The Dr. E. Grace Allen-Young Memorial Lecture 2014: “Pharmacists and Emergent Infectious Diseases”: Presentation by Hermine Metcalfe BH[M], Reg. Pharmacist: November 30, 2014, at the University of Technology, Jamaica West Indies
Salutation: Chairman, guests…. I feel especially privileged to have been invited to address this prestigious group in honour of an outstanding pharmacist, internationally renowned scientist, public servant and devout Christian, Dr. Grace Allen Young. Very important to me, Grace was my friend. She left us three years ago. (Thursday October 13, 2011).
Dr. Allen-Young spent a significant part of her professional life in the Public Sector and the health and welfare of the people were paramount to her. I wonder how she would manage this current Chikungunya outbreak in Jamaica. Would she approach it differently? Would the course of this infectious disease and the outcomes be different? What would be the role of pharmacists at this juncture?
This afternoon, we will focus on emergent and re-emerging infectious diseases and look at the role the pharmacist can play in prevention, treatment and eradication of these infections.
The organisms which cause infections are very small. Some of them, for example viruses and bacteria, can only be viewed with a powerful microscope. However, in spite of their small sizes, they have the capacity to ‘cut us down’.
Infectious diseases are a threat to our existence and outbreaks have been occurring from time to time in various parts of the world over the centuries. Let us refer to a few past outbreaks. Various “Plagues” are recorded from biblical times.
- There was the Plague of Athens in ancient times (450 BC): Typhoid/typhus
- The Black Death of the Middle Ages (1300’s), one of the most devastating pandemics in human history, which resulted in the deaths of an estimated 75 to 200 million people. Causative organism, a bacterium: Yersinia pestis
- Tuberculosis, commonly known as ‘consumption’, phthisis (thysis) or the “white plague” is reported to have been the cause of more deaths in industrialized countries than any other disease during the 19th and early 20th centuries. By the late 19th century, 70 to 90% of the urban populations of Europe and North America were infected with the TB bacillus, and about 80% of those individuals who developed active tuberculosis died of it
- The 1918 “Spanish Flu” pandemic killed 50 million, three times the deaths in World War 1. According to Medline Plus, a service of the National Institute of Health, communicable diseases claim more lives globally than other fatal events.
Lack of information about causative organisms, poor sanitation, religious rituals, superstition and other factors have contributed to the spread of infection in the past and continue to do so even today. Improved educational standards, advances in medicine, advancement in pharmacy and continued research has helped us to understand more about the organisms, their spread and how they cause diseases.
Although it was once imagined that serious infectious disease threats would by now be conquered, re-emerging and newly emerging diseases continue to appear throughout the world.
- Severe Acute Respiratory Syndrome (SARS): Southern China Nov. 2002- July 2003
- Avian Influenza A (H7N9) Virus: 1st reported in China in March 2013
- Middle East Respiratory Syndrome (MERS): viral respiratory illness first reported in Saudi Arabia in 2012. Coronavirus (MERS-CoV).
- Enterovirus 68 (EV68, EV-D68, HEV68) Enterovirus, Picornavirus family. First isolated in California in 1962. Once considered rare, on a worldwide upswing in the 21st century. Outbreak in US August 2014. Clusters of respiratory diseases.
- Cholera (Haiti 2010); Ghana outbreak (June 2014-Nov. 10, 2014. Spread to several countries in W and Central Africa.
- Bubonic Plague: (spread by rats) Madagascar 2014 (40 dead; 119 diagnosed)
- HIV/AIDS: In 2005: 45,000 cases, 17,000 deaths. Prior to 1981, there were about 100 cases with 30 deaths annually. There was significant surge in 1984
- Chikungunya: December 2014, first case in the Caribbean.
- Ebola: 2014: Guinea, Liberia, Sierra Leonie (entire country), Mali. Case fatality rate 25%-90%.
Jamaica has had very few infectious disease outbreaks over the past 10 years. Vaccine preventable childhood diseases have been eradicated in Jamaica, due to the country’s compulsory immunization policy, unlike countries where immunization is optional. Jamaica was declared malaria free in the 1950’s and 60’s. There was an outbreak of malaria in 2006 and in 2007, the WHO again declared Jamaica malaria free. Dengue outbreaks in the island occurred in 2010, 2011-2012, 2013 and now in 2014. Chikungunya is new in 2014.
Diseases which were once confined to certain parts of the world are now appearing in other areas due to ease of travel.
In Dallas, Texas, improper diagnosis of a patient infected with Ebola, travelling from West Africa led to the infection of to two nurses and had the potential to spread even further in a city with one of the world’s largest international hubs, home to two major airlines: American Airlines and Southwest.
Closer to home, the economy of Caribbean countries depends largely on income from tourism. Figures from the Statistical Institute of Jamaica (STATIN) indicate that in 2013, Jamaica’s income from tourism was J$98.9 billion roughly 7% of the country’s gross domestic product. The Chik V epidemic has the potential of crippling tourism. A case of Ebola would seal the fate of the industry.
Over the past decade, there has been considerable progress in identification and characterization of infectious agents, the underlying pathways by which they cause disease and development of preventative measures and treatments for many of the world’s most dangerous pathogens.
In today’s data intensive world, data mining and mathematical modeling techniques are used to study current and past outbreaks and determine future spread. Information from health insurance claims and from doctors reporting is relied upon. Unfortunately due to medical claims lagging and imperfect communication between medical professionals and institutions, sometimes an epidemic isn’t identified until many are already infected. Social media accounts have helped with speeding up the identification of outbreaks especially in the case of flu, however more can be done.
As medical costs go higher and access to care decreases, individuals will seek to self-medicate, heading to pharmacies for over the counter drugs and other non-prescription pharmacy dispensed items, making pharmacists the front line for identifying if there is a new infectious disease emerging. Given that individuals will also shop closer to home, pharmacists and pharmacies can more greatly identify where these outbreaks are starting.
The pharmacist is usually the first point of contact. When persons start feeling sick, which is the health care professionally first contacted? They usually go to the pharmacy to try to get something to provide relief.
- The pharmacist is knowledgeable about medications, their applications, dosing, side effects, contra-indications, etc.
- The pharmacist is easily accessible; no appointment is required
- The pharmacist provides this information free of cost
In the recent Chikungunya outbreak, there was a very significant increase in the number of persons seeking medication for fever and pain. This would have indicated to the pharmacist that there is a problem. Immediate notification of the health authorities by the pharmacist may have initiated action by the Ministry of Health, thereby minimizing the crisis, which we have been facing through suffering and loss of productivity.
Many patients infected with Chik V never visited the doctor, resulting in significant under-reporting of cases. Pharmacists can therefore play an important role in the collection of epidemiological statistical information. They are well positioned to quickly identify emerging infections and clusters of infections, as persons tend to seek advice and relief from the pharmacist first and will go to their community pharmacies.
Pharmacists have a unique role in this fight against infectious diseases. This is the profession to which Dr. Grace Allen-Young devoted her working life.
Pharmacists can play a vital role in the prevention of outbreaks of infectious diseases as they interface with more persons than any other health care professional and are well positioned to quickly disseminate information to the public.
They should provide information:
- In a timely manner
- In a way that can be easily understood by the layman (through use of flyers, talks in schools, churches, etc. Employ social media Facebook, Twitter, text messaging, email, etc.)
- In a responsible way so as not to cause panic and fear
- Continuously so that the population is kept informed
Remember prevention of infection is Key!
Pharmacists are the custodian of drugs and should ensure adequate supplies of the most cost effective medications. They should lobby the health authorities to involve members of the profession in epidemiologic surveillance. They should show leadership and get involved in the national action plan.
Dr. Allen –Young was for a number of years responsible for procurement and distribution of pharmaceuticals in the public sector in her capacity of head of the Jamaica Commodity Trading Company, the precursor of Health Corporation of Jamaica and the National Health Fund Pharmaceutical Division. She was instrumental in the upgrading of the drug distribution systems in Jamaica and her expertise was sought by the WHO to assist other countries to update their distribution systems and institute alternative supply chains.
Through Dr. Allen-Young’s instrumentality, Jamaica was designated the Caribbean Centre of Excellence for Health Workforce Panning and Research in 2009.
In conclusion, I urge one and all to be vigilant. As the front line for medical treatment in the new care structure, pharmacists can be the difference between a limited outbreak and a new epidemic.
Dr. Grace Allen-Young has set very high standards for pharmacy and it is incumbent on us and future pharmacists to continue on this path.