measles & rubella) vaccine became the subject of now fully debunked criticism and theories that took hold particularly in the US & UK as well as other, predominantly high-income countries.
The increase in measles outbreaks is attributed to disruptions in vaccination programs, including during the COVID-19 pandemic, leading to doubling the number of affected countries to over 50. While vaccine misinformation contributed to hesitancy, the primary barrier to vaccination remains access and service quality. The WHO has emphasized the importance of vaccine pre-qualification as assurance of their safety and efficacy.
Additionally, concerns were raised over Hepatitis E. The Strategic Advisory Group of Experts (SAGE) also pointed out the limited circulation of wild poliovirus - now controlled - and the emergence of vaccine-derived polio strains in Africa.
In the United States, measles outbreaks have coincided with the country's lowest child immunization rates in a decade. The decrease in vaccination rates, largely due to parental exemptions, has left approximately 250,000 under 5s at risk. The CDC highlighted a national MMR vaccine coverage of 93%, below the herd immunity threshold.
Lifestyle based infectious diseases
Another infectious disease that is on the rise is dental caries. The global burden of this largely lifestyle based infectious disease has increased. And this is something that I discuss on this fortnight’s podcast episode with Ema.
Dental caries is no longer viewed solely as a consequence of individual pathogens but as a consequence of dysbiosis within the oral microbiome. Longitudinal studies demonstrate shifts in microbial composition preceding caries diagnosis, emphasizing the complex interplay between various bacterial species and environmental factors. Nevertheless, the primary driver of dysbiosis is the frequent consumption of sugars, leading to acidic conditions favoring acid-producing microorganisms. Thus, dental caries is now technically recognized as a non-communicable disease (NCD), sharing risk factors with other chronic conditions.
Ultimately, a shift towards preventive strategies and interdisciplinary collaboration is essential for mitigating the global burden of dental caries and improving overall public health. Global initiatives like the WHO's oral health strategy are gaining momentum and more and more, infections like dental caries will be treated as NCDs.
Novel infectious disease outbreaks
So, talking about factors that cause outbreaks in the first place; or provide optimal conditions to encourage viral mutation increasing the likelihood of optimised viruses -
Climate change is increasingly being recognized as a key driver of infectious disease outbreaks, with global warming contributing to the spread of diseases beyond their traditional tropical zones into temperate regions. A review in Nature Climate Change highlighted that 58% of 375 infectious diseases studied are exacerbated by climate change. Diseases such as dengue and chikungunya are expanding their geographical reach, putting half the world's population at risk. This expansion is partly due to warmer climates allowing pathogens and their vectors, like mosquitoes, to inhabit new areas. For example, flesh-eating bacteria Vibrio vulnificus, which thrives in warm waters above 20°C, has seen an eight-fold increase in infections along the US east coast between 1988 and 2018. Similarly, erratic weather conditions are linked to cholera outbreaks, and mosquitoes carrying malaria and dengue are reaching higher altitudes and new regions. This shift poses significant health challenges, particularly in areas previously unexposed to such diseases, underscoring the need for global attention to the impacts of climate change on health.
Raina Plowright, an infectious disease ecologist, emphasizes that pandemics primarily stem from ecological issues—spillovers of viruses from animals to humans driven by the intricate relationship between wildlife, habitat, climate, and human activity. Despite the focus on biomedical solutions once an outbreak begins, there's a critical need to address its ecological origins if the goal is also to prevent outbreaks. A One Health approach is proposed that considers the entire ecosystem, including animals, microorganisms, and the environment, highlighting the importance of ecological interventions, such as protecting natural habitats and implementing measures to minimize human-wildlife conflict, to prevent zoonotic spillovers.
This approach emerged largely from extensive research on bats and in todays application, suggests that maintaining and restoring natural environments can significantly reduce the risk of future pandemics, advocating for a balanced integration of ecological and biomedical approaches in pandemic prevention efforts. (More on protect bats)
Existing, recurring endemic disease outbreaks - bigger than before
The first human case of Mpox was discovered in 1970. In 2022 the most recent outbreak began with individual cases being identified in the United Kingdom and the United States - generally following the pattern of other, recent viral endemic disease outbreaks that made headlines when discovered far from their source. We live in a global world - so outbreaks will travel faster and further today than in the past.
This fortnight, public health experts are sounding the alarm over a significant outbreak of mpox in the DRC, highlighting a ‘triple threat’ that complicates the global response. Firstly, the DRC is experiencing unprecedented levels of mpox, with around 400 suspect cases reported weekly, primarily among children. Secondly, the circulating strain, known as Clade I, is particularly lethal, with a fatality rate of up to 10%. Unlike Clade II, which is less deadly and was responsible for the global outbreak, Clade I has caused the majority of infections in children under 15 in the DRC. Thirdly, the virus is presenting new challenges; it's appearing in new areas, affecting new populations, including sex workers, and spreading in novel ways, while also evading some diagnostic tests.
Experts have express concern over the lack of established countermeasures for mpox, contrasting the situation with better understood diseases like measles, cholera, and polio. The DRC recorded over 14,500 suspected cases and 650 deaths last year, a significant increase over previous years. The virus typically spreads in remote, densely forested villages, often starting from zoonotic transmission and then moving within communities through close contact. The high fatality rates among children, changes in virus behavior, and challenges in disease management underscore the urgent need for a global health response. The outbreak's potential for greater regional spread highlights the evolving epidemiological landscape. This situation calls for increased research, resources, and international cooperation to manage the outbreak effectively.
Behind the scenes:
So much goes on in this (otherwise) sleepy city. Some of you might know that I am a proud UCL alumna. I am organising an alumni networking in Geneva with the UCL alumni society in May. Here’s the sign up link if you’re interested. This fortnight I scoped out the venue, did some planning, relaxed at the spa (thank you, Leena), went to pilates, breathed deeply and received a lovely postcard from Japan from two, dear friends.
Recent Episodes: In case you missed them! 💃🏾
Episode 15: Why do Americans pay (so much) more for healthcare?
In this solocast we discussed the cost of medical care. Particularly, I attempted to answer the question: Why do Americans pay (so much) more for healthcare? With my health economist hat on - I looked into transparency, drug prices and administrative costs. But are these only reasons that the US has the world’s third highest out of pocket health expenditure? And, moreover, how does this affect patients and patient outcomes?
Episode 16: Tackling Cervical Cancer: Health Equity in Focus (International Women's Day Special)
This episode is in recognition of International Women's Day. We talk about cervical cancer and discuss its significance as a symbol of global health disparities and gender inequality. Cervical cancer incidence is exacerbated by socio-economic factors and disproportionately affects women in poverty. We discuss the importance of HPV vaccination, regular screening, and innovative prevention strategies like diagnostic tools to enable self-sampling. And the incredible toll of the devastating disease.
If you enjoy this newsletter, please share or forward it to a friend. :)
Yours,
C