Archive for the ‘Infectious Diseases’ Category

The Polio crisis in Syria: targeting healthcare workers in the chaos

August 27, 2018

IMG_2945On October 29, 2013. The WHO reported the first polio case in Syria since 1999. 36 polio cases were reported inside the areas out of the government control in Syria, 26 of those cases were in Der el Zor (eastern Syria).  Vaccination rate in Syria dropped from 99% to 52% in 2012, leaving many kids under certain age with no immunization. The WHO report in 2014 estimated around 500,000 children under the age of five in Syria with no vaccination. According to UNICEF, despite vaccinating around 1.6 million children until the end of 2015, many were left un-vaccinated especially in the areas north of the Euphrates.

It is estimated that 60% of the hospitals in Syria have been affected. Many of the healthcare providers have been killed, injured, or left the country. In 2015, it was reported that there are only 40 doctors for every 2.5 million people comparing to 2000 before 2011.

On top of the major shortage in healthcare providers, around 700 medical workers have been killed since the conflict started in 2011. More than 300 facilities were hit by missiles or bombs.

The first Geneva convention in 1864 sat a principle to protect healthcare workers and medical space from violence and armed attacks. In 1949, 196 countries including Syria agreed on the update of this principle during the four Geneva convention. Since 1990, multiple violations to this principle have been reported around the world and most recently in Syria where multiple organization are risking human lives to deliver the Polio vaccine to children under the age of five.


Syrian American Medical Society (SAMS) has established multiple medical sites in the areas out of the Syrian regime control to provide medical care to both armed and non-armed population. They also have medical providers localized in Turkey that cross the Syrian border to offer medical help funded mainly by Syrian physicians in the US. They also established collaboration with multiple humanitarian organizations both international and local.

Why Maryland Should Cautiously Consider Repealing Non-Medical Exemptions for School’s Immunization Requirement

August 19, 2018

The Educational Division in the State of Maryland has rules and regulations that require immunizations for enrollment in schools. However, these rules have allowed for religious exemptions to this requirement in which parents do not have to present an immunization certificate for enrollment in any school.

In Maryland, vaccine hesitancy leads to gaps in health where less than 80% of children age 19-35 months receive a full schedule of recommended immunizations, contributing to the re-emergence of outbreaks, morbidity and mortality associated with vaccine preventable illness.

In 2011, up to 1.4% of kindergartners and 1.7 % of students in grades 1-12 had obtained an immunization exemption which permits them the ability to attend Maryland schools without receiving required vaccinations.

A lack of education and understanding of how vaccines work as well as concerns over their safety seem to be important factors leading to vaccine refusal. Most major religions have views that are compatible with the use of immunizations to protect the health of those around them; it is only individual parents or religious leaders with questionable interpretation of their religious practices that have been outspoken about their opposition to vaccination.

There are several groups that are against any form of non-medical exemption to the Maryland school system’s immunization requirements. For example, both the American Academy of Pediatrics and the American Academy of Family Physicians support the use of legislature to limit non-medical immunization exemptions. However, such policy changes can create unintended justification for ant-vaccination proponents to cite if they are unsuccessful at increasing vaccination rates.

Several organizations oppose the limiting of exemptions, especially those based on a religious reasoning. For example, high ranking members of the Catholic Church have put out a statement saying that it is immoral to use vaccines derived from the use of embryonic stem cells. Other organizations, for example the American Chiropractic Association, have members with differing views on vaccines. That has not halted efforts from members in these organizations to lobby against limiting immunization exemptions.

Although for state legislators, limiting non-medical immunization exemptions in the state of Maryland sounds like a good way to increase heard immunity and prevent disease, such a strategy must consider the broader political and social context in relation to the anti-vaccination movement. A failure in this policy can increase the small, but vocal opposition to vaccination coverage.

Human papillomavirus vaccination crisis in Japan

August 16, 2018

Human papillomaviruses (HPV) are associated with the development of cervical cancer, and the mortality and incidence of cervical cancer is increasing in the last decade among Japanese women. Two prophylactic vaccines, a bivalent vaccine and a quadrivalent vaccine, were licensed in Japan, and in 2011, the Japanese Ministry of Health, Labor and Welfare (JMHLW) recommended a fully financed HPV vaccination policy of girls aged 12 to 15. However, in 2013, several cases of “vaccination-associated neuro-immunopathetic syndrome” were reported (although it was not based on scientific evidence), and it was lionized by the media. After these events, the JMHLW suspended the policy and stopped promoting the vaccine usage, leading to drastic decrease in vaccination coverage from 70% to less than 1% (figure).

Uptake rates for the human papillomavirus vaccine in Sapporo, Japan, as of March, 2014. Lancet. 2013;382:768

Uptake rates for the human papillomavirus vaccine in Sapporo, Japan, as of March, 2014. Lancet. 2013;382:768.


Many stakeholders support the resumption of HPV vaccination policy. For instance, Japan Society of Obstetrics and Gynecology (JSOG) approved of the resumption of HPV vaccination policy in 2015. And in 2017, JSOG and other organizations proposed a joint statement calling for the prompt resumption of the HPV vaccine policy. The statement also demanded scientific research for “HPV vaccine-related side effects” claimed by the All Japan Coordinating Association of HPV Vaccine Sufferers . In fact, several members of this organization demanded compensation from the government and vaccine manufacturers and instituted proceedings in Tokyo court.

The governmental action has been stagnant for fear of harmful rumors and misinformation by opposing organizations and media; however, we firmly support the resumption of HPV vaccination policy in Japan because it is one of the most effective primary prevention methods to combat the scourge of HPV-related cervical cancer and it would save future healthcare cost.

The result of the Nagoya study, showing no association between HPV vaccines and reported post-vaccination symptoms, was a ray of hope for the JMHLW to advocate for the resumption of the HPV vaccine policy.

We make two requests to the JMHLW: (1) providing correct information of HPV vaccines and prevent the public from being deceived by the flood of disinformation; (2) supporting scientific research for “HPV vaccine-related side effects.”


In support of universal syphilis screening in Chicago

August 14, 2018

syphilis testing

For many young Americans, syphilis seems like a disease of the past; something to read about in history books but not concerning today. However, syphilis is on the rise in the United States, which has seen a 74% increase in cases since 2012. The epidemic is centered on dense urban areas like the city of Chicago, where syphilis rates are four times the national average. Syphilis is often a silent disease, but eventually it can result in blindness, neurologic problems, stillbirth, and other devastating medical consequences. The combination of poverty, uninsured populations, lack of routine medical care, and cultural norms leading to unprotected sexual intercourse with multiple partners leads to high rates of transmission in the neediest neighborhoods. Many of these same factors contribute to decreased awareness of the problem and lack of testing for syphilis, which allow the epidemic to spread unabated.

Despite US Preventive Services Task Force recommendations to screen all patients at risk for syphilis, including those at risk by virtue solely of their location or ethnicity, the Illinois Department of Public Health (IDPH) still recommends only limited testing, targeted to pregnant women, men who have sex with men, HIV positive patients, and those patients with identified “high risk behaviors” such as multiple or anonymous sex partners. This relies on medical care providers taking the time to ask about these high risk behaviors and on the patients to be forthcoming. In all liAlberta_Department_of_Public_Health_Venereal_Disease_Poster_26534416996kelihood, many of those people truly at high risk in Chicago are completely missed and never screened.

Given that even with the little testing currently being performed it is already known there is an unusually high incidence of syphilis in Chicago, the IDPH should recommend universal screening of all patients in Chicago for syphilis, and this testing should be covered by all insurers. The only way to curb the syphilis epidemic is to find cases early before they are spread to others. Once patients develop symptoms, it is usually too late, and relying on behavior reporting or only testing small minority groups will not be sufficient.


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

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.

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).


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.