Friday, June 29, 2018

Why No News Isn't Necessarily Good News


As economic, societal, and political winds shift around the world - the willingness of many countries to publicly (and apparently, even privately) acknowledge infectious disease outbreaks tends to change - sometimes dramatically. 
A positive example, five years ago, we saw a remarkable (and highly praised) shift in reporting of avian flu details out of China following  the emergence of H7N9 in 2013.  
After the debacle of trying to hide the SARS epidemic burning through Chinese hospitals in 2002-2003, and a 10-year history of minimizing H5N1 cases, we were suddenly flooded with detailed epidemiological information on this new novel flu threat.
That openness ended early in the spring of 2015, when China's MOH went strangely silent on H7N9 (see H7N9: No News Is . . . . Curious), and the level of patient detail reported to the WHO dropped dramatically.
This subdued reporting continued until January 2017 - when faced with a sudden avalanche of human H7N9 cases - the MOH belatedly announced a batch of cases from the previous month (see HK CHP: China Reports An Additional 83 H7N9 Cases For December).
While reporting improved somewhat - at least temporarily - it has never returned to the level of detail we were enjoying in 2013 and 2014. 
At roughly the same time Egypt - which had seen a record setting outbreak of human H5N1 infections beginning in November of 2014 - stopped nearly all reporting of cases on their MOH website (see Revisiting Egypt’s Murky H5N1 Battle) in late January of 2015 - and began issuing denials of new cases to the local media.

For the past three years, avian flu news out of Egypt - whether it be from the MOH, MOA, or their local media (ranked 161st in press freedom) - has been eerily subdued.
More recently, 45 days ago the Saudi MOH stopped reporting on MERS-CoV cases, and removed months worth of accrued data from their surveillance website.

The site is supposedly `under construction', but will hopefully come back online at some point. For now, however, our visibility of MERS cases in KSA - just 6 weeks before the start of the Hajj - is pretty much absent. 
Since the Saudi press (ranked 169th in press freedom) is even more tightly controlled than is Egypt's, there is little help to be found there.
It is now nearly the end of June, and the last MERS case publicly revealed was part of a household cluster which began in May, where the latest (June 10th) WHO EMRO report stated:

The index case had a date of onset of symptoms on 17 May 2018 and by 31 May, seven symptomatic secondary cases were reported from this cluster. More cases are expected to be reported from this cluster as the close contacts are being followed up and the laboratory test result of some of the close contacts are awaiting.
Saudi Arabia appeared to reach their peak in MERS-CoV openness between the fall of 2015 and the middle of 2016, with the publication of a Weekly MERS Monitor report from their CCC (Command & Control Centre).
Not only was this excellent weekly report discontinued in August of 2016, the repository of old reports now only returns a 404 error. 
Granted, the list of countries that try to keep disease outbreak information close to the vest extends far beyond just China, Egypt, and Saudi Arabia.  But these three countries have a recent history of novel virus outbreaks, and are therefore of greatest concern. 

While these pullbacks are both disappointing and worrisome, sovereign nations are under no legal obligation to publicly acknowledge disease outbreaks to their public - or for that matter - to provide us with detailed epidemiological data.

But under the terms of the 2005 IHR (International Health Regulations) - WHO member countries have agreed to develop mandated surveillance and testing systems - and to report certain disease outbreaks and public health events to WHO in a timely manner. 
Thirteen years after it was approved, however, fewer than half the countries of the world self-report having met the core requirements of the IHR. 
But even among those who have - timely reporting continues to be problematic. While public chastisement is uncommon in diplomatic circles, in recent years we've seen signs of growing frustration over the lack of progress on the IHR, including:

It is one thing to try to overcome the limited resources preventing some countries from conducting adequate surveillance and reporting their findings to the WHO, while it is quite another if some countries are deliberately slow walking disease outbreak information for political or economic reasons.  
A reminder that `No news isn't necessarily good news', and that the current lull in infectious disease outbreaks around the globe may be - at least partly - illusory, and at the very best, temporary.  
All reasons why pandemic planning needs to be an ongoing priority, and not just ramped up based on the most recent 24-hour news cycle.