H5N1

The politics of public health investments

Via PubMed, a discouraging but all too believable study: The politics of public health investments. The abstract:

Public health investments help to prevent mortality and reduce health care costs. Yet very few studies have examined the determinants of preventive care investments across countries and over time. We develop a theory of health spending priorities contrasting preventive and curative care. 

Preventive care is particularly unlikely to be prioritized by governments since it is a public good that requires the allocation of scarce resources in the present to generate diffuse benefits that unfold only in the long-term. As such, public health is a "quiet" policy that is not supported by interest groups or public opinion. 

These characteristics have two implications: like other long-term investments, public health programs are particularly vulnerable to fiscal austerity, and prevention expenditures are not influenced by government partisanship since parties cannot attract votes with such low visibility, long term investments. 

We use a dataset covering 25 OECD countries from 1970 to 2018 to demonstrate that fiscal consolidations are negatively associated with the absolute level of preventive care and with its proportion relative to curative care. 

We also confirm that left-wing governments are not more likely to invest in public health than right-wing governments. 

Finally, contributing to the literature on comparative health care systems, we show that National Health Services systems maintain higher preventive care investments than Social Health Insurance systems.

Uganda: MSF responds to Ebola outbreak

Via Doctors Without Borders USA: Uganda: MSF responds to Ebola outbreak.

NEW YORK, SEPTEMBER 23, 2022—Following the September 20 declaration of an Ebola outbreak in Uganda in the country’s central Mubende district, the ministry of health has asked the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) to support its efforts in the fight against the spread of the disease.  

On September 21, an MSF team of six people—including doctors and logisticians—traveled to the town of Mubende to carry out an assessment of the situation and the needs at the regional referral hospital, where the first case was detected. The virus has been confirmed to be the rarer Sudan strain of Ebola for which there is no approved vaccine or treatment, unlike the Zaire strain that caused the last several outbreaks in the Democratic Republic of Congo.  

Since carrying out this assessment, MSF has begun setting up an Ebola isolation and treatment center in the Mubende hospital to help improve patient care. Teams are also exploring the possibility of setting up a second center in the town of Madudu, which is approximately 25 kilometers [15 miles] north of where the first person who died from Ebola originated and where several suspicious cases are reported.  

MSF is currently putting together a team of health workers, epidemiologists, and logisticians with experience in hemorrhagic fevers to start work next week.  

The last Ebola outbreak in the country occurred in 2019. MSF intervened at that time to support the Ugandan health authorities in the management of people who had been in contact with these confirmed cases, the establishment of an Ebola treatment unit, and the improvement of infection prevention and control measures in health facilities.

The Ugandan Ministry of Health has tweeted an update:

Uganda: Second suspected Ebola victim dies

Uganda's new Ebola outbreak hit the news yesterday, but it seems to have started several weeks ago. Via New Vision: Second suspected Ebola victim dies.

Another man suspected to be infected with Ebola has died at Mubende Regional Referral Hospital.  

He was part of the 14 people who checked into Mubende Regional Referral Hospital with symptoms of Ebola on September 20, 2022.  

Emmanuel Ainebyoona, the health ministry spokesperson, confirmed the death of suspected victim.  

"Yes, there is a child who died yesterday but we are waiting for test results  from UVRI. It is a suspected death at the moment," he said.  

According to Mubende RDC Rosemary Byabashaijja, a man from Madudu Sub County in Mubende died yesterday (September 20) after he was admitted at Mubende Regional Referral Hospital.  

The RDC is heading the Mubende Rapid Response team, which is working with Ministry of Health to track down contacts for the person who died on Monday and investigate the six deaths that occurred earlier in the month.  

The six deaths occurred suddenly and the local people say they died of strange illness.  

Byabashaijja said they had identified 14 contacts of the person who died on September 19, 2022. They included 10 people from Madudu Sub county including the one who passed on yesterday (September 20) and four people from neighbouring Kyegegwa district in Toro.  

“Since we registered the first case, we sent a surveillance team which goes around where they even sensitize the people. In Madudu, we have been asking those who were in touch with first victims to willingly come up and be tested and we are happy that some are turning up,” she said.  

On September 20, the team of medics took away the body of the first victims from Mubende hospital and buried. The body of the person who died on September 20 is awaiting burial today (September 21), according to sources.  

Byabashaijja noted that the six people expected to have died of Ebola form Madudu died because of self-medication.  

An isolation center has been set up at Mubende Regional Referral Hospital where suspected cases are being quarantined pending the results from samples picked from them.

Oxfam: Response to Lancet Commission on lessons from COVID-19 for future pandemics

Via Oxfam International: Response to Lancet Commission on lessons from COVID-19 for future pandemics.

Responding to The Lancet COVID-19 Commission’s report on lessons for future pandemics, Anna Marriott, Health Policy Manager at Oxfam and Policy Co-Lead for the People’s Vaccine Alliance, said: 

“The Lancet Commission details the utter failure of rich country leaders and pharmaceutical companies to ensure the tools needed to end this pandemic were accessible to everyone, everywhere. The findings of this commission should shame the international community. Nationalism, racism, profiteering, and an overreaching intellectual property system all prevented lower-income countries from accessing or producing vaccines.  

“It is vital that we learn the lessons of this report, end pharma’s deadly monopolies, and build more capacity for the development and manufacturing of vaccines, tests, and treatments in low and middle-income countries. Governments need to act immediately to extend an agreement made earlier this year on overriding COVID-19 vaccine patents to cover lifesaving treatments and tests. And they must safeguard World Health Organisation backed efforts to produce mRNA vaccine manufacturing on every continent from the threat of litigation from companies like Moderna.  

"The pandemic treaty currently under discussion needs to make clear that saving lives must come before profits and decisions about who lives and who dies are never again outsourced to the CEOs of big pharma.”

COVID-19: The case for prosociality

An editorial in The Lancet: COVID-19: the case for prosociality.

The Lancet Commission on lessons for the future from the COVID-19 pandemic, published on Sept 15, lays bare what has been nothing less than a massive global failure—a failure of rationality, transparency, norms of public health practice, operational coordination, and international solidarity. 

The Commission shows that national governments were too slow and too cautious in their response to the outbreak of SARS-CoV-2. They paid too little attention to the most vulnerable groups in society. Their responses were hampered by low public trust and an epidemic of misinformation and disinformation. The result was millions of preventable deaths and a reversal in progress towards sustainable development for many countries. 

A multilateral system developed after the World War 2 did not hold up to a modern pandemic. Global collaboration and solidarity were good in business and science but poor in politics and international relations. 

The Commission proposes five pillars that are essential in fighting emerging infectious diseases: prevention, containment, health services, equity, and global innovation and diffusion. To achieve these pillars the Commission argues that governments, regulators, and institutions must be reoriented toward society as a whole, rather than the interests of individuals—a concept the Commissioners call prosociality. Without this shift, the world is vulnerable and unable to tackle effectively any global threat. 

The Commission gives recommendations in three main areas. First, practical steps to finally control and understand the COVID-19 pandemic, such as a vaccination strategy that is sustainable and not just reactive, with the goal of protecting populations. Second, realistic, feasible, and necessary investments to improve the first line of defense in countries by strengthening health systems and widening universal health coverage. Third, ambitious proposals to ignite a renaissance in multilateralism, integrating the global response to the risk of future pandemics with actions to address the climate crisis and reversals in sustainable development. 

In this way, the Commission boldly sets out a vision of a different future, defined by a properly financed and better-prepared global architecture that is driven by cooperation and shared responsibility rather than globalised profit-seeking. • View related content for this article 

The Commission began with a task force on the origins of the pandemic. But, regrettably, the divisive public discussion about the source of SARS-CoV-2 damaged the trust needed for the task force to complete its work. This Commission therefore has no additional new evidence to contribute to the ongoing investigation of the pandemic's origins. The recommendation to intensify the search for the source of the pandemic is an urgent plea for countries to strengthen cooperation to elucidate the causes of this catastrophe. This will aid the prevention of future pandemics. Some Commissioners have come under unprecedented attack and pressure as a result of their work. The Lancet thanks them for their time and dedication to scientific enquiry.

There have been an estimated 17·7 million excess deaths due to COVID-19 globally, and this number is likely to be an underestimate. The number of reported new weekly cases decreased or remained stable across all six WHO regions. However, many countries have reduced their surveillance, causing uncertainty about the true number. Surveillance and testing capacity must be safeguarded and rescaled to prepare for potentially increasing numbers during winter in the northern hemisphere. Japan, South Korea, Australia, Chile, and parts of Europe such as Greece continue to have very high numbers of new cases.

The risk of new variants remains elevated and there are uncertainties around the strength and duration of immunity from vaccination. But perhaps most importantly, as many countries and institutions try to find a path out of the pandemic, many questions about what went wrong and how future pandemics can be prevented remain unanswered.

The war in Ukraine and climate and economic instability have diverted attention away from COVID-19. But as the Commission demonstrates, reassessing and strengthening global institutions and multilateralism will not only benefit the response to COVID-19 and future pandemics but also to any crisis that has global ramifications.

The release of The Lancet Commission on COVID-19 offers the best opportunity to insist that the failures and lessons from the past 3 years are not wasted but are constructively used to build more resilient health systems and stronger political systems that support the health and wellbeing of people and planet during the 21st century.

Serial cross-sectional estimation of vaccine and infection-induced SARS-CoV-2 sero-prevalence in children and adults, British Columbia, Canada: March 2020 to August 2022

Via medRxiv: Serial cross-sectional estimation of vaccine and infection-induced SARS-CoV-2 sero-prevalence in children and adults, British Columbia, Canada: March 2020 to August 2022. The underestimates of infections are breathtaking. The abstract:

Background  

We chronicle SARS-CoV-2 sero-prevalence through eight cross-sectional sero-surveys (snapshots) in the Lower Mainland (Greater Vancouver and Fraser Valley), British Columbia, Canada from March 2020 to August 2022.  

Methods  

Anonymized-residual sera were obtained from children and adults attending an outpatient laboratory network. Sera were tested with at least three immuno-assays per snapshot to detect spike (S1) and/or nucleocapsid protein (NP) antibodies. Sero-prevalence was defined by dual-assay positivity, including any or infection-induced, the latter requiring S1+NP antibody detection from January 2021 owing to vaccine availability. Infection-induced estimates were used to assess the extent to which surveillance case reports under-estimated infections.  

Results  

Sero-prevalence was ≤1% by the 3rd snapshot in September 2020 and <5% by January 2021 (4th). Following vaccine roll-out, sero-prevalence increased to >55% by May/June 2021 (5th), ∼80% by September/October 2021 (6th), and >95% by March 2022 (7th). In all age groups, infection-induced sero-prevalence remained <15% through September/October 2021, increasing through subsequent Omicron waves to ∼40% by March 2022 (7th) and ∼60% by July/August 2022 (8th). By August 2022, at least 70-80% of children ≤19 years, 60-70% of adults 20-59 years, but ∼40% of adults ≥60 years had been infected. 

Surveillance case reports under-estimated infections by 12-fold between the 6th-7th and 92-fold between the 7th-8th snapshots. 

Interpretation  

By August 2022, most children and adults had acquired SARS-CoV-2 vaccine and infection exposures, resulting in more robust hybrid immunity. Conversely the elderly, still at greatest risk of severe outcomes, remain largely dependent on vaccine-induced protection alone, and should be prioritized for additional doses. 

Competing Interest Statement  

DMS is Principal Investigator on grants from the Public Health Agency of Canada and Michael Smith Foundation for Health Research, paid to her institution, in support of this work and has received grants from the Canadian Institutes of Health Research and the BCCDC Foundation for Public Health, also paid to her institution, for other SARS-CoV-2 work. As the Provincial Health Officer with authority under the emergency provisions of the Public Health Act, BH authorized the access to and analysis of the anonymized sera used in this study; the study was separately reviewed and approved by the University of British Columbia Clinical Research Ethics Board. MK received grants/contracts paid to his institution from Roche, Hologic and Siemens. No other authors have conflicts of interest to disclose.

WHO sees October COVID surge in Ukraine, cites polio concerns

Via Reuters: WHO sees October COVID surge in Ukraine, cites polio concerns. Excerpt:

JERUSALEM, Sept 12 (Reuters) - The World Health Organisation expects a rise in COVID-19 in Ukraine to peak in October, possibly bringing hospitals close to their capacity threshold, WHO's director-general Tedros Adhanom Ghebreyesus said on Monday.  

"We are now seeing an increase in cases of COVID-19 in Ukraine. We project that transmission could peak in early October and hospitals could approach their capacity threshold," Ghebreyesus told WHO'S Regional Committee for Europe conference in Tel Aviv.  

"Oxygen shortages are predicted because major supply sources are in occupied parts of the country," he said. Oxygen is essential for patients with a range of conditions, including COVID-19 and those with other critical illnesses stemming from complications of pregnancy, childbirth, sepsis, injuries and trauma.  

Russia's February invasion of Ukraine has greatly impacted healthcare, with the WHO confirming more than 500 attacks on health infrastructure there, resulting in some 100 deaths. Ghebreyesus also said that the war could increase polio spread. 

"We are also deeply concerned about the potential for the international spread of polio due to the gaps in immunization coverage and mass population movement linked to the war," he said.  

Ukraine has low vaccination coverage for both COVID and polio, an infectious disease mainly affecting children that can cause paralysis and kill in rare cases. Two cases of polio were reported in Ukraine in 2021.

Molecular evidence for SARS-CoV-2 in samples collected from patients with morbilliform eruptions since late 2019 in Lombardy, northern Italy

Via ScienceDirect, a report in Environmental Research that could change the origin story of SARS-CoV-2: Molecular evidence for SARS-CoV-2 in samples collected from patients with morbilliform eruptions since late 2019 in Lombardy, northern Italy. The abstract:

As a reference laboratory for measles and rubella surveillance in Lombardy, we evaluated the association between SARS-CoV-2 infection and measles-like syndromes, providing preliminary evidence for undetected early circulation of SARS-CoV-2. 

Overall, 435 samples from 156 cases were investigated. RNA from oropharyngeal swabs (N = 148) and urine (N = 141) was screened with four hemi-nested PCRs and molecular evidence for SARS-CoV-2 infection was found in 13 subjects. Two of the positive patients were from the pandemic period (2/12, 16.7%, March 2020–March 2021) and 11 were from the pre-pandemic period (11/44, 25%, August 2019–February 2020). 

Sera (N = 146) were tested for anti-SARS-CoV-2 IgG, IgM, and IgA antibodies. Five of the RNA-positive individuals also had detectable anti-SARS-CoV-2 antibodies. No strong evidence of infection was found in samples collected between August 2018 and July 2019 from 100 patients. 

The earliest sample with evidence of SARS-CoV-2 RNA was from September 12, 2019, and the positive patient was also positive for anti-SARS-CoV-2 antibodies (IgG and IgM). Mutations typical of B.1 strains previously reported to have emerged in January 2020 (C3037T, C14408T, and A23403G), were identified in samples collected as early as October 2019 in Lombardy. One of these mutations (C14408T) was also identified among sequences downloaded from public databases that were obtained by others from samples collected in Brazil in November 2019. 

We conclude that a SARS-CoV-2 progenitor capable of producing a measles-like syndrome may have emerged in late June-late July 2019 and that viruses with mutations characterizing B.1 strain may have been spreading globally before the first Wuhan outbreak. Our findings should be complemented by high-throughput sequencing to obtain additional sequence information. 

We highlight the importance of retrospective surveillance studies in understanding the early dynamics of COVID-19 spread and we encourage other groups to perform retrospective investigations to seek confirmatory proofs of early SARS-CoV-2 circulation.

Health officials link four pneumonia deaths in Tucumán to Legionnaires' disease

Via the Buenos Aires Times: Health officials link four pneumonia deaths in Tucumán to Legionnaires' disease. Excerpt:

Tucumán health officials said Saturday that four people in a clinic in northwestern province had died of Legionnaires' disease, a relatively rare bacterial affliction of the lungs.  

Health Minister Carla Vizzotti told reporters that Legionnaires' had been identified as the underlying cause of double pneumonia in the four, who had suffered high fevers, body aches and trouble breathing.   

The deaths, all since Monday, occurred in a single clinic in the city of San Miguel de Tucumán.  

The latest, on Saturday morning, was that of a 48-year-old man with underlying health problems. A 70-year-old woman who had undergone surgery in the clinic was also a victim.

Seven other non-fatal cases have been identified, all in the same establishment and nearly all involving clinic personnel, provincial officials said.  

The disease, which first appeared at a 1976 meeting of the American Legion veterans group in the US city of Philadelphia, has been linked to contaminated water or unclean air-conditioning systems.  

When the outbreak in Tucumán was first detected, doctors tested the afflicted for Covid-19, flu and the hantavirus, but ruled all of them out.   

Samples were then sent to the prestigious ANLIS-Malbran Institute in Buenos Aires. Tests at the research body pointed to Legionnaires'.

Bilateral pneumonia outbreak in Tucumán, Argentina

Thanks to Giuseppe Michieli for tagging me in a tweet about this news release from the Ministry of Public Health in the province of Tucumán, Argentina: El ministerio de Salud Pública informó sobre la situación sanitaria del brote de neumonía bilateral (Ministry of Public Health reports on the health situation of the outbreak of bilateral pneumonia). Excerpt from the Google translation, lightly edited:

In a new press conference, the head of the Health Portfolio, Dr. Luis Medina Ruiz, reported the death of a 70-year-old patient and the identification of 3 employees of the sanatorium experiencing the same outbreak.

In this regard, the minister announced: “The sanatorium informed us of the death of a 70-year-old patient who was hospitalized there, we needed the family to know first to be able to communicate it. In addition, we identified 3 more employees of the private agent who began with symptoms around August 20 to 23 (that is, they correspond to the same outbreak and place of contagion in principle). That is why at this moment 3 more people are added to the 6 initial patients”.

Regarding the 70-year-old patient who died today, the minister stated: “She was hospitalized and she underwent surgery for a gallbladder problem. She was re-operated twice. From then on, an infectious pulmonary disease took place, the date of which coincides with the onset of symptoms in the other patients, around August 20. Although it is not yet clear which came first, at first she was considered patient zero, but she is under study based on the deepening of the analyses that are being carried out”.

At the same time he added: “We informed about the 3 identified employees. One of them is a 40-year-old pharmacy assistant and she was hospitalized a few days ago in a public hospital with a fever. In the active search that we are carrying out, especially in health personnel, we detected that it is a person who has non-severe bilateral pneumonia with an oxygen requirement under study. The other person is a 44-year-old nurse; she is at her home and we are following her evolution, since her clinical condition does not warrant hospitalization. The third case is a 30-year-old nurse with comorbidities, who was admitted to hospital this morning. His symptoms began around the same days and on the date he was present to be evaluated, at which time we decided to hospitalize him."

Following this line, the official explained that these three people have bilateral pneumonia as a clinical characteristic and have in common the origin of the focus, the epidemiological link with the 6 initial patients. The criterion of incorporating them as suspected patients to the outbreak in principle is based on the employment relationship with the sanatorium, bilateral pneumonia and that with all the study panels its etiology has not yet been found.

“Last night and this morning we had information from the Malbrán Institute and so far all the studies that we had as negative -for Covid, Hantavirus and some strains of Legionella- are also giving negative results there. We continue to carry out the research protocol for blood cultures, sputum cultures, urine cultures and all the viruses and bacteria that we have available in the province. We are in direct communication with Minister Carla Vizzotti, who is available, as well as all the epidemiology and infectious disease teams of the Nation, we are working as a large medical board in which we all participate with the information we have, there are hypotheses of the etiology that are being put on the table, although what we have specifically is the common origin and evolution of the disease”, he added.