Archive for the ‘Infectious Diseases’ Category

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.

Picture3

Credit: Ruralmadison.org

Increasing HIV Incidence in Uganda – Education Efforts Aimed Towards Women

March 12, 2017

The HIV incidence rate in Uganda was the third highest in Sub-Saharan Africa in 2014.  There are 1.5 million people living with HIV and a 7% HIV prevalence. uganda-2015

As is shown in the graph below, HIV prevalence decreased in the 1990s; however, since the introduction of anti-retroviral drugs, HIV incidence has been increasing.  People have become more careless in their sexual practices as they now believe that if they contract HIV, they can simply take anti-retrovirals and live a long and prosperous life.

screen-shot-2016-03-05-at-8-42-43-am

 

HIV is transmitted through body fluids to include blood, semen and breast milk.  The main interventions have previously focused HIV transmitted through sexual contact and educating on condom use and condom distribution.  However, the key drivers of HIV incidence are the following: 1.) high risk sexual behavior, to include early sexual debut, multiple sexual partners, and inconsistent condom use; 2.) low individual level risk perception; 3.) high STI prevalence; 4.) low utilization of antenatal care and breast feeding education; 5.) safe male circumcision services; 6.) sub-optimal scale up of ART; and 7.) gender inequalities including gender based violence.  Further, the rate of HIV is higher in women (8.3%) than in men (6.1%).

A comprehensive policy that attempts to address the many issues that face women would greatly assist in lowering the incidence rate in Uganda.  In an effort to stay aligned with President Museveni’s National HIV and AIDS Strategic Plan 2015/2016 – 2019/2020, President Museveni should also write and enforce an education policy to be implemented in the local hospitals around the country.  (See link for more information on the National HIV and AIDS Strategic Plan 2015/2016 – 2019/2020 nsp2015.)

This education policy should attempt to deliver key health messages specific to the key drivers that affect HIV incidence in women and children, specifically early sexual debut, multiple sexual partners, antenatal care, and gender inequalities.

Averting a Crisis: Legalization of Needle Exchange Programs in Virginia

March 12, 2017
ACT UP march for syringe exchange

CREDIT: KAYTEE RIEK VIA FLICKR

In February 2017, Virginia governor Terry McAuliffe signed legislation that legalizes syringe access programs in the state. Needle exchange programs provide anyone needing a clean needle with a place to exchange their used needle for a sterile needle at no cost. These programs can also offer HIV testing and counseling, alcohol swabs, and male and female condoms, among other resources that vary by organization.

According to the approved bill, these programs will only be implemented in regions meeting certain criteria created from information such as overdose rates, number of Hepatitis C cases, and morbidity data. Thanks to several federal and private funds, these programs will not take away from the state’s general funds.

467450471-used-syringes-are-viewed-at-a-needle-exchange-clinic-crop-promo-xlarge2

CREDIT: SPENCER PLATT/GETTY IMAGES

There has been controversy regarding whether needle exchange programs are helpful or detrimental. In 2011, Archbishop Francis Chullikat spoke on behalf of the Catholic Church at the United Nations in opposition of harm-reduction programs. The Catholic Church believes that people dealing with drug addictions should be given tools and assistance to break free from their addiction as opposed to measures that allow them to “continue” in their cyclic, addictive behavior. On the other hand, the CDC and NIH both advocate that needle exchange programs play a role in preventing HIV transmission and other health problems among people who inject drugs.

A needle exchange program in Virginia is important for preventing an HIV outbreak, considering an outbreak like this has happened in Indiana and the number of HIV cases rose from a typical 5 cases a year to 200 cases in 2015. It is important for local government officials and residents to voice their support for needle exchange programs to ensure the continuity and growth of such programs. A needle exchange program can be the difference between a public health crisis and a public health victory.

Decreasing Household Costs of Dengue Prevention at Low-Altitudes in Colombia: Redirecting Resources into the Hands of People Who Slap Mosquitoes Everyday

August 23, 2016

Squito

Photo by James Gathany

Colombia bears high burdens associated with dengue.  During the 2010 epidemic, disability-adjusted-life-years lost were 1178.93 (per 1 million inhabitants) versus just 88.38 averaged for 2011-2012.  Rodriguez et. al (2016) estimated economic burdens higher than $129.9 million USD each year, with most of the burden at the individual household level (46%, 62%, and 64%) for preventing/controlling mosquitos.

The Colombian Ministry of Health and Social Protection uses the 1,800m elevation mark when allocating money to low-altitude departments for dengue-related expenditures.  This suggests that only half of Colombia’s 47 million residents are at risk for dengue.  However, many people vacation at low altitudes where they risk becoming infected and bringing dengue back home.  If low-altitude residents were better equipped to control mosquitos, then both residents and visitors would be better protected.  Unfortunately, low-altitude residents shoulder a greater financial burden for mosquito prevention than the government.  Rodriquez et al. (2016) reported that almost $85 million USD was the highest household burden (for prevention alone) between 2010 and 2012, while the highest government burden was only $35 million USD (for prevention, awareness campaigns, and control combined).

If the Ministry of Health and Social Protection’s vision of equity-based protection and healthcare resources for all is to come to fruition, more money must flow into prevention and control.  Residents should not have to buy expensive sprays when they already live in poverty.  If Ministry-controlled finances were earmarked for inexpensive yet effective household supplies, such as curtains and water container covers, then less money would be required for treatment.  I advocate for reshuffling some of the dengue-related funds to reflect the prevention priority; increase amounts for household prevention and decrease treatment allocations.

Let’s not make low-altitude residents choose between buying expensive sprays or food to eat.  It’s hard enough already just to slap together supper.

Updating Florida’s Vector-Borne Surveillance: Addressing the Growing Concern for Mosquito-Borne and Tick-Borne Illness

August 19, 2016

Vector-borne diseases make up some of the more common infections throughout the globe. The Centers for Disease Control and Prevention acknowledges mosquito-borne denque mosqdiseases, such as West Nile Virus, and tick-borne infections, such as Lyme disease, have a great impact on the United States. These vectors have found favor in climate change as they continuing to breed and pose a public health risk; carrying infectious agents that may be transmitted to humans through a bloodmeal.

In 2014, the State of Florida Department of Health published their mosquito borne diseases surveillance guidebook. Within these guidelines, specific mosquito-borne infections were addressed in regards to both detecting and preventing such diseases. Unfortunately, since this publication, the Zika virus outbreak developed and was found to have recently reached Miami-Dade county in Florida, where locally transmitted cases were confirmed. Given these locally acquired infections in Florida, the surveillance guidelines should be updated accordingly.

FL Zika

Number of Florida Acquired Zika Virus (gray line: per million)

While the Northeastern regions of the US are known to have their “tick season” in the Spring and Summer, Florida’s climate allows for a year-long risk of contracting a tick-borne diease. The standard lab diauos in newsgnostic criteria for Lyme disease, the ELISA, detects antibodies against the bacterium, Borelia burgdorferi sensu stricto. However, it has continued to demonstrate poor sensitivity and overall reliability. Research from the University of North Florida has identified different strains of Borrelia that cause disease in humans. Thus, should one be infected with one of the different strains of Borrelia, one’s test is likely to be negative despite having actual disease. In recent years, Florida was found to have a 140% increase in Lyme disease cases since 1993 while reports of other tick-borne diseases have also increased. Hence, Florida researchers and public health professionals must partner together to revise and implement more up-to-date/accurate screening and awareness for vector-borne diseases.

Curing the Hepatitis C Virus in the Veteran population

August 19, 2016

Hepatitis C Virus (HCV) is the leading cause of mortality among all causes of hepatitis in the United States (US). It is estimated that 3-4 million people in the US are infected with HCV, with a prevalence of about 1.8% of the general population compared to 5.4% in the Veteran population. Veterans born between 1945-1965 and those in the Vietnam war were at higher risk for HCV due to blood products and the use of air jet guns for mass immunization. About ~175,000 Veterans in 2013 had documented HCV, and is likely underestimated  due to marginalized patients.

Prior to 2012, treatment of HCV was limited to combination therapy with pegylated-interferon and ribavirin, which created several adverse effects. With the introduction of Direct Acting Antivirals (DAAs) to the drug market in 2013, we now have the ability to cure HCV with little to no side effects. These medications inhibit various stages of the virus life cycle, leaving the virus undetectable in the body. Gilead Sciences, Inc., is the pharmaceutical company in in charge of producing most of these novel medications. Some argue that the majority of people with HCV do not require treatment because they can remain in a chronically infected compensated state. The extremely high morbidity and mortality associated with the complications of HCV is reason alone to treat all patients.

Given that the Veterans Health Administration (VHA) is the “largest integrated healthcare system” with the highest proportion of HCV infected individuals, they must create an efficient process for identifying and treating those with HCV by 2017.  The VHA should also create a multidisciplinary team at each Veterans Affairs (VA) consisting of physicians, social workers, hepatologists, midlevel providers, and case managers who follow patients with HCV. The hepatology specialist should educate primary medical providers and the team about initiation and monitoring of HCV treatment for those who require it most. Lastly, while cost is the major barrier to treatment, policy makers must work with Gildead Science to close the gap between the marketing and production drug price. Let’s make it a priority to start taking care of those who took care of us.

Emergency Funding for Zika Virus Response

August 19, 2016
zikamapgif_1200

Source: wh.gov/Zika

On February 22nd, the Presidential office requested $1.9billion in emergency funding to support activities related to Zika virus, but these efforts have dangerously stalled in Congress. To date, nearly $600 million has been redirected by the Obama administration to fund Zika related research, front line response efforts, and vaccine development. More than half of this money was redirected from within the U.S. Department of Health and Human Services (DHHS).

burwellhimsshitn_4

Source: Healthcareit

On August 3rd, Sylvia Burwell, DHHS Secretary, informed Congress that due to the delay in approving the emergency funding, the DHHS had been forced to further reallocate up to $81 million from other programs, including the National Institutes of Health. This was extremely important because it could impact the progression of the vaccine studies currently underway, as Secretary Burwell suggested in her letter to Congress. Her letter also outlined the response by the CDC and predicted that they too would be out of Zika funding by the end of the fiscal year (Sept 2016).

 

Funding approval for Zika virus related activities from the U.S. is more urgent than ever. As of August 17th, the U.S. has confirmed 14 cases of locally acquired Zika virus disease – all from Florida. This was after the U.S. Centers for Disease Control (CDC) announced on August 2nd that an additional $16 million was awarded to 40 states and territories to support Zika related public health activities.

So what can you do? It is time we let our political leaders know that their constituency will not wait any longer. Follow Secretary Burwell’s lead – petition your local congressional representatives (House, Senate) and let them know this is an issue you care about. Or submit pre-formatted online petitions at Project Hope and AmeriCares. And spread the word and call to action amongst your peers.

zuyjbxluizyaxlw-1600x900-nopad

Source: Project Hope

 

Low HPV Vaccination Rates in Tennessee: A Call for Patient Education

August 18, 2016

The Gardasil Vaccine, which has been available to both boys and girls aged 9-26 in United States for years, is a three-shot series defensive against four strains of the Human Papilloma Virus (HPV), a sexually transmitted infection which can lead to anal warts, and vaginal, vulvar, cervical and anal cancers.  After vaccination, 50-90% of these conditions can be protected against, and since the initial release of the vaccine, rates of HPV among adolescent girls have fallen.

Despite the apparent benefits, less than 40% of American adolescents in 2014 had completed the vaccination series, with some states, such as Tennessee, experiencing rates of less than 30%. Public support for the vaccine has been given by the Tennessee Commissioner of Health, yet unlike the Centers for Disease Control, the vaccine does not appear on Tennessee’s current immunization schedule, even as a recommendation.

Tennessee is also a state noted not to require public education regarding the vaccine, but studies have shown that improved education can increase rates of vaccine uptake. If the Tennessee Department of Health (TN DOH) were able to fund it, an educational campaign to increase awareness of what HPV is and how Gardasil works could help boost the rate of vaccine series completion.  Other advocacy groups working in the state, such as Team Up TN, have already created and been distributing educational materials about HPV and the vaccine to families and healthcare providers; they could prove a useful resource to the TN DOH. Concurrently, it will be important to find sources of outdated or incorrect information that are circulating, especially from groups fighting against routine Gardasil administration, to better address specific concerns consumers may have. For families deterred by cost, information about the Vaccines for Children program will be imperative. The campaign, occurring via television and radio PSAs, as well as pamphlets in public schools and clinics, may be the start to raising HPV vaccine compliance rates within Tennessee.

A Hepatologist’s Perspective: Why a Unified National Program for Infant Immunization Against Hepatitis B Should Be Implemented

August 17, 2016

Hepatitis B virus (HBV) is a highly contagious viral infection of the liver that can lead to cirrhosis and liver cancer. Transmission occurs vertically from mother to infant or horizontally, through exchange of bodily fluids including saliva or open wounds which can occur in preschools and at daycare. A safe and effective vaccine is available, and as of 2007, 171 of 193 WHO members had implemented a policy of universal HBV vaccination in infants. In contrast, based on ecologic data suggesting a higher risk in adolescents than in infants, Canada adopted an immunization policy for youth aged 9-13, coordinated at the provincial, rather than national level.

This has important consequences as infants and young children remain susceptible to horizontal transmission from family members and peers. Furthermore, no national level systems are in place to identify children who miss grade level vaccinations due to within country relocation. Importantly, in contrast to adults who develop chronic infection after acute HBV exposure in just 1-5% of cases, 90% of infants infected with acute HBV will develop life-long chronic infection with its associated risk of life threatening liver disease.

Infant immunization against HBV can work in Canada. In 2001, British Columbia became the only province to offer universal infant vaccination, and since then, acute HBV incidence has declined more than in any other province in the country with rates consistently remaining below the national average. Many professional societies including CASL, the CLF, and CPS have strongly advocated for a unified national immunization program though the federal government has been slow to adopt these recommendations.

HBV Vaccination BC

Figure 1. Reported incidence of acute HBV in all ages in Canada, 1992-2007

The National Advisory Committee on Immunization should immediately recommend that the Public Health Agency of Canada within the federal government implement a unified nationwide infant immunization policy against HBV to protect infants and children who remain unnecessarily susceptible to this dreadful disease.

Why California voters should uphold Senate Bill 277

August 14, 2015
Girl getting immunization: Getty Images

Getty Images

On June 30th, 2015, Governor Jerry Brown signed Senate Bill 277 into law. SB277 amended the vaccine requirements for California school children by banning religious and personal belief exemptions of childhood vaccinations. Starting January 1, 2016, students attending California schools must receive all childhood vaccinations as recommended by the AAP and CDC unless they have a medical exemption signed by a physician. The California State PTA and the California Department of Public Health supported this legislature in light of a recent measles outbreak that began in California’s Disneyland. The outbreak was perpetuated by low inoculation rates that decreased herd immunity and led to cases across 24 states and the District of Columbia.

While side effects exist for all medications, the risk of vaccination is highly outweighed by the benefit of eliminating suffering and death from vaccine preventable diseases. Serious allergic reaction to the Measles Mumps and Rubella vaccine has been reported in less than 1 out of a million doses given. In contrast, 1 to 2 out of every 1,000 children who get measles will die. In addition, research has thoroughly discredited any connection between childhood vaccinations and neurodevelopmental disorders such as autism.

Despite the fact that research has clearly proven childhood vaccines are both safe and effective, former assemblyman Tim Donnelly filed a referendum to oppose SB277. Opponents of the bill, such as anti-vaccine group the California Coalition for Vaccine Choice, need to collect 365,880 valid referendum signatures in order to delay the implementation of SB277 by bringing the bill to a vote in November of 2016, after the start of the school year.

Young children and persons who are chronically ill or immunocompromised are at increased risk for contracting diseases such as measles and suffering more severe sequelae of such diseases. The California government has the responsibility to protect these individuals, and to do so vaccination rates must be increased to levels sufficient for herd immunity. SB277 is an evidence-based policy that supports the public health of all Californians. California voters need to unite in favor of protecting their neighbors and fellow citizens and uphold SB277.