H5N1

Traumatic injury mortality in the Gaza Strip from Oct 7, 2023, to June 30, 2024: a capture–recapture analysis

Via The Lancet: Traumatic injury mortality in the Gaza Strip from Oct 7, 2023, to June 30, 2024: a capture–recapture analysis. The summary:

Background  

Accurate mortality estimates help quantify and memorialise the impact of war. We used multiple data sources to estimate deaths due to traumatic injury in the Gaza Strip between Oct 7, 2023, and June 30, 2024.  

Methods  

We used a three-list capture–recapture analysis using data from Palestinian Ministry of Health (MoH) hospital lists, an MoH online survey, and social media obituaries. After imputing missing values, we fitted alternative generalised linear models to the three lists' overlap structure, with each model representing different possible dependencies among lists and including covariates predictive of the probability of being listed; we averaged the models to estimate the true number of deaths in the analysis period (Oct 7, 2023, to June 30, 2024). Resulting annualised age-specific and sex-specific mortality rates were compared with mortality in 2022.  

Findings  

We estimated 64 260 deaths (95% CI 55 298–78 525) due to traumatic injury during the study period, suggesting the Palestinian MoH under-reported mortality by 41%. The annualised crude death rate was 39·3 per 1000 people (95% CI 35·7–49·4), representing a rate ratio of 14·0 (95% CI 12·8–17·6) compared with all-cause mortality in 2022, even when ignoring non-injury excess mortality. Women, children (aged <18 years), and older people (aged ≥65 years) accounted for 16 699 (59·1%) of the 28 257 deaths for which age and sex data were available.  

Interpretation  

Our findings show an exceptionally high mortality rate in the Gaza Strip during the period studied. These results underscore the urgent need for interventions to prevent further loss of life and illuminate important patterns in the conduct of the war.

See also this report in The Guardian.

Violence against health care: Attacks during a pandemic

An interactive report from the UC Berkeley Human Rights Center and Insecurity Insight: Violence Against Health Care: Attacks During a Pandemic. Excerpt:

Atlas of Attacks 

While health care workers worldwide have been lauded as heroes for providing much-needed medical services to fight COVID-19, countless others have faced attacks directly related to their essential work. 

In the midst of a global pandemic, attacks on health workers and services further exacerbate fragile health care systems, highlight weaknesses in resources and equipment, and deprive citizens of basic rights to health, medicine, and protection under international human rights and humanitarian law. 

The UC Berkeley Human Rights Center and Insecurity Insight documented more than 1,100 attacks and threats of violence against health care, including medical personnel, patients, health care facilities, and transport. Some 400 of these attacks appear to be specifically COVID-19 related. 

The Atlas of Attacks maps each report of a violent attack or reported threat of violence against health care, which may include attacks on people or health facilities. Where multiple events are reported, these events will be displayed on the map in clusters, with the number of unique events displayed.

Health care attacks during a pandemic 

Attacks on health care have become more apparent in the midst of the pandemic and impeded the response to COVID-19 in numerous countries. Health workers caring for the infected or sick have been subjected to individual and collective assaults as well as coercion and punishment by security forces for speaking up about their or their patients’ needs. 

While attacks on health care have been prominent in conflict settings, the COVID-19 pandemic has thrown into stark relief the risks health workers face from both the virus and public violence as communities grow fearful, angry, and frustrated. Moreover, health workers have suffered psychologically as a result of these constant threats while having to deal with the trauma of watching patients die.

Plane carrying WHO trauma and surgical supplies arrives in Beirut, Lebanon

Via WHO EMRO: WHO EMRO | Plane carrying WHO trauma and surgical supplies arrives in Beirut, Lebanon. Excerpt:

5 August 2020, Beirut, Lebanon – A plane carrying 20 tonnes of WHO health supplies has landed in Beirut, Lebanon, to support the treatment of patients injured by the massive blast that occurred in the city on 4 August. The supplies will cover 1000 trauma interventions and 1000 surgical interventions for people suffering from injuries and burns resulting from the blast.  

The shipment was airlifted from WHO’s logistics hub in Dubai earlier this afternoon using a plane donated by the Government of the United Arab Emirates, a key WHO partner in health emergency response.  

“Our hearts and prayers are with all those affected by this tragic event as we continue our mission to serve all people in Lebanon with life-saving and essential health care services. We are working closely with national health authorities, health partners and hospitals treating the wounded to identify additional needs and ensure immediate support,” said WHO Representative in Lebanon Dr Iman Shankiti. 

As a result of the blast, 3 hospitals in Beirut are now non-functional and 2 hospitals are partially damaged, leaving a critical gap in hospital bed capacity. Injured patients are being transferred to hospitals across the country, as far as south Saida and north Tripoli, and many facilities are overwhelmed. WHO will distribute the supplies to priority hospitals across Lebanon receiving and treating injured patients.

COVID-19: A public health approach to manage domestic violence is needed

Via The Lancet Public Health: COVID-19: a public health approach to manage domestic violence is needed.

The negative consequential effects of the measures adopted by the UK and other countries to tackle the spread of coronavirus disease 2019 (COVID-19) on society are beginning to unfold. An area of concern is the impending crisis of domestic violence—gender-based violence and child abuse and neglect, due to movement restrictions, loss of income, isolation, overcrowding, and stress and anxiety, all which put women and children at a disproportionally increased risk of harm. 

This increased risk is not surprising. Previous epidemics, such as the Ebola virus disease outbreak in west Africa, but also cholera and Zika virus disease outbreaks, led to regional environments where domestic violence became more prevalent; there were reductions in funding for specialist gender-based violence public health services; and, for survivors of gender-based violence, there was reduced access to health-care services. 

Although we are not aware of published studies to date that have tracked the national trends in gender-based violence related to COVID-19, initial reports from UK support services such as the National Domestic Abuse helpline have already shown increases in service use, a pattern seen elsewhere (with notable examples in China, Spain, and France). 

In the UK, before the coronavirus crisis, gender-based violence was already deemed as highly prevalent, associated with substantial negative downstream social, psychological, and physical outcomes. Therefore, any resultant increases in the rates of domestic violence would not only be a further travesty of human rights but also be associated with further long-term costs to society, which might be irreparable beyond the immediate threat of COVID-19. It has never been more important than now to implement a public health approach to gender-based violence in the UK.

Similar to an approach that has been put in use to improve the management of physical violence in cities such as Cardiff, Glasgow, and London, the principles of a public health approach should be implemented to support survivors of gender-based violence. The WHO public health approach consists of four steps, which we have suggested the adaptation of to aid in the prevention of domestic violence during this pandemic (appendix). 

Without adequate surveillance, it is not possible to capture the burden of domestic violence during this pandemic. Because of selection biases, administrative datasets have consistently shown underestimates in the expected rates of domestic violence. Potential approaches to improve the surveillance of domestic violence could include the routine inquiry (feasibly integrated into remote primary care consultations or active syndromic surveillance from local health protection teams) and the urgent implementation of linked datasets between police and health records datasets to identify individuals at risk. Enhancing surveillance would also provide the opportunity to offer targeted support and interventions. 

Though formal evaluations of current interventions have not yet taken place during the pandemic, national charities (such as, but not limited to, Women's Aid, Safelives, and the National Society for the Prevention of Cruelty against Children) have produced guidance for how survivors can both report violence, abuse, and neglect and keep themselves safe, including information on remote reporting and support mechanisms. 

There are substantial gaps in the literature relating to the surveillance and evaluation of effective interventions to support those at risk of domestic violence, child abuse and neglect during this pandemic. The medical profession has a duty to provide support in overcoming these problems—to provide a public health approach to supporting those most vulnerable in society.

DR Congo: MSF urges humanitarian organisations to return to southern North Kivu

Via MSF.org, a sobering account of the other problems North Kivu is dealing with: DR Congo: MSF urges humanitarian organisations to return to southern North Kivu. Excerpt:

KINSHASA – For years, the territories of Masisi, Walikale and Rutshuru, in the southern part of North Kivu, Democratic Republic of Congo, have been plagued with armed violence and banditry. In the past months, these armed clashes have intensified, further aggravating the dire humanitarian situation, leading to significant numbers of displaced people and worrying signs of malnutrition, sexual violence and gunshot wounds among them. 

“Since the start of the year, the number of victims of sexual violence treated by MSF in Masisi has doubled compared to last year, and we have seen an increase in malnutrition cases”, says Ewald Stals, MSF field coordinator in Masisi health zone. “The escalation of armed clashes has also led to more people being treated for bullet wounds, and to a surge of displaced families arriving in already overcrowded camps where access to water and sanitation is scarce. Unsurprisingly, cholera cases have been reported and we’ve had to rapidly set up a cholera treatment centre.” 

“Where are the humanitarians?” 

From January to September 2019, MSF teams working in the territories of Masisi, Rutshuru and Walikale treated more than 11,220 malnourished children, 2,310 victims of sexual violence and 1,980 people with weapons injuries. Despite this critical situation, these territories – often referred to as the ‘Little North’ of North Kivu in the aid sector – suffer from a glaring lack of assistance from humanitarian organisations.   

“In recent years, several NGOs have left the ‘Little North’ because of insecurity, difficulties in movement around the region, and a lack of funding,” says Karel Janssens, MSF Head of Mission in DRC. “Given this reduction in the number of organisations, we have been responding to an increasing number of medical, but also non-medical, needs, especially in camps. Now we’re running at maximum capacity, and other emergency organisations must urgently come back and help respond to the massive humanitarian needs on the ground.” 

According to recent estimates, more than 687,000 people are living in camps for internally displaced people or are being hosted by local families in the territories of Masisi, Rutshuru and Walikale. For months, MSF has been advocating for the on-the-ground return of other humanitarian organisations. These efforts resulted in the arrival of a handful of organisations with temporary funding from the DRC Humanitarian Fund in mid-November.  

“This support is temporary and far from enough to meet the needs,” says Janssens. “Given the scale of the crisis, a much larger humanitarian response is needed in southern North Kivu, with organisations being present on the ground and benefitting from longer-term funding. The Humanitarian Response Plan 2020 for DRC must clearly take this into account in its upcoming revision.”

Hong Kong: Counting the health cost

An editorial in The Lancet: Hong Kong: counting the health cost. And Hong Kong isn't the only city dealing with such issues.

Civil unrest in Hong Kong, stemming from the introduction of a controversial extradition bill, has been marked by fierce conflict between protestors and law enforcement, along with extensive use of weapons, including tear gas and water cannons. As the unrest continues, the effects of ongoing violence on the health of the population of Hong Kong should be urgently examined. 

Violent clashes with police have resulted in a wave of physical injuries. Some injured police have alleged bias and poor treatment from public hospitals. Among the civilian population, doctors are concerned about the number of head injuries from batons and rubber bullets. In The Lancet, Darren Mann has described the fear of being arrested while receiving first aid. A World Report this week describes growing tensions between doctors and police, including in hospitals. The combination of violence and the breakdown of trust in the public medical-care service has led to a surge in undocumented and untreated injuries, particularly in Hong Kong's youth. 

Concerns are also growing about exposure to chemical hazards in Hong Kong's densely populated urban landscape. Tear gas, a chemical weapon with respiratory and ophthalmic effects, has been used extensively, and is reported to have seeped into public and residential buildings, including at least one hospital. Potentially toxic by-products from petrol bombs or burning tyres and unknown irritants in water cannons have unknown health effects. Without understanding a weapon's composition or the risks, doctors are unsure how to manage exposure or whether to recommend any public health measures. 

Exposure of the population to violence on this scale is also likely to have mental health effects. The harms from the conflict could do long-term damage to the health of the people of Hong Kong, and stoke further unrest. A systematic, transparent, and robust documentation of the health impacts of these events is necessary not only to calculate and manage the currently unknown health effects, but also to rebuild trust.

MSF opens trauma hospital amid Haiti’s deepening health crisis

Via MSF.org: MSF opens trauma hospital amid Haiti’s deepening health crisis. Excerpt:

PORT-AU-PRINCE, HAITI — A deepening political and economic crisis is putting a severe strain on all aspects of medical care in Haiti, Médecins Sans Frontières (MSF) said today as we announced the opening of a hospital in Port-au-Prince for patients with traumatic injuries. 

The hospital, which opened on 27 November in the Tabarre area of Port-au-Prince, specialises in treating patients with life-threatening injuries, including open fractures and gunshot wounds. In its first five days of operations, the hospital admitted 21 patients, about half of whom had injuries from violence.  

"We are responding to a vital need with the opening of the Tabarre emergency trauma hospital, but this will not be enough," said Jane Coyne, MSF head of mission in Haiti. "The country is undergoing a severe economic and political crisis, and hospitals are struggling to stay open." 

MSF originally opened a hospital in Tabarre in 2012 to provide emergency care to people with traumatic injuries in the years following the Haitian earthquake. The hospital, named "Nap Kenbe," progressively reduced its services in recent years and admitted its last patient in late 2018.  

Since September, when Haiti's economic and political crisis deepened, MSF has decided on a new initiative to care for patients with life-threatening injuries, which the Haitian medical system now struggles to treat. 

Working in the same location in Tabarre, the new MSF hospital currently employs 170 medical personnel, including eight surgeons. After opening with 25 beds, the hospital is preparing to increase its capacity to 50 beds. 

As economic troubles and political tensions have intensified, medical facilities, including those operated by MSF, have struggled to meet the needs of patients. Since September, streets have regularly been blocked by barricades made of burning tyres, cables and even walls built overnight. These have made it more difficult for ambulances to move and for medical facilities to receive fuel, oxygen, blood, medicines and other supplies.

MSF's medical facilities in Haiti are seeing a high level of need amid the current crisis. So far in 2019, MSF's emergency stabilisation centre in the Martissant area of Port-au-Prince has received an average of 230 patients per month with gunshot wounds, lacerations or other injuries from violence. MSF's hospital in the Drouillard area of Port-au-Prince saw a peak in activity in September, when it admitted a total of 141 patients with severe burns, primarily caused by accidents. 

Insecurity affects health care workers as well. For months, the national Haitian ambulance service has experienced repeated incidents affecting its ability to respond to medical emergencies. 

To keep MSF's health facilities functioning during the tensions of recent months, MSF has needed to transport hundreds of staff to work each day in MSF vehicles. 

"Thanks to the positive reputation of MSF in Haiti, our vehicles are generally respected and are able to pass through the barricades," said Ella Lambe, MSF project coordinator in the town of Port-à-Piment. "However, some health centre where we have referred our patients have been looted, and some of our vehicles have been hit with stones."

Effects of tranexamic acid in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial

Via The Lancet: Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. The summary:

Background 

Tranexamic acid reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury (TBI) and can cause brain herniation and death. We aimed to assess the effects of tranexamic acid in patients with TBI. 

Methods 

This randomised, placebo-controlled trial was done in 175 hospitals in 29 countries. Adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major extracranial bleeding were eligible. The time window for eligibility was originally 8 h but in 2016 the protocol was changed to limit recruitment to patients within 3 h of injury. This change was made blind to the trial data, in response to external evidence suggesting that delayed treatment is unlikely to be effective. 

We randomly assigned (1:1) patients to receive tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was head injury-related death in hospital within 28 days of injury in patients treated within 3 h of injury. 

We prespecified a sensitivity analysis that excluded patients with a GCS score of 3 and those with bilateral unreactive pupils at baseline. All analyses were done by intention to treat. This trial was registered with ISRCTN (ISRCTN15088122), ClinicalTrials.gov (NCT01402882), EudraCT (2011-003669-14), and the Pan African Clinical Trial Registry (PACTR20121000441277). 

Results 

Between July 20, 2012, and Jan 31, 2019, we randomly allocated 12 737 patients with TBI to receive tranexamic acid (6406 [50·3%] or placebo [6331 [49·7%], of whom 9202 (72·2%) patients were treated within 3 h of injury. Among patients treated within 3 h of injury, the risk of head injury-related death was 18·5% in the tranexamic acid group versus 19·8% in the placebo group (855 vs 892 events; risk ratio [RR] 0·94 [95% CI 0·86–1·02]). In the prespecified sensitivity analysis that excluded patients with a GCS score of 3 or bilateral unreactive pupils at baseline, the risk of head injury-related death was 12·5% in the tranexamic acid group versus 14·0% in the placebo group (485 vs 525 events; RR 0·89 [95% CI 0·80–1·00]). 

The risk of head injury-related death reduced with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64–0·95]) but not in patients with severe head injury (0·99 [95% CI 0·91–1·07]; p value for heterogeneity 0·030). 

Early treatment was more effective than was later treatment in patients with mild and moderate head injury (p=0·005) but time to treatment had no obvious effect in patients with severe head injury (p=0·73). The risk of vascular occlusive events was similar in the tranexamic acid and placebo groups (RR 0·98 (0·74–1·28). The risk of seizures was also similar between groups (1·09 [95% CI 0·90–1·33]). 

Interpretation 

Our results show that tranexamic acid is safe in patients with TBI and that treatment within 3 h of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.

WHO gravely concerned about humanitarian situation in northeast Syria

By email, a statement from WHO:

13 October, Cairo, Egypt — WHO is gravely concerned about the humanitarian health situation in northeast Syria, where up to 200,000 people have been displaced as a result of increased military operations since 9 October, and almost 1.5 million people are in need of health aid. Many of those affected by the recent hostilities have already experienced immense physical and mental stress as a result of years of conflict and repeated displacement.

People in need of essential health care services face challenges related to insecurity and limited access to health care. Already weakened health services in northeast Syria have been severely impacted by the latest security developments. The national hospital in Ras Al-Ain is currently out of service, and the national hospital and two health centers in Tel Abyad are also currently non-functional. The three field hospitals in Al-Hol camp have limited their services since 12 October as a result of the escalation of hostilities which has impeded access of health staff to the camp. All health facilities in camps hosting displaced people in Ain Issa and Ras al Ain have also been evacuated, with additional facilities under threat as the conflict rapidly escalates.

A number of health partners have already suspended services due to insecurity, further disrupting access to essential health care services. On 12 October, a trauma stabilization point located south of Ras Al Ain was evacuated after being reportedly attacked, resulting in two health staff injured and two ambulances destroyed. On the same day, the hospital in Ras Al-Ain was also reportedly attacked. There were no casualties as the facility had already been evacuated.

Across northeast Syria, shortages of health workers is widespread as they too have been among those displaced by the ongoing insecurity, aggravating an already critical situation and further depriving underserved populations of access to medical care.

Damages to the pumping station in Ras Al Ain, the main water source for most of Al Hassakeh governorate, has increased the risk of outbreaks of infectious diseases. Even before the current escalation in conflict, acute diarreah and typhoid were two of the most reported diseases among people in northeast Syria in August 2019. Ongoing displacements, overcrowded living conditions, and limited access to safe water and sanitation services, will likely lead to an increase in the number of people affected by water-borne diseases.

Amid this chaotic and fast-moving situation, WHO and health partners are working hard to respond to urgent health needs. Almost 314,000 medical treatments, vaccines, in addition to trauma medicines for 500 trauma patients have already been prepositioned in Qamishly hub. An additional shipment of more than 100,000 treatments and medicines for 640 trauma patients will be airlifted to Qamishly in the coming week. Medicines for diarrheal diseases, have also been prepositioned for delivery to health facilities as needed. Despite the challenges, many health NGOs continue to operate or shift to new locations. Some casualty cases requiring hospitalization are referred to a WHO-supported facility in Al-Hassakeh, and WHO is in the process of contracting two additional hospitals in Al-Hassakeh and Al-Raqqa to support referral services.

As the situation evolves, WHO and partners will continue to assess health needs and scale up their response as needed.

WHO calls on all parties to the conflict to preserve the right to health for hundreds of thousands of innocent civilians in northeast Syria, and comply with International Humanitarian Law to protect all civilians, including health care workers and patients, as well as health facilities.

A medic's responsibility: A report from the Paris refugee camps

Aletter in The Lancet: A medic's responsibility: a report from the Paris refugee camps.

We agree with the Editors that health-care professionals have a duty to care for vulnerable populations. We report on the situation for refugees in France. Since the shutdown of the so-called Calais Jungle refugee camp in Calais, France, in autumn 2016, more refugees have moved to the streets of Paris. 

Many refugees, including young children and pregnant women, now live in unofficial, rat-infested, flooded camps in the Port de La Chapelle and Porte D'Aubervilliers areas in northern Paris. A large number of these refugees are from Afghanistan, Eritrea, and Somalia. Many of these refugees have health problems such as respiratory disease, scabies, malnutrition, and injuries, including stab wounds, and they have little or no access to health care. 

The police conduct regular mass evacuations in the area by confiscating tents, sleeping bags, and personal belongings. Across Europe, many refugees have their fingerprints recorded taken before they reach France; in doing so, a refugee's application for asylum falls under the Dublin Regulation, meaning that the French Government will not process their asylum claim for at least 18 months, leaving the refugees with no access to housing or health care. 

As health-care professionals, we condemn the introduction of the Dublin Regulation by the EU and the enforcement of it by the French authorities; we see it as ethically cruel and neglectful of the basic human right to health according to the 1946 WHO Constitution. We have a duty to serve every patient in need, regardless of their asylum status, and to continue to hold European governments and other bodies enforcing these laws accountable for their actions.