H5N1

Liberia post Ebola: Ready for another outbreak?

Via The Lancet, an excellent report: Liberia post Ebola: ready for another outbreak? Excerpt:

Comfort Gbainsay is huddled on a bed under a mosquito net at the CB Dunbar Maternity Hospital in Gbarnga, a small city about a 3 hours' drive from Liberia's capital Monrovia. A few days ago, she started feeling weak. She had stomach cramps and was breathing fast. At the hospital, she was diagnosed with stomach ulcers and typhoid fever. The 37-year old is 3 months' pregnant. 

The ward is veiled in darkness. With a torch in one hand and a spoon in the other, Gbainsay is eating her dinner from a plastic container. There are not enough funds to run the hospital generators 24 h a day, so electricity is scheduled. This will be her third child, says Gbainsay. Her large eyes look exhausted, her voice is muted. She gave birth to her other two children at CB Dunbar, but back then, she says, she did not have to pay for any of her medication. 

CB Dunbar is a government hospital and therefore drugs and services should be free. The National Health and Social Welfare Policy 2011–2021 focuses on an essential package of health services, and the country has set itself the goal of reaching universal health coverage. However, the coverage index for essential health services lies at 34, the target value being 100. Gbainsay has already spent more than LRD3000, or around US$18, on medication during her stay, a third of her monthly income as a teacher. 

“The drugs that were here, they gave me; the ones that were not here, they told me to go out and buy”, she says. One of the prescribed medicines is out of stock at all pharmacies in Gbarnga and she had to send her husband to Monrovia to buy it. 

“Everything is becoming very difficult because of, I don't know, the economic condition or because of the new president”, she says. “Over the past year, things that we easily used to do just can't be done easily nowadays. If you don't have money, things don't work for you.” 

The new president Gbainsay is referring to is ex-footballer George Weah, who was sworn in as head of state in January, 2018. Voters had high expectations and hoped he would rein in corruption, kick-start the economy, alleviate poverty, and rebuild the health system after the Ebola outbreak of 2014–15, which killed 4810 people in Liberia, including almost 180 health workers. When the haemorrhagic fever struck, the health sector was on a slow path to recovery after years of brutal civil war that had ended in 2003. 

However the new president has other priorities, as he highlighted in his second annual message in January, of this year. “…I have set my eyes on roads as my administration's path to delivering a better living condition for the Liberian people”, he said and added that good road connectivity will, among other things, “reduce travel times to schools and hospitals”. Health care was otherwise barely touched upon.

The scary shortage of infectious-disease doctors

Via The New York Times, an op-ed: The Scary Shortage of Infectious-Disease Doctors. Is this also true of countries with reasonable health-insurance systems? Excerpt:

Many have heard of the rise of drug-resistant infections. But few know about an issue that’s making this threat even scarier in the United States: the shortage of specialists capable of diagnosing and treating those infections. 

Infectious diseases is one of just two medicine subspecialties that routinely do not fill all of their training spots every year in the National Resident Matching Program (the other is nephrology). Between 2009 and 2017, the number of programs filling all of their adult-infectious-disease training positions dropped by more than 40 percent. 

This could not be happening at a worse time. Antibiotic-resistant microbes, known as superbugs, are pinballing around the world, killing hundreds of thousands of people every year. The Times recently reported on Candida auris, a deadly new fungus that has infected hospital patients in Illinois, New Jersey and New York. 

Everyone who works in health care agrees that we need more infectious-disease doctors, yet very few actually want the job. What’s going on?  

The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist. 

 This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. The formula prioritizes invasive procedures over intellectual expertise.

The problem is that infectious-disease doctors don’t really do procedures. It is a cognitive specialty, providing expert consultation, and insurance doesn’t pay much for that. 

For example, I recently diagnosed a case of fungal pneumonia. To arrive at this diagnosis took hours: first, speaking with the patient’s primary care doctor and pulmonologist, followed by a long stretch reviewing chest X-rays and other imaging studies with a radiologist, before examining the cells in the patient’s lung tissue under a microscope to confirm the diagnosis and report back to the anxious patient and family. Most of this work was done free. 

A generation ago, most well-rounded doctors knew what to do when a patient developed a fever. Not anymore. New threats like Candida auris pop up all the time, and to identify a deadly pathogen, we often have to use a sophisticated technique called matrix-assisted laser desorption ionization time-of-flight mass spectrometry. As the name suggests, it requires a bit of expertise.

Back in the day, there were only a handful of reliable antibiotics to choose from. But as more bugs have emerged, and more have become resistant to standard treatments, we’ve had to develop new drugs to fight them. The good news is that in 2018, the Food and Drug Administration approved a cadre of new antibiotics to confront the rising threat of superbugs, including eravacycline, plazomicin and omadacycline, and we can expect even more this year. But very few physicians know how to use these powerful new drugs. Many don’t even know how to pronounce them.  

Infectious-disease specialists are often the only health care providers in a hospital — or an entire town — who know when to use all of the new antibiotics (and when to withhold them). These experts serve as an indispensable cog in the health care machine, but if trends continue, we won’t have enough of them to go around. 

The terrifying part is that most patients won’t even know about the deficit. Your doctor won’t ask a specialist for help because in some parts of the country, the service simply won’t be available. She’ll just have to wing it.

Venezuela: UN should lead full-scale emergency response

A news release from Human Rights Watch: Venezuela: UN Should Lead Full-Scale Emergency Response. Excerpt:

The combination of severe medicine and food shortages within Venezuela, together with the spread of disease across the country’s borders, amounts to a complex humanitarian emergency that requires a full-scale response by the United Nations secretary-general, researchers from Johns Hopkins Bloomberg School of Public Health and Human Rights Watch said in a report released today. The Venezuelan authorities during the presidency of Nicolás Maduro have proven unable to stem the crisis, and have in fact exacerbated it through their efforts to suppress information about the scale and urgency of the problems.

The 71-page report, “Venezuela’s Humanitarian Emergency: Large-Scale UN Response Needed to Address Health and Food Crises,” documents increased numbers of maternal and infant deaths; the unchecked spread of vaccine-preventable diseases, such as measles and diphtheria; and sharp increases in the transmission of infectious diseases such as malaria and tuberculosis in Venezuela. Available data shows high levels of food insecurity and child malnutrition, as well as of hospital admissions of malnourished children.  

“No matter how hard they try, Venezuelan authorities cannot hide the reality on the ground,” said Shannon Doocy, Ph.D., associate professor of International Health at Johns Hopkins Bloomberg School of Public Health, who conducted research at Venezuela’s border. 

“Venezuela’s health system is in utter collapse, which, combined with widespread food shortages, is piling suffering upon suffering and putting even more Venezuelans at risk. We need UN leadership to help end this severe crisis and save lives.”

Uneven access to health services drives life expectancy gaps: WHO

A WHO news release: Uneven access to health services drives life expectancy gaps. Excerpt:

• Where women can access health services, maternal deaths decrease, lengthening women’s life expectancy.  

• In many circumstances, men access health care less than women. 

• Men are much more likely to die from preventable and treatable noncommunicable diseases and road traffic accidents. 

• 18.1-year gap in life expectancy between poorest and richest countries. 

Women outlive men everywhere in the world – particularly in wealthy countries. The World Health Statistics 2019 – disaggregated by sex for the first time – explains why.  

“Breaking down data by age, sex and income group is vital for understanding who is being left behind and why,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. 

“Behind every number in the World Health Statistics is a person, a family, a community or a nation. Our task is to use these data to make evidence-based policy decisions that move us closer to a healthier, safer, fairer world for everyone.”  

The gap between men’s and women’s life expectancy is narrowest where women lack access to health services. In low-income countries, where services are scarcer, 1 in 41 women dies from a maternal cause, compared with 1 in 3300 in high-income countries. In more than 90 per cent of low-income countries, there are fewer than 4 nursing and midwifery personnel per 1000 people.  

Attitudes to healthcare differ. Where men and women face the same disease, men often seek health care less than women.  In countries with generalized HIV epidemics, for example, men are less likely than women to take an HIV test, less likely to access antiretroviral therapy and more likely to die of AIDS-related illnesses than women. Similarly, male TB patients appear to be less likely to seek care than female TB patients.  

The report also highlights the difference in causes of death between men and women – some biological, some influenced by environmental and societal factors, and some impacted by availability of and uptake of health services.  

Of the 40 leading causes of death, 33 causes contribute more to reduced life expectancy in men than in women. In 2016, the probability of a 30-year-old dying from a noncommunicable disease before 70 years of age was 44% higher in men than women. 

Global suicide mortality rates were 75% higher in men than in women in 2016. Death rates from road injury are more than twice as high in men than in women from age 15, and mortality rates due to homicide are 4 times higher in men than in women. 

Published to coincide with World Health Day on 7 April, which this year focuses on primary health care as the foundation of universal health coverage, the new WHO statistics highlight the need to improve access to primary health care worldwide and to increase uptake. 

“One of WHO’s triple billion goals is for 1 billion more people to have universal health coverage by 2023,” said Dr. Tedros. “This means improving access to services, especially at community level, and making sure those services are accessible, affordable, and effective for everyone – regardless of their gender.”

WHO scales up health response to Cyclone Idai in Mozambique

WHO AFRO has published WHO scales up health response to Cyclone Idai in Mozambique. Excerpt:

Beira, 1 April 2019 – Today the World Health Organization (WHO) Regional Director for Africa, Dr Matshidiso Moeti, took a first-hand look at response efforts to save lives and protect health for the people in Beira, the city hardest hit by Cyclone Idai in Mozambique. 

“The next few weeks are crucial and speed is of the essence if we are to save lives and limit suffering,” said Dr Moeti after visiting devastated communities and witnessing the damage to health centres caused by the cyclone. 

To expand the emergency response, WHO has deployed experts, including epidemiologists, logisticians and disease-prevention experts, to build a 40-strong team.  

Restoring regular health services is equally imperative as mitigating the spread of cholera and other diseases, Dr Moeti stressed. “I saw the paediatric ward of Pontagera Health Centre had been completely destroyed, the roof had been torn off and the equipment and supplies ruined by water. We must do everything we can to protect the people of Mozambique from a disease outbreak or other health problems caused by lack of access to essential services,” she said. 

WHO is helping to restore primary care services so that facilities can deliver essential services, including immunization, basic treatment for common illnesses, acute malnutrition and maternal care while ensuring the ongoing supply of medications for people living with HIV, tuberculosis or diabetes.   

Also of concern, Dr Moeti emphasized, are the health workers whose own families and homes have been affected. WHO is working to support them in their health care roles as well as rehabilitating the health facilities where they work.  

On her visit to Beira, Dr Moeti visited the Central Hospital, a general health centre, a cholera treatment centre and two field hospitals set up by emergency medical teams from Italy and Portugal. She also visited a health clinic in a settlement camp where more than 1000 people are living temporarily.  

Planning for cholera has been one of the Organization’s top priorities in its support to the Ministry of Health for this emergency. WHO has deployed cholera specialists and supported the deployment of supplies, including life-saving intravenous fluids, diagnostic tests, oral rehydration solution and other medical supplies to support cholera treatment centres.   

As of this week, 500 beds are now open in seven cholera treatment centres across the affected area, with plans to boost the capacity significantly to cope with an expected increase in cases. WHO is training 30 health workers on case management for cholera and on setting and monitoring standards and protocols in those centres.

Venezuela: PAHO reports ten deaths and over 160 cases of diphtheria in 2019 alone

Via Efecto Cocuyo, a March 19 report: Diez muertes y más de 160 casos de difteria registra OPS en Venezuela solo en 2019. [PAHO reports ten deaths and over 160 cases of diphtheria in Venezuela in 2019 alone] Excerpt, with my translation, and then a comment:

La epidemia de difteria continúa activa. El brote que inició en el estado Bolívar a mediados de 2016 todavía persiste tres años después y sigue cobrando vidas. En su última actualización epidemiológica, con fecha de este lunes, 18 de marzo, la Organización Panamericana de la Salud (OPS) confirmó 10 muertes por esta enfermedad en Venezuela hasta la semana epidemiológica 8, es decir, hasta el 24 de febrero. 

The diphtheria epidemic continues active. The outbreak that began in Bolívar state in mid-2016 persists three years later and keeps taking lives. In its latest epidemiological bulletin, date Monday, March 18, the Pan American Health Organization (PAHO) confirmed ten deaths from this cause in Venezuela as of epidemiological week 8, February 24.

El organismo regional detalló que entre enero y febrero de este año se han contabilizado un total de 164 infecciones. Hasta la fecha, solo Venezuela y Haití han reportado casos de esta enfermedad.  

The regional agency noted that between January and February this year, 164 cases have been recorded. To date,only Venezuela and Haiti have reported cases of this disease.

Desde el inicio de la epidemia, la OPS señala en su reporte que Venezuela ha notificado más de 2.700 casos sospechosos, con 2018 como el año en el que se registró mayor número de contagios, un total de 1.198 casos.  

From the start of the epidemic, PAHO says in its report, Venezuela has reported over 2,700 suspected cases, with 2018 as the year with the largest number—a total of 1,198 cases.

Del total de notificaciones, 1.612 casos han sido confirmados hasta la fecha: 128 por análisis de laboratorio y 1.084 por criterio clínico o nexo epidemiológico.  

Of the reports, 1,612 have so far been confirmed: 128 by laboratory tests and 1,084 by clinical or epidemiological criteria.

De 2016 a 2019, la enfermedad ha cobrado la vida de 280 personas. El año pasado también fue el período en el que se registró mayor número de defunciones, con 150 muertes. Le siguieron 2017 (con 103) y 2016 (17).  

From 2016 to 2019, the disease has taken 280 lives. Last year was also the period in which most deaths were reported, 150. The year 2017 was second, with 103, and 2016 saw 17.

La OPS alerta que la tasa de letalidad de los casos confirmados aumentó, pasando de 20% en 2018 a 26% para este 2019.

PAHO warns that the case fatality rate of confirmed cases has risen, from 20% in 2018 to 26% in 2019.

Venezuela's health department stopped publishing regular bulletins sometime in 2016 or thereabouts. Since then, various professional groups have tried to estimate just how many Venezuelans have been falling ill with various diseases, of which diphtheria is only one. 

So I guess it's nice that the Maduro government is at least talking to PAHO. To the best of my knowledge, Venezuela never reported reliable numbers during the Zika outbreak, whether of Zika itself or Zika-related microcephaly and other neurological disorders. We will be a long time repairing the grievous lapses in South American public health caused by purely political decisions in Caracas.

Ebola simulation in three counties gives Liberia’s health system a failing grade

Via The Bush Chicken: Ebola Simulation in Three Counties Gives Liberia’s Health System a Failing Grade. Excerpt:

SUAKOKO, Bong – The chief medical officer of Liberia, Dr. Francis Kateh, said Liberia scored an ‘F’ in a recent simulation of the country’s resilience and preparedness to handle another Ebola epidemic. 

The simulation was simultaneously done by the National Public Health Institute of Liberia in three counties: Bong, Lofa, and Nimba, with cases of the Ebola virus disease reported at separate health facilities. 

“Couple of days ago, we had a simulation exercise portraying EVD entering the country. And so what we were doing was basically testing our system to see how strong the system is if we were to have anything like Ebola or other virus hemorrhagic fever,” Kateh said. 

He clarified that there is no case of Ebola in Liberia; rather, the National Public Health Institute of Liberia and partners were testing the country’s resilience and preparedness to fight Ebola in case of a reemergence of the disease. 

The simulation created panic amongst citizens and health workers in the three counties, with fears that the disease that killed almost 5,000 people in Liberia between 2014/2015 was once again in the country. 

Kateh spoke with reporters on Friday at the Phebe Hospital in Suakoko, Bong following a debriefing meeting to discuss the simulation exercises across the three counties.  

The gathering was attended by health workers as well as local and national partners working in Liberia’s health sector. 

Kateh said he graded the overall result of the simulation with a failing grade because there were a lot of lapses on the part of health workers who handled the Ebola cases during the simulation.

“There were lots of things that we anticipated to have happened with the resources that have been placed into the health sector. There were lots of missteps at various areas,” he said. 

Lofa was the best performing county in the simulation, followed by Bong. Kateh said Nimba performed the worst.  

Considering the overall result of the exercise, Kateh said the Ministry of Health and partners will conduct refresher training on how to respond to Ebola and other diseases for health workers across the country.

Venezuela: Clinics at bare minimum to ensure critical attention during failures of light and water

Via Efecto Cocuyo, a very sad report: Clínicas operan al mínimo para garantizar atención crítica ante fallas de luz y agua [Clinics at bare minimum to ensure critical attention during failures of light and water]. Excerpt, with my translation:

Ni las clínicas privadas se salvan de la crisis eléctrica ni de sus secuelas. Desde el pasado 7 de marzo, día en el que se produjo el megaapagón, los centros asistenciales de la capital han tenido que reducir sus consumos de electricidad y agua al mínimo para poder preservar la atención en las áreas críticas, como cuidados intensivos y emergencia. 

Not even private clinics have escaped the electric crisis or its consequences. Since March 7, the day that produced the meda-blackout, the capital's health centres have had to reduce their consumption of electricity and water to a minimum to be able to care for critical areas like intensive care and emergency.

Esto se ha traducido, en algunos casos, en la suspensión de los servicios de laboratorio, cirugías electivas y consultas médicas, en cuatro centros asistenciales visitados por Efecto Cocuyo en los municipios Baruta, Libertador y Chacao.  

This has resulted in some cases in suspension of laboratory servides, elective surgery, and medical consulting in four centres visited by Efecto Cocuyo in the neighbourhoods of Baruta, Libertador, and Chacao.

Este miércoles, 13 de marzo, el acceso al Hospital de Clínicas Caracas estaba restringido por la seguridad del centro de salud. Las áreas de laboratorio y de consulta tenían sus puertas cerradas.  

This Wednesday, March 13, access to Caracas Clinical Hospital was restricted for security reasons to the health centre. The doors were closed in the lab and consulting areas. 

En las áreas comunes que dan hacia la entrada principal, el aire acondicionado estaba apagado. Todo operaba al mínimo. “Desde el jueves racionan el agua porque no hay. Solo  la ponen tres veces al día por tiempo limitado para nosotros poder hacer nuestras labores”, explicó un trabajador del área de la cocina. 

In common areas around the main entrance, air conditioning was off. Everything was operating on a minimum. "Since Thursday they're rationing water because there isn't any," said a  kitchen worker. "They turn it on three times a day so we can do our work."

Los cuatro días que Caracas pasó a oscuras, Clínicas Caracas también estuvo en penumbras. La energía generada por la planta eléctrica interna se utilizó para mantener operativas las áreas de atención crítica. En las habitaciones, la cocina y el resto de las instalaciones, la gente se alumbraba con las luces de emergencia o los celulares. 

In the four days that Caracas has been in the dark, Caracas Clinical was also in the shadows. Engery generated by the internal power plant has been used to maintain critical-care areas. In the wards, the kitchen, and the rest of the centre, people are using emergency lights or their cell phones.

“Aquí en la clínica solo hay 13 pacientes y solo se les está dando atención a ellos. No están ingresando a nadie más”, agregó otro trabajador al equipo de Efecto Cocuyo. Debido a la falta de luz, agua y medios de transporte, entre ellos el Metro de Caracas, personal de la clínica ha tenido problemas para trasladarse hasta su sitio de trabajo.

"Here in the clinic we have have only 13 patients, and they're the only ones getting attention," another worker told Efecto Cocuyo. "They're not admitting anyone else." Owing to the lack of light, water, and means of transportation, including the Caracas Metro, clinic personnel have had problems just getting to work.

How Africa can quell the next disease outbreaks

Via Nature News & Comment, an op-ed by Dr. John N. Nkengasong, head of the Africa Centers for Disease Control and Prevention: How Africa can quell the next disease outbreaks. Excerpt:

This week, African and global health experts and policymakers are gathering in Addis Ababa to discuss how to enable national public-health institutions (NPHIs) to keep emerging and re-emerging infectious disease in check. At the top of the agenda must be empowering local leadership to act fast.  

Africa’s population is expected to double from 1.2 billion now to 2.4 billion by 2050. People are travelling greater distances, too. Last year, Ethiopian Airlines alone transported more than 10 million passengers — a 21% rise from 2017. Africa’s ambitious plans to establish free trade and travel across the continent will increase movement even more. 

Although economically advantageous, these plans could set the stage for HIV, Ebola, pandemic influenza, chikungunya, plague, Lassa fever and antimicrobial-resistant bacterial infections to spread farther and faster.  

Waiting for emergency help from the West costs lives, health and resources. African leaders are starting to take ownership of investments in their citizens’ health, but fewer than 15 countries on the continent currently have institutions that can perform the functions of an effective NPHI, such as disease surveillance linked with a diagnostic laboratory, and the capacity to activate a rapid-response team for outbreaks and serve as an operation centre in public-health emergencies.  

As head of the Africa Centres for Disease Control and Prevention (African CDC), I call on all 55 member states to establish or strengthen NPHIs. And I urge the private sector in Africa and worldwide, and bodies everywhere, to invest in these efforts. According to the World Bank, Africa needs between US$2 billion and $3.5 billion a year for epidemic preparedness; in 2015, 8 African nations received from various donors about $700 million for this cause.  

I think that much of the gap can be filled from within Africa, where the 2014–16 Ebola outbreak cost roughly $53 billion.The African Business Coalition for Health, formed in 2017, and the United Nations Economic Commission for Africa are encouraging investment and coordinating efforts by African philanthropists and business leaders to support health programmes. The African Union (AU), a 55-member continental organization based in Addis Ababa, has set up a programme to tax imports of goods to Africa, designed to shift AU running costs away from donors. A fraction of these funds should go towards NPHIs.  

NPHIs are a health-security imperative in a changing Africa, where rapidly expanding populations mean greater urbanization and more people in slums. Currently, not even half of urban dwellers in sub-Saharan Africa have access to sanitation; even fewer have received the recommended suite of childhood vaccinations. Old diseases, and those once limited to rural and remote areas, are appearing in cities — plague in Antananarivo, Ebola virus in capitals across West Africa. And we have seen time and again that an outbreak in Africa is a global threat.

Venezuela's public health crisis: A regional emergency

Via The Lancet: Venezuela's public health crisis: a regional emergency. The article itself is behind a paywall. The summary:

The economic crisis in Venezuela has eroded the country's health-care infrastructure and threatened the public health of its people. Shortages in medications, health supplies, interruptions of basic utilities at health-care facilities, and the emigration of health-care workers have led to a progressive decline in the operational capacity of health care. 

The effect of the crisis on public health has been difficult to quantify since the Venezuelan Ministry of Health stopped publishing crucial public health statistics in 2016. 

We prepared a synthesis of health information, beyond what is available from other sources, and scholarly discussion of engagement strategies for the international community. Data were identified through searches in MEDLINE, PubMed, and the grey literature, through references from relevant articles, and governmental and non-governmental reports, and publicly available databases. Articles published in English and Spanish until Dec 1, 2018, were included. 

Over the past decade, public health measures in Venezuela have substantially declined. From 2012 to 2016, infant deaths increased by 63% and maternal mortality more than doubled. Since 2016, outbreaks of the vaccine-preventable diseases measles and diphtheria have spread throughout the region. From 2016 to 2017, Venezuela had the largest rate of increase of malaria in the world, and in 2015, tuberculosis rates were the highest in the country in 40 years. Between 2017 and 2018, most patients who were infected with HIV interrupted therapy because of a lack of medications. 

The Venezuelan economic crisis has shattered the health-care system and resulted in rising morbidity and mortality. Outbreaks and expanding epidemics of infectious diseases associated with declines in basic public health services are threatening the health of the country and the region.