Professional Documents
Culture Documents
Health Policy
journal homepage: www.elsevier.com/locate/healthpol
a r t i c l e
i n f o
Keywords:
Communicable diseases
Communicable disease control
European Union
Economic crisis
a b s t r a c t
Objectives: The effects of the current global economic crisis on the spread and control of
communicable diseases remain uncertain. This study aimed to explore experts views about
the impact of the current crisis and measures that have been undertaken by governments
to mitigate an alleged adverse effect of the crisis on communicable diseases.
Methods: An online survey was conducted during November 2009February 2010 among
experts from national agencies for communicable disease control from European Union
(EU) and European Free Trade Association (EFTA) countries.
Results: There were few specic national policies and programmes aimed at mitigating the
impact of the economic crisis. Prevention services were deemed particularly susceptible to
budget cuts (68%) as a result of the economic crisis compared to primary care (28%), according to survey respondents. Services targeted at vulnerable and hard-to-reach population
groups were perceived to be at particular risk of deterioration (67%) in contrast to travel
medicine (11%), according to respondents.
Conclusions: There is a need for sustainability of nancial resources, public health workforce
and infrastructures to ensure that the services and programmes for the surveillance and
control of the spread of communicable disease are maintained and developed. There is also
a need to explore and foster better linkage in data on socioeconomic circumstances and
communicable disease outcomes.
2011 Elsevier Ireland Ltd. All rights reserved.
1. Background
The global economic crisis that began in 2008 is likely to
have a lasting negative impact on poverty, nutrition, education and health [1]. Studies of previous economic recessions
have shown that recession affects health primarily through
labour market and healthcare pathways [2], posing poten-
Corresponding author. Tel.: +46 76 101 0711; fax: +46 8 5860 1296.
E-mail address: Jan.Semenza@ecdc.europa.eu (J.C. Semenza).
0168-8510/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2011.06.013
tial risks and benets. Both fear of job losses and actual
unemployment create short-term risks of poor health from
increased stress, anxiety, and unhealthy coping behaviours
such as hazardous drinking or tobacco use [3,4]. Income
losses may worsen quality of diets but also lead people
to scale back so-called afuent lifestyles, as they spend
less disposable income on tobacco, alcohol, eating outside
the home, and walk instead of drive. Less income effectively increases nancial barriers to accessing health care,
especially in healthcare systems reliant on out-of-pocket
spending. Increasing real prices of medical supplies and
services can make health services unavailable or unaffordable [2], exacerbated by potential government budget cuts
of public health services and prevention programmes [5].
The net consequences of these impacts on health can be
difcult to predict [2224].
Although majority of existing studies have focused on
risk factors of chronic noncommunicable disease, concerns have also been expressed that the economic crisis
could have detrimental effects on the spread and control
of communicable diseases [6,7]. A recent systematic literature review on the impact of earlier economic crises
on communicable diseases partially conrms this view
[8], indicating several examples of infectious disease outbreaks from changing human consumption patterns. Two
examples are the spread of West Nile virus in California,
resulting from housing foreclosures and stagnant pools,
creating breeding grounds for mosquitoes [25]; another is
the increase in tick-borne encephalitis in eastern Europe
in regions where people turned to mushroom farming in
an attempt to cope with income losses, increasing their
exposure to ticks [26].
The two main mechanisms identied by which economic crisis could contribute to an increase in communicable disease reects standard Susceptible-Latent-Infected
models of disease spread: (i) by increasing those susceptible in populations, such as an increase in effective contact
rates and exposure to infectious agents and (ii) by constraining the capacity of the health system to respond to
existing and emerging infectious diseases. Thus far, however, evidence on the effects of past crises on infectious
diseases is limited [8]. It is likely that the impact will vary
widely among countries, depending on the epidemiology
and risk factors of particular infectious diseases.
One recent assessment of the potential impact of the
global economic crisis identied implications for tuberculosis and other diseases of poverty arising from changes in
several health systems functions: nancing, prioritization,
government regulation, integration and decentralization
[9]. In this report we draw on that model of key health
system functions, while recognising that control of tuberculosis and other communicable diseases depends as much
on social and economic development as on health systems
responses [10]. The economic and political crisis of the
1990s after the collapse of the Soviet Union was associated
with a rise in incidence of and mortality from tuberculosis in Central and Eastern Europe, and concerns have
been expressed in some countries that the current economic crisis might have similar effects [7]. HIV prevention
and treatment programmes in particular are under threat
with increased risk of HIV transmission and interruptions
or restricted access to antiretroviral treatment [6]. Recent
experience with the H1N1 pandemic shows that infectious disease management can require signicant nancial
resources, despite the relatively small impact of the pandemic [11].
Where quantitative scientic evidence is scarce or
weak, and the epidemiologic situation can change rapidly,
it is relevant to draw on expert opinions about potential
concerns and health effects [12]. In this paper we describe
the ndings of a survey of key informants from across
Europe on the perceived current and potential effects of
169
the recent economic crisis on infectious diseases. In particular, we mapped the key issues of concern to experts
involved in addressing the potential impact of the current
crisis on the spread and control of infectious diseases in
the European Union (EU) and European Free Trade Association (EFTA) countries and identied the types of measures
being undertaken by governments to mitigate any potential adverse effects of the crisis on communicable diseases.
We were especially interested in evidence on the impact
of the crisis on communicable disease control and on those
aspects of health systems most vulnerable to nancial cutbacks, those groups in the population at most risk, and
those communicable diseases most likely to be affected.
2. Methods
Our analysis of expert opinions was a scoping study,
complementing and informing a parallel systematic literature review of the evidence of the impact of previous
economic crises on infectious diseases [8]. A scoping
study differs from a systematic review in that a systematic review might typically focus on a well dened
question where appropriate study designs can be identied in advance whilst a scoping study tends to address
broader topics where many different study designs might
be applicable. Second, the systematic review aims to provide answers to questions from a relatively narrow range
of quality assessed studies, whilst a scoping study is less
likely to seek to address very specic research questions
nor, consequently, to assess the quality of included studies
[13].
The expert survey was undertaken between November 2009 and February 2010. The survey instrument was
piloted between October 2009 and November 2009 with
ve experts in communicable disease control. Surveys were
sent to European Centre for Disease Prevention and Control
(ECDC) Competent Bodies for Scientic Advice. Competent Bodies are institutions or scientic bodies providing
independent scientic and technical advice or capacity for
action in the eld of the prevention and control of infectious diseases; they are ofcial contact points for ECDC,
as designated by Member States governments. The questionnaire was completed by these national representatives
or assigned to other national public health experts with a
leadership position in infectious disease surveillance, and
control in their country. The survey was also disseminated
in the journal Eurosurveillance to capture other infectious
disease experts [3]. Informants completed an on-line questionnaire on the expected impact of the current crisis on the
spread and control of infectious diseases in their country
and corresponding measures being undertaken to mitigate the effects of the crisis [3]. The questionnaire (see
Annex) consisted of 13 questions in the following broad
areas: (a) existing studies, datasets or surveillance by socioeconomic characteristics that would allow monitoring and
assessment of the differential impact of the economic crisis on communicable diseases within the population; (b)
anticipated impact of the economic crisis on communicable disease control; (c) existing policies and programmes to
prevent potential adverse effects, and (d) policies and pro-
170
171
Table 1
Policies and programmes of communicable disease control likely to be affected by the current economic crisis.
Question
Number of
respondents
Yes (%)
No (%)
27
33.3
48.1
18.5
27
14.8
59.3
25.9
Tuberculosis
Antimicrobial resistance
National immunization programmes
Surveillance of STI
Programmes in developing countries
(tuberculosis, malaria, HIV, inuenza
A)
Reduction in the workforce and
recruitment freeze
Antimicrobial resistance
27
3.7
85.2
11.1
Strengthening of health
infrastructure
Global vaccination programme
Quality improvement
27
40.7
44.4
14.8
27
29.6
55.5
14.8
Table 2
Likely impact of the economic crisis on aspects of communicable disease control systems and health services.
Number of respondents
Aspects of the health system for the control of communicable diseases
27
Financial resources
25
Human resources
28
Non-physical
infrastructure/networks (e.g.
provision of vaccines,
laboratory network, etc.)
26
Physical infrastructure (e.g.
buildings, equipment, etc.)
Aspects of the health service for the control of communicable diseases
25
Prevention of disease
24
In-patient care
25
Surveillance
25
Out-patient care/follow-up
care
Primary care
25
85.2
72.0
57.1
3.7
4.0
17.9
11.1
24.0
25.0
42.3
15.4
42.3
68.0
50.0
44.0
44.0
20.0
16.7
24.0
16.0
12.0
33.3
32.0
40.0
28.0
32.0
40.0
172
Table 3
Analysis of free-text responsesmost frequently identied aspects of communicable disease control.
Disease/risk group/aspect mentioned by respondents
Diseases
Tuberculosis/TB
HIV/AIDS
STI/syphilis/LGV/STD
Hepatitis B/hepatitis C/hepatitis
Inuenza A/u/pandemic
14
9
9
5
5
Risk groups
Migrants/in Europe/persons from third world countries seeking work here/sub-Saharan
Africans/language barriers
Drug users/drug abusers/drug addicts/IVDU/needle exchange
Homeless
Gay men/MSM
Aspects of communicable disease control
Vaccination/immunization/vaccine/HPV/VZV
Human resources/understafng/brain drain/turnover of staff/reduction in the workforce/lack of
human infrastructure
Drug resistance/resistant bacteria/MDR TB/AMR/resistant cases/resistance management
Quality of data/quality control of microbiological diagnosis/quality improvement/poor quality
Screening
Inner cities/major cities
14
9
8
4
19
9
7
4
3
2
173
Table 4
Aspects of communicable disease control programmes that may be affected by the current economic crisis.
Aspect
Number of respondents
No effect (%)
Services aimed at
particularly vulnerable
groups
Infectious disease research
programmes
Hospital infection control
activities
Health service capacity to
respond to outbreaks
Diagnostic microbiology
provision services
Community infection
control activities including
contact tracing
Service provision for
patients with infectious
diseases
Occupational health
services
Immunization programmes
Genito-urinary medicine
provision
Food safety inspection
Travel medicine
27
66.7
18.5
27
55.6
25.9
11.1
7.4
26
53.8
26.9
11.5
7.7
26
46.2
38.5
7.7
7.7
26
42.3
34.6
15.4
7.7
27
37.0
51.9
7.4
3.7
27
37.0
48.1
11.1
3.7
26
30.8
46.2
3.8
19.2
27
27
29.6
18.5
55.6
48.1
7.4
0
7.4
33.3
27
27
14.8
11.1
55.6
59.3
11.1
7.4
18.5
22.2
Table 5
List of participating countries and positions of respondents.
Country (alphabetically)
Number of participants
Austria
Belgium
Bulgaria
Denmark
Estonia
France
Hungary
Iceland
Ireland
Italy
Latvia
Luxembourg
Malta
Netherlands
Norway
Poland
Portugal
Romania
Spain
Sweden
Switzerland
Turkey
UK
2
3
1
1
2
4
3
1
2
4
2
1
4
1
1
3
1
2
3
3
1
1
8
4. Discussion
To the best of our knowledge this is the rst attempt
to elicit and synthesise expert opinions on the impact of
the current economic crisis on communicable disease epidemiology and policy in Europe. In the light of limited
evidence from previous economic crises, and in the absence
of quantitative evidence on the current crisis, undertaking
a qualitative exercise offers a means of at least partially
lling this important gap and may help inform policy and
research responses.
174
Acknowledgements
We would like to thank all participants in the survey
who contributed their time to this study. The study was
funded by the European Centre for Disease Control and Prevention. We thank in particular Sandra Alves from ECDC for
your valuable help in disseminating the questionnaire.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the online version, at
doi:10.1016/j.healthpol.2011.06.013.
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