H5N1

Ebola or violence: Which is the greater threat to public health?

Via Nature News & Comment: Experimental Ebola drugs face tough test in war zone. Excerpt and then a comment:

Health workers fighting the ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC) have given nearly 20 people experimental drugs to treat the virus since mid-August. But because the drugs have been dispensed on a case-by-case, ‘compassionate use’ basis, it is hard to know whether any are effective. Now, desperate to determine which therapy works best, researchers from the DRC and US governments, the World Health Organization and other groups are meeting this week to plan a clinical trial that will compare multiple drugs as the outbreak continues.  

For ethical reasons, the trial scientists say they do not intend to give any study participants a placebo. Instead, they hope to compare the two experimental medicines now in use to ZMapp, an antibody therapy that showed promise in limited tests three years ago during a major Ebola epidemic in West Africa. Patients in the coming trial would receive one of these three drugs at random. The study design draws on a flexible clinical-trial framework that the WHO expects to unveil early next week. The framework is intended for use in multiple Ebola outbreaks, to produce data that can be pooled over time. 

The scientists working on the DRC trial hope to launch the effort in the coming weeks. “A clinical trial will give us the scientific evidence we need,” says Jean-Jacques Muyembe-Tamfum, director-general of the National Institute for Biomedical Research in Kinshasa, which will lead the study. 

But planning for the trial is complicated by the realities of working in a conflict zone: the DRC’s North Kivu and Ituri provinces, where fighting has killed more than 5 million people over the past two decades. Instability in the region could prevent clinicians from giving patients repeated infusions of drugs and collecting the biochemical data that a trial would require. “We can’t control what happens around a treatment centre,” Muyembe-Tamfum says. “Armed groups can do what they want.”  

Moving quickly 

The current outbreak began on 1 August, and has grown to include 115 confirmed and probable cases of Ebola — including 77 people who have died, the DRC health ministry said on 28 August. Public-health workers have vaccinated 4,645 people, and doctors have given 3 people the antiviral drug remdesivir, made by Gilead Sciences of Foster City, California. Another 13 patients have received mAb114, an experimental treatment derived from antibodies found in the blood of a person who contracted Ebola in 1995 and survived.  

That swift response is a major shift from the handling of the Ebola epidemic that struck West Africa in 2014. Experimental drugs were not used widely in West Africa then because there was no proof of their safety or efficacy — clinical trials did not begun until the outbreak was near its end. That delay helped to drive the death rate among Africans infected with Ebola to 63%. But several Westerners infected with Ebola received the nascent therapies in top hospitals; the fatality rate for this group of patients was just 18%2. The controversy over this disparity eventually prompted the WHO to develop guidelines aimed at ensuring wider access to experimental treatments during future Ebola outbreaks.  

But the only way to determine how well a drug works — and to rule out confounding factors, such as overall quality of medical care — is through a randomized, controlled clinical trial. Thus far, researchers have not managed to complete a trial of any experimental Ebola drug, because outbreaks of the disease have ended before enough patients enrolled in the studies. So the WHO has been working with international experts to create a basic trial design that can be adapted as data accumulate and logistical challenges change.

Note the statistic buried in the fourth paragraph: "fighting has killed more than 5 million people over the last two decades" in North Kivu and Ituri provinces. Presumably this slaughter has gone unnoticed in the Western media because the region offers little or nothing of strategic value to Western nations.

Yet we see no dramatic international action to suppress the violence that's a far, far greater threat to public health than Ebola will ever be. 

EBOLA DRC - Evolution of the response to the Ebola epidemic in North Kivu on Friday, August 31, 2018

The Ministry of Health has published EBOLA DRC - Evolution of the Response to the Ebola Epidemic in North Kivu Province on Friday, August 31, 2018. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCE OF NORTH KIVU 

Friday 31 August 2018   

The epidemiological situation of the Ebola Virus Disease  dated 30 August 2018:   

• A total of 118 cases of haemorrhagic fever were reported in the region, 88 confirmed and 30 probable. 

• 13 suspected cases are under investigation. 

• 2 new confirmed cases in Beni. 

• No new deaths.   

Remarks: 

• To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table. 

The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not. 

News of the response    

Day of Traditional Medicine 

• This Friday, August 31, 2018, African countries celebrated the Day of Traditional Medicine. Traditional medicine practiced by traditional healers remains particularly popular with the Congolese population, especially in rural areas. In many areas, traditional healers are the primary providers of primary care because people first go to their homes before seeing a conventional doctor at a health center. This is an important factor to consider in the context of an Ebola outbreak. Therefore, sensitization and involvement of traditional healers in the response is essential. It is for this reason that the Social Mobilization Commission organized today a briefing with the traditional healers of Beni. During this briefing,   

Vaccination 

• Since the start of vaccination on 8 August 2018,  5,150 people have been vaccinated , including 2,707 in Mabalako, 1,286 in Beni, 1,017 in Mandima, 121 in Oicha and 19 in Kinshasa.

Ebola: Heads of Beni neighbourhoods equipped with cell phone to alert officials over suspected cases

Via Digitalcongo.net, a report from Actualite.CD: Ebola : Heads of Beni neighbourhoods equipped with cell phone to alert officials over suspected cases. The Google translation:

The Ministry of Health on Thursday, August 30, 2018, the heads of neighborhoods of the city of Beni (North Kivu) mobile phones as part of the response to the Ebola virus disease. 

A total of 30 neighborhood leaders who benefited from this allocation to alert health officials about possible suspected cases.  

"The grassroots authorities are our real partners in the response. We gave them the phones so they can alert us whenever there is an alert or suspicion. They are the guardians of the community, they each received a phone to raise awareness and especially report suspicious cases," said Dr. Oly Ilunga, Minister of Health. 

Neighborhood leaders also visited the Ebola Treatment Center (ETC) built at the Beni Reference General Hospital where patients are being cared for. 

The epidemic has already killed about thirty people. Since vaccination began on August 8, 2018, 4,645 people have been vaccinated, including 2,372 in Mabalako, 1,135 in Beni, 1,017 in Mandima and 121 in Oicha.  

A total of 115 cases of haemorrhagic fever were reported in the region, of which 85 were confirmed and 30 were probable.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published Ebola virus disease – Democratic Republic of the Congo. Excerpt:

The outbreak of Ebola virus disease (EVD) in the Democratic Republic of the Congo is at a key juncture. Recent trends (Figure 1) suggest that control measures are working. Over the past week, contact follow-up rates have substantially improved, most patients recently admitted to Ebola treatment centres (ETC) received therapeutics within hours of being confirmed, and ring vaccination activities have scaled to reach contacts (and their contacts) of most confirmed cases reported in the last three weeks. 

However, the outbreak trend must be interpreted with caution. Since the last Disease Outbreak News on 24 August 2018, 13 additional confirmed and probable cases have been reported, the majority (n=8) were from the city of Beni. Moreover, substantial risks remain, posed by potential undocumented chains of transmission; four of the 13 new cases were not known contacts. 

Likewise, sporadic instances of high-risk behaviours in some communities (such as unsafe burials, reluctance towards contact tracing, vaccination and admission to ETCs if symptoms developed), poor infection prevention and control (IPC) practices in some community health centres, and delays in patients reaching ETCs when symptoms develop, all have the potential to further propagate the outbreak. 

As of 29 August 2018, a total of 116 EVD cases (86 confirmed and 30 probable) including 77 deaths (47 confirmed and 30 probable)1 have been reported in five health zones in North Kivu (Beni, Butembo, Oicha, Mabalako, Musienene) and one health zone in Ituri (Mandima). Eight suspected cases from Mabalako (n=5) and Beni (n=3) are currently pending laboratory testing to confirm or exclude EVD. The majority of cases (65 confirmed and 21 probable) have been reported from Mabalako Health Zone (Figure 2). The median age of confirmed and probable cases is 35 years (interquartile range 19–45.5 years), and 56% were female (Figure 3).

Credit: WHO
 

Fifteen cases have been reported among health workers, of which 14 were laboratory confirmed; one has died. All health worker exposures likely occurred in health facilities outside of the dedicated ETCs. WHO and partners continue to work with health workers and communities to increase awareness on IPC measures, as well as vaccinate those at risk of infection. 

In addition to the ongoing response activities within outbreak affected areas, the MoH, WHO and partners will be implementing a 30-day strategic plan to ensure operational readiness measures against EVD are strengthened in all provinces of the Democratic Republic of the Congo. The first phase of implementation will prioritise six provinces at highest risk of case importations: South Kivu, Maniema, Ituri, Tanganika, Haut Uele and Bas Uele. The main objective is to ensure that these provinces implement essential operational readiness measures, including enhancing surveillance, IPC and social mobilization to mitigate, rapidly detect, investigate and effectively respond to a possible outbreak of EVD.

ECDC weekly updates: 2018 West Nile fever transmission season

ECDC has published Weekly updates: 2018 West Nile fever transmission season. The situation update:

Between 24 and 30 August 2018, EU Member States reported 300 human cases of West Nile fever: Italy (144), Romania (61), Greece (41), Hungary (38), Austria (8), France (6), Croatia (1) and Slovenia (1). EU neighbouring countries reported 55 cases: Serbia (54) and Kosovo* (1). In six areas, human cases were reported for the first time: Italy (3), Austria (1) and Slovenia (1). All other human cases were reported from areas that have been affected during previous transmission seasons. 

This week, 25 deaths were reported by Romania (6), Serbia (6), Italy (7), Greece (5) and France (1). In the same week, 13 outbreaks among equids were reported, all by Hungary. 

According to the Friedrich-Loeffler-Institut (FLI), West Nile virus infection was detected in birds in Germany for the first time. The infection was detected in two dead owls in a bird park in Halle (Saale River), Saxony-Anhalt, Germany. 

In 2018, as of 30 August 2018, EU Member States reported 710 human cases: Italy (327), Greece (147), Romania (117), Hungary (96), France (11), Austria (8), Croatia (3) and Slovenia (1). EU neighbouring countries reported 265 human cases: Serbia (213), Israel (49) and Kosovo* (3). To date, a total of 64 deaths due to West Nile fever have been reported by Serbia (21), Greece (16), Italy (13), Romania (12), France (1) and Kosovo* (1).  

During the current transmission season, 77 outbreaks among equids have been reported by Italy (41), Hungary (31) and Greece (5).  

*This designation is without prejudice to positions on status, and is in line with UNSCR 1244 and the International Court of Justice Opinion on the Kosovo Declaration of Independence.

Polio vaccination: Health zones dealing wth Ebola are not affected

Via Radio Moto Mutembo-Beni: Polio Vaccination: Health Zones Dealing With Ebola Are Not Affected. The Google translation:

The announcement was made in Goma. The Minister of Health, Dr. Oly Ilunga Kalenga, launched in the capital of North Kivu the first phase of the polio vaccination campaign. Nearly five years without a new case of polio, the Democratic Republic of Congo recorded, this year, about twenty cases of vaccine-derived poliovirus.  

This prompted the Government to launch this new vaccination campaign. The first phase concerns 9 provinces: Bas-Uele, Haut-Uele, Mongala, North and South Kivu, North and South Ubangi, Tshopo and Ituri. 

Due to the ongoing Ebola outbreak in North Kivu Province, several risk areas have been temporarily excluded from the polio vaccination campaign. These areas include Beni, Butembo, Mabalako, Musienene, Katwa, Kalunguta and Oicha.  

As soon as the Ebola outbreak is under control, polio vaccination in these areas can begin, reports the bulletin of the Ebola Response Directorate, published on Wednesday, August 29, 2018. This bulletin reviews the epidemiological situation in the province of North Kivu.

Beni: Chlorinated water and contactless thermometers to fight Ebola in schools

Via Radio Okapi: Beni: chlorinated water and contactless thermometers to fight Ebola in schools. The Google translation:

The Minister of Health, Oly Ilunga announces that the government of the Republic and its partners will place chlorinated water and thermoflash (contactless thermometer) in schools to fight the Ebola epidemic in schools. He made the announcement Thursday, August 30 during his meeting with school officials in the presence of journalists in Beni North Kivu. 

"All the staff of the pension committee, all the teams of the psychosocial commission with their partners: UNICEF and others; they are there to make sure that in schools, we have water points, that there is chlorinated water, that there are thermoflashes. So that's really the message I had for you, " said Oly Ilunga.  

According to him, the points of chlorinated water for hand washing should be visible at the entrance and exit of the classes. Thermoflash will be available in each school for monitoring student temperatures.  

"If we love our children, if we want to make them safe, it's the school that has to be clean, it's the school that needs to be cleaned up. And the sanitation of the school is first and foremost the two measures there: water, washing hands and monitoring the temperature. And those habits must stay. Even when we have finished Ebola, if we keep these habits, it means that all diseases that affect our children: diarrhea, dysentery ... You will find that they will decrease," said the minister. 

The minister expressed the wish to see this epidemic be mastered in September in North Kivu and that there is no 11th Ebola outbreak in the DRC. 

Civil society organizations proposed the postponement of the school year due to the Ebola outbreak. But the Ministry of Health said the arrangements were made for a safe return to school.

MMWR: Opportunities to prevent overdose deaths involving prescription and illicit opioids, 11 states, July 2016–June 2017

Via MMWR: Opportunities to Prevent Overdose Deaths Involving Prescription and Illicit Opioids, 11 States, July 2016–June 2017. The summary:

What is already known about this topic?  

In 2016, opioids were involved in 42,249 U.S. overdose deaths.  

What is added by this report?  

Among 11 reporting states, most (58.7%) opioid overdose deaths involved illicit opioids only, followed by those where both illicit and prescription opioids were detected (18.5%); 17.4% of deaths involved prescription opioids only. Bystanders to the overdose, who could potentially intervene, were documented in 44% of deaths; however, laypersons rarely administered naloxone.  

What are the implications for public health practice? 

Development of overdose prevention programs should consider the types of opioids contributing to deaths, link persons to treatment during and upon release from an institution or after a nonfatal overdose, and expand naloxone distribution to laypersons.

41,000 measles cases in Europe since the beginning of 2018

Via The Lancet: 41 000 measles cases in Europe since the beginning of 2018. Excerpt:

Despite her country having the highest number of measles deaths in Europe this year, Jovana Kostic is adamant that she will not have her 2-year-old vaccinated. She was fined 150 000 Serbian dinars (€1200) for her refusal. “I was convinced that the first round of vaccination weakened his immune system. He was never sick before that and after the first dose he had a fever for more than 7 days,” the 24-year-old from Subotica in northern Serbia told The Lancet. 

Kostic is one of a growing number of people in Serbia and across Europe who are refusing, or questioning, vaccinations against measles and other diseases. And this, say health experts, is contributing to low vaccine coverage that is driving a measles epidemic that has swept across Europe this year, claiming 37 lives—14 of which were in Serbia—with more than 41 000 cases reported in the first 6 months of the year. 

The number of cases is an 8-year high and almost twice as much as in the whole of 2017. WHO and other global health groups have called on European countries to step up efforts to halt the spread. They have also described the outbreak as “unacceptable”. 

“We have the means to avoid measles cases and deaths, and the fact that this has happened in Europe is completely unacceptable”, Nedret Emiroglu, director of Health Emergencies and Communicable Diseases, WHO Regional Office for Europe, told The Lancet. 

Measles is one of the most infectious diseases, but can be almost entirely prevented by vaccination. To eliminate the disease, vaccine coverage needs to be at 95%. But data from the European Centre for Disease Prevention and Control (ECDC) shows that only four EU/European Economic Area states met that target for 2017. 

Experts point out that some countries, such as Ukraine, which has had the highest number of reported measles cases this year, face problems with vaccine supply, whereas in others people access medical services with difficulty and cannot get the vaccines that are available. But in many countries, there is also a growing level of scepticism and even active campaigning against vaccinations. 

Heidi Larson of the London School of Hygiene & Tropical Medicine and director of the Vaccine Confidence Project, told The Lancet: “there has always been some historic distrust of vaccines and people not wanting to take them, but what we have seen recently is an acceleration of this and more polarisation on the issue”. 

“The MMR controversy from the late 1990s has not been forgotten, partly because of active support for it by groups in some parts of the continent, while there are strong anti-vaccine movements elsewhere, some of which have been picked up on by populist politicians. The vaccination issue is becoming more politically driven.” 

Some prominent politicians have indeed spoken out against vaccines. Marine Le Pen, the leader of France's far right National Rally party, publicly opposed mandatory vaccinations; founder of Italy's Five Star Movement, Beppe Grillo is a known vaccine sceptic.

Rod Rosenstein’s cheap and dangerous shot at Vancouver’s Insite

The Tyee has published my article Rod Rosenstein’s Cheap and Dangerous Shot at Vancouver’s Insite. Click or tap through for the full article with many links. Excerpt:

Canadians, like Americans, know Rod J. Rosenstein, the deputy attorney general of the United States, only because he appointed Robert Mueller as special counsel to investigate possible Russian meddling in the 2016 election. That makes him something of a hero, one who often comes under attack from Donald Trump.  

On Monday, Rosenstein went from hero to zero just by publishing an op-ed in The New York Times. “Fight Drug Abuse, Don’t Subsidize It,” he urged — and especially don’t fight it by establishing safe injection sites. 

Rosenstein may be a great lawyer, but as a public health expert he’s just another charlatan. The great 19th-century German doctor and politician Rudolf Virchow famously observed that “Medicine is a social science, and politics is nothing else but medicine on a large scale.” Or, in Rosenstein’s case, malpractice on a national scale. 

Rosenstein notes that drug overdoses are now killing over 60,000 Americans a year (and doesn’t mention that’s almost twice as many as die by gunshot). He laments that “remarkably, law enforcement efforts actually declined while deaths were on the rise… The Trump administration is working to reverse those trends. Prosecutions of drug traffickers are on the rise, and the surge in overdose deaths is slowing.” 

He gives no source for “slowing.” The most recent information from the U.S. Centers for Disease Control is from 2016, when the CDC reported that overdoses killed 63,632 Americans — two-thirds of them involving opioids. And that was a 21.5-per-cent increase from 2015. 

Injection sites ‘dangerous’? 

Rosenstein is alarmed that “some cities and counties are considering sponsoring centers where drug users can abuse dangerous illegal drugs with government help. Advocates euphemistically call them ‘safe injection sites,’ but they are very dangerous and would only make the opioid crisis worse.”  

He goes on to describe how these sites’ “staff members help people abuse drugs by providing needles and stand ready to resuscitate addicts who overdose.” Clean needles! Resuscitated overdose cases! The horror! 

After a litany of American cities considering such sites, Rosenstein says “they’re illegal,” and threatens the cities “should expect the Department of Justice to meet the opening of any injection site with swift and aggressive action.” He frets about the obvious — drugs may be laced with fentanyl or carfentanil — and warns that “a bystander or emergency medical worker who comes in contact with such drugs can be gravely harmed.” Perhaps so, but bystanders and first responders are more likely to come in contact with such substances in some dark alley than in a safe injection site. 

And it’s precisely Insite that Rosenstein attacks. He cites just one source, a scandalized city councillor in Redmond, Washington, who visited the Downtown East Side last year and said “It was the most depraved scene I’ve witnessed in person.” He derided “Seattle’s far left politicians” for wanting safe injection sites there.  

Rosenstein certainly didn’t check with Vancouver Coastal Health, which helps run Insite and reported last year: 

“From Jan. 1 to Nov. 30, 2017, there were 119,395 visits to the supervised injection room at Insite. Among those, 1.2 per cent visits resulted in an overdose. 10,534 visits used the injection room in November 2017, that was 4.1 per cent decrease over the average number of visits in the previous three months (10,980) visits, and nine per cent decrease over the number of visits in November 2016 (11,544 visits). 94 visits resulted in an overdose in November 2017, a 19 per cent decline over the average overdoses during the previous three months (117 overdoses), and 61 per cent decrease over the number of overdoses in November 2016 (239 overdoses).”

Sure, the DTES is a grim place, and all of B.C. suffers a growing number of overdose deaths. The B.C. Coroners Service recently reported 134 suspected drug overdose deaths in July, a 25-per-cent increase over June. We are now running an average of 125.4 overdose deaths a month in 2018, up from 120.8 last year, 82.8 in 2016, and 30.7 in 2014.

But there were no deaths at supervised consumption or drug overdose prevention sites.