Public Health Laboratory Service,. London NW9 5EQ. DAVID BROWN. Director. Enteric and Respiratory Virus Laboratory,. Public Health Laboratory Service.
with experience in the previous outbreak to coordinate these responses. Within days, surveillance systems were operating and early exaggerated reports were contradicted. International teams soon arrived to provide additional epidemiological and clinical support. Bodies are now being picked up and disposed of by the Red Cross, and the community has been educated about the simple measures necessary to minimise risk. Active case finding is taking place at health centres within Kikwit and at remote sites within a radius of 150-200 km; cases and deaths are being systematically identified and contacts exhaustively traced. Gowns, gloves, and masks have been flown in; nurses from peripheral health posts are receiving training. Kikwit's hospital now has access to drinking water and a few hours of electricity daily; surfaces are regularly disinfected. Despite all this, the number of cases will inevitably rise in the next three weeks among those already infected. The experience so far underlines the importance of disease surveillance for an early response and provokes a commitment to support the intensive efforts until the outbreak is contained. But the outbreak also highlights the difficulties poorer countries have in sustaining the simple measures that could have prevented or minimised not only Ebola transmission but other more ordinary but no less dangerous nosocomial risks. Deaths from an exotic, incompletely characterised virus should not be necessary to remind us of the need for barrier nursing supplies and routine precautions when there is
exposure to body fluids. The present opportunity for rich countries to bring the weight of modem molecular virology to bear on Ebola virus should not deflect from the greater priority to strengthen training of health care staff and improve facilities in poorer countries. DIANE BENNETT Consultant epidemiologist
Communicable Disease Surveillance Centre, Public Health Laboratory Service, London NW9 5EQ DAVID BROWN Director
Enteric and Respiratory Virus Laboratory, Public Health Laboratory Service 1 Report of an International Commission. Ebola haemorrhagic fever in Sudan, 1976. Bull World Health Organ 1978;56:247-70. 2 Report of a WHO/International Study Team. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ 1978;56:271-93. 3 Baron RC, McCormick JB, Zubeir OA. Ebola virus disease in southern Sudan: hospital dissemination and intrafamilal spread. Bull World Health Organ 1983;61:997-1003. 4 Jahrling DB, Geisbert TW, Dalgard DW, Johnson ED, Ksiazek TG, Hall WC, et al. Preliminary report: isolation of Ebola virus from monkeys imported to USA. Lancet 1990;335:502-5. 5 Ebola haemorrhagic fever. Wkly Epidemiol Rec 1995;70:147. 6 Kiley MP, Bowen ETW, Eddy GA, Isaacson M, Johnson KM, McCormick JB, et al. Filoviridae: a taxonomic home for Marburg and Ebola viruses? Intervirology 1982;18:24-32. 7 Feldmann H, Klenk HD, Sanchez A. Molecular biology and evolution of filoviruses. Arch Virol 1993;7:81-100. 8 Fisher-Hoch SP, Brammer TL, Trappier SG, Hutwagner LC, Farrar BB, Ruo SL, et al. Pathogenic potential of filoviruses: role of geographic origin of primate host and virus strain. J Infect Dis 1992;166:753-63. 9 Department of Health and Social Security and the Welsh Office. Memorandum on the control of viral haemorrhagicfevers. London HMSO, 1986. 10 Outbreak of Ebola viral hemorrhagic fever-Zaire 1995. MMWR Morb Mortal Wkly Rep 1995; 44:381.
Spinal cord injuries in rugby union players How much longer must we waitforproper epidemiological studies? Recognition nearly 20 years ago of a high incidence of spinal cord injuries in rugby union players' led eventually to changes in the rules in most rugby playing countries. New Zealand changed its rules in 1980 and 1984; Britain in 1979, 1984, and 1985; Australia in 1985; and South Africa in 1990. The consensus is that these changes have produced the desired effect, but how robust is the evidence? The week in which the Rugby World Cup begins in South Africa seems an apt time to address this question. Silver's study of 63 spinal cord injuries in rugby union players between 1952 and 1982 was important in identifying mechanisms of injury in a representative sample of rugby players.2 But it was not a study of incidence. Two further studies by him included all spinal cord injuries in rugby players treated in eight spinal units in England and Wales between 1980 and 1986. By this time the incidence of spinal cord injuries should have begun to fall if the actions taken by the English Rugby Football Union had been effective. These data show that, although the annual incidence of spinal cord injuries at Stoke Mandeville Hospital fell steadily from a peak of nine admissions in the 1980-1 season to two in 1986-7, the overall incidence of reported spinal cord injuries in rugby union players in England and Wales remained fairly constant between 1980 and 1986. Clearly these data do not support Silver's conclusion that a fall in the incidence of serious injury in Britain has followed changes in the laws of rugby.5 Until complete data from all spinal units in Britain have been analysed (the numerator) and the total number of rugby players in Britain is known (the denominator), no conclusions regarding the effects of recent rule changes can be drawn. Similar uncertainty exists in other rugby playing countries. Burry and Calcinai reported that the average annual incidence BMJ VOLUME 310
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of spinal cord injuries in New Zealand fell from nine between 1973 and 1978 to less than three in 1985-6 as a result of specific rule changes that reduced the number of injuries in scrums and loose rucks or mauls.6 Calcinai's more recent data show that the number of spinal cord injuries in New Zealand rugby players rose again in the 1988 and 1989 rugby seasons: incidence in 1989 was not lower than that before the rules were first changed in 1980.7 (Only three further injuries were reported in the 1990 and 1991 seasons so the average annual incidence between 1988 and 1991 fell back to four.) But the accuracy of these data must now be questioned in the light of Dixon's analysis of hospital discharges for rugby injuries, including spinal cord injuries, in New Zealand rugby players between 1980 and 1990. 8 If we assume that Dixon's methods were correct Calcinai and Burry apparently identified only about half of all spinal cord injuries in New Zealand rugby players. Interestingly, Dixon showed that spinal cord injuries peaked in 1984 and 1986-after the introduction ofwhat were considered to be effective rule changes. It is therefore premature to conclude that the incidence of spinal cord injuries related to rugby has fallen in New Zealand. The sole data for spinal cord injuries in South African rugby players come from a 30 year survey of admissions to the spinal unit at the Conradie Hospital in Cape Town, the source of the original study of spinal cord injuries in rugby players.' 9 The most recent analysis of those data shows that admissions of rugby union players with spinal cord injuries rose progressively during the 1980s with a peak incidence of 12 admissions in 1989.10 In the past four seasons (1990-93), there have been a further 31 spinal cord injuries in rugby players. This is fewer than the 1345
37 such injuries in the four preceding seasons, owing mainly to a 33°/0 reduction in the incidence of spinal cord injuries in schoolboys after rules were changed for under 19 rugby at the start of the 1990 season. Hence the evidence from South Africa is that the incidence of spinal cord injuries has altered recently only in schoolboy rugby players. Assessment of the effects of rule changes in Australian rugby depends on follow up data to Taylor and Coolican's study,"l which have yet to be published. An official publication of the Australian Rugby Football Union, however, notes that since the introduction of rule changes to schoolboy rugby, no serious spinal cord injuries have been reported in Australian schoolboy rugby players in the past eight seasons (1985-92)." Awareness is now growing of the lack of data on "near miss" injuries, in which serious cervical injury occurs without damage to the spinal cord. Calcinai found that whereas his method of analysis identified only one spinal cord injury in New Zealand rugby players in 1991 there were at least 10 "near miss" injuries.7 Similarly, in a prospective one year study of rugby injuries at 25 high schools in the Cape Province of South Africa, cervical ligament injuries were reported, seven of which were associated with cervical fracture or dislocation but none ofwhich caused cervical injury. 13Analysing only those injuries that cause spinal cord injury therefore identifies only a small fraction of the total number of cervical injuries in rugby players. The mechanisms causing near miss injuries are similar to those causing spinal cord damage 713; hence effective interventions to prevent paralysing injuries would also reduce the incidence of these injuries. Nearly 20 years after the BMJ first drew attention to the issue we still do not know the true incidence of either spinal
cord or all cervical injuries in rugby players in any rugby playing country. This unacceptable situation will continue until accurate data are collected, an idea that editorials in this and other journals have been promoting for years.' 1415 The international community of doctors involved in rugby must convince rugby administrators in all countries to set up epidemiologically valid surveys of injuries. Until they do so there will not be enough accurate data to support change. TIMOTHY NOAKES Professor Department of Physiology, University of Cape Town Medical School, Observatory 7925, South Africa
ISMAILJAKOET Medical consultant
South African Rugby Football Union, Sports Science Institute of South Africa, Newlands 7700, South Africa Editorial. Rugby injuries to the cervical cord.BMJ 1977;i: 1556-7. Silver JR. Injuries of the spine sustained in rugby.BMJ 1984;288:37-43. SilverJR. The need to make rugby safer.BMJ 1988;296:429. Silver JR, Gill S. Injuries of the spine sustained during rugby.Sports Med 1988;5:328-34. Silver JR. Injuries of the spine sustained during rugby.BrJ Sports Med 1992;26:253-8. Burry HC, Calcinai CJ. The need to make rugby safer.BM_ 1988;296:149-50. Calcinai C. Cervical spine injuries.NZJ Sports Med 1992;20:14-5. Dixon G. Morbidity of rugby union injuries in New Zealand.NZJSports Med 1993;21:18-20. Scher AT. Rugby injuries to the cervical spinal cord.SAfrMedJ 1977;51:473-5. 10 Kew T, Noakes TD, Roux C, Kettles AN, Goedeke RE, Newton DA,et al. A retrospective study of spinal cord injuries in Cape Province rugby players: 1963-1989.SAfrMedJ 1991;80:127-33. 11 Taylor TKF, Coolican MRJ. Spinal cord injuries in Australian footballers: 1960-1985.Med J Aust 1987;147:1 12-8. 12 Australian Rugby Football Union.ARFU handbook. Kingsford: Australian Rugby Football Union, 1 2 3 4 5 6 7 8 9
1993. 13 Roux CE. The epidemiology of schoolboy rugby injuries [MSc thesis]. Cape Town: University of Cape Town, South Africa, 1992. 14 Garraway WM, Macleod DAD, Sharp JCM. Rugby injuries. The need for case registers.BMJ 1991;303:1082-3. 15 Editorial. Cervical spine injuries and rugby union.Lancet 1984;i: 1 108.
Primary care at last for Brazil? Much training is needed Brazil has one of the most unequal distributions of income in the world.' Its health system is dominated by hospital care, and around 80% of hospital admissions paid for by public funds are to hospitals in the private sector.2 Because pay is so poor in the public sector many doctors are forced to have two or more appointments to earn a reasonable income. Although the country produces more doctors per capita than many other comparable middle income countries, most are "specialists" with limited training, and few want to work in primary care. Community nurses are also in short supply. There are only two sizeable programmes for training primary care doctors, both based in the southern city of Porto Alegre. These train about 50 doctors a year. The Ministry of Health in Brasilia recognises the impossibility of developing a national health system without investing in primary care and is creating a family health programme. This programme intended to establish 2500 primary care teams nationwide in the first year.' It was proposed that nearly half would be in the impoverished north east. Nine months after the programme was launched in March 1994, 765 teams were working in 66 cities-just over half in the north east. Each team has a minimum of a doctor, a nurse, a nurse auxiliary, and several community health agents recruited from the local community and trained to undertake not only curative work but also prevention, health promotion, and, in some cases, basic epidemiological monitoring. It is responsible for 800-1000 families. Staff will be paid much more than current rates in the public sector and 1346
will be required to work full time in the programme. Since a change in the national constitution in 1988 the health system is being decentralised. Municipalities (the equivalent of local authorities) are now responsible for organising much of the health care for local populations. The system has problems. Some state governments are reluctant to pass the money from the federal ministry on to the municipalities for political reasons, and some local authorities are not ready to administer the money. Nevertheless, the process offers an important opportunity for primary care to take root because of the need to develop locally accountable services. The experience of some of the well organised municipalities, such as those in Ceara in the north east of the country, show that it is possible to develop cost effective services that have a real impact on public health and a considerable input from the local community.4 There is always a danger that proposals put forward in an election year (the elections were on 3 October last year) may turn out to be cosmetic. But it seems likely that some concrete progress will be made in the family health programme, although at a slower rate than originally intended because local authorities increasingly need primary care. The major omission so far is the training needs of the new teams. With few general practitioners or community trained nurses in Brazil, the teams will have to use health professionals trained mainly in hospitals, at least in the early years. Inappropriately trained specialists (many with only two years' specialist training) and nurses with purely hospital experience will be BMJ VOLUME 310
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