Archive for global-health-academy

From the normal to the uncertain

An Earthquake is a massive event in every way, it quite literally shakes you out of your normal life and immediately throws you into uncertainty.

Unlike a hurricane or typhoon you can’t see it coming and you don’t know exactly when you will be in the clear. It is precisely this uncertainty that makes the union of individuals, communities ,governments and organizations in the relief efforts following an earthquake all the more remarkable.

All of those who arrived in Nepal following the quake have no certainty that they will not experience an aftershock that might again throw everything into chaos. They are putting their lives at risk just as much as those of us who experienced the quake on April 25th. They have all come together , Saudi Arabia, South Africa, Israel, France, China, the United States and many more ignoring the usual political tensions that exists between nations to work together. Despite the press the government of Nepal has received we have witnessed hundreds of government officials of all levels working tirelessly to deliver aid, to make sure the wounded receive treatment and that people have shelter.  There are also amazing local NGOs here in Nepal such as BibekSheel that alone has delivered more than 10 tons of aid to Gorkha , that’s more than most large INGOs have delivered!

All of the Nepalis who have worked non-stop during this response have left their own families and homes to help others in their country. Many have suffered damage to their own houses but have chosen to give to others. While the disaster here in the Kathmandu valley and in other districts in Nepal has been devastating, underneath that layer of debris and ruble that we see on television is : dedication, caring and a deep love for humanity from all who are here and all who have come to serve.

Let’s lift that debris off and let those values be seen both here on the ground in Nepal and in each of our lives every day.


Jay Evans, Regional Director , Asia for Medic Mobile
Jay Evans TH





Twitter: @jaymedicmobile

Why it is critical to genotype the causative agents of tuberculosis

Sun Tzu, a Chinese military philosopher in the 6th century BC, said “ if you know your enemy and yourself, you will not be imperiled in hundred battles”.

If not taken in literal terms, it would suggest that learning more about the humanity and livestock’s arch enemy Tuberculosis (TB), with whom we have been battling for millennia, can only arm us all the better for the fight.  As part of this battle, The University of Edinburgh has long been contributing to the research and development arm of the World Health Organisation’s “Stop TB Global Strategy”. 

The WHO has achieved the 2015 Millennium Goal of halting and reversing the incidence of the disease.  Despite this great acheivement, in 2013 alone the WHO registered 9 million cases of TB, half a million of which succumbed to the disease.  Horrifyingly this latter number loosely translates to four super jumbo jets crashing every day for the entire year.  Going forward to 2035, the WHO has set yet more ambitious goals to end the global TB epidemic with corresponding targets of 95% and 90% reduction in TB deaths and incidence respectively.

Knowing your enemy

In order to achieve this mighty aim, now more than ever, it is critical for the definitive diagnostics to not only reveal the mycobacterial species but also the genotype.  The majority of cases of human TB are caused by Mycobacterium tuberculosis, however a small, but significant geographically-limited, proportion is due to Mycobacterium bovis the causative agent of bovine tuberculosis. The latter is what is commonly referred to as zoonotic tuberculosis. The current statistics shows that when considered as a proportion of the global TB burden, zoonotic tuberculosis accounts for a small proportion however, if reported in absolute terms it translates to between 95,000 and 150,000 cases of which 15% succumb to this disease form globally. It is noteworthy that 9 out of the 22 high-burden TB countries are responsible for ~70% of the global zoonotic TB cases.

Vaccination as a defence against infection

In general, vaccination is an effective method of controlling infectious diseases.  The BCG vaccine, developed agianstM. bovis, is the most widely administered TB vaccine in the world.  However its varied efficacy globally has always been a challenge to the TB control strategy.  If the endemic population of infective bacteria is different from that contained in the vaccine, this can lead to vaccine failure.  Vaccines that target a narrow range of phenotypes may not offer sufficient prevention against infections in settings where multiple different strains of the infective agent may be present.

This is particularly relevant to areas where several different strains of M. bovis are prevalent, and where the TB burden is correspondingly high. It is also reasonable to argue that some of the TB treatment failures in these areas are likely due to species and genotypes un-accounted for in the treatment protocols.  Thus it is critical to document the diversity of M. bovis, and use this data to increase the phenotypic range in novel vaccines, thereby improving patient immunity.

Sequencing the genomes of the bacteria that cause TB

The currently documented genotypes of M. bovis in high-burden settings lack “granularity” because they are based on PCR methods that target less than 0.005% of the genome.  It is therefore likely that niche and host-specific polymorphisms that are critical for population-based vaccine implementation, are left unused in determining these genotypes.

This disparity in genotype diversity and breadth of target phenotype is likely part of the reasons why the efficacy of BCG vaccination is lowest in Africa.  A solution to this comes in the form of whole genome SNPs based genotyping, which offers high definition genotyping power capable of revealing subtle niche and host specific diversity.

Large international collaboration fighting the disease

Researchers from the University of Edinburgh are now part of a large international collaboration that will sequence and genotype 254 isolates of Mycobacterium bovis from eight African high burden countries.

They will be working alongside colleagues from eight African research institutions, and from the United States Department of Agriculture, Colorado State University, the University of Georgia, the University of Tromsø, theNorwegian Veterinary Institute, and the Norwegian University of Life Sciences.

The new data the team generates will be made freely available for researchers and industry involved in TB vaccine, diagnostics and therapeutics development.  By piecing together more and more information about the strains of Mycobacteria causing TB in different areas, researchers will generate the ammunition needed to finally defeat TB.

adrian m a


                    Adrian Muwonge (DVM, MSc, PhD), Research Fellow, Roslin Institute, 

                   Edinburgh Infectious Diseases, University of Edinburgh, UK








Unhealthy investments

I have been involved with the fossil fuel divestment movement over the past year, both with the University and through Healthy Planet UK, after coming to terms with the enormity of climate change and the need for urgent action. As a medical student I am compelled by a similar duty of care towards our ecosystem, on which our health depends, and am called to respond to its current symptoms of distress. Divestment offers a way to treat one of the root causes of these symptoms – the continued burning of fossil fuels – through moving investments away from the fossil fuel industry whose business model relies upon burning reserves which currently hold over five times that which is safe to burn if we are to stay below the 2 degrees celsius limit of global warming[1] Akin to the health sector leading divestment from the tobacco industry, there is a similar narrative in the response to the health threat of climate change further weighted by tactics utilised by the fossil fuel industry to thwart climate mitigation policy and mar public perception of the reality of climate science[2]. UK universities hold around £5.2 billion worth of investments through their endowment funds in the fossil fuel industry[3]. However, divestment is not simply a matter of money, most divestment decisions have been driven by a moral case. It rests on a simple principle -if it is wrong to wreck the planet, then it is wrong to profit from that wreckage. For the medical tradition investing in fossil fuels can be seen to contradict the fundamental principle to “first do no harm”. So far 21 universities, 35 cities, 65 religious organisations and numerous other organisations from around the world including the British Medical Association have committed to divesting from fossil fuels[4].


Medical institutions and the health community have a unique awareness of climate change through its current and future impacts on human health, but also through the potential immense health co-benefits of tackling climate change such as reducing the disease burden of air pollution, which has been attributed to 2000 premature deaths annually in Scotland[5], and encouraging active travel through reducing our reliance on fossil fuel guzzling cars. This gives an important dimension to the divestment dialogue and the engagement of medical schools and health organisations is sure to be very valuable. On the 3rd February, Healthy Planet are publishing their report “Unhealthy Investments”, co-authored with MedAct, The Climate and Health Council, Medsin and the Centre for Sustainable Healthcare. This will be a crucial step towards further engagement on fossil fuel divestment from the health sector. It will involve a panel of expert speakers to discuss the question of whether organisations which work to improve health should continue to invest in fossil fuel extraction and production companies. Should the health sector be taking more of a lead in this issue? There is certainly great potential in engaging with the process and evaluating how best our pension and endowment funds can be invested towards a healthier and more sustainable future.


More information on the report launch can be found here:










Eleanor Dow – Medical student at the University of Edinburgh and coordinator of Healthy Planet UK, a network of students raising awareness of the links between climate change and health.


Global mental health – its time to pull together

The recent report from the UK’s All-Party Parliamentary Group on Global Health and Mental Health (MH) is very welcome. Not only does it describe the parlous state of MH services in many parts of the world, it presents an evidence-base for global action. It is important to acknowledge, for example, that patients can be caged, chained or subjected to abusive traditional approaches and that Western mental health services are not all bad. The report summarises the growing body of research showing that there are cost-effective solutions to mental health problems that even the poorest countries could implement and benefit from. These include improving social and economic environments, integrating mental health into general health care, using trained and non-specialist health workers to provide culturally appropriate community care, increasing access to self-help and empowering people with mental health problems to support and advocate for themselves and each other.

Further, and more specifically, the WHO (1) have previously shown that interventions such as psychosocial and antidepressant treatment are ‘very cost-effective’ interventions for panic disorder and depression throughout the world, and that psychosocial treatments plus older antipsychotic and mood stabilising drugs are ‘cost-effective’ for schizophrenia and bipolar disorder.

Another report released in November, from the Overseas Development Institute (2), gives a complimentary perspective – mental (ill) health does not receive due policy attention due to stigma and a lack of coherence across the mental health community. The time has come for the mental health community to work together to achieve shared goals such as reducing stigma and increased funding for MH services across the globe.



Professor Stephen Lawrie, Head of Psychiatry, University of Edinburgh


1.Chisholm D, on behalf of WHO-CHOICE. Choosing cost-effective interventions in psychiatry: results from the CHOICE programme of the World Health Organisation. World Psychiatry 2005; 4: 37-44.
2. Mackenzie J. Global mental health from a policy perspective: a context analysis. Overseas Development Institute 2014.

Reflections from the HIV, Human Rights and Development (HHRD) Network on World AIDS Day, December 1, 2014

The Joint United Nations Programme on HIV/AIDS (UNAIDS) (2014) Report “Fast-Track: Ending the AIDS epidemic by 2030” provides more than a beacon of hope on World AIDS Day 2014.

It states boldly that “The world is embarking on a Fast-Track strategy to end the AIDS epidemic by 2030”.

It envisages that if the world scales up its HIV prevention and treatment programmes and reaches certain fast-track targets or goals, it will manage to prevent almost 28 million new infections and more crucially “end the AIDS epidemic as a global health threat by 2030”.

The report points to a number of “fast-track targets” that need to be achieved in the next five years by 2020. These optimistic targets include: attaining a 90-90-90 target, i.e. 90 percent of people with HIV knowing their status, 90 percent of those who know their status being on treatment, and then 90 percent of those on treatment suppressing the virus. For the year 2030, this goal goes up to 95-95-95. New infections will be reduced by 75 percent to 500,000 by the year 2020, and then to 200,000 by 2030. And, it points to the overarching goal of zero discrimination and zero tolerance for both years—2020 and 2030.

However, to achieve this monumental, yet attainable goal, the report cautions that “countries will need to use the powerful tools available, hold one another accountable for results and make sure that no one is left behind”.

We at the HHRD Network believe that the commitment to human rights will provide the bedrock of the AIDS response, and that human rights will need to remain in the fore front of all efforts. Moreover, that there is a need for a sustained and continued investment to build and promote the capacity of health systems all over the world, but particularly in the context of developing countries and forced migration. We need to consider on how best we can attain the theme of World AIDS Day 2014 to “Focus, Partner, Achieve: An AIDS-free generation – to highlight the need to for governments and health officials, NGOs and individuals to address AIDS prevention and treatment”. And, finally, the “fast-track targets” need to be held closely by all players across the globe if we are to not just bend the epidemic trajectory, but to break it irreversibly”.


Dr George Palattiyil and Dr Dina Sidhva

Joint Convenors, HIV, Human Rights and Development Network

Critically Analysing the IFC’s Health in Africa initiative’s opportunistic strategy to reach the poor.


 In September 2014 Oxfam released a report entitled: Investing For the Few: The IFC’s Health in Africa Initiative. Their report highlights the lack of transparency within the International Finance Corporation’s (IFC) Health in Africa (HiA) strategy and the overall lack of monitoring and evaluative (M&E) institutions.1 Concluding that the IFC has done little to demonstrate the role of the private health sector in pro-equity health system strengthening.1

Earlier in 2014, I had completed my own research attempting to answer: To what extent has the IFC’s HiA initiative improved financial protection and access to quality health goods and services for the poor?

My research objectives were to map the IFC’s HiA activities by workstream, then use peer-reviewed and grey-literature (including World Bank monitoring and evaluation data) to investigate the extent to which HiA interventions (from analysis, to policy, to type of investment) improved health outcomes for the Sub-Saharan Africa’s poor.

This proved to be a difficult endeavour, as the IFC’s lack of transparency in HiA’s operational strategy, access/publication of information, and results frameworks, made it difficult to understand how the IFC was taking an opportunistic approach in HiA’s analytic, policy, and investment interventions to improve financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor.

Lack of Transparency

In Spring 2014 I had requested (via the World Bank and the IFC’s online information request portals) the following documents: (1) A country/client specific operational plans and corresponding Results Measurements Frameworks; and (2) HiA’s Equity Investments Framework. These M&E institutions were chosen for request, as the nature of these documents fall under SECTION III, Information Routinely Made Available by IFC, in IFC’s (2012) Access to Information Policy.2 Within a week of the request, the World Bank responded with directions to forward this request through the IFC portal. Unfortunately the IFC has yet to respond, although had initially promised a response within 30-working days of a request.

Interesting to note, Oxfam (2014) has reportedly requested HiA’s Results Framework, only to be unsuccessful in their request as well. Oxfam (2014) and the Health in Africa Mid-Term Report (MTR) (2012) have both commented on the lack of transparency within the IFC and their trouble with defining HiA’s anticipated results. Leading to difficulties in understanding, measuring, and evaluating HiA’s opportunistic pathway in order to measure the extent to which the HiA initiative is reaching the poor.1,3 The Independent Evaluation Group (2014) have also recognized this lack of transparency and how little the IFC is engaged with creating M&E institutions.4

In line with my own findings, both Oxfam and the MTR have recognized the difficulties in measuring the extent to which HiA was improving financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor.1,3

HIA performing Poorly

Overall, the HiA initiative is implemented over three workstreams (Analyses, Policy, and Investment) to: provide analytic products on Sub-Saharan Africa’s public and private health sectors, assist governments with health policy, and to improve access to credit for private health small- to medium-sized enterprises through equity funds, debt financing and technical assistance.5 In 2011, foreign direct investments were included/added in the HiA Factsheet as a new component of HiA’s investment workstream.6

Research revealed HiA’s Analytic workstream failed to provide a direct analysis linking the IFC’s private health sector interventions with improved health outcomes for the poor.2 Failure to provide this analytic link prompted the IFC to take an opportunistic operational strategy to understand which pathway (from analysis, to policy, to type of investment) works best to meet the IFC’s stated HiA development objectives.7

Consequently, the IFC’s HiA analytic and policy workstream activities were implemented based on the opportunistic strategy that they would create a sustainable investment climate and encourage a socially responsible private health sector to facilitate investments and help meet the estimated US$11-20billion in demand for private health goods and services.8 My findings, however, revealed that the IFC’s HiA investment activities have so far demonstrated little to no capacity to achieve the IFC’s stated HiA development objectives.

Additionally, without any of the IFC’s M&E institutions available (either publicly or upon request) I was unable to understand how the IFC was taking an opportunistic approach to find the best pathway/mechanism (from analysis to policy to type of investment) best improved financial protection and access to quality health goods and services for the poor.

Based on these findings, I question how the IFC is investing its resources for future HiA activities. Without available M&E institutions, the workstream activities which fail to improve financial protection or fail to improve access to health services may be insufficiently monitored and could potentially be continued and/or built-upon. Thus without published M&E institutions, it is possible for HiA activities to weaken Sub-Saharan Africa’s health systems and consequentially move it away from improving financial protection and access to quality health goods and services for the poor.9


If the IFC had adequate evidence to suggest it was improving health outcomes for the underserved through the HiA initiative, this would provide insight into the positive role of the private health sector in pro-equity health system strengthening. However, the evidence presented in my report suggested HiA is performing poorly to achieve the IFC’s stated HiA development objectives. Until M&E institutions are released, research will be unable to understand the extent to which HiA is increasing financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor. 

Publishing the IFC’s Health in Africa activities to Date




  1. Oxfam (2014) Investing for the Few – The IFC’s Health in Africa initiative. London: Oxfam Great Britain.
  2. International Finance Corporation (2012e) IFC Access to Information Policy. Washington: Office for International Finance Corporation World Bank Group.
  3. Brad Herbert Associates (2012) Health in Africa Mid-term Evaluation Final Report. Maryland: Office of Brad Herbert Associates prepared for the International Finance Corporation.
  4. Independent Evaluation Group (2014) World Bank Group Support to Health Financing for Improving Health Systems Performance FY03-FY12.Washington: World Bank.
  5. International Finance Corporation (2013) The Health in Africa Initiative – Improving the Role of Private Sector in Healthcare. Washington: Office for the International Finance Corporation World Bank Group. [Online]. Available at: [Accessed: 10 May 2014].
  6. International Finance Corporation (2011a) IFC – History. [Online]. Available at:$FILE/ifctFS.htm [Accessed: 30 May 2014].
  7. World Bank Group (2012) World Bank Group Management Response: Health in Africa Independent Mid-Term Evaluation. Washington: Office for International Finance Corporation World Bank Group.
  8. International Finance Corporation (2007a) The Business of Health in Africa – Partnering with the Private Sector to Improve People’s Lives. Washington: Office for the International Finance Corporation World Bank Group.
  9. Kutzin, J. (2013) Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organization, 91(8), p.602-611. PubMed Central [Online]. DOI: 10.2471/BLT.12.113985 [Accessed: 26 May 2014].


Danielle Howe is a recent graduate from the University of Edinburgh MSc in Global Health and Public Policy

What are the long-term consequences of deworming programmes?

Dr Francisca Mutapi, University of Edinburgh

What happens afterwards? This apocalyptic question is one that is integral to all forms of intervention in human and animal diseases. This is particularly important in cases where the intervention occurs at a national scale. My research group has been asking this question in relation to the current global efforts to control worm (helminth) infections which significantly impact on the health and development of children. Specifically, we work on bilharzia (urinary schistosomiasis) an important, but neglected infectious disease caused by the blood fluke Schistosoma haematobium. Although we hear occasional reports of tourists infected during visits to resorts in endemic areas, bilharzia is typically a disease of poverty due its association with poor sanitation and unsafe water. People become infected when they come into contact with the infective stage in freshwater after it has been released by freshwater snail- hence the other name of the disease- snail fever. The disease affects over 100 million people, mainly in Africa.  Children carry the heaviest burden of infection; as a result, they experience bladder and kidney disorders, stunted growth and poor development.

Current global initiatives from Partners of Parasite Control including the World Health Organization (WHO), Bill and Melinda Gates Foundation, UNICEF, Schistosome Control Initiative and the World Bank are advocating regular school-based de-worming interventions to reduce the development of morbidity, promote school-child health and improve cognitive potential of the children. Children are treated with the antihelminthic drug praziquantel. Over the past decade, there has been a concerted global effort to control bilharzia, galvanised initially by the Millennium Development Goal (MDG) 6 to combat HIV/AIDS, malaria and other diseases by 2015 and the World Health Assembly resolution 54.19 to treat at least 75% of all school-age children at risk of schistosomiasis by 2010. The most recent schistosomiasis resolution, World Health Assembly resolution WHA65.21 passed in 2012 is advocating for the elimination of schistosome transmission and the WHO Schistosomiasis Strategic Plan 2012-–2020 sets out its vision of for a world free from schistosomiasis. This represents a real drive at the global scale not previously seen, to control this important disease of childhood.

Millions of school children in Africa are currently being treated with this drug resulting in significant health improvements. In several countries where the control programmes are currently being implemented, they are typically running for 5 years. The questions we are asking is what will happen to 1) the children who have been treated, 2) the rest of the population that has not been treated and 3) the parasites? The overall, long-term outcome of these treatment programmes for human health is believed to be good- but what evidence do we have for this? In my research group, we are interested in the long-term consequences of praziquantel treatment. Our studies and those of others have shown that the effects of praziquantel treatment go beyond the transient reduction of infection intensity and morbidity. Treatment with the antihelminthic also reduces future pathology and induces immune responses protective against re-infection by the parasites. What will be the effect of the 5-year treatment programmes on the host immune system and overall health?  Experimental studies of the regulation of the immune system suggest that treatment of helminth infection results in susceptibility/worsening of immune disorders (explained through the hygiene hypothesis). What is the relevance of these studies to human helminth infection? What are the long-term health implications in children treated through these national treatment programmes? Similar to malaria, people exposed to schistosome parasites develop natural acquired immunity to the parasites following repeated infection with the parasites. What is the consequence of praziquantel treatment on schistosome immunity and disease, decades after cessation of the control programmes? Providing answers to these questions is critical for informing strategic planning for ministries of health and prioritisation of resources as well as formulating /directing global health policy.

These really interesting scientific questions and the potential impact of the findings for human health are the drivers of research for Dr Francisca Mutapi and her group, the Parasite Immuno-epidemiology Group, at the University of Edinburgh.



The health & environmental impact of global health research

“How does one cross the Atlantic in an environmentally-friendly way?” I asked myself.* A few weeks earlier I had been challenged by a fellow student who had attended a university-run course “Carbon Conversations”. I then began to reflect on the health and environmental impact of my global health research and to consider ways in which I might reduce my climate change burden. Struggling to find a satisfactory answer to my question, I approached a local sustainability advisor who explained that the alternatives to “door-to-door” air travel were likely to involve significant time costs and/or financial costs. No feasible alternatives. It was a disappointing response, especially after reflecting on the potential global health cost of spending over 20 hours on aeroplanes for my research. Could a solution be found to minimise the global health impact of overseas travel which remains essential for many studying and working in global health with limited time and restricted budgets?

It is widely accepted that high carbon usage and emission contributes to global climate change. Studies have reported that the likely direct health impacts of global climate change include those associated with an increase in heatwaves and a rise in vector-borne diseases such as malaria. Indirect health impacts may include sanitation problems secondary water shortages and malnutrition due to a rise in food costs as a result of reduced food production. People living in less developed regions are predicted to experience the greatest direct and indirect health impacts of climate change.

Hard policies are already being implemented by national and global bodies to reduce carbon emissions through initiatives such as improving rail networks and increasing taxes on fuel and high-emission vehicles. Could “softer” approaches at a local level be effectively employed by individual members of the working and studying global health community in order to tackle the problem of climate change which threatens to have a negative health impact on many populations? It is certainly never too late to consider this suggestion. It was only in 2013 that the UN Development Programme for Europe and Asia for the first time assessed the carbon footprint of one of its global health projects. We know that travel and transportation are important contributors to the climate change problem, and that many staff and students in global health are likely to travel for work purposes. Perhaps responsible travel is an approach and practice that could be promoted more widely and emphasised more strongly within the global health community.

Practically speaking, adopting this approach might mean that within academic departments of global health, individuals who plan to travel would be encouraged to consider and attempt to address the issue of climate change when writing project proposals, funding applications, dissertations, and theses. For example, a postdoctoral researcher applying for funding to attend a global health conference in Brussels might choose to budget for the additional time and financial cost of travelling to Paris by ferry and train. At the same time she could be offset these extra costs against savings made by booking more modest accommodation. Similarly, a PhD student involved in global health data collection in Asia might include a reflective paragraph in his thesis acknowledging the health impact of climate change due to travel. He could also describe the challenges encountered and steps taken to reducing the travel-related carbon emissions associated with his research.

Finally, we need to consider not only the immediate costs of changing our travel habits, but also the longer-term global health costs of not taking action to promote a low carbon future worldwide. Time and money are important and even when both are limited, global health workers and students can still explore and consider more responsible ways of travelling. If we choose to spend years studying and working to improve global health today, let us also choose to leave a shrinking carbon footprint that will have not have a significant negative impact on global health tomorrow .



Dr Anne Aboaja

Dr Anne Aboaja, is a Global Health PhD Researcher, Psychiatrist and Member of the Global Health PhD Network at the University of Edinburgh


Foot note

*When I asked this question, I did not have in mind ticking a box during an online airline booking in order to offset my carbon emissions. Instead I entertained the idea of spending a couple of weeks on a low-cost transatlantic crossing followed by a scenic, and possibly bumpy, road trip on public transport to my destination, sensibly using the time to read and critically review journal articles, write papers for publication, practise language skills, and creatively think through research problems encountered. Unrealistic? Maybe. Maybe not. In the spirit of sustainable global health? Definitely.



Hepatitis E Virus – An Emerging Infection in Scotland?


Globally, liver disease caused by hepatitis A, B, C, D and E viruses is estimated by the World Health Organisation (WHO) to cause the death of around 1.4 million individuals annually. On World Hepatitis Day, 28 July 2014, the WHO underlines the recent resolution of its World Health Assembly directing its 194 Member States to ensure they have national policies in place to address the challenge of viral hepatitis in a manner that builds on local, national and international expertise and experience with a view to combat the hepatitis viruses successfully.

Worldwide, hepatitis E virus (HEV) is an emerging infection with a current estimate of around 20 million infections occurring annually – with >3 million acute cases and around 57,000 deaths (WHO data). The virus is transmitted primarily through the faecal-oral route causing mostly asymptomatic infection but HEV acquisition may also develop into overt hepatitis and fulminant hepatic failure. Although HEV prevalence is highest in East and South Asia, it is now clear that the infection is a global challenge that does not require travel to such high prevalence areas. Instead, autochthonous (locally acquired) hepatitis E is now a recognised component of UK HEV epidemiology with an increase in HEV cases having been observed in the British nations. In particular, recent collaborative research between NHS Lothian and the University of Edinburgh has highlighted the situation within the Lothian health board. Equally, Health Protection Scotland (HPS) has observed a substantial national increase in laboratory reports of HEV infection rising from 15 cases in 2011 to 95 reports in 2013. Although no HEV outbreaks have been reported in Scotland, greater awareness of autochthonous HEV has led to a general increase in HEV testing with identification of cases.

As a result of the above, NHS Scotland is collaborating closely with the University of Edinburgh and other Scottish research institutions with a view to forge a national approach to the prompt identification and management of HEV infection as well as delineating some of the research required to further our understanding of the virus and its pathogenesis thereby supporting the WHO in its efforts to combat viral (HEV) hepatitis.


Ingólfur Johannessen, Specialist Virology Centre, Department of Laboratory Medicine, the Royal Infirmary of Edinburgh (University of Edinburgh)

Zoonotic diseases neglected for decades.

As part of a study to analyse changes in global health priorities at the global level of the resolutions adopted at the World Health Assembly – the decision making body of the WHO – the relative neglect of endemic zoonotic diseases has been highlighted. This work has recently been published in PLOS NTDs, and has received widespread media attention.

The eight diseases of interest (anthrax, bovine tuberculosis, brucellosis, cysticercosis, echinococcosis, human African trypanosomiasis (HAT), leishmaniasis, rabies) are part of the group termed Neglected Zoonotic Diseases (NZDs) at an international meeting in 2005, so called as they are “not adequately addressed” at national and international levels. Zoonotic diseases are defined as diseases that are transmissible between humans and animals.

In the last decade, the Neglected Tropical Diseases (NTDs) have received increased global attention, and recent events celebrated the increased advocacy and control that has occurred. The research highlighted that these diseases have received relatively little attention at the global policy level, living up to their neglected title. In developing countries where these diseases remain endemic and resources are limited, the control of these diseases is limited as other high profile diseases are prioritised.

Some of the diseases have high fatality and cause a high number of deaths globally each year. For example, rabies causes an estimated 60,000 deaths worldwide, yet this disease remains neglected despite evidence that the disease can be effectively controlled through dog vaccination.

Neurocysticercosis is the greatest cause of preventable epilepsy worldwide, causing an estimated 30% of the 17 million cases of epilepsy in areas where the causative parasite is endemic. This disease can be controlled through sanitation and improved pig husbandry, and improved diagnosis of human infection, requiring a multi-sector approach.

Following the London Declaration on NTDs, there has been increased focus on NTD control. Of the NZDs, only leishmaniasis and HAT are included in the ten diseases which are the focus of the declaration, meaning that the other diseases are not benefitting from the increased Research and Development and drug donations that the other NTDs are experiencing as a result of the declaration. This study highlighted three diseases in particular that are not included in the WHO NTDs. Anthrax, brucellosis and bovine tuberculosis have therefore not received the increased attention that the other NTDs have seen. Upon the inception of the WHO in 1948, around twenty zoonotic diseases were determined to be diseases of priority in the WHO, including bovine tuberculosis and brucellosis. Despite this, there have not been any resolutions adopted for these diseases since 1950.  For these diseases, effective and simple control methods exist, meaning that they are no longer endemic in many developed countries. It is therefore astonishing to many that they remain neglected.

It seems that these diseases are particularly neglected due to the complexities of controlling diseases that affect both humans and animals, and the required communication and collaboration between human and animal health sectors, both at community and ministerial levels, that is sometimes lacking. This despite the dual benefits that would be received by both human and animal health sectors upon increased effective control methods.

The international attention that has been received following the publication of this research may be indicative that the neglect of these diseases – some of which are well known and well controlled in some countries – may be something which is surprising, but that there is desire to reduce this neglect and therefore the deaths that occur as a result. In order to reduce this neglect, we must see increased cooperation and communication between human and animal sectors at all levels, and efforts to increase the advocacy for the control of these diseases.








Ms Hayley Mableson is in the final stages of completing a PhD from the University of Edinburgh.  Her research to date has focussed on global health advocacy and its application, with particular emphasis on the neglected tropical and zoonotic diseases.