H5N1

Syndemic responses to COVID-19 should include an ecological dimension

Correspondence in The Lancet: Syndemic responses to COVID-19 should include an ecological dimension

Richard Horton argued persuasively that COVID-19 should be addressed as a syndemic of biological and social interactions. When planning the “national revival” he calls for, I consider it crucial that this syndemic approach includes an ecological dimension. Studies have found that widespread anthropogenic ecosystem degradation has played a crucial role in explaining why the rate of emergence of zoonoses has been increasing over the past 40 years. 

For example, deforestation, intensified agriculture and livestock production, and climate change have been linked to the emergence of Ebola virus, HIV, Nipah virus, severe acute respiratory syndrome coronavirus, and Zika virus. Unless reversed, the anthropogenic destruction of habitats will probably lead to the continued emergence of new zoonoses from the estimated 700 000 other unidentified viruses with zoonotic potential. 

As argued in the recent Living Planet Report, COVID-19 is “nature sending us a message”: we need to cut human consumption to within the planet's “safe operating space”. For the vital reasons Horton outlines, this needs to be done in a way which promotes, rather than exacerbates, national and international socioeconomic equity. National revival plans could play an important role in this process but should be subordinate to international plans that are based on determinations of both global equity and ecological constraints.

The COVID-19 syndemic is not global: Context matters

A letter in The Lancet: The COVID-19 syndemic is not global: context matters.

Richard Horton recently called COVID-19 a syndemic. He aptly used this concept to describe how COVID-19 clusters with pre-existing conditions, interacts with them, and is driven by larger political, economic, and social factors. 

Calling COVID-19 a global syndemic is misguided. Syndemics matter because they focus on what drives diseases to cluster and interact. What is driving coronavirus to move through the population in the USA and interact with biological and social factors, however, differs from other contexts. US political failures have driven COVID-19 morbidity and mortality, and this cannot be divorced from our historical legacy of systemic racism4 or our crisis of political leadership.  

This matters because in other contexts COVID-19 is not syndemic. New Zealand's political leadership in response to the crisis has been exemplary. COVID-19 is not syndemic there. 

In this sense, syndemics allow us to recognise how political and social factors drive, perpetuate, or worsen the emergence and clustering of diseases. Recognising contexts are different matters a great deal. For instance, contexts throughout sub-Saharan Africa are doing much better than the most burdened contexts, like the USA, Brazil, and India. Many people have questioned, why? Some have argued that this reflects a racist frame thinking that African contexts should suffer more. Yet, many African governments acted more swiftly and confidently than wealthier countries. The political leadership in these contexts, therefore, prevented the extensive death tolls, compared to contexts like the UK and the USA, where political leadership failed. 

Recognising political determinants of health is central to the syndemic construct. By calling the COVID-19 syndemic global, we miss the point of the concept entirely. 

I do not write this to dampen Horton's use of the term, as I believe COVID-19 is syndemic in my country (the USA). This is precisely because pre-existing conditions such as hypertension, diabetes, respiratory disorders, systemic racism, mistrust in science and leadership, and a fragmented health-care system have driven the spread and interacted with the virus. These synergistic failures have caused more death and devastation than many other contexts. 

Recognising failures of wealthy countries is imperative as we think about where global knowledge and power sit within fields like global health. Syndemic frames provide us with an opportunity to do this.

Intersectionality and inequalities in medical risk for severe COVID-19 in the Canadian Longitudinal Study on Aging

Via The Gerontologist: Intersectionality and inequalities in medical risk for severe COVID-19 in the Canadian Longitudinal Study on Aging. Excerpt:

Background and Objectives 

Older populations with underlying medical conditions are at higher risk of COVID-19 severity and mortality once infected. Intersectional gerontology considers the compounding effects of multiple forms of social inequity. This study explores how racial-nativity status, family income, education level and the intersecting profile of these three social standings stratify differential patterns of chronic conditions among Canadians aged 45 years and older.  

Research Design and Methods 

Using the baseline Canadian Longitudinal Study on Aging (n = 29,748), multinomial logistic regression analyses were conducted to estimate multivariable-adjusted odds of having one and/or two (≤ 2) or multiple (≥3) medical conditions (i.e., diabetes, asthma, cancer, previous heart attack, cardiovascular disease, kidney disease, hypertension, chronic obstructive pulmonary disease, and obesity) based on socio-demographic characteristics.  

Results 

There were significant racial-nativity disparities and social-class gradients in multimorbidity. The odds of having ≥3 medical conditions were greater for Black immigrants (OR=1.79, 95% CI=1.13, 2.82), South Asian immigrants (OR=1.49, 95% CI=1.02, 2.19) and close to double for Aboriginal Canadians (OR=1.96, 95% CI=1.37, 2.80) relative to Canadian-born Whites. Black, South Asian and Aboriginal populations from disadvantaged socioeconomic backgrounds had the highest odds of having ≥3 medical conditions (OR=3.50, 95% CI=1.41, 8.70).  

Discussion and Implications 

Despite a universal health system, marginalized older Canadians who are racialized foreign-born, less educated, and/or low-income have a higher prevalence of multimorbidity that are associated with COVID-19 severe illness and mortality. Upstream health policy and social care tackling intersecting structural inequities should be undertaken to prevent increasing multimorbidity among underserved aging populations.

Horton: COVID-19 is not a pandemic

In The Lancet, editor Richard Horton makes an important point: Offline: COVID-19 is not a pandemic.

As the world approaches 1 million deaths from COVID-19, we must confront the fact that we are taking a far too narrow approach to managing this outbreak of a new coronavirus. We have viewed the cause of this crisis as an infectious disease. All of our interventions have focused on cutting lines of viral transmission, thereby controlling the spread of the pathogen. The “science” that has guided governments has been driven mostly by epidemic modellers and infectious disease specialists, who understandably frame the present health emergency in centuries-old terms of plague. 

But what we have learned so far tells us that the story of COVID-19 is not so simple. Two categories of disease are interacting within specific populations—infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs). These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. 

COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities. 

The notion of a syndemic was first conceived by Merrill Singer, an American medical anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall and colleagues, Singer argued that a syndemic approach reveals biological and social interactions that are important for prognosis, treatment, and health policy. Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic inequality than has hitherto been admitted. 

A syndemic is not merely a comorbidity. Syndemics are characterised by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes. In the case of COVID-19, attacking NCDs will be a prerequisite for successful containment. As our recently published NCD Countdown 2030 showed, although premature mortality from NCDs is falling, the pace of change is too slow. The total number of people living with chronic diseases is growing. Addressing COVID-19 means addressing hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer. 

Paying greater attention to NCDs is not an agenda only for richer nations. NCDs are a neglected cause of ill-health in poorer countries too. In their Lancet Commission, published last week, Gene Bukhman and Ana Mocumbi described an entity they called NCDI Poverty, adding injuries to a range of NCDs—conditions such as snake bites, epilepsy, renal disease, and sickle cell disease. For the poorest billion people in the world today, NCDIs make up over a third of their burden of disease. The Commission described how the availability of affordable, cost-effective interventions over the next decade could avert almost 5 million deaths among the world's poorest people. And that is without considering the reduced risks of dying from COVID-19.

The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged—namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail. 

Unless governments devise policies and programmes to reverse profound disparities, our societies will never be truly COVID-19 secure. As Singer and colleagues wrote in 2017, “A syndemic approach provides a very different orientation to clinical medicine and public health by showing how an integrated approach to understanding and treating diseases can be far more successful than simply controlling epidemic disease or treating individual patients.” 

I would add one further advantage. Our societies need hope. The economic crisis that is advancing towards us will not be solved by a drug or a vaccine. Nothing less than national revival is needed. 

Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus.

COVID-19 and flu, a perfect storm

An editorial in Science: COVID-19 and flu, a perfect storm.

The world is in uncharted waters for the 2020 respiratory virus season. For the first time in modern history, the Northern Hemisphere faces the prospect of the coronavirus disease 2019 (COVID-19) pandemic and a simultaneous epidemic of seasonal influenza. Each causes life-threatening illness and death, especially in older adults, people with chronic diseases, and other vulnerable populations. How can we prepare for this convergence? 

The timing and severity of a COVID-19 wave in the fall and winter are uncertain, but past experiences with the 1918 and 1957 influenza pandemics point to the possibility of a resurgence. Almost nothing is known about the interaction of influenza virus and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2, the cause of COVID-19) within individuals. Does coinfection increase the risk of severe illness or amplify virus shedding? Few coinfections have been reported from China during the early phase of the pandemic. The Southern Hemisphere influenza season is just beginning, and it may provide some clues as to what can be expected in the Northern Hemisphere later this year. 

Much of the population remains susceptible to SARS-CoV-2, and the stress on hospitals will be greatest if the COVID-19 and influenza epidemics overlap and peak around the same time. It is possible that the number of individuals infected with each virus will peak at different times, reducing the peak demand for hospital beds. If a surge in COVID-19 cases occurs this fall, tightening mitigation strategies will be necessary. Social distancing and stay-at-home orders are socially and economically disruptive, but can reduce demand on hospitals and protect vulnerable populations. They will also reduce transmission of other respiratory viruses, including influenza and respiratory syncytial virus. Supplies of personal protective equipment must sufficiently meet the projected demand of a severe influenza season along with COVID-19.  

There are important differences in the epidemiology of COVID-19 and seasonal influenza, but symptoms overlap. Molecular diagnostic testing for SARS-CoV-2 is critical for all patients with acute respiratory illness, especially during periods of co-circulation. Rapid-turn-around testing is necessary to distinguish between influenza and COVID-19, guide patient care, and support a comprehensive COVID-19 control program (including isolation of cases and rapid identification and quarantine of contacts). Every effort should be made to ensure that resources will be available for combined testing for COVID-19 and influenza. These tests should be without charge to patients because they serve a dual purpose for public health and patient care. 

We do not yet have a COVID-19 vaccine, but safe and moderately effective influenza vaccines are available. Their widespread use is more important now than ever, and we encourage health care providers, employers, and community leaders to promote vaccination. Vaccine effectiveness varies by season and subtype, but vaccination offers similar protection against laboratory-confirmed influenza hospitalization and outpatient illness. Widespread misinformation on social media includes the false claim that influenza vaccination increases the risk of SARS-CoV-2 infection. Scientists, health care providers, and public health leaders must counter these claims with clear, evidence-based information on the importance of influenza vaccination during the COVID-19 pandemic.  

The prospect of a second COVID-19 wave requires planning to ensure optimal delivery of influenza vaccines starting in the early fall. Community vaccination sites are often set up for maximum volume and efficiency, and alternative approaches will be needed to maintain physical distancing and minimize the risk of SARS-CoV-2 transmission, particularly because many influenza vaccine recipients are at high risk for both influenza and COVID-19 complications. Randomized trials have shown that some enhanced influenza vaccines (e.g., high-dose inactivated vaccine and recombinant vaccines) generate greater protection in older adults compared to standard-dose inactivated vaccine. The optimal timing of influenza vaccination in patients with confirmed COVID-19 is uncertain. There are no clinical studies on the effects of influenza vaccination in patients with COVID-19, but it may be prudent to delay vaccine administration until after the acute illness has resolved. 

Over 400,000 COVID-19 deaths were reported worldwide by 6 June, including over 109,000 in the United States. The actual death count is almost certainly higher, and we are still in the early phase of the pandemic. The U.S. Centers for Disease Control and Prevention estimates that influenza has killed 12,000 to 61,000 each season over the past decade. Will there be a perfect storm of COVID-19 and influenza during the 2020–2021 season? We do not yet know, but we must start preparing in the coming months.

Medical screener at LAX airport tests positive for coronavirus

Via NBC News: Medical screener at LAX airport tests positive for coronavirus. Excerpt:

WASHINGTON — A medical professional who conducted passenger screenings at Los Angeles International Airport tested positive for the coronavirus late Tuesday night, according to the Department of Homeland Security and an internal email obtained by NBC News. 

The person last worked screening air travelers for illness on Feb. 21, the DHS said in a statement, which also said the medical professional had worn the proper protective gear while working. The internal email described the person as a "contract medical screener" for the Centers for Disease Control and Prevention. 

The email also said "these screeners are predominantly assigned to the CDC in-transit lounge and a few support jetway screening on direct flights from China." 

In its statement, the DHS said: "Late last night, DHS headquarters was alerted to a situation where one of our contracted medical professionals conducting screenings at LAX international airport had tested positive for COVID-19, also known as the coronavirus. This individual is currently under self-quarantine at home with mild symptoms and under medical supervision. Their immediate family is also under home quarantine."  

According to DHS, the individual began to exhibit cold-like symptoms on Saturday and visited a primary care doctor on Sunday and was tested for COVID-19, which came back positive on Tuesday.  

The individual's last shift at LAX was Feb. 21, more than a week before the appearance of symptoms. According to the internal email, the screener worked at LAX from Feb. 14 to 21 and became symptomatic on Feb. 29.

"DHS is happy to report that this individual was highly trained and did everything right both on the job and when they began to feel sick," the DHS said. "We are told the individual wore all the correct protective equipment and took necessary protections on the job. Additionally, as soon as the individual began to feel sick, they self-quarantined, saw a physician, and reported to the appropriate authorities and officials."  

DHS said it is working to communicate with the individual's co-workers and to trace contacts. 

"At this time we do not know if this case is a result from community spread or through their work as a medical screener," DHS said. "There have been no positive COVID-19 detections reported from the LAX screened travelers. This is an evolving situation that the CDC, DHS and county public health officials continue to examine."

COVID-19 coronavirus’ assault on Wuhan mental hospital alarms experts

Thanks to David Paulk for tweeting the link to this report in Sixth Tone: Coronavirus’ Assault on Wuhan Mental Hospital Alarms Experts. Excerpt:

Experts are for calling for more stringent measures to protect people with psychological conditions after at least 80 patients and staff at a mental health facility in Wuhan contracted the coronavirus that has now killed more than 1,300 people in China and infected over 60,000 worldwide. 

Domestic magazine China Newsweek reported last weekend that over 80 patients and medical workers at Wuhan Mental Health Center had been diagnosed with novel coronavirus pneumonia, or COVID-19. An employee of the center who declined to use her name because she was not permitted to speak with media told Sixth Tone on Wednesday that the hospital had stopped admitting new patients “for fear of cross-contamination.” 

“We have suspected patients, confirmed patients, and severely ill patients,” the staff member said. “All of our (spare) rooms are being used to accommodate infected patients, and we have a shortage of protective gear.”  

Wuhan Mental Health Center, also known as Wuhan Psychiatric Hospital, is the largest mental hospital in the central Hubei province. Isolation wards comprise much of the hospital’s facilities, posing a high risk of cross-contamination among patients and medical professionals alike. 

A former patient who was hospitalized at the facility last year told Sixth Tone that the conditions in her ward were poor. She described how the primary and secondary care areas were kept segregated by a sturdy metal door: In the primary care area, most of the rooms had three beds, she said, while in the larger secondary care area, five or six people might share the same living space.  

“One side of each bed was attached to the wall — otherwise they wouldn’t all fit,” she said, adding that most rooms did not have their own toilet.  

A doctor at the facility told China Newsweek that some 10 inpatients developed fevers beginning around Jan. 12. The hospital’s infection control personnel assumed the fevers were the result of a common cold. 

“At first, we didn’t know that the (coronavirus) disease could be transmitted from one person to another,” an employee from the hospital’s publicity office told online media outlet Pear Video. “We didn’t have sufficient awareness of the disease.” 

The first symptoms were observed the day after Wuhan’s health commission claimed on Jan. 11 that there was no clear evidence of human-to-human transmission, and that no new cases had been detected since Jan. 3. The city’s health authorities also denied that medical workers were contracting the virus from their patients — though an investigation by domestic media outlet Caixin later found otherwise.

Japan confirms first case of coronavirus that has infected dozens in China

Via The Japan Times, a Kyodo report: Japan confirms first case of coronavirus that has infected dozens in China. I don't find anything  about this on Japan's website for the Ministry of Health, Labour and Welfare. 

Japan has confirmed its first case of a new coronavirus from China, the health ministry said Thursday. 

A Chinese national who has traveled to Wuhan, eastern China, tested positive in Japan, the ministry said. The man in his 30s man lives in Kanagawa Prefecture. He returned from Wuhan on Jan. 6 and was hospitalized on Jan. 10. He has already recovered and was discharged from the hospital on Wednesday, the ministry said.  

A ministry official said there are no other confirmed cases in Japan. 

The pneumonia-like virus has infected dozens of people in Wuhan, with preliminary evidence suggesting the outbreak was associated with exposure at a seafood market.  

The man treated in Japan has not been to the Wuhan seafood market, according to the health ministry. It is possible that he came in close contact with a person infected with the virus while in Wuhan, the ministry said. 

Coronaviruses usually cause common-cold symptoms, infecting the nose, sinuses or upper throat, and are spread through sneezing, coughing or direct contact. 

The health ministry issued a message to the Japanese public that it is important to wash hands and take other preventive measures similar to those taken against the common cold or influenza. 

It also called on those who returned from Wuhan and have experienced fever and coughing to wear masks and visit medical institutions promptly. It advised them to report that they have been to Wuhan when seeing a doctor.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published its weekly update: Ebola virus disease – Democratic Republic of the Congo. Excerpt:

The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces in the Democratic Republic of the Congo continued this week with similar transmission intensity to recent weeks, with an average of 81 cases per week (range 68 to 91 cases per week) in the past six weeks (Figure 1). There are currently no confirmed cases of EVD outside of the Democratic Republic of the Congo. 

This week, initial data from a randomized clinical trial (RCT) of EVD therapeutics were announced. The data showed that two of the four treatments trialled were more effective in treating EVD. As a result, patients in the four Ebola treatment centres that participated in the RCT will now be randomized to receive the two better performing treatments. Patients in treatment centres not participating in the RCT will continue to be able to access those treatments under a compassionate use protocol. This change will help ensure that every treatment centre patient receives the best possible treatment with the greatest chance of survival, based on the most recent evidence. 

The data indicates that when people are willing and able to access care soon after the onset of symptoms, they have an increased chance of survival. Providing each patient with optimal supportive care, closely monitoring their progress, and addressing any other health issues has saved lives and will continue to be a top priority. More information is available in the following update and press release.  

No new confirmed cases have been reported in Goma city since our last report, with a total of four confirmed cases reported from Goma (n=1) and Nyiragongo (n=3) health zones to date. Two cases, who were infected via direct contact with the case reported on 30 July, received treatment at an Ebola Treatment Centre in Goma city and were discharged on 13 August. A total of 203 contacts of the Nyiragongo cases remain under surveillance.  

In the 21 days from 24 July through 13 August 2019, 66 health areas within 17 health zones reported new cases (Table 1, Figure 2). During this period, a total of 228 confirmed cases were reported, with the majority coming from the health zones of Beni (42%, n=96) and Mandima (20%, n=46). A case was confirmed in Lolwa Health Zone, which is the first confirmed case in that health zone to date, bringing the total number of affected health zones over the course of the outbreak to 27. The case travelled from Mandima to Lolwa, where they became symptomatic. Currently, there is no evidence of local transmission of EVD in this health zone. Close identification and follow up of contacts is ongoing to minimize the chance of local transmission. 

New infections continue to be reported among personnel working in community health posts and other facilities. In the last 21 days, 11 new cases were reported among health workers from Beni (n=3), Mandima (n=2), and one each in Katwa, Mabalako, Mambasa, Masereka, Mutwanga, and Vuhovi. Cumulatively, 151 (5%) health workers have been infected to date.  

As of 13 August, a total of 2842 EVD cases were reported, including 2748 confirmed and 94 probable cases, of which 1905 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 57% (1608) were female, and 29% (815) were children aged less than 18 years.

Preparing for emerging infections means expecting new syndemics

A letter in The Lancet: Preparing for emerging infections means expecting new syndemics.

When several sources of morbidity come together to produce interlinked and worse health outcomes, they are sometimes called a syndemic. Research on syndemics explores how two or more diseases cluster together; how social, political, economic, and ecological factors drive those clusters; and how clustered conditions interact via biological, psychological, or social pathways. Syndemic interventions target underlying patterns of multidirectional causality to achieve better overall health in susceptible and often dispossessed populations. 

So far, syndemic theory has found limited traction in fields such as ecoepidemiology that dominate emerging infectious disease research, despite a natural fit for three major challenges: proliferation of closely-related emerging viruses; co-occurence with endemic infections; and broader interactions with other aspects of health, including non-communicable diseases, mental health, and stigma. We show the relevance of syndemics for ecoepidemiology by showing how each of these complicates our understanding of the Zika virus epidemic in Latin America and the Caribbean. 

First, the idea of a syndemic formalises existing knowledge about co-occurrence of Aedes mosquito-borne viruses. Dengue and chikungunya viruses have had substantial comorbidity and co-infection with the Zika virus, including at least one case of triple coinfection. Many studies implicitly examine the three viruses as syndemic but do not refer to this linkage using the term. All three viruses are linked through Aedes mosquitoes to urbanisation, driving a broad spatial correlation between poverty, chikungunya, and Zika congenital syndrome (ZCS) in Brazil. Thinking syndemically could lead to mosquito control and public health education that targets several Aedes-borne viruses at once. 

Second, syndemic thinking has the potential to broaden conversations about co-occurring morbidities without adding confusion about causality. After scientific consensus resolved that ZCS was responsible for Brazil's microcephaly epidemic, conversations about other possible drivers were mostly sidelined. However, Brazil is a global hotspot of congenital toxoplasmosis, and microcephaly cases attributable to toxoplasmosis were observed during the Zika virus outbreak. 

Zika, toxoplasmosis, and microcephaly could create a syndemic, even without links between toxoplasmosis and the 2015–16 ZCS epidemic; poverty and environmental degradation connect them, as could fear and stigma. Syndromic surveillance for emerging pathogens like Zika the virus might be weakened by syndemic clustering between endemic and emerging infections of similar pathology or etiology, especially in poor and undersurveilled populations. 

Third, sexual transmission of the virus and fetal effects of ZCS introduced two new topics—safe sex and abortion access—that had never before been extensively discussed in an arboviral outbreak. Already, work focused on the syndemic of Zika virus, HIV, and unintended pregnancy, has identified marital and cultural risk factors that can help target interventions such as condom use and social policy, emphasising the promise of syndemic thinking, and the need for social scientists' involvement in outbreak prevention and management. 

The long-term effects of Zika virus might also be syndemic, as surviving babies become adults with a range of disabilities and sequelae. Although virologists work tirelessly to understand ZCS, this basic medical research remains disconnected from broader anthropological inquiries about the ongoing social effects of Zika. Bridging this gap is imperative to understand and improve quality of life in affected communities. 

The Zika virus outbreak in Latin America and the Caribbean will not be the last major outbreak; several new outbreaks have been reported across India. Other diseases will also raise complicated issues regarding safe sex or access to safe and legal abortions, and virologists have begun to anticipate sexual transmission and teratogenic effects of other emerging viruses. Increased knowledge of these select pathogens can help emerging disease researchers plan for syndemics of the future.