An epidemic problem
Frightening new diseases and the return of old killers focuses the negative side of increased global travel. Roger St Pierre warns insurers on new and emerging threats
First published in ITIJ 91, August 2008
Frightening new diseases and the return of old killers focuses the negative side of increased global travel. Roger St Pierre warns insurers on new and emerging threats
Global warming, ever-bigger natural disasters, premium wars – how about the following to give underwriters something more to worry about? The world is shrinking. More and bigger planes, added routes, ever growing travel – both business and leisure – with whole new markets opening up, are all factors that are making humanity more mobile and, if it's easier for more and more of us to take to the skies, the same applies to infectious diseases.
There are several ways the global travel insurance and assistance industries can prepare for a pandemic or deal with minor outbreaks. Here, ITIJ looks at what threats might be round the corner, and steps the industry can take to mitigate the risk associated with the often frighteningly quick spread of silent killers such as flu epidemics in today’s ever more mobile and adventurous society.
Waging war
Here’s a sobering fact. The so-called 'Indian' flu epidemic of 1919 killed more people around the world than died in battle during the entire First World War, with many towns and villages decimated, not just in Asia but in Europe and beyond too. That particular virus travelled by sea and took months on its lethal journey. In chilling contrast, the SARS epidemic had the potential to leapfrog from nation to nation just as quickly as a jet plane could fly between them.
According to the experts, pandemics work on a cyclical basis and we are about due for the next big flu epidemic following those of 1919 and 1968. Says Bonnie Arquilla, director of disaster preparedness for Central Brooklyn and a member of the New York City Department of Health disaster committee: “The critical period of a major pandemic will last for six to eight weeks. During that period, around 35 per cent of the employed population will be off work; schools and many businesses will be forced to close and the knock-on effect will be colossal. You could almost call it viral terrorism.” Many hospitals and other facilities around the world stage exercises once or twice a year to make sure everything is in place to deal with such a crisis, but Arquilla is concerned by the number of communities that will still be caught on the wrong foot. “The big concern with flu is over how quickly it strikes: it takes 24 hours for the symptoms to manifest themselves but during that time the infected person is highly contagious.”
the SARS epidemic had the potential to leapfrog from nation to nation just as quickly as a jet plane could fly between them.
Of course, the World Health Organisation (WHO) and national governments around the globe have measures in place to give early warning and to hopefully eliminate epidemics before they spread, but there are flaws in the system. Moreover, several major killers that were once believed to be all but eradicated have rebounded strongly. Just recently, a visitor to Glasgow brought TB – an illness we once thought to have been banished for good – back into the Scottish city. Years of development and fine-tuning brought the WHO’s International Health Regulations to a point where many battles seemed to have been won, but winning a battle is not winning a war.
Crossing borders
With the ever increasing reduction of international trade barriers and the demand for easier movement of goods, livestock and people, there has arisen a situation where a better balance needs to be struck between protecting our health and avoiding undue constraints on the global economy. What’s more, countries, especially developing ones, sometimes resist giving early warnings about disease outbreaks for fear of the damage that bad publicity will wreak on their tourism industries and their economy in general.
Moreover, according to the WHO’s recently published ‘A Safer Future’ report, there is major concern over the emergence of new, ever more virulent diseases that are now potentially able to span the world in days rather than months. Recently, 2003’s SARS outbreak rightly caused great alarm. Here was something highly contagious, with a very high death rate, but whose symptoms take a week to emerge. A 72-year-old Chinese victim took at least one airplane trip in the days before he fell ill and doctors feared he may have infected more than 20 others before being diagnosed. Tracking down and quarantining those possible victims was a logistical nightmare. Soon after, cases popped up not only across China but as far away as Canada. In the following months, several hundred people died but, fortunately, the survival rate proved better than expected and the virus was contained within a year.
In countries like the UK, every winter, seasonal influenza kills very old and very young people and others already weakened by illness, but current fears among the world’s medical experts are of a new and potentially deadly version – like that of 1919 – jumping from animals to humans, and governments internationally are already planning for its hoped for containment.
developing countries urgently need outside assistance to help them control epidemic outbreaks, with the provision of an incentive for early notification.
More recent, and indeed current, focus has been on so-called avian flu, a pandemic disease that could possibly become a mass murderer. At present, this virulent strain attacks and kills only people who have been in close contact with infected poultry, because it is unable to spread from person to person, but the fear is of a mutation that will be able to do just that. This could cause a death rate running into thousands if not millions.
In worse case scenarios, nine out of 10 people diagnosed with the Ebola or Marburg viruses in tropical Africa have died within days. The ever-growing fear is that, given the growth of modern day travel – with a year-on-year increase of seven per cent, and a volume now well exceeding 600 million international flights a year – such nightmare outbreaks of various killer viruses could soon become pandemics.
The big comeback
Along with the emergence of fresh enemies, new, more resistant strains of old illnesses are making a return, so much so that there is already serious talk of reintroducing the toxic DDT as a means of containing malaria, which still kills more than a million people every year and is becoming more resistant to treatment. Likewise, all but eradicated in the developed world, polio has rebounded in India where WHO statistics point to 249 cases in 2006 compared to 35 the previous year. Says Jay Wenger, of the country’s National Polio Surveillance Project: “What started in the north of Uttar Pradesh has now spread into neighbouring states and beyond.”
Measles, too, had seemed to be defeated but has returned to haunt anxious parents in the US. Other comeback killers include cholera – with an estimated 50,000 dying in the first month of an outbreak in the Congo – and tuberculosis. Says Bonnie Arquilla: “In normal times, cholera is easily contained. It is simply a matter of following good practice in terms of hygiene and sanitation, but when a disaster such as a flood, an earthquake or the destruction of a war takes place, these things fall down and cholera is quick to step in. I was frankly amazed that we did not experience a major outbreak in the aftermath of the tsunami. Certainly, the recent increase in natural disaster occurrences gives cause for worry over potential cholera outbreaks.”
Furthermore, TB now kills around 1.5 million people annually around the world, and is the terminal illness that finally kills many AIDS victims. Worryingly, the TB bacterium is proving increasingly resistant to antibiotics.
Then there is the plague, that traditional, much-feared ally of the Grim Reaper. Down the millennia, outbreaks have killed as much as 40 to 50 per cent of some nations’ populations as the so-called Black Death has struck people down and killed them within days. Untreated, the mortality rate for bubonic plague victims is 75 per cent; for septicemic plague it is 100 per cent. The current worry is that the next big outbreak will prove resistant to treatment.
Comments Carolyn Walker, of Healix International, a UK-based medical case monitoring and evacuation services company: “Diseases are now able to spread far more rapidly than in the past,” and explains: “There are two major types of infectious diseases that can develop into epidemics. These are common source epidemics that arise from a contaminated source, such as food or water, and host-to-host infections, which are transmitted from one infected individual to another via various, perhaps indirect, routes. The ultimate scourge of mankind has, of course, been the deservedly much feared Plague, which also affects more than 300 species of animal, but there are lots of other highly contagious killers to worry about.”
Prior planning
Epidemics of contagious diseases are a concern not just for governments but for companies that, in an era of ever growing international commerce, need to send their representatives scouring the globe for business opportunities. iJET is an American-based organization that runs a World Pandemic Monitoring Service, providing real-time alerting, authoritative analysis and best practice tools to help business organisations address a wide number of global health concerns. The business started with a unique piece of software that links into corporate travel systems and allows executive travellers to be automatically re-routed around terrorists, hurricanes, riots and whatever else comes along. It now extends its surveillance to take care of infectious disease concerns, and recently published an extremely detailed Avian Influenza and Pandemic Planning report.
pandemics work on a cyclical basis and we are about due for the next big flu epidemic following those of 1919 and 1968.
Based in Maryland, US, iJET’s intelligence operations’ centre monitors more than 150 countries on a round-the-clock basis, analyzing and verifying information from well over 3,000 sources. Health is one of 10 categories of information featured, with others including security, transportation, entry and exit rules and communications. The searchable service delivers intelligence in a brief, need-to-know format that is frequently updated to reflect changing conditions. The ‘at a glance’ screen provides information on health warnings and immunisation needs along with current visa conditions, currency conversion rates and weather forecasts. Besides reaching end-users, the service targets such travel advisors as travel agents, corporate travel managers, and travel health specialists, as well a providing useful data for travel insurers and assistance companies.
Fast-flowing, detailed and accurate information is key to the war against epidemics. The first-time appearance or resurgence of an infectious disease requires timely and coordinated action across the international community. For example, when it comes to infectious disease control, member states of the European Union have effectively become one country, an essential requirement in the creation of an internal market that requires the free movement of people and animals, as well as goods.
Under the 1993-8 Maastricht and Amsterdam treaties, the EU was given over-riding competency in the field of public health. This has led to the detailed setting up of a network to ensure surveillance and to control outbreaks of contagious diseases that have extended to more than one member country; deal with the spatial or temporal clustering of cases of disease of a similar type, if pathogenic agents are a suspected cause and there is a risk of the outbreak spreading to other member countries; spatial or temporal clustering of cases of a disease of a similar type outside the community, if pathogenic agents are a possible cause and there is a risk of propagation into the community; and monitoring the appearance or resurgence of a communicable disease or infectious agent that may require timely and coordinated community action for containment.
Under the treaties, member states are required to coordinate both prevention and control and to inform the EU Commission about the control measures that have been adopted. Interestingly, these measures arose not so much in response to the concerns and demands of the medical profession and public health authorities but from the commercial requirements of the open market demanding an end to the knee-jerk reaction to shut the gates and pull up the national drawbridge whenever an outbreak or epidemic occurred in a neighbouring country. Helpfully, there have already been a number of instances when this reporting system has helped prevent the cross-border spread of infectious disease within the Community.
Global reach
In a wider sphere, things aren’t quite so good. The current WHO International Health Regulations only contain reporting requirements for cholera, plague and yellow fever and do not address such already well-known highly contagious and killer diseases as Ebola, other haemorrhagic fevers and meningococcal meningitis, or new threats such as avian flu or Nipah virus. What’s more, there is no incentive provided for reporting an outbreak, while the WHO can only act on information given by an official government source in the country concerned and can do nothing to prevent over-protectionist reaction to outbreaks.
Perhaps the most pressing requirement of any revision of the status quo is for the WHO to involve the World Trade Organisation (WTO) in improving the regime. The risk of the international spread of disease through trade is now being debated and assessed within the WTO, but what is really needed is a dialogue between the two organisations, in the spirit of the International Sanitary Conferences of the Victorian era.
Revised International Health Regulations should require the WHO to provide a world alert system about potentially dangerous outbreaks of all communicable diseases; coordinated international action for early containment and the authority to restrain over-reaction in the form of over-zealous quarantine rules or the erection of trade barriers in cases that lack a scientifically proven public health justification. Furthermore, developing countries urgently need outside assistance to help them control epidemic outbreaks, with the provision of an incentive for early notification. There is a real cost benefit to donor countries through such a process, as early containment is far more effective, both on a cost and a humanitarian basis, than waiting for an outbreak to spread into the developed world.
With any such measures, there is also an urgent need to involve charities such as Oxfam and Médecins Sans Frontières, other NGOs and commercial organisations working in the health sphere and that, of course, involves travel and health insurers and assistance providers. The latter, of course, have a vested interest in improved containment. An outbreak of food poisoning or flu rampaging through a cruise ship can produce a rash of costly claims. Not to mention the choices they need to make regarding the level of coverage to offer to today’s intrepid traveller when it comes to underwriting for covered ailments.
member states are required to coordinate both prevention and control and to inform the EU Commission about the control measures that have been adopted.
Where future risks seem likely to prove extremely high, insurers can of course opt to include specific diseases in their terms and conditions, just as they exclude coverage of injuries arising from high risk sports, but this could be unpopular with travellers, so to would be the exclusion of coverage of travel to areas where infectious diseases are known to be rampant. Insurers can, however, inject a measure of risk management by insisting, as many a host government does, on comprehensive inoculation for those policyholders travelling to certain regions of the globe.
Today’s epidemics strike fast and hard; the medical profession, health organisations and health insurers all now have their eye on the ball and the mood is to react just as rapidly. “The concerted efforts we are putting into conserving the ecology need to be reflected in the vigilance and action we take when it comes to looking after our own health,” says a WHO spokesman.