H5N1

The Lancet Commission on 21st-Century Global Health Threats

Via The Lancet, December 15, 2022: The Lancet Commission on 21st-Century Global Health Threats. 

The world has lived through an extraordinary global health threat, the COVID-19 pandemic, leading to nearly 20 million deaths, staggering economic losses, a generational decline in human capital, and the first decline in global life expectancy since 1950 (the first year when UN estimates were published). Another major threat, climate change, now has broad scientific, political, and social recognition. The spectre of nuclear confrontation has re-emerged as a serious threat during the ongoing Russian invasion of Ukraine. 

The three Cs—COVID-19, climate change, and conflict—highlight that the steady global health progress of the past 70 years will not necessarily continue in the next 70 years. But there are many other threats beyond the three Cs that threaten to undermine future global health progress, including rising antimicrobial resistance, increasing obesity, inverted population pyramids, eroding sexual and reproductive rights for women, food insecurity, and fraying multilateralism. How global health advances or retreats will depend crucially on the multiplicity of these threats and how they intersect. 

The global community and many nations have launched commissions, task forces, and panels to draw lessons from the COVID-19 pandemic. The Pan-European Commission on Health and Sustainable Development explored the post-pandemic world for Europe and made far-reaching recommendations based on a One Health lens. The Independent Panel for Pandemic Preparedness and Response and the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response called for the creation of new institutions and financing mechanisms to prepare the world for new pandemics and other threats. 

Multiple commissions, task forces, and panels have addressed climate change, including two Lancet Commissions, and the Intergovernmental Panel on Climate Change produces regular multistakeholder assessments. These global convenings have been mirrored by multiple national reviews. Although there are high-profile initiatives for pandemics and climate change, other threats have received less widespread attention or have been debated largely in academic subdisciplines.  

Governments, international organisations, and local communities will need to manage multiple threats at the same time. Many of these threats interact and lead to complex health, economic, social, and geopolitical consequences. Climate change, population growth, and political fragility may coincide leading to large-scale migration. Food systems can be designed to improve health, reduce poverty, and slow climate change, or the reverse.  

Specific and cross-cutting technologies and policies are needed to reduce the risk of emerging threats or to decrease the harms from threats as they unfold. The most important strategies for risk and harm reduction are unlikely to emerge if each threat is examined in isolation from the others.  

We have established the Lancet Commission on 21st-Century Global Health Threats to examine the broad set of threats facing the world over the rest of the century. This long perspective is needed since threats such as climate change, food systems, antimicrobial resistance, or inverted population pyramids require many decades for actions to alter future trajectories. The Sustainable Development Goal focus on 2030 is an important motivator for immediate policy action, but a longer-term perspective is needed to fully assess and respond to emerging threats.

This Commission's work will be informed by diverse expertise. The Commission members are drawn from many distinct groups: current and former heads of state, intergovernmental organisation leaders, leaders of public health institutions, global health funders, global health thought leaders, and civil society and youth organisations. The Commission represents a diverse group with gender parity and regional balance so that many perspectives are brought to bear on finding cross-cutting tools and solutions for future threats. The Commission will meet over the next 2 years to assess the evidence produced by various working groups and will release its analysis and recommendations by the end of 2024.

Symptoms and risk factors for long COVID in non-hospitalized adults

Via Nature Medicine: Symptoms and risk factors for long COVID in non-hospitalized adults. The abstract:

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is associated with a range of persistent symptoms impacting everyday functioning, known as post-COVID-19 condition or long COVID. We undertook a retrospective matched cohort study using a UK-based primary care database, Clinical Practice Research Datalink Aurum, to determine symptoms that are associated with confirmed SARS-CoV-2 infection beyond 12 weeks in non-hospitalized adults and the risk factors associated with developing persistent symptoms. 

We selected 486,149 adults with confirmed SARS-CoV-2 infection and 1,944,580 propensity score-matched adults with no recorded evidence of SARS-CoV-2 infection. Outcomes included 115 individual symptoms, as well as long COVID, defined as a composite outcome of 33 symptoms by the World Health Organization clinical case definition. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) for the outcomes. 

A total of 62 symptoms were significantly associated with SARS-CoV-2 infection after 12 weeks. The largest aHRs were for anosmia (aHR 6.49, 95% CI 5.02–8.39), hair loss (3.99, 3.63–4.39), sneezing (2.77, 1.40–5.50), ejaculation difficulty (2.63, 1.61–4.28) and reduced libido (2.36, 1.61–3.47). 

Among the cohort of patients infected with SARS-CoV-2, risk factors for long COVID included female sex, belonging to an ethnic minority, socioeconomic deprivation, smoking, obesity and a wide range of comorbidities. The risk of developing long COVID was also found to be increased along a gradient of decreasing age. 

SARS-CoV-2 infection is associated with a plethora of symptoms that are associated with a range of sociodemographic and clinical risk factors.

This article in The Guardian is likely only the first of many to discuss these findings.

Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study

Via The Lancet Regional Health - Americas: Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study. The summary:

Background  

Before widespread vaccination, the United States was disproportionately affected by COVID-19 with a mortality rate several times that of other affluent societies. Comparing regions with different rates of health insurance, we assess how much of this excess mortality may be due to the relatively large population without health insurance.  

Methods  

We use daily surveillance data from the US Centers for Disease Control and Prevention (CDC) stratified by region, age group, gender, and race in regression analysis of daily COVID-19 cases, hospitalization, and mortality. COVID-19 data have been matched with structural characteristics of the region including average proportion with health insurance. As checks, we have estimated regressions for different time periods, different groups of states, and by comparing adjacent counties between states with and without Medicaid expansion.  

Findings  

Groups with lower health insurance coverage had significantly higher mortality as well as greater case counts and hospitalization. Early in the pandemic, they were also less likely to be tested for COVID-19. Applying our regression estimates, we estimate that had there been full health insurance coverage of the population, there would have been 60,000 fewer deaths, 26% of the total death toll in the period of this analysis.  

Interpretation  

Our study demonstrates that a significant share of COVID-19 mortality in the United States, and much of the excess mortality in the United States compared with other countries, is due to our reliance on a system of market-driven healthcare. Providing universal insurance coverage should be part of our campaign to reduce COVID-19 mortality. It also suggests that these concerns should not be restricted to COVID-19 but apply across all diseases, contributing to many unnecessary deaths in the United States each year even apart from the COVID-19 pandemic.

Provisional COVID-19 age-adjusted death rates, by race and ethnicity — United States, 2020–2021

Via MMWR: Provisional COVID-19 Age-Adjusted Death Rates, by Race and Ethnicity — United States, 2020–2021. The summary:

What is already known about this topic?  

In 2020, racial and ethnic disparities in COVID-19 age-adjusted death rates (AADR) were reported among U.S. residents.  

What is added by this report?  

From 2020 to 2021, disparities in AADR ratios from COVID-19 decreased significantly by 14.0%–40.2% for most racial and ethnic groups, including non-Hispanic White persons, who accounted for 59.6%–65.2% of all decedents; and increased nonsignificantly (7.2%) for non-Hispanic Native Hawaiian and other Pacific Islander persons (0.2%–0.3% of all decedents) compared with non-Hispanic multiracial persons.  

What are the implications for public health practice?  

Providing effective preventive interventions, including vaccination and clinical care, to all communities in proportion to their need for these interventions is necessary to reduce racial and ethnic disparities in COVID-19 deaths.

Mortality rates by college degree before and during COVID-19

Via the National Bureau of Economic Research, a paper by Anne Case and Angus Deaton: Mortality Rates by College Degree Before and During COVID-19. Click through to download the paper. The abstract:

It is now established that mortality and excess mortality from COVID-19 differed across racial and ethnic groups in 2020. Less is known about educational differences in mortality during the pandemic. We examine mortality rates by BA status within sex, age, and race/ethnic groups comparing 2020 with 2019. 

Mortality rates have increasingly differed by BA status in the US in recent years and there are good reasons to expect the gap to have widened further during the pandemic. Using publicly available provisional data from the National Center for Health Statistics we find that mortality rates increased in 2020 over 2019 for those with and without a BA, irrespective of age, sex, or race/ethnicity. Although mortality rates increased by more for those without a BA, the ratio of mortality rates for those with and without a BA changed surprisingly little from 2019 to 2020. The BA was protective against mortality prior to the pandemic, and it was equally protective during the pandemic. 

Among 60 groups (sex by race/ethnicity by age) that are available in the data, the ratio of mortality rates of those without a BA to those with a BA fell for more than half of the groups. Our results suggest that differences in the risk of infection were less important in structuring mortality by education than differences in the risk of death conditional on infection.

A new study ties lifespans to wealth gaps in Greater Vancouver

The Tyee has published my latest article: A New Study Ties Lifespans to Wealth Gaps in Greater Vancouver. Excerpt:

We like to think of Greater Vancouver as one of the best places to live in Canada, if not in the world. Yes, it is — especially for those of us living in the most affluent neighbourhoods. Those in the poorest neighbourhoods, however, are dying younger than their rich neighbours, sometimes by many years. And the gap between them was getting wider even before the opioid-overdose crisis and the COVID-19 pandemic became twin health emergencies. 

That’s an easy conclusion to draw from a recent study published in the journal Health & Place. Of course it’s more complicated than that, but it still seems paradoxical that a region as prosperous as Greater Vancouver should see some people die years younger than others living just a few kilometres away.  

The study involved UBC researchers working with the Institute for Health Metrics and Evaluation at the University of Washington and with Imperial College, London. Its ambitious goal was to track life expectancy and major causes of deaths in Greater Vancouver over a quarter-century, from 1990 to 2016. Moreover, they broke the numbers down to the census-tract-level — in effect, neighbourhood by neighbourhood. Overall, the study offers an invaluable portrait of our collective health before the pandemic.  

In some ways, it’s a very flattering portrait. Even the poorest males, in the tenth percentile, had a median life expectancy in 2016 of 77.6; that is, half died before that age and half later. For tenth-percentile females, median life expectancy was 82.5.  

But in the 95th percentile, the richest five per cent of our population, median male life expectancy was 87.1. For females in the 90th percentile, it was 90.8. The poor were paying with almost a decade of their lives for the privilege of living here. 

 The study makes a striking observation: “Between 1991 and 2016, there was a downward trend in the LE [life expectancy] gap, whereby the lowest gap was observed in 2001 (6.9 years for females and 7.9 for males), but this reversed and increased by 1.4-1.6 years between 2001 and 2016.” By a wild coincidence, 2001 was the year the BC Liberals won a huge majority over the NDP and ran the province under Gordon Campbell and then Christy Clark until 2017.  

British researchers noticed a very similar effect during Margaret Thatcher’s years in power: Around 1980, British and Japanese life expectancy were about the same, but then, as the U.K. income gap widened, British lives grew shorter. In Japan, with a much narrower income gap, life expectancy rose to among the highest on the planet.  

What we’re dying of  

And what have Greater Vancouver residents been dying of? Between 1990 and 2016, deaths from cardiovascular diseases, neoplasms (cancers) and unintentional injuries dropped sharply. Clearly, we’ve been exercising more, smoking less, and taking care of ourselves, at least up to a point.  

But we’ve also seen a 10 per cent increase in neurological disorders, a catch-all term that can include everything from Alzheimer’s to eating disorders to meningitis. Other noncommunicable diseases like diabetes mellitus and kidney disease rose by almost four per cent.  

And while the richest of us had little to fear from infectious diseases in 1991, the poorest were already contending with (and dying from) HIV-AIDS and sexually transmitted infections at 12 times the rate as the richest. The poorest faced seven times the rate of maternal and neonatal disorders. They died of neoplasms at over four times the rate of the richest.

New Zealand Covid update: 82 new cases as outbreak worsens despite nationwide lockdown

Via The Guardian: New Zealand Covid update: 82 new cases as outbreak worsens despite nationwide lockdown.

New Zealand’s Covid-19 outbreak has worsened, with 82 new cases taking the total infected to 415. 

All of Saturday’s cases were in Auckland, with the Pacific community again over-represented with 62 cases. 

New Zealand has reached day 11 of a harsh lockdown designed to curb the spread of the virus. The vast majority of recent cases are coming from household contacts, and not gatherings or essential workplaces. However, New Zealand’s battle to eliminate the highly infectious Delta variant appears delicately poised.

The NZ prime minister, Jacinda Ardern, has previously advised she expected cases to near a peak after eight to 10 days, and on Friday said the government did not expect further “big jumps” in cases. 

New Zealand has extended its nationwide lockdown until Tuesday. Ardern said her cabinet would decide on the lockdown setting in Auckland and the neighbouring Northland region on Monday, but said it was likely Auckland would stay in level 4 – the highest setting – for another two weeks. 

Saturday’s total of 82 – up from 70 on Friday – is New Zealand’s fifth-worst day for cases during the entire coronavirus pandemic. 

On 17 August, the government put the nation into full lockdown after only a single community case was detected in the city of Auckland. New Zealand has reported 26 deaths from the virus in a population of 5 million since the pandemic began. 

New Zealanders lived virus-free in the six months leading up to the latest outbreak, going to workplaces, shops and sport stadiums without needing to wear masks, while children attended school. Then a traveller returning from Sydney brought the Delta variant, which escaped from a quarantine hotel.

The outbreak has grown to about 350 known cases and is straining New Zealand‘s contact-tracing system as workers try to track down 30,000 other people who might have been exposed. 

The lockdown prevents most people from leaving home other than to exercise, or to buy groceries or medicine. Retail stores are closed, as are restaurants – including takeaway – schools and most businesses. 

New Zealand’s vaccine rollout has been the slowest of any developed nation, with only 39% of people having gotten at least one shot and 22% fully vaccinated. The country chose to use only the Pfizer vaccine and did not approve its use until two months after US regulators first approved it for emergency use. 

The government blamed the initial slowness of the rollout on Pfizer’s delivery schedule. 

Vaccinations have sped up rapidly since the outbreak began, with health workers now giving doses to nearly 2% of the population every day.

Race-based data crucial in combatting COVID-19, experts say

Via The Globe and Mail: Race-based data crucial in combatting COVID-19, experts say. Excerpt:

For much of the pandemic, Dr. Madhu Jawanda struggled to get a clear picture of how the virus was spreading in racialized communities in B.C.’s Lower Mainland. 

The province’s health authority was refusing to release race-based data on COVID-19 cases, citing fears that the information would stigmatize neighbourhoods that had high infection rates. So Dr. Jawanda and other members of the South Asian COVID Task Force, a group she co-founded that supports COVID-19 prevention and education in South Asian communities, began gathering their own. 

“We didn’t have a choice. We were like, ‘Okay, how can we figure this out?’ ” she said. 

The task force compared ethnic data from the 2016 census with information about outbreaks across the Lower Mainland to deduce how they were impacting South Asians and other racialized populations. They reached out to community leaders for help understanding the situation on the ground. From there, they developed videos, infographics and virtual town halls in languages such as Hindi and Punjabi. 

And then, in May, they received some assistance from an unexpected source. The Vancouver Sun obtained leaked reports containing neighbourhood-level data on COVID-19 case counts and vaccination rates from the BC Centre for Disease Control (BCCDC). The leaked information confirmed much of the work that Dr. Jawanda and her fellow task force members had already done themselves. COVID-19 cases, they now knew beyond a doubt, were clustered in neighbourhoods with racialized populations. 

After more than a year of calls from public-health experts and journalists for B.C. health officials to release neighbourhood-level information about infection and vaccination rates in the province, the BCCDC data leak made plain the way COVID-19 was disproportionately affecting lower-income communities of colour. In the months since, the leak has prompted a new conversation among public-health officials and advocates about whether keeping such data under wraps was ever a good idea. 

Now, experts and advocates say that further transparency, through race-based data collection, could prove crucial in combatting current and future public-health emergencies. 

Despite concerns about stigmatizing racialized communities, community groups and public health officials say B.C.’s data leak has proved to be a positive development. They say having official data to back up their efforts has helped them overcome skepticism among members of the public. 

“I think this is a watershed moment for Canada in terms of transparency not being harmful, but actually being helpful,” said David Fisman, an infectious disease specialist and member of Ontario’s COVID-19 Science Advisory Table. 

After the May leak, the B.C. government began releasing some neighbourhood-level data regularly. Dr. Jawanda found herself wishing that her team could have had access to this information when they first began their education efforts.

If they had, she said, the task force would have been able to mobilize more quickly and with more precision to address the dire toll of the second wave – and potentially save lives in the process. Instead, it them took months of work to understand the severity of the pandemic’s impact on South Asian communities and bring crucial COVID-19 prevention and vaccination information to those most at risk. 

Dr. Jawanda said it wasn’t that surprising to her when Surrey, which is home to many racialized and low-income people, proved to be the hardest-hit city in B.C., according to the leaked reports. The city represented 10 per cent of the provincial population, but 29 per cent of COVID-19 cases.

High and rising working-age mortality in the US: A report from the National Academies of Sciences, Engineering, and Medicine

Via JAMA Network: High and Rising Working-Age Mortality in the US: A Report From the National Academies of Sciences, Engineering, and Medicine. Excerpt:

Life expectancy has increased in the US and in the world for the past century. In 2010, life expectancy plateaued in the US while continuing to increase in other high-income nations. In the US, life expectancy declined for 3 consecutive years (2015-2017) due primarily to an increase in mortality among working-age adults (those aged 25-64 years). Although the increase in mortality was first described among White middle-aged adults, mortality is now increasing among young and middle-aged adults and in all racial groups. 

This increase in premature death, claiming lives during the prime working ages, has important implications for individuals, families, communities, employers, and the nation. 

A new report from a National Academies of Sciences, Engineering, and Medicine committee studied mortality data from 1990 to 2017 by cause of death, age, sex, race/ethnicity, socioeconomic status, and geography. It found that average working-age mortality rates decreased after 2010 in 16 high-income countries but increased in the US. 

Three causes of death were identified as chiefly responsible: (1) drug poisoning and alcohol-induced causes, (2) suicide, and (3) cardiometabolic diseases. The first category includes mortality from mental and behavioral disorders, which often involve drugs or alcohol. Cardiometabolic diseases include endocrine, nutritional, and metabolic diseases (eg, diabetes, obesity); hypertensive heart disease; and ischemic heart disease and other diseases of the circulatory system (eg, arrhythmia, cardiomyopathy, heart failure). 

Mortality among working-age adults increased from other causes (eg, liver cancer, neurological diseases, homicides, transportation injuries), but none individually made large contributions to the overall trend.

COVID-19 in Brazil: 'The health system has already collapsed, and will continue to collapse'

Via DW Brasil: ″The health system has already collapsed, and will continue to collapse.″ Excerpt from the Google translation:

In the midst of the worst moment of the covid-19 pandemic in Brazil, with the health system overburdened and vaccination moving at a slow pace , the country registered this Tuesday (04/04) another record of deaths related to the disease: there were  4,195 in 24 hours. 

Brazil is currently the world leader in new daily deaths, and accounts for about 28% of new deaths by covid-19 in the world, according to data from the website Our World in Data, linked to the University of Oxford. In absolute numbers, Brazil is the second country with the most infections and deaths, behind only the United States. 

This Tuesday, the Oswaldo Cruz Foundation (Fiocruz) released an extraordinary bulletin from the Covid-19 Observatory in which it predicts that the pandemic will remain at critical levels throughout the month of April. According to an analysis by the Institute of Metrics and Health Assessment at the University of Washington, United States, after living in March,the deadliest month of the pandemic , with 66,000 deaths linked to the covid-19, Brazil may come to register 100,000 deaths this month. 

Infectologist David Sufiate works on the front lines in several hospitals in the state capital. In an interview with DW, he reports a dramatic picture. "I, as a doctor, an infectologist, an intensivist on the front line, get very discouraged. We are very sad to realize that the government's priority is not collective, the government's priority is individual", he says. 

Sufiate predicts another two or three months with high mortality in the country, with up to 5,000 or 6,000 deaths by covid-19 per day. Regarding a collapse in the health system, he is categorical: "It will not collapse - it will continue to collapse. Because the collapse has already arrived. We are in it." 

DW: Is the pandemic out of control in Brazil? 

David Sufiate: It is difficult to even define control within a pandemic context. What is control? But, in fact, there is an overload on the health system as a whole. From the private network to the public network - both scenarios are very difficult. 

At Fiocruz, we have been at full load for a month, or, better, above the maximum load in some moments. Currently, only [new patient after] enters what we are able to discharge or, unfortunately, the deaths. You can't even say it's worse, because it's been overloaded for at least three weeks. 

Do you notice that the profile of patients is changing, since the elderly have been vaccinated? 

Yes, this is very evident in all spheres of care. In the ICU that I coordinate, at Fiocruz, since yesterday, we no longer have patients with more than 80 years in hospital. This clearly reflects the vaccine's role in the pandemic. Now we have a scenario in which the youngest are exposed, because government policies encourage people to leave home, to expose themselves more. Thus, they get sicker. 

Which age group is most affected today? 

Between 40 and 60 years old, they are perhaps the most affected and most hospitalized people.