Emergency medicine
How is WHO responding to global health threats?

The World Health Organisation has long been the brunt of criticism, but with the recent, and long overdue, revision of the International Health Regulations the WHO has a new tool with which it can demonstrate that the organisation is essential to ensuring the cohesive co-operation of the global health community. However, it must overcome a range of technical, logistical and, importantly, financial obstacles to make certain the efficacy of this instrument. Middle East Health publishes this report by the editors of PLoS Medicine.

It is a favoured pastime of medical editors and journalists to criticise the World Health Organisation (WHO) for, among other things, its “fossilised bureaucracy,” its lack of clear direction and priorities, the dysfunctional relationship between its headquarters and regional offices, and its faltering steps towards building partnerships[ 1,2]. But with the arrival of so many new players on the global health scene, and the subsequent fragmentation of global health governance, we surely need WHO more than ever[3]. It is the best placed of all health agencies to coordinate the disparate, often overlapping global health initiatives and to set global norms and standards in health care, and its convening power (its ability to bring together experts) is unparalleled. Two recent WHO initiatives on preparing for and responding to global public health threats show the organisation at its best, although there are, as always, some important caveats.

The first initiative, described by Holger Schünemann and colleagues in the 29 May 2007 issue of PLoS Medicine, is the development and pilot testing of the new WHO Rapid Advice Guidelines Group[4]. WHO's standard process for guideline development typically takes years of consultations and endless rounds of revisions, a process that is wholly inadequate for dealing with emergency health threats such as severe acute respiratory syndrome (SARS) or H5N1 avian influenza. In response to requests for advice from frontline clinicians and public health professionals on how to treat H5N1 infections, WHO convened a new type of panel to issue rapid, evidence-based advice. It took one month to convene an expert team, and five weeks for the team to summarise the evidence and prepare draft guidelines. The guidelines were then discussed at a two-day meeting, after which a draft manuscript for publication was prepared within 10 days.

In WHO terms, this time scale was miraculously quick, but there is clearly room for improvement – an even quicker time frame is likely to be needed for future health emergencies. The process could be expedited, say the authors, by identifying or establishing collaborating centres skilled in producing evidence-based guidelines and by building in-house capacity to reduce the time needed to organise a review team. It will also be vital for this new rapid advice group to make its process of panel selection as transparent as possible if the group is to garner the trust of the public health community. WHO has previously come under fire for allowing industry to unduly influence its expert committees, and for failing to ensure that committee members declare their competing interests[3]. The rapid advice group must not sacrifice transparency in the interests of urgency.

The second initiative is the long overdue 2005 revision of the International Health Regulations (IHR 2005), which came into force on 15 June 2007[5]. These regulations are an international legal instrument designed to ensure maximum protection against the international spread of infectious disease while minimising restrictions on travel and trade. Up until the 2005 revision, the regulations in force since 1969 (IHR 1969) required notification of just three diseases: yellow fever, cholera, and plague. The instrument was therefore hopelessly outdated for dealing with the new infectious diseases that have emerged at a rate of about one per year over the last 20 years[6], or indeed for dealing with established threats such as pandemic influenza. IHR 1969 had several other limitations – for example, surveillance relied totally upon individual governments notifying WHO and there were no specific strategies to help build the capacity of resource-poor countries to monitor or respond to outbreaks[7]. Compliance was poor, in part because countries feared that reporting of outbreaks would lead to unwarranted and damaging travel and trade restrictions[5]. China’s initial reluctance to disclose the SARS pandemic was motivated by such fears[7].

Under IHR 2005, WHO member states are now required to notify WHO of “all events which may constitute a public health emergency of international concern”, which can include noninfectious events (such as chemical or radiation hazards)[5]. A new algorithm has been devised to aid states in determining what constitutes such an emergency. Criteria for reporting are whether the public health impact of the event is serious, whether it is unusual or unexpected, whether there is a risk of international spread, and whether there is a risk of international restrictions to trade and travel. The algorithm includes a long list of specific diseases that must always be notified, such as viral hemorrhagic fevers, SARS, and human influenza caused by a new subtype.

IHR 2005 requires all states to develop “core surveillance and response capacities” and requires WHO to assist in this development process. Each country must now have a “National IHR Focal Point” to maintain communications between WHO and the member state. When an event is reported, WHO will guide the appropriate response by issuing timelimited recommendations to the member state tailored to the assessed risk of the event. An important new feature of IHR 2005 is that WHO can now use information about health emergencies not just from governments but from a range of sources, including nongovernmental organisations and the media. WHO can also raise the alarm itself about an emergency even when a country has not voluntarily notified the organisation.

IHR 2005 is undoubtedly “a great step forward for international public health practice”[8]. On paper at least, the radical revision to the IHR, which took ten years to finalise, gives WHO the teeth it needs to prepare for and respond to any global health threat. But WHO will have to address several important concerns if IHR 2005 is to become a real force for strengthening our collective defenses against public health threats.

The first, and most obvious, concern is that many developing countries lack the financial resources to build core surveillance and response capacity. These countries will be unable to comply with IHR 2005 through no fault of their own. Unless WHO helps to mobilise new funding, an upgraded global surveillance and response system will remain just an aspiration. Donors have taken an interest in preparing for at least one “public health emergency of international concern” – pandemic influenza – but without a way of ensuring equitable distribution of funds, it is the donor countries themselves that will largely benefit from these extra resources. For example, in December 2005 the United States congress allocated US$3.8 billion to help prepare for the next pandemic, of which US$3.3 billion went to the US Department of Health and Human Services[9]. Threequarters of this departmental funding is allocated to the stockpiling of antiviral drugs and vaccines for use in the US, while only 3.8% is dedicated to “international activities”. Poor countries are understandably concerned that the stockpiling of tools for pandemic influenza control will be the preserve of the rich world.

A related concern is that IHR 2005 appears to have no remit to help developing countries deal with national public health emergencies. The event must be “of international concern” for the IHR machinery to kick in. It would arguably be better for a country to adopt a precautionary principle rather than to wait until a disease has crossed its borders to become an “international” epidemic. The woolly language of IHR 2005 also leaves the regulations open to the criticism that they are there simply to prevent infectious diseases of the poor world from encroaching upon rich countries.

There are other potential barriers to the success of IHR 2005. The division of power within federations may make it difficult for them to meet the surveillance and reporting requirements of IHR 2005[10]. It is unclear whether the instrument will have any power to assist states that are not members of WHO, such as Taiwan, which suffered a major SARS outbreak in 2003 and which is at risk of pandemic influenza. It is too soon to tell how IHR 2005 will interact with other guidelines on public health emergencies. The European Union, for example, already has its own network for reporting unusual events that may constitute a public health emergency[11] – does this network supersede the IHR 2005? And it is too soon to tell whether IHR 2005 gives countries enough of an incentive to report epidemics or whether compliance will be just as poor as with IHR 1969.

IHR 2005 has been hailed as “a governance regime unlike anything in the history of international law on public health”[7]. Margaret Chan, WHO's director-general, believes that the new regulations give the organisation the preemptive powers it needs to detect an outbreak early and stop it at its source[12]. IHR 2005 certainly gives the health community a new tool that could promote collective action against global health threats, but the tool will be weakened unless the technical, logistical, and, most crucially, financial hurdles are overcome.

Credit:

The PloS Medicine Editors (2007) “How Is WHO Responding to Global Public Health Threats?” PLoS Med 4(5): e197doi:10.1371/ journal.pmed.0040197


Reducing stress for emergency nurses

Nurses working in an accident and emergency department reported that their anxiety levels fell dramatically when they were given aromatherapy massages while listening to music, according to research in the September issue of the UKbased Journal of Clinical Nursing.

Two 12-week alternative therapy sessions were provided over the course of a year. Eighty-six nurses participated in the study, with 39 taking part in both the summer and winter sessions.

Researchers found that 60% of the staff – 54% in summer and 65% in winter - suffered from moderate to extreme anxiety.

But this fell to just 8%, regardless of the season, once staff had received 15- minute aromatherapy massages while listening to relaxing new-age music.

The study also sought to examine whether there were any seasonal differences in stress levels.

“There’s always been a perception that staff feel more stressed in the winter months – when they deal with more serious respiratory and cardiac cases – and the stress levels we recorded would seem to support this” says Marie Cooke, deputy head of the School of Nursing and Midwifery at Griffith University, Queensland, Australia.

“But when we analysed the workload figures and case distribution we found little difference between winter and summer patient levels during the study periods. Staff dealt with just over 10,700 patients each season and the number of deaths and the percentage of patients in each triage category (which determines how quickly people need to be seen) was fairly consistent between the seasons.

“However, the fact remains that providing alternative therapy was more effective during the winter months.

During both study periods the number of staff feeling stressed fell to 8%, but there was a greater reduction in winter, when the number fell from 65%, than in the summer, when the pre-massage score was 54%. “There is scope for a lot more research into this area” concludes Dr Cooke.

“We would be interested to see if different types of alternative therapy produced different results and whether factors such as age, gender and health status had any effect on the outcome.

“But what is clear from this study is that providing aromatherapy massage had an immediate and dramatic effect on staff who traditionally suffer high anxiety levels because of the nature of their work.

“Introducing stress reduction strategies in the workplace could be a valuable tool for employers who are keen to tackle anxiety levels in high pressure roles and increase job satisfaction.”


New guidelines put spotlight on psychosocial support

International humanitarian agencies have agreed on a new set of guidelines to address the mental health and psychosocial needs of survivors as part of the response to conflict or disaster.

The Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings clearly state that protecting and promoting mental health and psychosocial well-being is the responsibility of all humanitarian agencies and workers.

Until now, many people involved in emergency response have viewed mental health and psychosocial well-being as the sole responsibility of psychiatrists and psychologists.

“These new IASC guidelines are a significant step towards providing better care and support to people in disaster- and conflictaffected areas worldwide,” said Dr Ala Alwan, assistant director-general for Health Action in Crises at the World Health Organisation.

Recent conflicts and natural disasters in Afghanistan, Indonesia, Sri Lanka and Sudan among many others involve substantial psychological and social suffering in the short term, which if not adequately addressed can lead to long-term mental health and psychosocial problems.

These can threaten peace, people’s human rights and development. Yet, when communities and services provide protection and support, most individuals have been shown to be remarkably resilient.

While this is increasingly recognised, many actors identified the need for a coherent, systematic approach that can be applied in large emergencies. The guidelines address this gap.

The guidelines have been published by the IASC, a committee that is responsible for world-wide humanitarian policy and consists of heads of relevant UN and other intergovernmental agencies, Red Cross and Red Crescent agencies, and NGO consortia. The guidelines have been developed by staff from 27 agencies through a highly participatory process.

“Drafting the guidelines has been a joint effort of a broad range of key actors in the diverse sectors of humanitarian aid and we are happy to see the synergy and commitment,” said Jim Bishop, vice president for Humanitarian Policy and Practice of InterAction, the consortium of US-based international NGOs.

The guidelines lay out the essential first steps in protecting or promoting people’s mental health and psychosocial well-being in the midst of emergencies. They identify useful practices and flag potentially harmful ones, and clarify how different approaches complement one another.

“The new guidelines present a major step forward to much better protect the mental health and psychosocial well-being of displaced persons using an integrated approach in collaboration with all partners” said Ruvendrini Menikdiwela, deputy director, Division for International Protection Services at the Office of the United Nations High Commissioner of Refugees.

The guidelines have a clear focus on social interventions and supports. They emphasise the importance of building on local resources such as teachers, health workers, healers, and women’s groups to promote psychosocial wellbeing. They focus on strengthening social networks and building on existing ways community members deal with distress in their lives.

The guidelines include attention to protection and care of people with severe mental disorders, including severe trauma-induced disorders, as well as access to psychological first aid for those in acute distress.

The guidelines stress that the way in which humanitarian aid is provided can have a substantial impact on people’s mental health and psychosocial well-being. Treating survivors with dignity and enabling them to participate in and organise emergency support is essential.

Co-ordination of mental health and psychosocial support is difficult in large emergencies involving numerous agencies. Affected populations can be overwhelmed by outsiders, and local contributions to mental health and psychosocial support are easily marginalised or undermined.

Dr Bruce Eshaya-Chauvin, head of the Health and Care Department at the International Federation of Red Cross and Red Crescent Societies, remarked: “Achieving improved psychosocial support for populations affected by crises requires co-ordinated action among all government and non-government and humanitarian actors.

These guidelines give sensible advice on how to achieve that.” Manisha Thomas, acting co-ordinator of the International Council of Voluntary Agencies, said: “These guidelines now need to be transferred from paper into concrete action at the field level so that those affected by disasters and conflict will benefit from the work done on them.

NGOs can play a major role in this regard.” The guidelines will be available in different languages and can can be downloaded here: www.who.int/mental_health/ emergencies/guidelines_iasc_ mental_health_psychosocial_ june_2007.pdf


Statscan provides full-body x-ray to assess trauma patients



– A study of the efficacy of Statscan at the Accident and Emergency Trauma Center at Rashid Hospital, Dubai

Dubai is one of the fastest growing cities in the world. The current population is around 1.4 million and is expected to increase rapidly in the next 10 years.

The many construction sites in the city and the increasing number of vehicles on the roads is cause for a large proportion of the city’s trauma-related accidents – the most common of which is blunt trauma.

The state-of-the-art Accident and Emergency Trauma Center at Rashid Hospital in Dubai opened in September 2006. It is the receiving site for all traumas in Dubai. The Emergency Department sees approximately 400 patients every day.

One of the five Emergency Department Resuscitation rooms at the Accident and Emergency Trauma Center contains a full-body x-ray machine known as the Statscan. Statscan is an ultra low dose full-body x-ray machine which was first developed in 1991 for use in the South African mining industry to detect smuggling of diamonds by the workers.

It was first commissioned for medical use in 1997 and is currently in use in North America and South Africa. The Statscan at Rashid Hospital is the first such x-ray machine in the Middle East.

The Statscan provides two full-body x-ray images which can be enlarged to provide normal chest and pelvis images as well as thoracolumbar spine and long bones. Because of positioning it cannot accurately exclude distal limb injuries and a third lateral neck view is required to provide a complete series of c-spine imaging. Each image takes 13 seconds with a patient time in Statscan of five to six minutes.

The radiation dose to the patient for the two Statscan images is 72% of the dose of a plain chest x-ray and 2% of the dose of a plain pelvic x-ray.

Thus when replacing the traditional trauma series of plain x-ray with Statscan the dose of radiation is 6% of the plain x-ray images as published in Emergency Radiology 2003. Thus the potential advantages of Statscan over the traditional trauma series are speed and lower dose of radiation.

In addition to this there is the added advantage of early imaging of long bone fractures. These are only advantages if it can be shown that Statscan diagnoses injuries as accurately as plain x-ray, hence the following study.

We studied 500 Statscan studies taken between 1 October and 15 December 2006, an average of 6.5 Statscans per day.

All Statscan studies were included. In a retrospective review of patient case notes and radiologist reports of Statscan/x-ray/CT, we looked only at the comparison of the traditional trauma series of c-spine, chest and pelvis.

We have also reported on limb injuries diagnosed on Statscan which required no further imaging prior to operative management. Of the studies, 429 (86%) were male and 71 (14%) were female; and 247 required hospital admission.

Most of the patients seen were within the 18-46 year age group with road traffic accidents being the leading cause of injury followed by a fall from greater than three metres and less then three metres.

Of the 500 studies, 292 patients had no further imaging of cspine/ chest/pelvis while 208 had further imaging.

Cervical Spine

No cervical spine injuries were missed on Statscan when compared with plain x-ray.

Fourteen injuries (10.4%) were missed on Statscan when compared with CT scan. Of these, six of the injuries were described as undisplaced and therefore may not be expected to be visible on plain x-ray.

Current literature with evidence of missed c-spine fracture when comparing plain x-ray and CT scan of cspine varies from 5% to 40%, therefore our initial results suggest the Statscan provides us with information as good as expected from plain x-ray of the cervical spine.

Chest

Forty one patients had undetected injuries of the chest (36%). There were nine injuries undetected when comparing Statscan with plain chest x-ray: eight lung contusions and 1 rib fracture.

The average time delay from Statscan to chest x-ray in the eight patients with missed lung contusions was 4.9 hours. It is known that lung contusions may take up to 24 hours to be visible on plain x-ray, thus it is difficult to say whether these contusions were definitely undetected on Statscan.

The majority of injuries missed when comparing Statscan with CT chest were also lung contusions. Of the 24 undetected contusions 10 were described as posterior basal contusions which would not be expected to be visible on plain x-ray.

Of the 11 undetected haemathoraces six were described as minimal, again these would not be expected to be visible on a plain supine trauma series chest x-ray. There were 12 pneumathoraces missed, three of these patients also had a plain chest x-ray which also missed the pneumothorax.

Thus although there are a large number of missed injuries of the chest on Statscan, a significant number of them are unlikely to have been picked up by plain x-ray. Our evidence for the accuracy of chest findings needs further evaluation.

Pelvis

No fractures of the pelvis were missed when Statscan was compared to plain x-ray however the numbers available for comparison were small.

Sixteen patients had undetected fractures when Statscan was compared with CT scan of the pelvis. Of these injuries four involved the acetabulum and seven involved the sacrum. These are known to be the difficult areas to detect fractures on plain x-ray.

Conclusion

Our initial results suggest that there are no missed injuries of c-spine or pelvis when Statscan is compared with plain x-ray. Those missed on CT scan are within the current expectations of literature comparisons of plain x-ray and CT. There are a small number of lung contusions not seen on Statscan, but seen on plain x-ray. However, there is a time delay which might partly explain these findings.

We have now used the Statscan to x-ray more than 2,000 patients and plan to evaluate a larger patient group. We need to further evaluate our patient episode times in Statscan and have a blinded radiologist to further evaluate the missed injuries.

Ninety two patients (18.4%) had their limb injuries managed with no further pre-operative imaging required and therefore reduced time delay to theatre. The largest number of these was femur fractures.

We know that the Statscan exposes the patient to a lower dose of radiation than plain x-rays and we plan to use this for the evaluation of other patient groups such as children and pregnant women.

Dr Lorna McLeod, FRCSEd FFAEM is a senior emergency physician with InterHealth Canada Management Limited. InterHealth Canada is commissioner, manager and operator of the Accident and Emergency Trauma Center at Rashid Hospital.

To contact Dr McLeod email: ihcan@interhealthcanada.ae

                                  
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