H5N1

Cholera: Fifty deaths and more than 1,500 people hospitalized in Haiti

Via Le Nouvelliste, which has temporarily ceased to publish on paper owing to the conditions in Haiti: Cholera: fifty deaths and more than 1,500 people hospitalized in Haiti. Excerpt from the Google translation:

After three years without any case of cholera in Haiti despite active research, the Ministry of Public Health and Population detected a first case a month ago, which signals the resurgence of this disease in Haiti. Known for its great contagiousness, helped by the humanitarian crisis that has plagued the country for more than two months, cholera is responsible for more than 1,500 hospitalizations and around fifty deaths, including 14 in the civil prison of Port-au-Prince.

Relegated to the background in the face of the multiple crises that dominate the news in Haiti, cholera continues its path, leaving in its wake more than a thousand patients and fifty people who died in less than a month.  

"Anyone presenting with acute watery, profuse diarrhea, with or without vomiting, with or without dehydration, is considered a suspected case", according to the Department of Epidemiology, Laboratories and Research of the MSPP.  

As of October 1, 2022, 2,274 people fit this case definition. Of these, 253 were confirmed by a positive culture for Vibrio cholerae or by epidemiological link, 1,642 were hospitalized, for a total of 52 deaths.  

Still according to the latest MSPP bulletin published on October 26, 2022, 271 suspected cases and 14 deaths were counted in the civil prison of Port au Prince.  

Two facts draw attention in the bulletin: "the distribution of cumulative suspected cases by age group and the distribution of cases by department."  

More than 1,000 suspected cases have been listed among children under 15. A situation that continues to worry epidemiologists and infectious disease specialists.  

A week ago, Dr. Jean William Pape illustrated the seriousness of the situation by informing that out of 79 patients seen in a ward at the Gheskio centers cholera treatment center, 54 were children.  

“Among the children, we have 39 between 0-5 years old, in this age group we have 3 children with severe acute malnutrition and septic shock,” he revealed.  

Pointing to insecurity and fuel shortages, Dr. Jean William Pape had advocated strengthening awareness campaigns and taking oral serum even before going to a cholera treatment center for suspected cases. 

 Another highlight of the epidemiological bulletin of the MSPP is the spread of cholera in 8 departments of the country. The North and South-East are the only departments absent in the distribution of suspected cases, tested and confirmed by the MSPP.

Ukraine: Almost 14 million displaced by war

Via Reliefweb: Statement by Amin Awad, Assistant Secretary-General and United Nations Crisis Coordinator for Ukraine marking 100 days since the onset of the Russian invasion of Ukraine on 24 February - Ukraine.

Today marks 100 days since the start of Russia’s invasion of Ukraine on 24 February. This invasion of Ukraine is a violation of its territorial integrity and of the Charter of the United Nations.  

This war has taken an unacceptable toll on people and engulfed virtually all aspects of civilian life. This war has and will have no winner. Rather, we have witnessed for 100 days what is lost: lives, homes, jobs and prospects. We have witnessed destruction and devastation across cities, towns and villages. Schools, hospitals and shelters have not been spared.  

Families and communities have been disrupted and uprooted. In just over three months, nearly 14 million Ukrainians have been forced to flee their homes, the majority women and children – a scale and speed of displacement not witnessed in history.  

More than 3 million children saw their education suspended – an entire generation of children whose future hangs in the balance. All over the country, hundreds of thousands of people do not have access to water and electricity, and millions do not know where their next meal is coming from. 15.7 million people are in need of humanitarian support now, with numbers growing.  

One hundred days on, the war ravages unabated especially in the east of the country. And with winter coming, millions of civilian lives could be in peril.  

The United Nations agencies and humanitarian partners in Ukraine continue supporting those whose lives have been shattered by war. In the past 100 days, we have provided immediate humanitarian aid to some 8 million people across the country, including in besieged cities in the east of Ukraine.  

At the same, the United Nations are pursuing every pathway to mitigate the global ramifications of the war’s devastating impact on food security by seeking to unblock critical grain and commodity trade.  

Our tireless efforts to respond to the war’s devastating impact will continue, robustly and stead-fast.  

But above all we need peace. The war must end now.

Marmot: Studying health inequalities has been my life’s work. What’s about to happen in the UK is unprecedented

Via The Guardian, Sir Michael Marmot writes: Studying health inequalities has been my life’s work. What’s about to happen in the UK is unprecedented. Excerpt:

Dignity. It is fundamental to who we are and our place in society. One way to deprive people of the opportunity to lead dignified lives is to take away the means to meet their material needs. It is undignified to have to resort to food banks to feed your children; to wear two coats indoors against the cold; to plead against eviction because of an inability to pay the rent; to deny children a birthday party because of cost.  

The poorest people in the UK are about to experience a fresh wave of such indignities. These psycho-social assaults will be joined by the physical ill-effects of poverty.  

My life’s work has been studying the relationship between social conditions and inequalities in health. In the UK, a decade of austerity damaged public health and made health equity worse. But the cost of living crisis – and the chancellor’s failure to deal with it – is unprecedented, with its threats to the health and wellbeing of the nation. A 54% rise in the energy price cap will now mean an average household will pay £1,971 a year for gas and electricity, at the same time that council tax, water bills and car tax are all increasing. In October, a further rise pushing the annual energy bill up to £2,300 is expected.  

The typical working-age household will, according to the Resolution Foundation, experience a 4% fall in income, £1,100, in 2022-23. Surely, one might think, 4% is scarcely noticeable, hardly a matter of life and death? It is if you are on the margins.  

The Resolution Foundation gives the example of a single parent, with one child, working 20 hours a week at a low-to-medium wage. In September 2021, this person might have had an income of £18,265. The precipitate removal of the universal credit boost will have reduced income by £1,040. The cost of living rise to September 2022 will take another £1,198 off income. With the chancellor’s changes to taxes and allowances, and salary increases, this person’s income in September 2022 will be £17,681 – £584 less than it was a year earlier. (By contrast, a couple working full-time, both at the median wage, will see their net income fall by 1%, £392.)  

Inflation of more than 8%, and the government’s failure to deal with the cost of living crisis for the poorest people – an unemployed single person will see a 15% drop in income – will put an extra 1.3 million people, including 500,000 children, below the poverty line.

COVID-19 is in for the long haul

Here's a screenshot of this evening's Johns Hopkins Coronavirus COVID-19 (2019-nCoV) dashboard:

It's notable for several reasons. First, the US is now far back in the 28-day case count—seventh, behind Germany, South Korea, Russia, Vietnam, France, and Brazil.

 

Second, almost all the case and mortality numbers are likely severe undercounts, since so many countries have simply abandoned any pretence of testing and contact tracing. I would not be shocked if the true number of cases were around 1.5 billion, and deaths close to 20 million.

 

The numbers for Russia (3.7 million cases in the last 28 days, 20,000 deaths) and Ukraine (458,000 cases, 3,800 deaths) are especially implausible, given the events of the past 15 days. But we'll surely see an explosive growth in cases as over 2 million Ukrainians move through Europe in search of refuge.

 

The early-success countries have largely succumbed to Omicron. While China pursues its zero-COVID policy, it's still recorded 539,000 cases and 2,600 deaths. Hong Kong has seen 533,000 cases in 28 days, and 2,600 deaths. Vietnam racked up 26 million cases in the last 28 days, and 2,400 deaths. New Zealand had 267,000 cases and 12 deaths; it had only 38,900 cases in the previous 23 months of the official pandemic.

 

The graphs on the right tell us that the Omicron spike has fallen sharply from its peak of 23,333,000 in the week ending January 23; we're now at 10,706,000 as of the week ending March 6. That looks impressive, but it's still about 5 million more than the three previous waves.

 

Omicron also drove a spike in deaths, peaking at 75,000 in the week of February 13 and now fallen to 50,400. Meanwhile, vaccinations have fallen from a recent high of 257,000 in the week of February 6 to 105,600 in the week ending March 6.

 

Yet many countries are effectively declaring the pandemic over, making masks and distancing optional, junking vaccine passports, and dropping regular reports by public health officials. Governments seem to think COVID-19 can now sink back into the background noise with other diseases, while we turn our attention to war and inflation and the next election.

 

On February 1, Johns Hopkins reported 381,232,070 cases, so we have seen almost 72 million cases of COVID-19 in the past six weeks alone. Even if the Omicron spike continue to drop, the next six weeks will see tens of millions more cases, and likely another 40 or 50 thousand people now alive will be dead before May 1. 

 

We are nowhere near the end of the pandemic. In fact, I expect it will in many ways get worse as healthcare systems really do collapse, and as sequelae like Long COVID affect more and more cases. The pandemic that began two years ago really is in the for long haul.

What was the plague of Athens?

In February I'll be teaching a 4-session course for our local ElderCollege: Perspectives on Pandemics. The first session will deal with outbreaks we know of in antiquity, and one of the most momentous of those was the plague of Athens. While it was not a pandemic, its focus on Athens weakened the city's military strength, demoralized and divided the population, and killed its leader Pericles; Athens and its empire never recovered, and eventually lost the war to Sparta and its allies. 

Background: In the second year of the Peloponnesian War (430 BCE), Sparta's army invaded Attica. Pericles adopted a defensive strategy, bringing rural residents into Athens. These tended to crowd into Piraeus, the harbour district, living in shacks and huts. Meanwhile, Pericles focused on building up the Athenian navy. His policies were unpopular, especially with wealthy landowners whose farms were now ravaged by the Spartans, and he was even ousted from power on a charge of embezzlement. Later he was re-elected to power, but he and members of his family contracted the plague also, and he died of it. 

Could it have been the ancestor of some modern disease, or an early variant of a modern disease? Or is it more likely a one-off that mercifully died out? Here are the symptoms as described by Thucydides (who survived it) in the Penguin Books edition translated by Rex Warner, 1954. 

“At the beginning the doctors were quite incapable of treating the disease because of their ignorance of the right methods. In fact mortality among the doctors was the highest of all, since they cam more frequently in contact with the sick.”

Origins: Ethiopia to Egypt, Libya, and much of Persia. Appeared suddenly in Athen in Piraeus (which was crowded with rural refugees who lacked adequate housing); then in upper city. That year saw no other serious outbreaks, but all who had any kind of previous illness caught the plague.

“In other cases, however, there seemed to be no reason for the attacks. People in perfect health began to have burning feelings in the head; their eyes became red and inflamed; inside their mouths there was bleeding from the throat and tongue, and the breath became unnatural and unpleasant.

“The next symptoms were sneezing and hoarseness of voice, and before long the pain settled on the chest and was accompanied by coughing. Next the stomach was afflicted with stomaches aches and with vomitings of every kind of bile that has been given a name by the medical profession, all this being accompanied by great pain and difficulty. In most cases there were attacks of ineffectual retching, producing violent spasms; this sometimes ended with this stage of the disease, but sometimes continued long afterwards.

“Externally the body was not very hot to the touch, no was there any pallor; the skin was rather reddish and livid, breaking out into small pustules and ulcers. But inside there was a feeling of burning, so that people could not bear the touch even of the lightest lien clothing, but wanted to be completely naked, and indeed most of all would have liked to plunge into cold water. Many of the sick who were uncared for actually did so, plunging into the water-tanks in an effort to relieve a thirst which was unquenchable …. Then all the time they were afflicted with insomnia and the desperate feeling of not being able to keep still.

“In the period when the disease was at its height, the body, so far from wasting away, showed surprising powers of resistance to all the agony, so that there was still some strength left on the seventh or eighth day, which was the time when, in most cases, death came from the internal fever. But if people survived this critical period, then the disease descended to the bowels, producing violent ulcerations and uncontrollable diarrhea, so that most of them died later as a result of the weakness caused by this.

“For the disease, first setting in the head, went on to affect every part of the body in turn, and even when people escaped its worst effects, it still left its trace on them by fastening upon the extremities of the body. It affected the genitals, the fingers, and the toes, and many of those who recovered lost the use of these members; some, too, went blind. There were some also who, when they first began to get better, suffered from a total loss of memory, not knowing who they were themselves and being unable to recognize their friends.”

Psychological effects: “The most terrible thing of all was the despair into which people fell when they realized that they had caught the plague; for they would immediately adopt an attitude of utter hopelessness, and by giving in in this way, would lose their powers of resistance. Terrible, too, was the sight of people dying like sheep through having caught the disease as a result of nursing others.”

Helen Branswell talks with Mike Ryan

Via STAT, Helen Branswell interviews Mike Ryan, head of WHO's health emergencies program: WHO official weighs in on Covid, vaccines, and mistakes that were made. This excerpt is a key part of an interview you should read in its entirety:

Are there things you wish the world had done differently from the jump? Where did we make our biggest mistakes? 

This interview could go on for a while.        

The biggest collective failing has been that we’ve underestimated this microbe. We’ve always made judgments assuming the best-case scenario. And I’m not one for assuming the worst-case scenarios as a modus operandi, because otherwise, you can strangle society. But I think at every opportunity we’ve seem to have taken the best-case scenario as the basis for our policy. And this virus, I think, has sequentially exploited that.  

In the end, the virus doesn’t have a brain. It’s just, from an evolutionary point of view, exploiting opportunities. And we seem to have consistently and persistently given it the opportunity.  

There’s been tremendous social, economic, and political pressure to go back to normal.   

Time and time again governments have tried to get back to normal and have overshot that runway by opening up too early. Releasing restrictions too early. They haven’t really convinced people or empowered people to continue with these basic measures to reduce the risk of infection. I think that’s been a problem, the whole way through the pandemic.  

I don’t mean getting rid of lockdowns. To me lockdowns have been last resort measures in most cases. Many countries in the East have managed to forgo lockdowns. But they’ve maintained quite strict measures in terms of mask wearing, in terms of crowds, in terms of testing and other stuff. So they’ve taken a much more comprehensive, layered strategy. They’ve maintained an intensity of control measures without ever going for full lockdown, without ever going for full open. They’ve taken the corner without under- or over-steering.  They’ve gotten people to buy into the idea that it’s going to take a long time and it’s going to have to be a sustained effort. I think if everyone had done that maybe we’d be in a better place.   

But I think for me just personally as a public health physician, the biggest tragedy has been the vaccine equity issue. It really has been horrific. Horrific. The world just has not ever come to terms with the fact that vaccinating the most vulnerable people first would have been a better bet, not only epidemiologically but just from an equity perspective.   

The idea of coherence and coordination and solidarity — these are all lovely words. But it’s very hard to deliver that in societies that don’t trust governments, [don’t buy into] that social contract, that inherent trust that a community should have in its government to say, “Yes, you are there to protect me.”  

What’s shocked me most in this pandemic has been that absence or loss of trust.  

It’s staggering to read about public health personnel quitting their jobs, being subjected to death threats during a pandemic. They’re facing hatred and vitriol from the people they’re trying to protect.   

It’s tragic. And it’s tragic to think that there are millions of people right now in the Northern Hemisphere who are not vaccinated because they don’t believe their government. Whatever the reasons for that are, whether it’s because governments perform poorly in building that trust, or whether they’ve been actively undermined by misinformation and by other things, historians and social historians will be talking about that one for decades.   

If we’re looking at pandemic preparedness for the future it’s not all going to be about technology and the machines that go ping and surveillance systems and AI and all of this stuff. We need a social solution for future pandemics, much more than we need a technological solution. Because we’re dealing with a fractured world, fractured communities. We’re dealing with a breach and prolonged breakdown in trust.

I shudder to think of going into a more severe pandemic with that level of community distrust. It has had a real negative impact on people’s awareness and willingness to sustain measures. Because they can constantly find lots of material and reasons not to do what they’re being asked to do, because there’s so much out there telling them that what’s going on there is a government conspiracy, what’s happening is hurting them.

Myanmar loses over 100 leading figures from COVID-19, junta’s poor health care

Via The Irrawaddy: Myanmar Loses Over 100 Leading Figures from COVID-19, Junta’s Poor Health Care. Excerpt:

Since July more than 100 prominent figures in Myanmar have died from COVID-19 and from the wider collapse of the public health system following the February coup. 

The list has included prominent politicians, artists, technocrats, journalists, architects and physicians. 

Previous coronavirus outbreaks in Myanmar since March 2020 happened under the National League for Democracy (NLD) government and caused fewer casualties. 

During last month around 6,000 deaths were reported by the junta-controlled health ministry, although other estimates have been far higher. In early August, the total COVID-19 death toll exceeded 10,000 since March last year, according to the regime. 

Many of the prominent figures, most of whom were relatively old, have died in July and August after the current wave was reported in late May. 

The deceased have included U Nyan Win, an NLD legal adviser. The 79-year-old NLD central executive committee member was detained during the Feb. 1 coup and held in Insein Prison where he caught coronavirus. 

The retired rector of Yangon University of Economics U Maw Than, who served as the union auditor-general under the NLD, died a few days after testing positive for COVID-19. The 82-year-old was removed from his post on Feb. 1. 

Among the dead is a pioneer of Myanmar’s modern poetry, Aung Cheimt, and modernist sculptor Sonny Nyein, an important figure in the development of modernism in Myanmar. He died of COVID-19 aged 72. He also took the famous photo of detained State Counselor Daw Aung San Suu Kyi making her first public speech in August 1988 outside Yangon General Hospital.

MSF in Haiti: Violence puts patients, staff, and medical activities at risk

A news release from MSF: Haiti: Violence puts patients, staff, and medical activities at risk.

Port-au-Prince, June 11, 2021—A spike in violence in Haiti's capital is putting medical activities in jeopardy, the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) said today, warning that medical care cannot be sustained while armed clashes and robberies affect patients, staff, health facilities, and vehicles. 

In the first week of June, clashes in the neighborhood of Martissant and other districts of Port-au-Prince caused many injuries and displaced more than 1,000 people, including MSF patients and staff. From June 2 to 4, MSF's emergency center in Martissant received 42 patients with gunshot wounds, many of whom were transferred to MSF's trauma hospital in the Tabarre neighborhood, which increased its capacity for trauma patients from 50 to 68 beds. 

"We are witnessing an extremely worrying deterioration in the security situation," said Alessandra Giudiceandrea, MSF head of mission. "Some armed clashes took place near MSF's emergency center and offices in Martissant, where staff had to take cover from stray bullets. Armed individuals robbed two MSF ambulance drivers among other vehicles traveling from Martissant. To protect our staff, we had to reduce our community activities, but we are still treating emergencies based on our initial admission criteria." 

Clashes also took place in the city's Cité Soleil and Bel Air neighborhoods from May 15 to 31, and MSF's Tabarre hospital reached the limits of its capacity after receiving 41 patients, including 32 with wounds from violence. In another incident, a staff member of the Tabarre hospital was shot and killed on May 25 while returning home from work. 

The increased level of chronic violence is taking place amid a broader political and economic crisis in Haiti that affects people in many ways. Health systems are strained not only by insecurity but by a current increase in COVID-19 cases, economic challenges, and a high level of medical needs. 

"At a time when we should be scaling up because of COVID-19 and other needs, we are struggling to keep our existing facilities open due to insecurity," Giudiceandrea said. "We ask everyone to respect the need for medical activities to continue." 

In Martissant, insecurity and displacement may be hindering patients' ability to reach health care services. While MSF's emergency center reported an influx of trauma patients following the largest incidents of violence last week, patient numbers have now dropped below the center's normal average. 

MSF also provides care to survivors of sexual and gender-based violence through clinics in Port-au-Prince and Gonaïves, but staff are now seeing fewer patients, as people may fear leaving their homes to seek medical attention. MSF is concerned that the general increase in violence in the country is affecting the ability of sexual violence survivors to seek much-needed care. 

MSF has provided life-saving medical care to communities in Haiti for 30 years, but to continue providing such services in any community, MSF must be able to ensure the safety of patients and staff en route to and inside health care facilities. MSF demands that all groups and individuals involved in incidents of violence in Haiti respect the safety of health care workers, patients, medical supplies and facilities and that health care vehicles are granted safe passage without risk of attack.

Health facilities targeted in Tigray region, Ethiopia

A news release from MSF.org: Health facilities targeted in Tigray region, Ethiopia. Excerpt:

ADDIS ABABA – Health facilities across Ethiopia’s Tigray region have been looted, vandalised and destroyed in a deliberate and widespread attack on healthcare, according to teams from Médecins Sans Frontières (MSF). Of 106 health facilities visited by MSF teams between mid-December 2020 and early March 2021, nearly 70% had been looted, and more than 30% had been damaged; just 13% were functioning normally. 

In some health facilities across Tigray, the looting of health facilities continues, according to MSF teams. While some looting may have been opportunistic, health facilities in most areas appear to have been deliberately vandalised to make them non-functional.  In many health centres, such as in Debre Abay and May Kuhli in North-West Tigray, teams found destroyed equipment, smashed doors and windows, and medicine and patient files scattered across floors. 

In Adwa hospital in central Tigray, medical equipment, including ultrasound machines and monitors, had been deliberately smashed. In the same region, the health facility in Semema was reportedly looted twice by soldiers before being set on fire, while the health centre in Sebeya was hit by rockets, destroying the delivery room. 

MSF teams recently visited 106 medical facilities across Tigray region, Ethiopia. Of the facilities visited: 30% had been damaged, 73% had been looted, and 87% were no longer functioning or fully functioning. 

Hospitals occupied by soldiers 

Every fifth health facility visited by MSF teams was occupied by soldiers. In some instances, this was temporary; in others the armed occupation continues. In Mugulat in east Tigray, Eritrean soldiers are still using the health facility as their base. The hospital in Abiy Addi in central Tigray, which serves a population of half a million, was occupied by Ethiopian forces until early March. 

“The army used Abiy Addi hospital as a military base and to stabilise their injured soldiers,” says Kate Nolan, MSF emergency coordinator. “During that time, it was not accessible to the general population.” 

“They had to go to the town’s health centre, which was not equipped to provide secondary medical care – they can’t do blood transfusions, for example, or treat gunshot wounds,” says Nolan.  

"Health facilities and health staff need to be protected during a conflict, in accordance with international humanitarian law. This is clearly not happening in Tigray," said Oliver Behn, MSF General Director. 

Ambulances seized 

Few health facilities in Tigray now have ambulances, as most have been seized by armed groups. In and around the city of Adigrat in east Tigray, for example, some 20 ambulances were taken from the hospital and nearby health centres. 

Later, MSF teams saw some of these vehicles being used by soldiers near the Eritrean border, to transport goods. As a result, the referral system in Tigray for transporting sick patients is almost non-existent. Patients travel long distances, sometimes walking for days, to reach essential health services. 

Many health facilities have few – or no – remaining staff. Some have fled in fear; others no longer come to work because they have not been paid in months. 

Devastating impact on people 

The attacks on Tigray’s health facilities are having a devastating impact on people,” says Oliver Behn. “Health facilities and health staff need to be protected during a conflict, in accordance with international humanitarian law. This is clearly not happening in Tigray.”

The crisis of health care in Myanmar

A letter in The Lancet:The crisis of health care in Myanmar.

We are writing in solidarity with the health workers of Myanmar during the worsening crisis following a military coup on Feb 1, 2021. Many UK health research and care institutions have worked with clinical colleagues in Myanmar over many years, building both partnership and friendship. Together we have seen significant improvements in the country's health system, providing life-saving care to mothers, newborns, infants, and children. Those improvements are now at risk. 

Large numbers of Myanmar civilians, including health workers, are committed to the Civil Disobedience Movement, believing that peaceful protest is the best way to avoid a politically and economically disastrous slide back into military dictatorship, and to arrive at a way forward for Burmese democracy. Demonstrations have spread to all parts of the country. Through personal communication with colleagues in Myanmar and news reports, it is clear that many protesters are in hiding, sleeping in a different place each night in fear of their lives. Petrol is now scarce, banks are closed, and internet, electricity, and water supplies are all disrupted. Meanwhile, although government hospitals, schools, and universities are shut, groups of doctors are treating patients quietly and without charge in a variety of settings. 

UN Resolution 2286 prohibits harm against health workers in situations of conflict. They must be protected now, not least by the vigilance of the global community. Myanmar's doctors and nurses are a vital constituency in the country's social development. We urge all parties to respect their humanitarian role and to ensure their safety. We hope that by bearing witness alongside our Myanmar friends and colleagues, we may help to galvanise international support for Myanmar's recent democratic process, a resolution to the current crisis, and a resumption of the country's path to prosperity.