Editorial
False economy and global health security
John Wessels/Stringer/Getty Images
For more on the Ebola outbreak
in DR Congo see https://www.
statnews.com/2018/05/09/new-
ebola-outbreak-congo-raises-
who-concerns/
For more on the costs of the
West African Ebola epidemic
see https://www.cdc.gov/vhf/
ebola/outbreaks/2014-west-
africa/cost-of-ebola.html
Mauro Fermariello/Science Photo Library
For more on the NICE guidance
on lower UTIs see https://www.
nice.org.uk/guidance/
indevelopment/gid-apg10004/
consultation/html-content
For more on the NICE guidance
on recurrent UTIs see https://
www.nice.org.uk/guidance/
indevelopment/gid-apg10006/
consultation/html-content
1966 www.thelancet.com Vol 391 May 19, 2018
Last week, the DR Congo declared a new outbreak of
Ebola, with two confirmed cases, 39 probable cases, and
19 deaths reported as we went to press. The threat of
a new outbreak highlights the need for a focused and
coordinated response from a broad range of international
governmental and non-governmental agencies and
organ­i­sations. The 2014–16 west African Ebola epi­demic,
with nearly 30 000 suspected Ebola deaths and thousands
more due to lack of access to an overwhelmed health-care
system, was devastating and cost more than US$3·6 billion
($2·4 billion from the USA), with an estimated $2·2 billion
in lost GDP in the affected countries.
In the USA, these past lessons are being ignored.
President Trump’s retreat on efforts to combat major glob-
al health security issues leaves the USA and the entire world
at greater risk: his administration announced its intention
to cut $252 million in funds already allocated to Ebola re-
sponse initiatives, on the same day that the latest outbreak
was declared. Trump is also poised to allow funding for the
Centers for Disease Control and Prevention’s Global Health
Balancing treatment with resistance in UTIs
Urinary tract infections (UTIs), defined by the presence of
bacteria in the urine combined with clinical features such
as urinary frequency or dysuria, affect 10–20% of women
at some time in their lives. New draft guidance from the
UK National Institute for Health and Care Excellence (NICE)
aims to improve the rational prescribing of antibiotics
for patients with lower UTIs and in a variety of special
circumstances, such as recurrent UTIs, catheter-associated
UTIs, prostatitis, and pyelonephritis. Although in most
situations antibiotics are required, inappropriate treatment
contributes to the growing problem of antibiotic resistance
in UTIs, with more than a third of UK laboratory-confirmed
Escherichia coli UTIs now resistant to key antibiotics.
The guidelines suggest that all patients presenting
with a lower UTI should be given advice on symptom
management with paracetamol or ibuprofen and adequate
fluid intake, and advised that there is no evidence for the
benefit of cranberry products. In non-pregnant women,
depending on symptom severity, the advice is now to
consider a back-up antibiotic (taken only if symptoms
worsen, or do not improve within 48 h), waiting for culture
Security Agenda to lapse in 2019. The Wellcome Trust and
DFID have pledged £2 million and £1 million, respectively,
in funding for Ebola response efforts in the DR Congo, but
alone cannot fill the gap left by the USA. As Trump aban-
dons long-held global health priorities, advocates in the
White House, Tim Ziemer and Tom Bossert (who was de-
veloping a biosecurity strategy), have abruptly resigned,
leaving a strategic vacuum in global health security—
one that an increasingly belligerent and inward-looking
US administration seems uninterested in filling.
The World Health Assembly is scheduled for next week,
and Director-General Tedros Adhanom Ghebreyesus was
sworn in last year on a platform of strengthening global
health security. While we are still early in Tedros’s 5 year
term, it unfortunately cannot be said that the world is safer
from global health security threats than it was a year ago.
The need for robust responses to global health security
dangers will not go away. We cannot afford to turn away
from proven and effective responses in the name of false
economy and blinkered nationalism. n The Lancet
and susceptibility results before prescribing, or giving an
antibiotic immediately. In all other groups, immediate
antibiotics are advised. Trimethoprim and nitrofurantoin
remain the first-line antibiotics of choice in all groups,
except pregnant women. Pivmecillinam and fosfomycin
are recommended as second-line choices for non-pregnant
women who do not improve after 48 h. For women with
recurrent UTIs, the NICE guidance now suggests that
clinicians consider recommending D-mannose (a sugar,
found naturally in many fruits, available in powder form),
and vaginal oestrogen (for postmenopausal women)
before considering single-dose antibiotic prophylaxis for
exposure to triggers, or continuous antibiotic prophylaxis.
This draft guidance is available for comment until
June 5, and is expected to be formalised in January, 2019.
Judicious use of antibiotics in common clinical situations
is crucial for minimising antibiotic resistance, but also
for the effective treatment of patients. Comprehensive
guidance, such as this from NICE, will support clinicians
in successfully achieving the balance between effective
treatment and minimising resistance. n The Lancet