H5N1

Financialisation: a 21st century commercial determinant of health equity

Via The Lancet Public Health: Financialisation: a 21st century commercial determinant of health equity. The summary:

In 21st century capitalism, financial markets reign supreme. The elevation of investing, trading, and speculating as a way of making profit has shifted economic power towards institutional investors and enhanced the power of financial capital.  

Financialisation has introduced uncertainty in the commitment to public provision of goods and services. The behaviours of corporations focus more on profit for shareholders and senior executives to the detriment of wages, worker protections, livelihoods, and impact on prices and the environment. The practices of this financial system pose major challenges to public health and planetary health equity through the influence on social inequality, climate change, and health outcomes.  

The aim of this Viewpoint is to expand the understanding of the commercial determinants of health to explicitly include the financial system and present key plausible pathways via which the financialisation of advanced economies influences public health and planetary health equity. The global public health community must pay close attention to these key commercial determinants of health.  

It is now crucial to reduce the power of financial actors and hold financial actors accountable. Civil society groups can highlight their practices, articulate alternative visions, and hold financial actors and governments to account. Interdisciplinary research must provide a diagnosis of the financial and public health issues, and, importantly, illuminate effective pathways forward. Financial and commercial worlds must return to stakeholder primacy rather than that of the shareholder.

Excess Death Rates by State During the COVID-19 Pandemic: United States, 2020‒2023

Via AJPH: Excess Death Rates by State During the COVID-19 Pandemic: United States, 2020‒2023. The full article is paywalled, but the abstract confirms some earlier studies:

Objectives. To estimate state-level excess death rates during 2020 to 2023 and examine differences by region and partisan orientation.  

Methods. We modeled death and population counts from the Centers for Disease Control and Prevention to estimate excess death rates for the United States, 9 census divisions, and 50 states. We compared excess death rates for states with different partisan orientations, measured by the party of the seated governor and the level of partisan representation in state legislatures.  

Results. The United States experienced 1 277 697 excess deaths between March 2020 and July 2023. Almost 90% of these deaths were attributed to COVID-19, and 51.5% occurred after vaccines were available. The highest excess death rates first occurred in the Northeast and then shifted to the South and Mountain states. Between weeks ending June 20, 2020, through March 19, 2022, excess death rates were higher in states with Republican governors and greater Republican representation in state legislatures.  

Conclusions. Excess death rates during the COVID-19 pandemic varied considerably across the US states and were associated with partisan representation in state government, although the influence of confounding variables cannot be excluded.

Stop H5N1 influenza in US cattle now

An editorial in Science; Stop H5N1 influenza in US cattle now.

The relentless march of a highly pathogenic avian influenza virus (HPAIV) strain, known as H5N1, to become an unprecedented panzootic continues unchecked. The leap of H5N1 clade 2.3.4.4b from Eurasia and Africa to North America in 2021 and its further spread to South America and the Antarctic have exposed new avian and mammalian populations to the virus and led to outbreaks on an unrivaled scale. 

The virus has infected wild birds across vast geographic regions and caused wildlife deaths in some of the world’s most biodiverse ecosystems. Hundreds of millions of poultry have died or been culled, affecting global food security in some of the world’s poorest regions. Numerous mammalian species, including sea lions and fur animals, have been infected. Outbreaks in dairy cows in the United States have been occurring for months, seemingly unchecked in most affected states. Why is there not a greater sense of urgency to control these infections? 

Although the H5 2.3.4.4b virus seems poorly optimized for infection or spread in humans, with fewer than 20 cases since 2016, influenza leaves no room for complacency. The sheer number of infected wild birds and poultry has caused spillover infections to occur in wild carnivores, marine mammals, and farmed animals, providing additional pathways for exposure and perhaps infection in humans. The H5 virus has evolved continuously since 1996 but has never infected so many bird species nor been able to transmit to, and replicate in, cows. 

The more than 140 dairy farms in 12 US states with the virus and the detection of viral RNA in milk products in grocery stores speak for themselves. Infection in cattle creates new possibilities for direct contact between the virus and humans, and also risks the virus evolving the ability to spread in cattle, a new livestock reservoir of around 1.5 billion animals worldwide. 

Until now, human infections with H5 viruses were mainly associated with the keeping of infected poultry. But over the past 3 months, the United States has identified human H5 cases in farmworkers associated with one of the world’s most industrialized dairy production systems. Even difficult viral adaptations can occur if there are enough opportunities for contact and replication in new host species. Adaptation of the virus to cattle must be prevented. The outbreak in cattle in the United States must therefore be brought under control quickly. 

Key measures that should be initiated or intensified immediately include surveillance of all US dairy farms by testing, for example, bulk milk for influenza virus RNA, implementation of strict quarantine for infected cattle, and restriction of within-state transport to stop the circulation of the virus in cows. Only a couple of states are attempting this currently. 

Biosecurity and hygiene measures on US dairy facilities must be enhanced to avoid virus spread and spillover infections. This should include simple and practical steps such as keeping work clothing on the farm, thoroughly decontaminating stock vehicles and equipment, ensuring restricted access and movement of personnel among premises, and providing appropriate personal protective equipment. 

Human influenza surveillance should be bolstered during the summer and before the usual human seasonal influenza wave begins in the fall. The timely development of vaccine candidates for both livestock and humans should be undertaken along with associated policies on their distribution. This is the ultimate insurance against a worst-case scenario in which viral variants emerge that spread more easily in mammals. 

Globally, surveillance of mammalian cases should be intensified and real-time genomic information on the virus should be made publicly available, especially in at-risk populations (such as pig and fur animal farms). There must be increased global awareness of data collection and data sharing on zoonotic influenza. Analyses for incursion risk and pandemic preparedness based on both genetic and phenotypic data (including identifying mammalian adaptive changes, antiviral therapeutic resistance, and diagnostic robustness) in all regions need to be substantially improved, and the detection of human infection clusters needs to be further optimized. 

National and international coordination in the spirit of a modern “One Health” approach is essential, and the quadripartite comprising the Food and Agricultural Organization of the United Nations, United Nations Environment Programme, World Health Organization, and World Organisation for Animal Health should step up to take a leading role.

H5N1: International failures and uncomfortable truths

An editorial in The Lancet: H5N1: international failures and uncomfortable truths.

If you ask an infectious diseases specialist whether we should start worrying about influenza A H5N1, they will probably tell you that we should always be worrying about it. An influenza pandemic has long topped the list of global threats to health, and avian influenza poses a particularly serious concern. 

H5N1 has infected over 800 people since its identification in 1996, with a mortality rate exceeding 50%. Since 2020, it has become endemic in bird populations, triggering an unparalleled animal pandemic, affecting at least 26 mammal species. There is nothing new in influenza strains evolving, shifting their epidemiological habits, and causing infections in people, although human-to-human transmission of H5N1 is rare. 

Nonetheless, although developments over the past 3 months may or may not signal the start of a global pandemic, they are at the very least a pressing and unwelcome reminder of the caprices of zoonotic influenza and our continued collective complacency about it. 

An unprecedented outbreak of highly pathogenic avian influenza A(H5N1), the first documented infection in dairy cows, was reported on March 25, 2024 in Texas, Kansas, and New Mexico, raising the potential of cow-to-human transmission. Three confirmed human cases in the USA, all farm workers, have been reported so far, with the third person presenting with respiratory symptoms. 

Genetic analysis shows that the virus lacks changes that would make it better adapted to transmit between people and the risk to human health remains low, but it did detect adaptation to mammalian hosts. 

Despite calls for increased surveillance, the US response has been slow, with many cases likely going undetected. There has been resistance from the farming industry around testing and prevention, driven by a lack of awareness or understanding around changing practice and fear of trade restrictions and product loss. The US Department of Agriculture (USDA) and the US Centers for Disease Control and Prevention are incentivising dairy producers to supply personal protective equipment and offer laundering services for employees, but the USDA has been accused of being slow in sharing crucial virus sequence data, complicating our understanding of the outbreak. 

In Canada, early warning systems have been implemented to screen for H5N1 in milk. The UK says it has intensified its response to the US outbreak, but according to a report last month, it is not yet testing cows for the virus.

Action to curb this outbreak is needed urgently, including improving testing, surveillance, and reporting of infected animals and food products; vaccinating animal populations; transparent information sharing; developing and stockpiling human vaccine; and promoting protective measures among farm workers. All countries should build capacities to test, detect, and report infections, cases, and deaths above expected levels and share this information. Countries in need of external assistance to bolster their capacity should receive support.

 

The need for a robust and coordinated response to highly pathogenic avian influenza A(H5N1), as described in a Comment by Kojima and colleagues, serves to highlight the scale of the failure of countries to secure an international agreement on the pandemic accord. The 77th World Health Assembly, which closed on June 1, was meant to see a finalised draft of an international instrument on pandemic prevention, preparedness, and response. As The Lancet has noted, negotiations have been mired in disagreement and draft provisions have been unjust and inequitable (although changes to the International Health Regulations have been agreed). The process is not over yet—discussions continue with the hope of securing an agreement by May, 2025. Until then, the continued absence of a meaningful and effective accord undermines the ability to respond appropriately to international health threats, such as H5N1. Despite COVID-19, most countries are not prepared for a new pandemic.

 

Beyond the proximal drivers of outbreaks and potential interventions though, there is a need to confront an uncomfortable truth that the US H5N1 outbreak once again raises. Spillover of zoonoses into human populations stems ultimately from our ways of life and how they shape the human–animal interface. Our diets, our intensive farming practices, our livelihoods, our behaviours, and our cultures. Our exploitation of the natural world and our destruction of the environment. These issues are tractable through interdisciplinary education, intersectoral collaboration, adequate funding, and integrated policies. The concept of One Health, although often acknowledged, is rarely prioritised and operationalised. The result is a missed opportunity to not just respond to pandemic threats, but to prevent them altogether.

 

Impacts of poverty and lifestyles on mortality: A cohort study in predominantly low-income Americans

Via the American Journal of Preventive Medicine: Impacts of poverty and lifestyles on mortality: a cohort study in predominantly low-income Americans. The full article is paywalled, but here's the abstract:

Introduction  

Low socioeconomic status has been linked to increased mortality. However, the impacts of poverty, alone or combined with health behaviors, on mortality and life expectancy have not been adequately investigated.  

Methods  

Data from the Southern Community Cohort Study was used, including nearly 86,000 participants recruited during 2002-2009 across 12 US southeastern states. Analysis was conducted from February 2022 to January 2023.  

Results  

During a median follow-up of 12.1 years, 19,749 deaths were identified. A strong dose-response relationship was found between household incomes and mortality, with a 3.3-fold (95%CI = 3.1 - 3.6) increased all-cause mortality observed for individuals in the lowest income group (< $15,000/year) compared with those in the highest group (≥ $50,000/year). Within each income group, mortality monotonically increased with declining healthy lifestyle score. Risk was significantly lower among those in the lowest income but healthiest lifestyle group, compared to those with the highest income but unhealthiest lifestyle (HR = 0.82, 95%CI = 0.69 - 0.97). Poor white participants appeared to experience higher all-cause mortality than poor Black participants. Life expectancy was more than 10.0 years shorter for those in the lowest income group compared with those in the highest income group.  

Conclusions  

Poverty is strongly associated with increased risk of death, but the risks could be modestly abated by a healthier lifestyle. These findings call for a comprehensive strategy for enhancing a healthy lifestyle and improving income equality to reduce death risks, particularly among those experiencing health disparities due to poverty.

Global pandemic agreement at risk of falling apart, WHO warns

Via The Guardian: Global pandemic agreement at risk of falling apart, WHO warns. Excerpt:

Plans for a global pandemic preparedness agreement risk falling apart amid wrangling and disinformation, according to the chief of the World Health Organization, who has warned that future generations “may not forgive us”.  

Shaken by the Covid-19 pandemic, the WHO’s 194 member states decided more than two years ago to start negotiating an international accord aimed at ensuring countries are better equipped to deal with the next health catastrophe, or to prevent it altogether.  

The plan was to seal the agreement at the 2024 World Health Assembly, the WHO’s decision-making body, which convenes on 27 May.  

However, Tedros Adhanom Ghebreyesus, the WHO’s director-general, said the momentum had been slowed down by entrenched positions and “a torrent of fake news, lies, and conspiracy theories”.  

He warned that if nobody was prepared to seize the initiative or give ground, the whole project risked going nowhere.  

Tedros told the WHO’s executive board in Geneva on Monday: “Time is very short. And there are several outstanding issues that remain to be resolved.”  

Failure to strike an agreement would be “a missed opportunity for which future generations may not forgive us”, he said.  

Tedros said all countries needed the capacity to detect and share pathogens presenting a risk, and timely access to tests, treatments and vaccines.  

He called for a “strong agreement that will help to protect our children and grandchildren from future pandemics”.  

Tedros said claims that the accord would cede sovereignty to the WHO or give it the power to impose lockdowns and vaccine mandates were “completely false”.  

“We cannot allow this historic agreement, this milestone in global health, to be sabotaged.”  

WHO member states decided in December 2021 to create a new international instrument on pandemic prevention, preparedness and response, aimed at ensuring the flaws that turned Covid-19 into a global crisis could never happen again.  

The WHO emergencies director, Michael Ryan, reminded countries how the pandemic “ripped apart our social, economic and political systems and became a multi-trillion dollar problem”.  

In the midst of major geopolitical conflicts, “this is one thing the world agrees on”, he said.  

Roland Driece, who is co-chairing the negotiations, said the project had condensed a seven-year process into two years.  

He said the accord should be ambitious, innovative and with clear commitments

Canada’s lack of public data about pediatric flu numbers leaves pediatricians ‘flying blind’

Via The Globe and Mail, health reporter Carly Weeks writes: Canada’s lack of public data about pediatric flu numbers leaves pediatricians ‘flying blind’. Excerpt:

At least two children have died in Canada after contracting influenza in recent weeks, but Ottawa has so far not released any data on how flu season is affecting pediatric patients across the country – a situation clinicians say is leaving them in the dark and may be compromising the response to emerging problems.  

“It’s really concerning that we don’t know what’s going on,” said Manish Sadarangani, a pediatric infectious diseases specialist. “I sort of feel like we’re flying blind.”  

“It really helps to know what infections are currently circulating and which infections are causing more severe illness and hospitalization in children,” said Ashley Roberts, a clinical assistant professor of pediatric infectious diseases at the University of British Columbia.  

“To not have that active data present for our clinical care is certainly a loss right now,” Dr. Roberts added.  

Each week, the Public Health Agency of Canada publishes a FluWatch report that details influenza trends across the country. Last season, for instance, the report helped pediatricians understand and respond to soaring rates of hospital admission for the flu at a time when COVID-19 and respiratory syncytial virus (RSV) were also sickening many kids across Canada.  

But as of Oct. 1, FluWatch reports have not included any information on the number of children who have fallen severely ill as a result of the flu. The reports simply state the data were “not available.” 

The lack of information appears to be the result of a decision by PHAC to put a new group in charge of collecting pediatric data on severe outcomes for respiratory viruses.  

On Nov. 1, the agency awarded a new contract to the University of Calgary, PHAC spokesperson Tammy Jarbeau wrote in an e-mail. She said the government is working with the group “on the implementation of the contract and the transition” to ensure the new data will be comparable to information collected in previous years.  

According to another PHAC spokesperson, Marie-Pier Burelle, the government received the first cache of data on Nov. 24, and the information is being used internally. It should be made public sometime this month, she wrote in an e-mail.  

For more than 25 years, Ottawa had been using the same surveillance network, IMPACT, to collect this data. IMPACT, which stands for Canada’s Immunization Monitoring Program ACTive, is run by the Canadian Paediatric Society and has experts based in 12 pediatric sites, representing 90 per cent of tertiary care pediatric beds in the country.  

Dr. Sadarangani, a co-principal investigator of IMPACT, said it’s critical to have data on pediatric respiratory virus outcomes for this season, given that last season hospitals saw an unusually high influx of flu, RSV and COVID-19 cases. And it’s expected that a new vaccine to prevent severe illness in infants with RSV will become available next season, so experts will need detailed information on RSV cases this season to help them determine who should get that vaccine and when, he said.  

“We really need that data this year, almost more than ever,” Dr. Sadarangani said.

New Year's Eve, 2023

Four years ago this morning, I was sitting right here at my kitchen table, checking to see what news was coming in. I think it was Helen Branswell's tweet that woke me up, then posts from Mike Coston, Giuseppe Michieli and Ian Mackay: something was up in Wuhan.

By 7:48 a.m. I'd posted my first item on what would be COVID-19, and who knows how many thousands I've posted (or tweeted about) since then. The last day of 2019 was the last day of a long era when pandemics were spoken of only in the past tense.

Most people refer to COVID-19 in the past tense now. It's very far from over, but most people and all governments have found the strength to bear the misfortunes of those who still fall ill, suffer long COVID, or die with one strain or another of this remarkable coronavirus. I hope that will pass as COVID's long-term effects become more obvious, and governments will have to find the strength to do something about an increasingly ill population.

It's been a highly instructive four years: We've learned a great deal about the virus, its effects, and ourselves. We have not handled it well, and many are disillusioned about our healthcare systems—including many who work in those systems.

I'm disillusioned too, but I don't use the word negatively. To be disillusioned is to be freed of an illusion. Hopefully one is then able to see reality more clearly than before, and to act more effectively. May we all live in the coming year with fewer illusions than we held on December 31, 2019.

Britain’s hunger and malnutrition crisis could be easily solved – yet politicians choose not to

Via the Guardian, an essay by Sir Michael Marmot: Britain’s hunger and malnutrition crisis could be easily solved – yet politicians choose not to. Excerpt:

What causes a famine? It isn’t a lack of food. Nor does lack of food cause the kind of food insecurity, just short of a famine, that Britain is facing. In analyses of specific famines, the economist and philosopher Amartya Sen showed that social organisation and a lack of access to food for socially deprived people were the real causes of starvation.  

As 2023 ends, Britain may not be facing a famine, as people are in north-eastern Nigeria, South Sudan, Yemen or Somalia, but that is a low bar. The UK’s current levels of food insecurity will damage physical and mental health and increase health inequalities for years to come.  

The Food Foundation tracks moderate or severe food insecurity in the UK, which is defined as how many people in the past month had smaller meals or skipped meals; had been hungry but not eaten; or had not eaten for a whole day – each because of lack of access or inability to afford food. In June 2023, the latest tracker, 9 million adults in the UK, 17% of households, experienced moderate or severe food insecurity (a massive rise from 7.3% in June 2021).  

Nearly a quarter of households with children experienced food insecurity. How will this widespread food poverty affect people’s health? Recent research has shown an alarming increase in admissions to hospital resulting from deficient intakes of micronutrients. And whereas lack of money (among individuals or groups) may lead to starvation in countries threatened by famine, moderate or severe food insecurity in Britain is associated with obesity.  

There is now fairly general agreement that a Mediterranean-style diet – rich in fruit and vegetables, olive oil, seeds and nuts, with modest intake of fish, meat and dairy – is good for health. But as is now well recognised, energy-dense food, high in fat, sugar (and salt), is cheaper. The inevitable result is that inequalities in childhood obesity are increasing. Obesity is linked to cancer, diabetes, high blood pressure, heart disease and arthritis.  

Crucially, food insecurity is also linked to more general economic insecurity. There is an important debate going on between those in government who think the way to combat obesity is information about healthy eating, and those who want more activist approaches such as restricting promotions of cheap calorie-dense foods, and advertising aimed at children. But fundamentally, people aren’t eating healthily, in part, because they cannot afford healthy food.

Unicef’s latest “report card”, which examined changes in relative child poverty between 2012 and 2021, found that the UK was the worst performer among 39 high-income countries. Our rates of relative child poverty had increased by nearly 20%. The government likes to claim that it has reduced absolute child poverty. It should be careful in making such claims. A recent report from the Joseph Rowntree Foundation defined destitution as doing without two or more of: housing, light, heat, food, appropriate clothing or toiletries.  

In 2022, 1 million children in the UK were in a state of destitution – 2.9 times the level five years earlier. Among adults, 2.8 million were in destitution because of inability to afford these six basics.

Theresa Tam reveals the toll handling COVID-19 took on her

Via The Star, a long interview with Canada's Chief Medical Officer of Health: Theresa Tam reveals the toll handling COVID-19 took on her. Excerpt:

In a wide-ranging interview with the Star, Tam reflected on that experience, opened up about the so-called “Freedom Convoy” movement, and shared what she thinks must be done to rein in an eruption of misinformation — an issue she says is the top threat facing public health today.   

It’s also a threat that targets health professionals themselves: especially the person with the unenviable task of guiding a nation through a crisis that was both catastrophic and poorly understood. 

For Tam, the experience was just as personal as it was punishing. Her words were broadcast across the country every day. People were stuck at home with little to do. And, Tam notes, it was the first pandemic in the social media age.  

“That throws yourself out there as an individual a lot more,” she said. “You're exposed to anyone who can comment in the comment sections. So that was tough.”  

Despite being born in Hong Kong and raised in the United Kingdom, she was accused by conspiracy theorists of working for Beijing and covering up the origins of the disease. Transphobic internet trolls claimed she was not a woman. Commenters seized on racist and misogynistic tropes to raise doubts about her expertise and credibility. None of it was true.  

“That was unacceptable,” Tam said.  

“You kind of had to call out people on that. Not even from a personal perspective — I just think it's unacceptable in our society.”  

She tried not to read the comments, which her communications team monitored closely. The posts disturbed her staff and colleagues. Tam was grateful her parents didn’t use social media, because they would have found the onslaught “very upsetting.”  

Still, she found ways to cope with the barrage of attacks and a relentless schedule that left little time for rest.  

A colleague’s husband helped her put her 1992 mountain bike on a set of rollers so she could cycle from the safety of her home. Before bed, she took up learning Korean: she likes the food, and was interested in the K-pop and K-dramas that have swept the pop culture landscape in recent years.  

She got her piano tuned — she also plays the cello, violin and trumpet — and listened to different kinds of music depending on her mood. If she needed structure, she turned to Bach. Other times, Taylor Swift did the trick.   

Sometimes, during the pandemic’s longest nights, a staff member would read out letters that kids wrote to her. The former pediatric disease specialist is particularly tickled by the LEGO displays she received, including one from colleagues that depicts her at one of her infamous pandemic news conferences, dressed as Wonder Woman. (Tam, a LEGO aficionado, keeps that one in her office.)  

Those were the kinds of handholds Tam hung on to when the “Freedom Convoy” — a demonstration that saw hundreds of vehicles gridlock downtown Ottawa in protest of COVID-19 vaccination mandates and other pandemic restrictions — rolled into town.   

“There were very, very targeted challenges to public health, and people like myself,” Tam recalled. “So that was hard. It meant maybe no movement, really, during that time. You're stuck at home. Friends bring you meals. It was a very restrictive time.”