Archive for the ‘Infectious Diseases’ Category

Could Biology Explain Racial Health Inequalities?

March 10, 2018

The consistently greater risk for infections and cancer among men of African ancestry compared to all other ethnic groups in the world suggests fundamental biologic causes that supersede social and geographic influences. One of the most popular arguments for the notion that race is a “social construct” is derived from the point made by the geneticist Richard Lewontin, to the effect that intra-racial genetic similarity among individuals classed within any given “race” typically accounts for only about 7% of genetic similarity. Lewontin concluded from this that racial classification is “meaningless.” While his data concerning intra-racial vs. interracial genetic similarity were correct, the inference from this data that racial classification is meaningless is widely referred to by evolutionary biologists today as “Lewontin’s fallacy.” Indeed, 7% of the genetic material consists of several thousand genetic loci, which is quite an impressive amount of genetic material.

Random studies have found higher Testosterone levels in African American men and higher Testosterone and Estrogen levels among African American women together with low Dehydroepiandrosterone levels (DHEA) compared to their racial counterparts, could explain the health inequality. DHEA levels decrease with old age and low levels are said to reduce body’s immunity against diseases increase the risk for infections and cancer; DHEA levels have been found to be particularly low in African Americans, increasing their vulnerability to diseases. This understanding is key to prioritizing health services to this community. We need policies to address early childhood education including health education; access to healthy food and eating right, and performing work and out of work activities according to your biological capabilities. We need to help people understand their biology and how it affects their health and behaviour and they can take advantage of their differences.racial differences

I advocate for health education and services to reach out to African American communities in their homes, work, schools, and churches. Early screening of African American women, for Breast cancer, Endometrial cancer, and Ovarian cancer and earlier screening of Lung cancer Prostate cancer and other common cancers among African American men; after reaching the age 40.

Featured picture by KANGSTAR
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The Return of a Disease of the Past: Diphtheria in Cox’s Bazar

March 9, 2018

Violence in Myanmar’s Rakhine State, a “humanitarian and human rights nightmare” as described by the UN Secretary-General Antonio Guterres, has created a refugee population of 688,000 people in Cox’s Bazar vulnerable to multiple threats, such as the looming monsoon and cyclone season, poor infrastructure, and diphtheria.

20171021_WOC994Image 1: Number of Rohingya Refugees fleeing to Bangladesh (The Economist)

Diphtheria has often been regarded as a disease of the past because it can be prevented through vaccination efforts, proper protection, and education. Refugees are a vulnerable population as they often lack access to health care and are living in temporary settlements. As of recently, there has been a dramatic increase in the cases of diphtheria in the Rohingya refugee population of Cox’s Bazar,  with 5,764 cases as of February that have led to at least 38 deaths. Diphtheria is an infection that predominately affects children and is spread by direct contact or respiratory droplets, a threat most likely exacerbated by the close living arrangements.

The WHO has been working with the Ministry of Health Family Welfare of Bangladesh to provide $3 million from its Contingency Fund for Emergencies (CFE) to support the essential health services needed for the Diphtheria crisis in Cox’s Bazar. However, due to the large flow of Rohingya refugees, Bangladesh has started to detain and forcibly return people to the country where they are at risk of serious human rights violations.

asj_npr_day3__17-56_custom-51a4054f44df8299be7bd19d1d9d2f1651dc35d4-s700-c85Image 2: Child being treated for Diphtheria (NPR)

As a result, although WHO’s vaccine initiative with the Bangladesh government has been successful in vaccinating children as of recently, this is not likely to be sustained as Bangladesh begins to  refuse entrance and refugee status to the Rohingyas.

Currently, the Bangladesh government has made no specific policy on how they intend to protect the Rohingya refugees. The Ministry of Health Family Welfare of Bangladesh should create a sustainable solution in Cox’s Bazar by offering health services to the vulnerable populations that offer a sound vaccination policy, an educational program on the spread of infectious diseases, proper infrastructure, and a sound surveillance system. As this is a global, humanitarian crisis, international agencies should help Bangladesh in this endeavor and offer financial aid.

The Hidden Epidemic: STIs in Onondaga County a Need for Routine STI Screening Among High Risk Populations

March 9, 2018

According to the most current data from the Centers for Disease Control and Prevention (CDC), Sexually Transmitted Infections (STI) remain on the rise nationwide. One area where STI prevalence remains high is in Onondaga County, NY. The county has one of the highest STI rates in the state with chlamydia and gonorrhea rates surpassing the state average and an increasing prevalence of syphilis. According to the Medical Director of the Onondaga County STD Center, Dr. Elizabeth Asiago-Reddy, two key determinants relevant to this issue are the high concentration of poverty and a large concentration of college students living in the county.     std

Continually, disparities pertaining to gender and ethnicity exist in regard to incidence and prevalence. Minority communities living in Onondaga County like many throughout the nation are disproportionately affected by STIs. Heterosexual women throughout the county are also disproportionately affected compared to heterosexual men with the greatest prevalence of infections reported among African-American women. Health professionals have referred to the high prevalence of STIs in Onondaga County as a hidden epidemic because many individuals are unknowing infected and unknowingly transmit diseases to their sexual partners. Most infected women are asymptomatic which is one of the factors which perpetuates the spread of disease and continues the cycle of infection.
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Most STIs can be easily cured with antibiotics, but if left undiagnosed and untreated they can have serious health consequences including infertility, increased risk for HIV transmission, and obstetrical complications such as ectopic pregnancy and stillbirth. In an effort to prevent serious health consequences from STIs, various health professionals and leaders as well as local, state, and national organizations have recommended routine STI screening for high risk populations. Identified high risk populations include adolescents & young adults, women, ethnic minorities, and men who have sex with men (MSM).

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At present time there is no specific policy or clinical practice standard for routine STI screening. However, the data which is available is supportive of STI screening, this will ensure that infected persons are detected, diagnosed, and treated in a timely and efficient manner. The Institute of Medicine identified policy development as one of the major public health functions with the ability to significantly impact the achievement of health outcomes. Support from local community health professionals and organizations such as ACR Health, the Onondaga County Health Department’s STD Center, & the Syracuse Community Health Center can significantly influence policy formation at the local level. Stronger support at the state and national levels from organizations including the CDC, ACOG, & USPSTF also have the potential to present a strongly united front among leading healthcare organizations. Therefore, legislative action to standardize STI screening in clinical practice has the potential to positively improve health outcomes among high risk populations through early detection and diagnosis. Encourage local health organizations and legislators to make Onondaga County a little more sexually healthy by advocating for routine STI screening.

Expanding the free HIV drug catalogue: benefitting PLWHs in China

March 9, 2018

China has made tremendous progress in the control of HIV epidemic. By the end of 2014, the reported number of people living with HIV in China was 501,000, and the number of people on treatment was close to 300,000. the country has maintained an HIV prevalence rate lower than 0.1%.china

HIV is incurable with current medication, people with HIV need to take daily dose of antiretroviral treatement(ART) to suppress the virus in their bodies. ART has produced a high disease burden on Chinese HIV patients most of whom are from rural areas, to tackle this critical public health dilemma, in 2004 Chinese government enacted the four free and one care policy that provides a short list of free medication to all Chinese citizens with HIV. However, comparing to various drugs approved by the US FDA, the number of choices in this Chinese free drug catalogue remain limited.

There are only 7 drugs in the free drug catalogue, the ART 20160619_drug_STprescriptions by physicians thus became insufficient to manage the various needs from people with HIV. However, there exist other HIV drugs available in China. With the evolution of time, new drugs, including long-acting injections and all-in-one daily therapy have begun to show up in the market.

With the enaction of the 13th five-year action plan for controlling HIV/AIDS by the State Council in 2017, it is stated that the Ministry of health should make proper and in-time adjustment to the free drug catalogue. However, no real change has been carried out to date.

It’s certainly a great disappointment to see such a favorable policy unimplemented in time, not only for the government department enacted it, but for numourous people with HIV in China as well. Obviously there are feasible solutions to carry out this policy. As indicated in the 13th five-year plan, the MOH, and China CDC as the key executor of this policy, ought to expedite the implementation of it thus benefitting Chinese patients and physicians, not to delay it until the next five-year plan.

Expanding National Influenza Immunization Program to Adolescents in South Korea – A social justice perspective

August 20, 2017

Influenza, or “the flu”, is a common infectious disease that ranges in severity, with some cases even resulting in death.

graph 1In South Korea, the number of the flu patients in 2016 was a record high, and more importantly, the flu season started 7 weeks earlier than usual (See Graph 1).

In an effort to curtail the effects of influenza, the Korean government introduced a Free Influenza Immunization Program for children ages 6-12 months in October 2016, and expanded the coverage up to 59 month-old children from September 2017.

In response to this, many people are now arguing for the expansion of the program to include school-aged children and teenagers (up to ages 18 years) as well.

Cost and Parental Concerns

The Korean government expressed its strong concerns at a policy forum held last month, and stated that covering 6,500,000 school-aged children every year is not practical due to a limited workforce and budget. However the socioeconomic cost of influenza is $25 billion USD, and it was also reported that vaccination in this age group could save the cost up to 7 billion USD.

Additionally any side effects from the vaccines are taken seriously by parents. However, the influenza vaccine safety has already been proven.

My position

Despite these concerns – which should be taken seriously – I, as a primary care physician and public health advocate, support the expansion of the program.

Regarding cost, it would be reasonable to cover younger children first and then expand to teens. Various parental concerns need to be fully addressed through community or school level meetings.

imageMore importantly, I would like to introduce the notion of social justice highlighting ‘herd immunity. Children respond well to the vaccine. Even though they are just a fraction of the population, immunizing them could significantly diminish the chance of a widespread outbreak.

This effort is part of being a good citizen, and enhancing our social benefit by protecting more people.

Yellow fever vaccine shortage: Time for policy on vaccine back up plans?

August 20, 2017

yf500,000 doses are distributed annuallySanofi Pasteur is the sole manufacturer of the only FDA approved yellow fever vaccine YF-VAX in the US.  500,000 doses are distributed annually, one third to the US military are two thirds to the civilian clinics. In November, 2015 the vaccine supply was impacted when Sanofi Pasteur began the process of moving manufacturing of the vaccine to a new facility.  A large number of vaccines were lost in a production problem therefore diminishing the supply.  Although efforts were made by Sanofi Pasteur to extend the supply by rationing the doses left, the CDC was not notified of the issue and imminent depletion of supplies until spring of 2016

Sanofi Pasteur does manufacture another yellow fever vaccine that is used widely around the world, Stamaril.  Special approval as an investigational new drug (IND) was obtained from the FDA to be allow supply and administration of Stamaril in the US.  Stamaril and the YF-VAX are stamarilcomparable in efficacy and risk of side effects therefore seen as interchangeable.  Usually, roughly 4,000 sites in the US administer YF-VAX, while only 250 have been chosen to be allowed to supply Stamaril.

Currently there is no policy in place to address vaccine production in a vaccine shortage situation, and this must be addressed in further regulation and policy.

This vaccine shortage is not the first nor unfortunately the last that will take place.  With this in mind, a policy addressing vaccine production issues has to be put forth. This should include a notification process allowing enough time for enacting a contingency plan to boost supply through alternate production and possible rationing.  A national policy that outlines the procedure of notifying the CDC of possible shortages along with penalties to the company if not followed is imperative to lessen the impact of a shortage or to prevent it altogether.  A new component of the FDA vaccine approval process and annual inspection should be added as well requiring an action plan to produce vaccines in case of a failure of supply or of production transfer in cases of withdrawal of the company from the market. It is unacceptable that one manufacturer’s difficulty, mistake, or withdrawal from the market impacts the health of the entire nation when this could be prevented with planning and coordination. 

Don’t Delay: National Uptake of Rotavirus Vaccine in India is Needed Now

August 20, 2017

RVIndia

Many people think that a bout of diarrhea is just an annoyance, but if left untreated, diarrhea can lead to severe dehydration, which can result in hospitalization or even death. Diarrhea remains a leading cause of death in children under five around the world. In 2013, over 570,000 children under five years of age died from diarrhea globally. And in India alone, diarrhea caused more than 130,000 child deaths in 2013. Not all diarrhea is avoidable, but with new vaccines some pathogens that cause moderate or severe diarrhea can be prevented, including rotavirus. It’s estimated that 40% of all diarrhea deaths are due to rotavirus.

After years of efforts, in March 2016 the Ministry of Health and Family Welfare added an indigenous rotavirus vaccine to the routine immunization schedule in four Indian States — Andhra Pradesh, Haryana, Himachal Pradesh and Odisha. For the first time, children in India have access to a life-saving rotavirus vaccine. This achievement was a critical milestone for the children of India. And in February 2017, the vaccine was launched in an additional five states.

The Government of India’s progress should be applauded, but national scale up is still lagging. The children living in the remaining states of India also deserve access to the rotavirus vaccine. Expanding rotavirus vaccine into the routine immunization schedule in all states will help protect millions of Indian children.

State parliamentarians, you must call on the Government of India to facilitate faster roll-out of the vaccine. It’s time to work with your state health teams to put the infrastructure and systems in place to introduce new vaccines in a safe and timely manner. The children in your states deserve better. As progress continues to lag, children continue to die from a preventable disease. The time is now, don’t wait.

Photo credit: http://www.medicaldaily.com

It’s time for Angola to step up: neonatal mortality can be tackled with chlorhexidine

August 18, 2017
medicalaidfilms chlorhexidine 3Medical Aid Films: How to use chlorhexidine for umbilical cord care

LUANDA — An unacceptable 2.7 million deaths occurred worldwide in 2015 in children under one month old, and infections were responsible for a significant portion of these deaths. There is a solution.

Chlorhexidine, a disinfectant already widely used in healthcare in high-income countries, was heralded as one of 13 “over-looked” life-saving commodities by the UN Commission on Life-Saving Commodities for Women and Children in 2012. This followed a growing, substantial evidence base demonstrating its effectiveness in reducing local and severe infections, and deaths, in neonates. Systematic reviews by Cochrane in 2013 and 2015 had shown 23% and 12% reduction in deaths among those born in the community in developing countries. Chlorhexidine was added to the WHO Model List of Essential Medicines for Children and WHO Guidelines on Postnatal Care for Mothers and Newborns in 2011.

However, progress has been slow. The Healthy Newborn Network tracks the status of chlorhexidine implementation worldwide. Many countries with the highest neonatal mortality rates (>30 deaths/1,000 live births) still remain in the “pilot/policy alignment”, “expressed interest”, and “no information” categories. Nepal started implementing its chlorhexidine program in 2011, and Madagascar in 2013. Nigeria and Afghanistan following suit only last year. Who is missing? The top three countries with the highest neonatal mortality: Angola, Pakistan, and Central African Republic.

HNN chlorhexidineThe Healthy Newborn Network: Current status of chlorhexidine for umbilical cord care implementation

At 50 cents per dose, and in a gel form that is straightforward to apply to the umbilical cord, it begs the question why chlorhexidine has not been implemented more widely. Certainly, there are challenges, such as “regulatory hurdles, supply issues, and misconceptions about guidelines for umbilical cord care”, but these are not insurmountable. The slow roll-out has consequences, given that chlorhexidine has the potential to save 422,000 lives over a five-year period.

It is time the world got its act together, and for Angola, as the worst-offending country, to demonstrate its leadership and tackle its mark of shame. We call on the Angolan Ministry of Health to work with international agencies such as WHO, USAID, and PATH to rapidly introduce and scale chlorhexidine disinfection across the country.

Suspension of Recommendation for HPV vaccines in Japan since 2013

August 12, 2017

cervarix_1703 

Roles of HPV vaccines

Human papillomavirus (HPV) causes more than 99 percent of cervical cancer. Persistent infection with certain types of HPV can lead to specific cancer such as cervix, anus, vagina, vulva, penis, mouth, or sinuses. In Japan, HPV infection leads to cervical cancer in about 10,000 women every year and 2,700 women die of cervical cancer every year. World Health Organization (WHO) recommends HPV vaccines in adolescents more than 9 years of age to prevent infection with types of HPV known to cause cervical cancer. It is clear that these vaccines significantly reduce the number of women who develop cervical pre-cancer. It is estimated that mortality rate of cervical cancer could be reduced by 70 to 80% if they are available diffusely on targeted population throughout the nation.

Government’s Decision to Suspend Recommendation of HPV Vaccines

There were two types of vaccines (Gardasil and Cervarix) available to prevent infection with types of HPV known to cause cervical cancer in Japan. In 2009, the Ministry of Health, Labour and Welfare (MHLW) started to approve HPV vaccines. The vaccination rate rapidly rose up to 70%. However, more than 30 cases of adverse effects were reported by mass media with emphasis in 2013, which led to viewpoint switching into not recommending these HPV vaccines by MHLW. The causal association between those reported adverse effects and vaccination had not been proved either epidemiologically or scientifically. The Representative of Japan Cervical Cancer Sufferers Organization announces and advocates complete withdrawal of HPV vaccines in Japan as well as victim’s compensation. WHO raised concern about case reports of pain syndromes in Japan because those reports did not show scientific causalities. These vaccines could be still available at government expense but the vaccination rate dramatically decreased to only 1 percent of targeted girls in 2016.

Increased Risk of HPV Infection Estimated Unless Encouraging Resumption

It was concerned that risk of HPV type 16/18 infection at the age of 20 would noticeably increased among girls born between 2000 and 2003 compared to other age groups (Fig A). This negative effect was estimated to be worse if resuming encouragement was extended until 2020. However, MHLW has not changed their policy yet in 2017 although the Japan Society of Obstetrics and Gynecology released statement of resumption of HPV vaccines encouragement.Graph1

How to resume HPV vaccines encouragement

Japan Medical Association issued guidelines for treating affected subjects with any symptoms after administering HPV vaccines in 2015. Those victims after HPV vaccination should be cared comprehensively even if the causality is not proved epidemiologically. Resumption of HPV vaccination is awaited to minimize the risk of cervical cancer in young girls and women in Japan because of recent evidence to support non-causality between HPV vaccination and presumed pain syndrome.

Antimicrobial Resistance: The Role of Food Animal Production

March 12, 2017

Picture1Antimicrobial resistance (AMR) can arise from inappropriate use of antimicrobial medications (AMMs).  In the United States, more than 80% of all AMMs are used in food animal production, including classes of medications that are on the WHO list of critically important AMMs. Prior to 2017, many AMMs for food animal production could be purchased and used without a prescription and for purposes such as “growth promotion,” rather than for treating a documented infection.

In 2012 and 2013, the FDA released Guidance for Industry, which sought to define judicious use of AMMs in food production, as well as to recommend that the animal pharmaceutical industry voluntarily change their labeling of critically important AMMs used in food production. In short, the FDA recommended that certain AMMs should no longer be used without veterinary oversight or solely for “growth promotion.” Using these medications against their labelled purposes would then constitute a violation of the Federal Food, Drug, and Cosmetic Act.

Picture2Despite pushback from industry groups such as the National Pork Producers Council and the National Turkey Federation, which argue that there is no firm science supporting the concept that AMMs in animal production result in AMR in humans, the FDA has shown some early successes of their new guidelines. According to reports published this year, the pharmaceutical industry voluntarily either changed all new drug applications to require veterinary oversight or withdrew    the applications from consideration by January 2017.                     Credit: wellnesswarrior.org

However, there is more work to be done. Further guidance from the FDA should tighten controls on the use of AMMs in food production for disease prevention purposes. Currently, use of AMMs for disease prevention can include prophylactic administration of subtherapeutic doses for prolonged periods, dosed imprecisely in feed or water, to entire herds or flocks. Additionally, organizations focused on veterinary medicine and animal care, such as the USDA, should be made part of the Transatlantic Task Force on Antimicrobial Resistance (TATFAR). Finally, improved animal husbandry in food production facilities (decreased crowding, improved sanitation) would lead to less infectious disease.

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Credit: Ruralmadison.org