H5N1

H7N9: "The worst bird flu crisis in history"

Via Meat Trade News Daily.co.uk: China - The Worse bird flu crisis in history. (They mean "worst," but they're in the meat trade and I'm in the grammar trade.) Excerpt:

The H7N9 avian influenza outbreak that has killed 20 people and infected more than 100 people in four provinces in China is also wreaking havoc on the poultry industry on a national scale, according the official Xinhua news agency.     

The director of the poultry association in south China’s Guangdong Province estimated that Wen’s Food Group Co. Ltd., one of the largest poultry producers in China, has lost 20 million yuan ($3.2 million) in a single day during the crisis. 

He called the latest outbreak “the worst in history,” the agency reported. The poultry industry lost at most 5 million yuan ($801,077) per company during the 2003 SARS outbreak, the H5N1 crisis in 2005 and the H1N1 infection in 2009, according to Xinhua. 

Drastic declines in poultry prices and consumption caused Wen’s Food Group to lose up to 100 million yuan ($16.2 million) between April 1 and April 14, with the total loss expected to hit 150 million yuan ($24.3 million) this month alone, the general manager of the company’s branch in Zhejiang Province told Xinhua.   

Some companies reportedly have been trying to get financing, but aren’t sure they can cover the financial gap caused by the drop in demand.

Quite apart from the damage done to an industry employing millions, millions more will have to do with less animal protein, or with other forms of it...perhaps the dubious pork that would otherwise have ended up in the local river as too diseased to sell.

In 1983, a Chinese colleague explained to me why everyone in China took a xiuxi, a siesta, after lunch: "We don't eat enough protein to get through the day without a nap." Better-fed relatives in Hong Kong thought their cousins up the Pearl River in Guangdong were a bunch of layabouts.

But it was sheer malnutrition behind that noonday sleepiness, and my family and I soon learned to enjoy a nap as well. So the economic and political consequences of H7N9 could undo 30 years of nutritional progress, and that would indeed be a major crisis.

Sudan: The silent catastrophe continues

As if to underline the post just below, this Radio Dabanga article reports: Ten thousands of Darfurians fleeing Sudan to seek refuge in Chad. Excerpt:

At least 50,000 people have been fleeing Sudan to Chad in the past week due to fightings between various groups in Central Darfur. The UN Refugee Agency (UNHCR) says it is the largest exodus of people from Darfur since 2005. 

UN agencies and local sources in Chad have confirmed the arrival of at least 50,000 people who are fleeing inter-tribal fighting in Central Darfur. They are joining another 24,000 who have previously sought shelter in Tissi town due to other conflicts. 

Civilians escaping the recent violent clashes in Umm Dukhun between the Salamat and Misseriya tribes do not have water, food or medicines and are sleeping under trees, a local source told Radio Dabanga. These claims were confirmed by the UN agency for refugees UNHCR:   

"They are in great risk of waterborne diseases as they drink water from a nearby river. More refugees continue to arrive daily. Among them are wounded by bullets that are abandoned to their fate and are sleeping on the ground”. 

It added that most of them are traveling on foot, donkeys or on carts to save their lives. People are "exhausted, traumatized and visibly disturbed by the recent violent events". 

Central Darfur refugees saw their houses being destroyed and villages completely burnt down. Many reported their relatives being killed in the latest round of violence, UNHCR reported. 

According to a Tissi native, refugees come mostly from Abugaratil and surrounding villages, which were heavily targeted during the tribal war. Besides Tissi, the villages of Killi, Rumaliya, Ratret, Haraza and Koza are also housing refugees. 

The source disclosed that the local health center is treating 40 injured people, noting that another eight persons who were in critical conditions have been transferred to a hospital in Abeche.  

"Thick heavy smoke" 

The government of Chad and aid agencies, which had been hosting the first wave of 24,000 displaced, are reportedly deploying committees to assess the current situation in Tissi and send aid to the new arrivals. 

Local authorities have provided 100 tons of food that have already been transported by UNHCR to Tissi. 

In a press statement, however, the UN agency expressed concerns that the number of refugees could increase as clashes continue across the border. 

Its staff has witnessed “thick heavy smoke in the Darfur skies fearing this may be the result of more houses being set on fire in the nearby Darfur villages.”

Could H7N9 spread out of China?

Via Shanghai Daily: Concern at spread across borders. Excerpt:

The exact source of infection remains unknown, though samples have tested positive in some birds in poultry markets that remain the focus of investigations by China and the UN's Food and Agriculture Organization. 

Speaking in Bangkok, the FAO's Subhash Morzaria said: "This particular region is land linked and so there is a possibility that if, inadvertently or advertently, somebody moves infected poultry across borders we can anticipate the spread of this virus." 

Morzaria added: "We are proactively initiating surveillance programs in neighboring countries like Myanmar, Laos and Vietnam which border China and are at particular risk and we are trying to understand how the poultry movement has taken place so we can identify more accurately where the risk is going to be." 

The new virus is severe in most humans, leading to fears that if it becomes easily transmissible, it could cause a deadly influenza pandemic. 

However, Morzaria said: "This new H7N9 virus hasn't been demonstrated to be transmitted between humans, so from that context we think that the H7N9 virus is not going to be a pandemic like H1N1 strains."

Given what we know so far, I tend to agree that we're not looking at a pandemic. But widespread H7N9 in poultry would create enormous economic and food-security problems. The costs of testing and inspection would be high, and even birds that passed the tests would be a hard sell in many Asian markets. So the industry would falter, thousands would be out of work, and consumers would need another source of animal protein. All of which would result in more public health problems stemming from stress, unemployment, and malnutrition. 

Cambodia: Sanitation, water link to malnutrition

Via The Phnom Penh Post: Sanitation, water link to malnutrition. Excerpt:

Lack of access to clean water and sanitation is a serious problem for a majority of rural Cambodians, but the consequences are particularly serious for children, the United Nations Children’s Fund says. 

Urging the government to organise further across sectors to combat these threats to children’s health, UNICEF representatives said in a statement for World Water Day today that widespread infection, encouraged by unsanitary conditions, meant many children failed to absorb critical nutrients. 

“Infection makes children lose their appetite and steals nutrients from their bodies — nutrients that are also lost through diarrhoea,” UNICEF’s Rana Flowers said. 

“Twenty-eight per cent of Cambodian children are underweight, and four out of 10 are stunted.” 

UNICEF says 22 per cent of Cambodia’s schools lack toilets and in schools with them, 30 per cent do not work.   

“In these circumstances, children are constantly exposed to infection,” it says. A study commissioned last year had found that children from poor households with functioning toilets were less likely to be underweight than children from otherwise comparable households that did not have proper toilets, Denise Shepherd-Johnson, UNICEF's chief of communications in Cambodia, said. 

“A sick child cannot absorb nutrients efficiently,” Flowers said. “Malnutrition leads to poorer cognitive development and schooling outcomes, and children are more likely to repeat a grade or drop out . . . They are less able to work, less productive, and earn less as adults.” 

Due to such taxes on productivity and health, Cambodia loses $146 million in GDP to vitamin and mineral deficiencies every year, according to UNICEF’s calculations.  

US: Thoughts on the baby cured of HIV, and 6.9 million child deaths

Via The New York Times, an editorial: The Intriguing Case of a Baby Cured of H.I.V. Excerpt:

In the latest case, a Mississippi woman, who was infected with H.I.V., did not get treatment during her pregnancy. Doctors gave her baby a three-drug treatment-strength regimen, some 30 hours after birth. They continued the treatments for 18 months, after which the mother stopped going to the hospital and stopped giving her baby the drugs. 

Five months later, the mother returned with her child, who turned out to be free of the active virus. The baby, now 2 1/2 years old, has been free of the active virus ever since. Although very sophisticated tests can find traces of the virus, it is not able to replicate and spread. This is described as a “functional cure.” 

There are reasons to treat this apparent breakthrough cautiously. Researchers must still demonstrate conclusively that the baby had truly been infected and was not simply prevented from absorbing its mother’s infection — a process achieved routinely in many babies. They must also show that this is not an exceptional, nonreplicable case with an atypical baby, but that the same treatment would work in other newborns. 

If the stronger early treatment is confirmed to work, it could become the standard of care around the world. Fewer than 200 babies a year are born with lasting H.I.V. infections in the United States, but some 300,000 babies a year are born with such infections abroad. 

Even if the treatment works, the best defense against mother-to-child transmission is still prevention, which will always be preferable to treatment after an infection has set in.

Apart from the truism of the last paragraph, we might reflect on the implications: If such a cure is possible, 300,000 babies yearly will need it. This will put a new burden on countries with high HIV rates (which tend to be very poor countries) and on the donors and agencies that now provide antiretroviral drugs.

Wikipedia, citing UN reports, tells us that 6.9 million children under age 5 died in 2011—half of them in sub-Saharan Africa. While this is mercifully less than the 12.4 million who died in 1990, it still amounts to a yearly Holocaust, inflicted mostly by such banal causes as respiratory infections, diarrhea, measles, malaria, and malnutrition. They need no miracle drugs, only clean water, nourishing food, and a few cheap vaccinations.

Every HIV-positive child deserves to live. So do the millions of others who won't live to see their fifth birthday.

Six million facing hunger in southern Africa: IFRC

Via Reuters AlertNet: Six million facing hunger in southern Africa-IFRC. Excerpt:

More than 6 million people across Angola, Lesotho, Malawi and Zimbabwe are at risk of severe food shortages because of repeated cycles of drought and flooding, the global humanitarian body IFRC said on Monday. 

The International Federation of Red Cross and Red Crescent Societies said the crisis was passing largely unnoticed in the outside world and its appeals for financial support had won limited support. 

"This is a chronic crisis in which cycles of drought and flooding are destroying crops, livestock and safe drinking-water supplies. People don't have enough to eat or clean water to drink," said IFRC official Alexander Matheou. 

"Malaria, cholera and diarrhoea are common," said Matheou, the Geneva-based body's regional representative in southern Africa, in a statement distributed to a news briefing. 

The IFRC said four countries were suffering particularly badly, with 725,000 people in Lesotho - about 40 per cent of the country's population - hit by the crisis. 

Nearly 2 million were at risk in Malawi, more than 1.8 million in Angola, and 1.6 million in rural areas of Zimbabwe. In all four, rates of child malnutrition were soaring, reaching 50 percent more than last year in some areas. 

An additional complication, Matheou said, was the prevalence of HIV across southern Africa. 

Some 34 percent of people around the world carrying the disease live in the region, and 23.2 percent of Lesotho's population were infected, the globe's third highest rate among adults, the IFRC official said. 

The organisation said lack of food can undermine efforts to counter the spread of HIV, because the sickening effect that the anti-retroviral treatment has on an empty stomach deters many sufferers from taking it.

Sudan: 13 million suffer food shortages

Via Radio Dabanga: Health Ministry: 13 million Sudanese suffer food shortages. 

The federal Minister of Health, Bahr Idriss Abu Garda, revealed that a survey conducted by the ministry in 13 states in Sudan indicates that around 13 million people suffer from food shortages and that a third of the Sudanese population is suffering from malnutrition. 

During a food security workshop organized by the Ministry of Agriculture, Abu Garda said malnutrition is one of the three main causes of infant mortality under the age of five. He pointed out that 1 out of 3 children suffers from malnutrition and that approximately 1 out of 12 Sudanese children suffers from severe famine. 

The minister also stated that, according to the survey, 15 % of the Sudanese population are suffering from malnutrition and 14 % are without health insurance coverage or health services. 

The governmental report on food security indicates that the Red Sea, Blue Nile, South Kordofan, South and West Darfur states are mostly affected by food insecurity. 

Furthermore, it mentions the lower consumption of food in the states of Darfur due to the unstable security situation, displacement and lack of access to food.

The disasters in Sudan and South Sudan go on and on, and the world ignores them.

Sudan: Hepatitis ‘kills 20, infects 300’ in Blue Nile state

Via Radio Dabanga: Hepatitis ‘kills 20, infects 300’ in Sudan’s Blue Nile state.

The population of Albow locality in Blue Nile state is complaining about the high incidence of hepatitis in the area, although the exact death toll remains inconclusive.   

Locals told Radio Dabanga on Wednesday that at least 20 people died of the disease and that some 300 are infected. 

However, the general director of the state’s ministry of health Dr. Amir El-Sheikh says that three people have died so far including a pregnant woman in the El-Shahid area. 

He denied the increasing incidence of hepatitis among citizens, although sources expressed their discontent to Radio Dabanga about the state’s “delay” in dealing with the epidemic.

In other news from Sudan, Radio Dabanga says 30 percent of the children in North Darfur are malnourished, and 23 children in Central Darfur have died from drinking water polluted by toxic bombs.

The narrative of H5N1 (and every other infectious disease)

I fretted all weekend, looking for new reports from Cambodia and China about their H5N1 cases. No reports on NCoV turned up either, though Gregory Härtl certainly gave us all an earful today about the misuse of "SARS-like" in describing the novel coronavirus.

When I think about it, these two stories have something in common, even if NCoV has little in common with SARS and H5N1 has even less. The common thread is that they're stories—narratives with beginnings, middles, and ends. The disease itself is what we writers call the McGuffin, the device (like the Maltese Falcon, or the One Ring) that triggers the plot. And the plot is what most of us nonspecialists care about.

So the sudden stutter of H5N1 cases around Phnom Penh in recent weeks got our attention like a burst of machine-gun fire. With a plot clearly under way, we wait for the next burst. How will the good guys respond? Is this a skirmish or a full-blown war? The suspense is agonizing. When an eighth suspected case was reported this morning, I dropped everything to post it. Now I'll fret until the case is confirmed or not. In the meantime, another plot turn: an H5N1 death in Egypt.

The emergence of a family cluster of NCoV cases in London was another alarming plot turn, telling us that the stakes are higher than we thought. And like a writer, I keep thinking about the first outbreak, the nosocomial cases in Jordan last April: surely the solution to the NCoV mystery, as in any good story, must be hidden in its beginning, awaiting a dramatic revelation by some Hercule Poirot of virology. 

One way we understand a story is to relate it to others in the genre. The James Bond franchise has been flourishing for half a century, each film and novel drawing on what we know from previous ones. So NCoV seems to make more sense, to be more of a McGuffin, if it's linked to a previously known outbreak like SARS. With H5N1, we seem to have more at stake if we invoke the pandemic of 1918-19. As a story, H1N1 was anticlimactic precisely because we compared it to 1918-19 rather than judging it on its own terms.

A story, whether gritty and realistic or surreal and fantastic, is a kind of anecdotal evidence for the author's view of the world. Better said, a smart author knows what the audience's view of the world is, and writes stories that strengthen that view. That, after all, is what makes popular fiction so popular: cheaters never prosper, the hero gets the girl, the villain gets his comeuppance, and the world is saved.

For people in public health, this demand for a popular storyline must be worse than frustrating. I suspect it's why neglected tropical diseases are neglected: they don't offer a mysterious and dramatic onset, the stakes aren't high (except for the unfortunate people who contract them), and no climactic resolution is anywhere in sight.

The problem is even worse because we like stories with characters we can identify with. For the affluent white nations of the west, that means we see no story in diseases afflicting poor nonwhite people in countries that are not tourist destinations. Dengue barely exists in the North American consciousness because the people who live in the worldwide dengue belt are mostly nonwhite and non-English-speaking. Similarly, cholera afflicts black people in poor countries: not exactly big box-office.

Worse yet, in stories disease is often a consequence of some moral lapse, the punishment of a vengeful god. That means the victims get the blame, and the story carries an implicit racism: Well, what can you expect from those backward people in Haiti or Sierra Leone or Zimbabwe? What kind of ignoramus would chow down on a mysteriously dead chicken? The only way to make such stories palatable to white western readers is to send NGOs (preferably led by whites) to the rescue, and make them the story.

So you could say that the psychology of the well-fed and healthy is a significant problem for the malnourished and ill. As La Rochefoucauld famously said, "Somehow we always find the strength to bear the misfortunes of others." Worse yet, we don't even want to think about those misfortunes unless they will entertain us—that is, tell us that our view of the world is absolutely correct. We don't want to hear that maybe the good guys brought cholera to Haiti (even if they did). 

This does not excuse the public health community from its duty to alert and where needed, to alarm. I'm really glad Gregory Härtl came after us with his impatient reminder that NCoV is not "SARS-like." We need more experts to sit down with more media people and aggressively promote sound science and hard facts in their reporting. And unlike vaccination, the media will need endless booster shots to keep them from relapsing.

That also means the experts need to understand their audience at least as well as the media do. It's idle to wish that everyone was intelligent, rational, and well-informed. They're not, and they're not likely to improve much in our lifetime. But that audience is still susceptible to a good story, well told. If the experts can trace the genome of H5N1 or NCoV, surely they can also understand the minds of their fellow-humans well enough to explain such diseases—their causes, cures, and prevention—in the storytelling terms we all understand.

West Africa: Conditions causing disease among Malian refugees

Via allAfrica.com, a news release from MSF: West Africa: Desperate Conditions Causing Disease Among Malian Refugees. Excerpt:

Conflict in the north of Mali is still causing massive movements of people across the Sahel region and the unacceptable conditions in the camps where they are living are leading to disease and suffering. 

According to the UNHCR, the UN refugee agency, approximately 150,000 refugees are living in camps in Burkina Faso (Ferrerio, Dibissi, Ngatourou-niénié and Gandafabou camps), Mauritania (Mbera camp) and Niger (Abala, Mangaize and Ayorou camps). 

Médecins Sans Frontières (MSF) has been working in these eight camps since March 2012, providing basic healthcare and maternal care, and treating malnutrition. MSF is also giving basic care and measles vaccinations to children aged between six months and 15 years. Nearly 12,000 consultations and 5,000 vaccinations have been carried out since the beginning of the year. 

"At the border crossing at Fassala, Mauritania, people are arriving thirsty and showing signs of fatigue," says Karl Nawezi, MSF project manager in Mauritania. Nearly 67,000 refugees - mainly women and children - have arrived in the border town of Fassala, since January 2012. 

Many have travelled by truck or with donkeys. After being registered by the authorities, the refugees wait in a transit camp before being transferred to Mbera, a small, isolated village in the Mauritanian desert, just 30 km from the Mali border. 

Poor conditions in the camps 

"In Mauritania, as is the case elsewhere, people are suffering from diarrhoea, respiratory infections and skin infections because of the poor conditions in the camps," says Nawezi. In Mbera, the refugees are totally dependent on humanitarian aid. To date, the number of tents that have been distributed has been insufficient. Families have been assembled under large tents called 'meeting points', which leave them exposed to the elements. Fed up with waiting, some have taken it upon themselves to construct makeshift shelters out of straw mats and pieces of fabric in order to protect themselves from sand and dust storms.

Meanwhile, IRIN reports that the Malian rebels, fleeing out of Mali, may cause instability in just those nations now harboring the refugees.