H5N1

'End war on Yemen's children': conflict escalates around Hodeidah hospital

Via The Guardian: 'End war on Yemen's children': conflict escalates around Hodeidah hospital. Excerpt:

Fighting has intensified around the largest hospital operating in the port city of Hodeidah, preventing access to severely malnourished and vulnerable children, the UN’s children’s agency has warned. 

The escalation in conflict follows US calls for a ceasefire and suggestions that peace talks may be held in Sweden. On Thursday, the Saudi-led coalition said it had attacked Sana’a international airport and an adjoining airbase being used by Houthi insurgents. 

“It’s very clear that, despite the call for talks, and despite the call for an agreement on the cessation of hostilities in the next 30 days, the parties are intensifying the fighting – unfortunately, with an incredible impact on children,” said Geert Cappelaere, Unicef’s regional director for the Middle East and north Africa, speaking from Sana’a.

Cappelaere said the few shipments of crucial medical supplies and food arriving in the port of Hodeidah were regularly blocked, sometimes for months. “Even the humanitarian aid is taken hostage at times. It’s just unacceptable. All parties are carrying responsibility,” said Cappelaere. “The war on children needs to stop.”  

Active fighting is taking place within a few hundred metres of the largest of Hodeidah’s handful of hospitals, according to Cappelaere, who visited the city this week. Families were delaying seeking medical attention because of the hostilities, or because they could not afford the transport costs. 

Hodeidah, which has been hit particularly hard by cholera and acute diarrhoea, was already among the worst places for children in Yemen, Cappelaere said. 

The latest Unicef figures show there are an estimated 1.8 million malnourished children in Yemen. Almost 400,000 children are suffering from severe acute malnutrition, which is life-threatening, with four in 10 of such cases in Hodeidah and neighbouring governorates. 

On a visit to Al-Thawra hospital, Cappelaere said he saw the emaciated bodies of acutely malnourished children, as well as several children paralysed by diphtheria, which is preventable by vaccine. Among them was a 10-year-old girl, Sara, who is paralysed from the chest downwards because of the infection.  

“I was just thinking overnight when I heard the shelling happening … What does that mean for that poor girl who is already half-paralysed and who now has to hear all these bombs around her? For what reason? To get a better negotiating position around the table in Sweden?” said Cappelaere. 

It is feared that intensified fighting in Hodeidah would not only have a devastating impact on its population but also cut off food, fuel and medical imports to the rest of the country. Aid agencies have repeatedly warned the conflict is driving Yemen to the brink of the worst famine in living memory.

Increasing mortality and declining health status in the USA: Where is public health?

In the Harvard Health Policy Review, Dr. Stephen Bezruchka of the School of Public at the University of Washington writes: Increasing Mortality and Declining Health Status in the USA: Where is Public Health? Excerpt:

Mortality increases at the national level are very rare phenomena this century. In the 1900s, mortality only increased in countries greatly affected by World War I and II, and in the 1990s in Sub-Saharan nations with high AIDS prevalence as well as after the collapse of the Soviet Union in 1991. 

Beginning this century, mortality is now increasing in the United States. The National Center for Health Statistics reports that life expectancy is declining, and infant mortality is increasing. The reported life expectancy decline is for the period 2014 to 2016 and will continue through 2017. This three-year decline is unprecedented in the U.S. All-cause death rates are similarly increasing except for those over age 65. For adults, aged 24 to 65, mortality has increased for all race-ethnicity groups. This includes all-cause mortality, as well as cause-specific mortality that includes hypertensive, alcoholic liver, and respiratory diseases, drug overdoses, as well as suicides and homicides.  

Relative declines in U.S. life expectancy compared to other nations have been observed for half a century. That is, while mortality had been decreasing in the U.S., the improvements were better in many other nations. Life expectancy in the USA lags 4.5 years behind Japan. If we eradicated our leading killer, heart disease, we still wouldn't bridge the gap. If health were an Olympic event, our performance would be falling behind 35 to 60 other nations depending on the mortality indicator chosen. 

This represents a marked change compared to the early 1950s when our mortality rates were among the lowest in international comparisons. The relative decline has been more marked in women. Huge expectations are placed on women in the US without much support from government in comparison to other nations. A 2013 report from the Institute of Medicine documenting this has received little attention or response by our federal institutions responsible for our health status.  

Public health agencies at the federal, state and local level have not drawn attention to this most mortal of all perils. Why? There are almost no public surveys of our health status as a nation. A population-based survey of medical students carried out in 2002 found that a third of medical students thought the United States led the world in the highest life expectancy and lowest infant mortality. No attention is devoted to our health as a nation, in comparison to other nations, in our health care schools. The same is true for schools of public health. 

Medical care is about diagnosing and treating illness and injury, which focuses on individuals and their issues. The United States spends more on health care than the rest of the world combined. Logically, medical care cannot be responsible for our health decline. Even with the advent of the Affordable Care Act, it is difficult to demonstrate related health improvements. The same was true after the adoption of Medicare. 

The public doesn't distinguish health from health care. We access health, we pay for health, we invest in health, we get health and so on, but those statements are all about health care. The question that should be asked is whether we want health or health care. Ideally we should have both. We do not.

Impact of monovalent rotavirus vaccine on diarrhoea-associated post-neonatal infant mortality in rural communities in Malawi

Via The Lancet Global Health: Impact of monovalent rotavirus vaccine on diarrhoea-associated post-neonatal infant mortality in rural communities in Malawi: a population-based birth cohort study. The summary:

Background 

Rotavirus is a major contributor to child mortality. The effect of rotavirus vaccine on diarrhoea mortality has been estimated in middle-income but not low-income settings, where mortality is high and vaccine effectiveness in reducing admissions to hospital is lower. Empirical population-based mortality studies have not been done in any setting. Malawi introduced monovalent rotavirus vaccine (RV1) in October, 2012. We aimed to investigate the impact and effectiveness of the RV1 vaccine in reducing diarrhoea-associated mortality in infants aged 10–51 weeks. 

Methods 

In this population-based cohort study, we included infants born between Jan 1, 2012, and June 1, 2015, in Mchinji, Central Malawi and analysed data on those surviving 10 weeks. Individual vaccination status was extracted from caregiver-held records or report at home visits at 4 months and 1 year of age. Survival to 1 year was confirmed at home visit, or cause of death ascertained by verbal autopsy. We assessed impact (1 minus mortality rate ratio following vs before vaccine introduction) using Poisson regression. Among vaccine-eligible infants (born from Sept 17, 2012), we assessed effectiveness (1 minus hazard ratio) using Cox regression. 

Findings 

Between Jan 1, 2012, and June 1, 2015, we recruited 48 672 livebirths in Mchinji, among whom 38 518 were vaccine-eligible and 37 570 survived to age 10 weeks. Two-dose versus zero-dose effectiveness analysis included 28 141 infants, of whom 101 had diarrhoea-associated death before 1 year of age. Diarrhoea-associated mortality declined by 31% (95% CI 1–52; p=0·04) after RV1 introduction. Effectiveness against diarrhoea-mortality was 34% (95% CI –28 to 66; p=0·22). 

Interpretation 

RV1 was associated with substantial reduction in diarrhoea-associated deaths among infants in this rural sub-Saharan African setting. These data add considerable weight to evidence showing the impact of rotavirus vaccine programmes.

Zika epidemic sheds light on Brazil's 'invisible children'

Via The Guardian, health editor Sarah Boseley writes: Zika epidemic sheds light on Brazil's 'invisible children'. Excerpt:

Brazil’s “invisible children”, the thousands of babies born with neurodevelopmental disorders, have been brought out of the shadows by the Zika virus epidemic and their families may get help for the first time.  

Almost 4,000 babies were born in Brazil with microcephaly as a result of Zika virus infection – a brain malformation that left them with small and misshapen heads and poor developmental prospects. 

But nobody knows how many babies have been born in Brazil with other developmental disorders. They are invisible all over the world, where it is estimated there are 250 million children with developmental delay or disability. The numbers are thought to be probably twice as high in the developing world as they are in the more prosperous countries of North America and Europe.  

“Zika affected probably a relatively small amount of children – a few thousand. The epidemic came and went and hasn’t come back,” said David Edwards, a professor of paediatrics and neonatal medicine at King’s College London. 

It was a tragedy for each of them and their families, he said, but the numbers “pale into insignificance compared with the large number of children who are affected by neurodevelopmental disorders.” 

The two most common causes of death and disability in newborn babies are birth asphyxia and prematurity. Well-equipped modern hospitals in the western world can prevent much of the death and damage from these causes. But women in poor countries may have far to go to reach a maternity unit and can have very long labours. A colleague of Edwards working in Uganda told him: “We think 12 hours is a long labour. They think 12 days is a long labour.”  

Many women in developing countries are malnourished, which increases the risk to mother and baby. Genetic factors causing such disorders as Down’s syndrome and fragile X play a part in all countries.  

“Brazil has invested heavily in child health [areas] such as immunisation, where we are very strong,” said Maria Elisabeth Lopes Moreira, professor of neonatal growth and nutrition at the Oswaldo Cruz Foundation in Brazil. “I think that there is a lack of data on the development of children and this is part of the problem. We don’t know exactly the numbers. They need support in the very early days of life. We really need some investment in these children.” 

Some of them, from the poorest families, have parents who work and older siblings are charged with looking after them. “We have children taking care of children,” she said. “It is too difficult for them.” 

She and Edwards were part of an expert group brought together to discuss childhood neurodevelopmental disorders in Brazil by the UK’s Academy of Medical Sciences and the Academia Brasileira de Ciências at a workshop in Rio de Janeiro. The group’s report calls for more to be done for the invisible children not only in Brazil but around the world.

Zika and health cuts blamed for rise in baby death rates in Brazil

Via The Guardian: Zika and health cuts blamed for rise in baby death rates in Brazil. Excerpt:

The number of children dying in their first year of life has risen in Brazil for the first time since 1990. 

It’s a worrying setback for a country once seen as a model of poverty reduction.  

The infant mortality rate rose by nearly 5% between 2015 and 2016, an increase health officials and specialists have blamed on the outbreak of the Zika virus that year, as well as cuts to health services prompted by an economic crisis from which Brazil is struggling to recover.  

Fatima Marinho, director of the non-communicable diseases department and information and analysis at the health ministry, said she expects the 2017 figures to exceed the 2015 levels.  

“We are going backwards, not forwards,” Marinho said. “We cannot go on with the situation. Or we lose everything we have gained in 15 years.” 

Denise Cesario, executive manager of the Abrinq Foundation, a non-profit group in São Paulo that focuses on children’s and teenagers’ rights, said: “The rate is very significant. It is very worrying if we consider that this economic crisis will still impact on social conditions for years to come.”  

Infant mortality is regarded as one of the key measures of a country’s development. Brazil was praised for its success towards meeting the UN millennium development goal targets in a 2010 study published in the American Journal of Public Health, which said the country had made “rapid strides in improving maternal, newborn, and child health”.  

But government figures for 2016 revealed by the Folha de S Paulo newspaper, and since published by the health ministry, showed that Brazil’s infant mortality rate rose from 13.3 deaths per 1,000 live births in 2015 to 14 deaths per 1,000 live births in 2016, a 4.8% increase and the first since the current system of tracking progress began in 1990.  

Even relatively affluent states like São Paulo showed a 2.7% increase. Nationally, the death rate for children up to the age of five also rose nearly 4%. 

Brazil had been lauded for combining economic growth with poverty reduction via landmark government programmes like the Bolsa Família – or family allowance – a cash-transfer scheme for families who made sure their children remained in school and were up to date with vaccinations. 

In 2014, however, the country fell into recession. Faced with a deficit after winning re-election, President Dilma Rousseff began to cut spending and in 2016 the budget for Bolsa Família failed to match inflation. 

Funding was slashed for the Rede Cegonha (the Stork Network), a government health programme for women that focused on birth, postnatal health and family planning, said Cesario. 

Rousseff was suspended in May 2016 and impeached three months later. Her replacement, Michel Temer, introduced more drastic cuts and froze spending.  

Government officials have been so alarmed by the increase in infant and child deaths that they called a special meeting of state health secretaries in June. Deaths from preventable diseases like diarrhoea and pneumonia also rose in 2016. Folha also reported a 12% increase in deaths from diarrhoea in under-fives, with 19% of those occurring in semi-arid regions that have been battling drought in recent years.  

“How can children in Brazil in the 2000s die of diarrhoea? This number is shocking,” said Marinho, noting that the birth rate fell by around 5% percent in 2016 because women were avoiding having children during the Zika epidemic.

Unilateral phrenic nerve palsy in infants with congenital Zika syndrome

Via Emerging Infectious Diseases: Ahead of Print -Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome. The abstract:

Since the first identification of neonatal microcephaly cases associated with congenital Zika virus infection in Brazil in 2015, a distinctive constellation of clinical features of congenital Zika syndrome has been described. Fetal brain disruption sequence is hypothesized to underlie the devastating effects of the virus on the central nervous system. However, little is known about the effects of congenital Zika virus infection on the peripheral nervous system. 

We describe a series of 4 cases of right unilateral diaphragmatic paralysis in infants with congenital Zika syndrome suggesting peripheral nervous system involvement and Zika virus as a unique congenital infectious cause of this finding. All the patients described also had arthrogryposis (including talipes equinovarus) and died from complications related to progressive respiratory failure.

This is what collapsing health, education, water and sanitation systems look like in Yemen

Via Thomson Reuters, a report by Henrietta H. Fore of UNICEF: This is what collapsing health, education, water and sanitation systems look like in Yemen. Excerpt:

In Yemen, one child dies every 10 minutes from a preventable disease, and on a recent visit to the country, I saw first-hand what that meant.  

At the Al Qateea hospital in Aden, southern Yemen, mothers hold frail, acutely malnourished babies while psychosocial workers offer counseling to terrified children, some of whom have experienced the horrors of war before they are even old enough to go to school. An eight-year-old girl draws a picture of the world she dreams of, one in which the streets are safe, the sun is shining and the birds are chirping – nothing like the real world around her. 

Further north, a similar scene is unfolding at the Al Sabeen hospital in Sanaa. Up to 30 new young patients stream in every day to the hospital’s malnutrition ward. In the neonatal intensive care unit, newborn babies in incubators struggle for every breath.  

Keeping babies alive in a country where nothing works any more is a real challenge: There are not enough respirators and not enough medicine. Health staff diligently report to work even though they have not received their salaries in two years. The malnutrition ward is packed. Parents have no money for health care and by the time they bring their sick babies in, it is often too late. 

This is what a collapsing health system in a war zone looks like. It has the face of a mother who looks on, powerless, as her eight-month-old child, who has the weight of a newborn baby, fights for his life. It has the face of a father who has to choose between buying food for the whole family or buying medicine for his sick wife.  

Yemen had some of the worst health indicators globally even before the current escalation of fighting. Stunting rates are among the highest in the world, at 47 per cent. 1 in 60 women runs the risk of dying from pregnancy-related complications. Under-five mortality is high, at 55 per 1,000 live births. 

Three years into this conflict, more than half of the health facilities are non-functional due to damage or a lack of operating budget and staff. Half of the country’s children do not have clean water. An outbreak of cholera/acute watery diarrhea last year, the biggest on record, killed more than 400 children under the age of five. At least 80 per cent of the population live below the poverty line. 

The whole public service sector in Yemen, not just health, has been left in tatters. Teachers have not been paid in months, forcing many to abandon their classrooms and find other sources of income. Up to 1,500 schools have been damaged due to airstrikes and shelling, or have been occupied by armed forces and displaced persons. 

Sanitation workers too have been expected to come to work although they are not paid. Not doing so poses a serious risk in a country where cholera and famine are persistent risks.  

UNICEF has supported the payment of incentives for doctors, nurses and health workers who run the newborn, pediatric and maternity wards in at least eight hospitals in Yemen that receive the highest number of patients. This support has been crucial since the conflict escalated as it helps maintain some social services at such a critical time for children.  

We need funding to offer similar incentives for teachers and water and sanitation workers. But more importantly, all authorities in Yemen need to step up, recognize the urgency and get public services in the country up and running again.

Trump administration's opposition to breastfeeding resolution sparks outrage

Via The Guardian: Trump administration's opposition to breastfeeding resolution sparks outrage. Excerpt:

Advocates for improved nutrition for babies have expressed outrage over reports that the Trump administration bullied other governments in an attempt to prevent the passage of an international resolution promoting breastfeeding. 

The US delegation to the World Health Assembly in Geneva reportedly deployed threats and other heavy-handed measures to try to browbeat nations into backing off the resolution. 

Under the terms of the original WHO text, countries would have encouraged their citizens to breastfeed on grounds that research overwhelmingly shows its health benefits, while warning parents to be alert to inaccurate marketing by formula milk firms. 

The New York Times first reported how the Trump administration reacted forcefully to the resolution, which otherwise had the consensus support of all other assembly members. It pushed to remove a phrase from the draft text that would exhort governments to “protect, promote and support breast-feeding”. 

The administration also used its network of diplomats to lean on member states. Turning on the delegation from Ecuador, the US government said that unless the South American nation withdrew its backing of the resolution it would face punitive trade moves and even the potential loss of military help in its battle against gang violence. 

The resolution was eventually passed with US support, but only after the Russian government reintroduced it using a modified text.  

Lucy Sullivan, executive director of 1,000 Days, the US-headquartered international group working to improve nutrition for babies and infants, said in a Twitter thread that the US intervention amounted to “public health versus private profit. What is at stake: breastfeeding saves women and children’s lives. It is also bad for the multibillion-dollar global infant formula (and dairy) business.”  

The online network of mothers, Moms Rising, called the US government’s move “stunning and shameful. We must do everything we can to advocate for public policies that support and empower breastfeeding moms.” 

Patti Rundall of the UK-based campaign Baby Milk Action told the New York Times: “We were astonished, appalled and also saddened. What happened was tantamount to blackmail, with the US holding the world hostage and trying to overturn nearly 40 years of consensus on the best way to protect infant and young child health.” 

Under an internal code of the World Health Organisation, baby formula companies are banned from explicitly targeting mothers and their health carers. Advertising is also controlled. 

A Guardian investigation with Save the Children earlier this year found that formula milk firms were using aggressive methods to skirt around the regulations in order to press mothers and healthcare professionals to choose powdered milk over breastfeeding. The measures were particularly intensively deployed in the poorest regions of the world, where most growth in the baby milk formula business is now concentrated.  

A plethora of studies have shown the stark health improvements brought about by breastfeeding in the US and around the world. A Harvard study in 2016 estimated that 3,340 premature deaths a year among both mothers and babies could be prevented in the US alone given adequate breastfeeding.

US: State health systems improving, but more people are dying deaths of despair

The Commonwealth Fund has published the 2018 Scorecard on State Health System Performance. It is a major document, and an alarming one. Click or tap through here to download the 62-page PDF. Excerpt from the overview:

Hawaii, Massachusetts, Minnesota, Vermont, and Utah are the top-ranked states according to the Commonwealth Fund’s 2018 Scorecard on State Health System Performance, which assesses all 50 states and the District of Columbia on more than 40 measures of access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities.

The 2018 Scorecard reveals that states are losing ground on key measures related to life expectancy. On most other measures, performance continues to vary widely across states; even within individual states, large disparities are common.

Still, on balance, the Scorecard finds more improvement than decline between 2013 and 2016 in the functioning of state health care systems. This represents a reversal of sorts from the first decade of the century, when stagnating or worsening performance was the norm.

Overall, four major trends emerge from our analysis of the Scorecard results:

• Rising death rates, high levels of obesity, and gaps in care are pressing challenges for states

• Regional differences in performance persist, as do within-state disparities

• Many states are not getting good value for their health care dollars

• States made progress in areas that were the target of efforts to improve

SCORECARD HIGHLIGHTS

Which states lead the rankings?

Hawaii, Massachusetts, Minnesota, Vermont, and Utah.

Which states are ranked at the bottom?

Louisiana, Oklahoma, and Mississippi.

Which states moved up the most in the rankings between 2013 and 2016?

California and Oregon rose the highest, jumping 9 and 10 spots, respectively. Both states expanded eligibility for Medicaid.

Which states improved on the most indicators?

New York improved on 18 of the 37 indicators we track over time — the most of any state. Arkansas, Louisiana, Oklahoma, and West Virginia each improved on 17 indicators. ...

Rising death rates, high levels of obesity, and gaps in care are pressing challenges for states.

Deaths from suicide, alcohol, and drug use are at an all-time high. In 2016, average life expectancy at birth declined for a second year in a row, driven in large part by a spike in deaths from opioid use and other substance abuse as well as suicide. The combined rate of deaths from suicide, alcohol, and drug use—sometimes referred to as "deaths of despair"—increased 50 percent from 2005 to 2016. Rates rose in all states, doubling or more in Delaware, New Hampshire, New York, Ohio, and West Virginia.

Venezuela: Infant with H1N1 flu dies in J.M. de los Rios Hospital

Efecto Cocoyu is a dissident website in Venezuela, and its health page is a litany of sorrow in a collapsed healthcare system. Here's a new report: Muere niño con influenza AH1N1 hospitalizado en el J. M. de los Ríos.[Boy with H1N1 influenza dies hospitalized in J.M. de los Rios] Excerpt, with my translation:

La noche del miércoles 25 de abril, se confirmó la muerte de un bebé por influenza AH1N1 en el hospital de niños José Manuel de los Ríos. El pequeño de nueve meses de nacido fue ingresado hace dos semanas en la Unidad de Terapia Intensiva Pediátrica (Utip) luego de ser referido del Hospital Elías Toro, en Catia.  

On the night of Wednesday, April 25, the death was confirmed of a baby from H1N1 influenza in the José Manuel de los Ríos pediatric hospital. The nine-month-old had been admitted two weeks earlier in the Pediatric Intensive Care Unit after being referred from Elías Toro Hospital in Catia.

El niño residía en Antímano e ingresó al J. M. de los Ríos con complicaciones respiratorias. El pasado 16 de abril, médicos del hospital confirmaron por una prueba de cultivo que se trataba de un caso de influenza AH1N1.  

The little boy lived in Antímano and entered J.M de los Ríos with respiratory complications. On April 16, hospital doctors confirmed his case was H1N1 influenza.

Efecto Cocuyo pudo conocer que otro dos casos de influenza fueron confirmados en el hospital el pasado miércoles. Los dos niños son atendidos en un área de aislamiento y los galenos activaron un plan estratégico de contención para prevenir el contagio. 

Efecto Cocuyo learned that two other flu cases were confirmed in the hospital last Wednesday. The two children are in isolation and doctors have launched a strategic plan to prevent contagion.

Otro caso sospechoso fue descartado luego de que se realizaran las pruebas correspondientes.  

Another suspected case was discarded after testing.

Vietnan Vera, médico intensivista de la Utip, indicó a Efecto Cocuyo que la unidad no cuenta con los medicamentos necesarios para tratar a los pacientes con el virus de la influenza. El niño que falleció fue tratado con el Oseltamivir disponible en el hospital, con fechas de vencimiento de 2011 y 2015.

Vietnan Vera, ICU physician, told Efecto Cocuyo that the unit lacks medications for treating influenza. The little boy who died was treated with Oseltamivir available in the hospital, with expiry dates of 2011 and 2015.