H5N1

DRC Ebola: CMRE update, September 6

It's not quite 5:00 a.m. on Saturday morning here in Helsinki, almost 7:00 p.m. Friday in Vancouver, but jet lag has ensured an early return to blogging.

The CMRE has emailed its daily update for September 6, with data for September 5. Excerpt from the Google translation:

SUBJECT: EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI AS AT SEPTEMBER 05, 2019

Date: Friday, September 06, 2019

Since the beginning of the epidemic, the cumulative number of cases is 3,069, of which 2,958 are confirmed and 111 are probable. In total, there were 2,057 deaths (1,946 confirmed and 111 probable) and 918 people cured.

• 415 suspected cases under investigation;

• 2 new probable cases in North Kivu, including 1 in Butembo and 1 in Biena;

• 13 new confirmed cases, including:

º 10 in North Kivu, including 4 in Kalunguta, 2 in Beni, 2 in Kayna, 1 in Butembo and 1 in Katwa;
º 3 in Ituri, including 2 in Mandima and 1 in Mambasa.

• 3 new confirmed deaths in North Kivu:
º 2 community deaths in North Kivu, including 1 in Kalunguta and 1 in Katwa;

º 1 death in the CTE in North Kivu in Mabalako.

• 4 people cured out of ETCs in North Kivu, including 3 Beni and 1 in Butembo.

• No health workers are among the newly confirmed cases. The cumulative number of confirmed / probable cases among health workers is 156 (5% of all confirmed / probable cases), including 41 deaths.

/!\ The data presented in this table are subject to change after extensive investigation and after redistribution of cases and deaths in their respective health areas.

DESCRIPTION OF PROBABLE CASES

• The case of Butembo is a girl, 2 weeks old infant, who died on March 20, 2019 at the "Everything is Grace" Hospital Center in the Vuvatsi Area (Vuthawa / Matembe) in Butembo, North Kivu. She was contacted by her mother, not followed for refusal and not vaccinated, who was confirmed EVD on March 14, 2019 and died on March 15, 2019 at CTE. This child was hospitalized at CH "Tout est Grâce" on March 19, 2019 following the occurrence of fevers, but without success. The alert was launched the same day by Community Relays (ReCo). There is reluctance for dignified and secure burial (EDS). 25 contacts, including 16 family members, 3 CH and 6 others were listed around this case;

• The case of Biena is a 22-year-old woman, unvaccinated, who died on December 16, 2018 at the home of a traditional healer, who was followed on an outpatient basis, but without success since December 09. This is an unlisted contact of her mother, confirmed Ebola case on November 24, 2018. The 22-year-old woman, accompanied by her older brother, had traveled by motorbike on December 10 to Biena. She remained in Biena until December 15 and her condition worsened with haemorrhagic signs. The alert was launched by the Vuvo IT, while the body was already buried before the arrival of the investigation team and EDS. 10 contacts, all members of his family, were listed around this case.

VACCINATION

• Since the beginning of vaccination on August 8, 2018, 213,814 people have been vaccinated;

• The only vaccine to be used in this outbreak is the rVSV-ZEBOV vaccine, manufactured by the pharmaceutical group Merck, following approval by the Ethics Committee in its decision of 20 May 2018.

MONITORING AT ENTRY POINTS

• Since the beginning of the epidemic, the total number of travelers checked (temperature measurement) at the sanitary control points, until 04 September 2019, is 91,667,203;

• To date, a total of 98 entry points (PoE) and sanitary control points (PoCs) have been set up in the provinces of North Kivu and Ituri to protect the country's major cities and prevent the spread of the epidemic in neighboring countries.

Air pollution and infant mortality: Evidence from Saharan dust

Via the National Bureau of Economic Research: Air Pollution and Infant Mortality: Evidence from Saharan Dust. The abstract:

Accurate estimation of air quality impacts on health outcomes is critical for guiding policy choices to mitigate such damages. Estimation poses an empirical challenge, however, because local economic activity can simultaneously generate changes in both air quality and in health impacts that are independent of air quality, confounding pollution-health estimates. 

To address this challenge, we leverage plausibly exogenous variation in local particulate matter exposure across sub-Saharan Africa due to dust export from the Bodele Depression, a remote Saharan region responsible for a substantial share of global atmospheric dust. Large scale transport of this dust is uncorrelated with local emissions sources and allows us to isolate the causal impact of air quality on infant mortality across Sub-Saharan Africa. 

Combining detailed information on nearly 1 million births with satellite measures of aerosol particulate matter, we find that a 10mg/m3 increase in local ambient PM2.5 concentration driven by distant dust emission causes a 22% increase in infant mortality across our African sample (95% CI: 10-35%), an effect comparable to quasi-experimental pollution-infant mortality estimates from wealthier countries. 

We also show that rainfall over the Bodele is a significant control on PM2.5 export and thus child health, and that future climate-change driven changes in Saharan rainfall could generate very large impacts on African child health through this pathway alone. 

We calculate that seemingly exotic proposals to pump and apply groundwater to the Bodele to reduce dust emission could be cost competitive with leading interventions aimed at improving child health.

MSF: Mothers and children left to die in Yemen without access to medical care

Via MSF.org: Mothers and children left to die in Yemen without access to medical care. Excerpt:

AMSTERDAM/BARCELONA/SANA’A – Many expectant mothers experiencing complications in childbirth and parents of sick children are unable to reach medical care in Yemen in a safe and timely manner, often with deadly consequences, a report by Médecins Sans Frontières (MSF) has found.

MSF’s new report, Complicated delivery: The Yemeni mothers and children dying without medical care, outlines the impact of the war on pregnant women, new mothers and children under 15 – who are some of the most neglected and vulnerable people in Yemen – as observed by MSF medical teams working in Taiz and Hajjah governorates.

Four years into the conflict, the warring parties in Yemen and their international backers have brought about the effective collapse of the country’s public health system, which cannot meet the needs of Yemen’s 28 million people.

Between 2016 and 2018, 36 mothers and 1,529 children died – 1,018 of whom were new-borns – in MSF’s Taiz Houban hospital, in Taiz governorate, and the MSF-supported Abs hospital, in Hajjah governorate. Of the deaths in Taiz Houban, almost one-third were children and new-borns who were dead on arrival. Many new-borns brought to MSF for care had a low birthweight or were born prematurely, at home or in small private clinics. The most common causes of deaths in neonates were prematurity, birth asphyxia and severe infection (sepsis). 

The high numbers of deaths are linked to a number of factors, with most being from a direct result of the war. These include the lack of functioning health facilities in Yemen, people’s difficulties in reaching them, and their inability to afford alternatives. Many people have to cross frontlines, pass through no-man’s land or negotiate their way through multiple checkpoints in order to reach a hospital that is still functional.

Eleven premature babies die in less than a day in Tunisian hospital, sparking outrage

Via The New York Times: 11 Premature Babies Die in Less Than a Day in Tunisian Hospital, Sparking Outrage. Excerpt:

TUNIS — Outrage grew in Tunisia this past week after 11 premature babies died in less than 24 hours from infections acquired in the same hospital as doctors and patients expressed frustration over the country’s struggling public health care system. 

The babies died recently at the Rabta hospital maternity ward in central Tunis, the country’s capital, after nosocomial, or hospital-acquired, infections led to deadly septic shocks, the health ministry said. 

Four more babies died later, and two of those deaths were also linked to the infection, said officials at a news conference at the health ministry on Friday.  

After the deaths, Abderraouf Cherif, the health minister, who had been nominated just months ago, quickly resigned. Several top health officials were fired. 

 Sonia Ben Cheikh, the interim health minister, called the deaths a “national disaster” and said officials suspected a problem with the sterile room where hospital staff members prepare the premature babies’ nutrients, which were delivered intravenously.

“We have doubts on the sterilization of the room and of the tools, which may have led to the infection,” she said at a news conference on Monday, adding later on local television that the department where the newborns died was short on workers, with only three doctors for 40 beds.  

The public outcry was worsened by the hospital’s handling of the deaths. 

Local television showed families holding the bodies of their newborns in cardboard boxes that had been handed to them by hospital staff members, sparking indignation on social media, especially after an official from the health ministry said on television it was not an “unusual practice” because “it can be less traumatizing than giving them in a simple blanket.”  

That official was fired a few days later. 

Prosecutors have opened an investigation, and the health ministry has asked a committee of doctors and pharmacists to investigate the deaths and the possible human errors that led to them.

Two babies die after contracting infection at Glasgow hospital

Via The Guardian: Two babies die after contracting infection at Glasgow hospital. Excerpt:

Two premature babies have died after contracting a bloodstream infection at a Glasgow hospital, the third infection-control crisis to hit the city’s health service within two weeks.  

NHS Greater Glasgow and Clyde confirmed on Wednesday night that it was investigating three cases in the neonatal unit at the Princess Royal maternity hospital. It said the infection was “one of a number of contributing causes” in the deaths of two “extremely premature” babies, and that a third had required treatment and was in a stable condition. 

On Tuesday Scottish prosecutors confirmed they were investigating the deaths of two patients, a 10-year-old boy and a 73-year-old woman, who contracted an infection connected to pigeon droppings at Queen Elizabeth university hospital in Glasgow. Another patient at that hospital remains seriously ill after contracting a separate fungal infection called mucor.

Dr Barbara Weinhardt, an infection control doctor, said a number of measures had been taken at the Queen Elizabeth university hospital, including a deep clean, isolation and barrier nursing, safety briefings to all staff and infection control advice to all visitors.  

She said: “Our thoughts are with the families affected. Results have confirmed that the three cases of Staphylococcus aureus are linked and our investigations continue into how they are linked.”

Syria: WHO concerned over critical health situation in Al-Hol camp, Al-Hasakeh

WHO EMRO has published WHO concerned over critical health situation in Al-Hol camp, Al-Hasakeh. Excerpt:

31 January 2019, Damascus, Syria – The World Health Organization is extremely concerned about the deteriorating humanitarian situation in Al-Hol camp in Al-Hasakeh governorate, and calls on all parties to the conflict to provide unhindered humanitarian access to people in need of life-saving aid.  

Over the last 2 months, approximately 23 000 people, mainly women and children fleeing hostilities in rural areas of neighbouring Deir-ez-Zor, have arrived in the camp. Many of them have walked or travelled in open trucks for several days and nights in the bitterly cold winter weather. Their journeys have been delayed en route by lengthy security screening procedures in an exposed field, and their ordeal has not ended on arrival to the camp. Thousands of new arrivals have been forced to spend several nights in the camp’s open-air reception and screening areas, without tents, blankets or heating. At least 29 children and newborns are reported to have died over the past 8 weeks, mainly from hypothermia, while travelling to the camp or shortly after arrival. 

The situation in the camp is now critical. Its population has tripled in size (from 10 000 to almost 33 000 people) in less than 2 months. The authorities are overwhelmed and struggling to cope with the sheer numbers of people. Many new arrivals are malnourished and exhausted following years of deprivation living under the control of the Islamic State of Iraq and the Levant. 

The camp is unheated and there are shortages of health care services, tents, latrines and sanitation facilities. Humanitarian access to the camp and surrounding roads is hampered by bureaucratic obstacles and security constraints. 

Since the beginning of January, WHO has delivered over 35 000 treatment courses to support the work of 2 mobile clinics donated by WHO, as well as 4 mobile health teams currently operating in the camp. WHO-supported teams are working round the clock to screen new arrivals and refer them to hospitals when required. Severely malnourished children are being referred to a WHO-supported hospital in Al-Hasakeh.

Why couldn’t my Ebola treatment center save this baby?

Via The New York Times, an opinion piece by Karin Huster, a field coordinator with MSF: Why Couldn’t My Ebola Treatment Center Save This Baby? Excerpt (but read the whole article):

That day when the mother and baby came to our center, I was standing on the other side of a fence that isolates the possibly contagious from the rest of us. I watched the young mother for a while, but I couldn’t catch her gaze. She appeared lost in her thoughts. 

We were all waiting on the medical team to see what was wrong with the baby. But moving, with Ebola, is frustratingly slow. Doctors and nurses must wear “Ebola armor” — plastic boots, two pairs of gloves, a face mask, goggles, a full-body impermeable plastic suit and a thick plastic apron. Because it’s as hot as a sauna inside it, they can’t wear the protective gear for very long. So every time a new patient arrives, a new team has to suit up.  

To partly remedy the problem, we are lucky to employ Ebola survivors to help in the triage area. Thanks to their acquired immunity to Ebola, they need much lighter protection, and so can be with patients much longer. They are the ones who spend the most time with patients as they are isolated for the three days it takes for testing. They are the ones who take care of the children and the babies who have to be separated from their mothers for this period. 

If the patients don’t have Ebola, they get to go home or to the hospital for further medical care. If they test positive, they will be transferred to the Ebola Treatment Unit just down the street, where they could remain isolated for weeks. 

Unlike us, unrecognizable in our scary spacesuits, survivors put a human touch to the frightening experience. And unlike us, they know what it feels like to be sick, unable to have your family at your side. 

They are the ones who started helping the mother and her baby while the medical team was suiting up. I watched as Chantal, a survivor who is also a nurse, began to carefully unwrap the baby in order to record its vital signs. 

She placed the baby in the hanging scale, carefully supporting its head. But something looked awfully wrong.  

“Lift the arm up and let go,” I said.  

The arm fell back, completely limp. I looked at Chantal, then looked at the mother. She didn’t seem to have noticed anything. Or if she did, she didn’t show it. The baby was carefully wrapped up again and the mother sat back down, waiting. A few minutes later, the medical team showed up, all dressed in their bright yellow suits.  

It was too late. The baby was dead. 

Perhaps the disease had progressed too quickly. Or perhaps the mother delayed coming. People often do, and it’s hard to blame them. There are rumors that Ebola is a business run by foreigners just to make money, and that the vaccine is a kind of poison. Such misinformation pushes people to seek care from traditional healers in hopes of avoiding the Ebola Treatment Units. Sometimes they even flee when an Ebola response team’s armada of SUVs, flanked by armed police officers, speeds toward their village.

Trends in infant mortality in Venezuela between 1985 and 2016

Via The Lancet Global Health: Trends in infant mortality in Venezuela between 1985 and 2016: a systematic analysis of demographic data. The summary:

Background 

Between the 1950s and 2000, Venezuela showed one of the most substantial improvements in infant mortality rates in Latin America. However, the recent economic crisis alongside an increase in infectious and parasitic diseases might be reversing previous patterns. Because no official updated mortality statistics have been published since 2013, the effect of these recent events has been difficult to assess accurately. We therefore aimed to estimate infant mortality rate trends and report the effect of the crisis. 

Methods 

We estimated infant mortality rates using direct methods (ie, death counts from Venezuelan Ministry of Health via yearbooks and notifiable diseases bulletins, and birth records published by the UN Economic Commission for Latin America and the Caribbean and the Venezuelan National Institute of Statistics) and indirect methods (using census data and a Living Conditions Survey ENCOVI 2016). We shaped yearly estimations using a semiparametric regression model, specifically a P-Spline model with a cubic thin plate base. The primary objective was to estimate infant mortality rate trends from 1985 to 2016. 

Findings 

Around 2009, the long-term decline in infant mortality rate stopped, and a new pattern of increase was observed. The infant mortality rate reached 21·1 deaths per 1000 livebirths (90% CI −17·8 to 24·3) in 2016, almost 1·4 times the rate of 2008 (15·0, −14·0 to 16·1). This increase represents a huge setback on previous achievements in reducing infant mortality. 

Interpretation 

Our conservative estimation indicates that Venezuela is in the throes of a humanitarian crisis. The increase in infant mortality rate in 2016 compared with 2008 takes the country back to the level observed at the end of the 1990s, wiping out 18 years of expected progress, and leaves the Venezuelan Government far from achieving the target of nine deaths per 1000 livebirths stated in the UN Millennium Development Goals.

'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.