Global & Disaster Medicine

Archive for January, 2019

WHO: Ten threats to global health in 2019

WHO

The world is facing multiple health challenges. These range from outbreaks of vaccine-preventable diseases like measles and diphtheria, increasing reports of drug-resistant pathogens, growing rates of obesity and physical inactivity to the  health impacts of environmental pollution and climate change and multiple humanitarian crises.

To address these and other threats, 2019 sees the start of the World Health Organization’s new 5-year strategic plan – the 13th General Programme of Work. This plan focuses on a triple billion target:  ensuring 1 billion more people benefit from access to universal health coverage, 1 billion more people are protected from health emergencies and 1 billion more people enjoy better health and well-being. Reaching this goal will require addressing the threats to health from a variety of angles.

Here are 10 of the many issues that will demand attention from WHO and health partners in 2019.

Air pollution and climate change


Nine out of ten people breathe polluted air
every day. In 2019, air pollution is considered by WHO as the greatest environmental risk to health. Microscopic pollutants in the air can penetrate respiratory and circulatory systems, damaging the lungs, heart and brain, killing 7 million people prematurely every year from diseases such as cancer, stroke, heart and lung disease. Around 90% of these deaths are in low- and middle-income countries, with high volumes of emissions from industry, transport and agriculture, as well as dirty cookstoves and fuels in homes.The primary cause of air pollution (burning fossil fuels) is also a major contributor to climate change, which impacts people’s health in different ways. Between 2030 and 2050, climate change is expected to cause 250 000 additional deaths per year, from malnutrition, malaria, diarrhoea and heat stress.In October 2018, WHO held its first ever Global Conference on Air Pollution and Health in Geneva. Countries and organizations made more than 70 commitments to improve air quality. This year, the United Nations Climate Summit in September will aim to strengthen climate action and ambition worldwide. Even if all the commitments made by countries for the Paris Agreement are achieved, the world is still on a course to warm by more than 3°C this century.

Noncommunicable diseases

Noncommunicable diseases, such as diabetes, cancer and heart disease, are collectively responsible for over 70% of all deaths worldwide, or 41 million people. This includes 15 million people dying prematurely, aged between 30 and 69.Over 85% of these premature deaths are in low- and middle-income countries. The rise of these diseases has been driven by five major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, unhealthy diets and air pollution. These risk factors also exacerbate mental health issues, that may originate from an early age: half of all mental illness begins by the age of 14, but most cases go undetected and untreated – suicide is the second leading cause of death among 15-19 year-olds.

Among many things, this year WHO will work with governments to help them meet the global target of reducing physical inactivity by 15% by 2030 – through such actions as implementing the ACTIVE policy toolkit to help get more people being active every day.

Global influenza pandemic

The world will face another influenza pandemic – the only thing we don’t know is when it will hit and how severe it will be. Global defences are only as effective as the weakest link in any country’s health emergency preparedness and response system.

WHO is constantly monitoring the circulation of influenza viruses to detect potential pandemic strains: 153 institutions in 114 countries are involved in global surveillance and response.

Every year, WHO recommends which strains should be included in the flu vaccine to protect people from seasonal flu. In the event that a new flu strain develops pandemic potential, WHO has set up a unique partnership with all the major players to ensure effective and equitable access to diagnostics, vaccines and antivirals (treatments), especially in developing countries.

Fragile and vulnerable settings

More than 1.6 billion people (22% of the global population) live in places where protracted crises (through a combination of challenges such as drought, famine, conflict, and population displacement) and weak health services leave them without access to basic care.

Fragile settings exist in almost all regions of the world, and these are where half of the key targets in the sustainable development goals, including on child and maternal health, remains unmet.WHO will continue to work in these countries to strengthen health systems so that they are better prepared to detect and respond to outbreaks, as well as able to deliver high quality health services, including immunization.

Antimicrobial resistance

The development of antibiotics, antivirals and antimalarials are some of modern medicine’s greatest successes. Now, time with these drugs is running out. Antimicrobial resistance – the ability of bacteria, parasites, viruses and fungi to resist these medicines – threatens to send us back to a time when we were unable to easily treat infections such as pneumonia, tuberculosis, gonorrhoea, and salmonellosis. The inability to prevent infections could seriously compromise surgery and procedures such as chemotherapy.

Resistance to tuberculosis drugs is a formidable obstacle to fighting a disease that causes around 10 million people to fall ill, and 1.6 million to die, every year. In 2017, around 600 000 cases of tuberculosis were resistant to rifampicin – the most effective first-line drug – and 82% of these people had multidrug-resistant tuberculosis.

Drug resistance is driven by the overuse of antimicrobials in people, but also in animals, especially those used for food production, as well as in the environment. WHO is working with these sectors to implement a global action plan to tackle antimicrobial resistance by increasing awareness and knowledge, reducing infection, and encouraging prudent use of antimicrobials.

Ebola and other high-threat pathogens

In 2018, the Democratic Republic of the Congo saw two separate Ebola outbreaks, both of which spread to cities of more than 1 million people. One of the affected provinces  is also in an active conflict zone.

This shows that the context in which an epidemic of a high-threat pathogen like Ebola erupts is critical –  what happened in rural outbreaks in the past doesn’t always apply to densely populated urban areas or conflict-affected areas.

At a conference on Preparedness for Public Health Emergencies held last December, participants from the public health, animal health, transport and tourism sectors focussed on the growing challenges of tackling outbreaks and health emergencies in urban areas. They called for WHO and partners to designate 2019 as a “Year of action on preparedness for health emergencies”.

WHO’s R&D Blueprint identifies diseases and pathogens that have potential to cause a public health emergency but lack effective treatments and vaccines. This watchlist for priority research and development includes Ebola, several other haemorrhagic fevers, Zika, Nipah, Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS) and disease X, which represents the need to prepare for an unknown pathogen that could cause a serious epidemic.

Weak primary health care

 Primary health care is usually the first point of contact people have with their health care system, and ideally should provide comprehensive, affordable, community-based care throughout life.

Primary health care can meet the majority of a person’s health needs of the course of their life. Health systems with strong primary health care are needed to achieve universal health coverage.Yet many countries do not have adequate primary health care facilities. This neglect may be a lack of resources in low- or middle-income countries, but possibly also a focus in the past few decades on single disease programmes. In October 2018, WHO co-hosted a major global conference in Astana, Kazakhstan at which all countries committed to renew the commitment to primary health care made in the Alma-Ata declaration in 1978.

In 2019, WHO will work with partners to revitalize and strengthen primary health care in countries, and follow up on specific commitments made by in the Astana Declaration.

Vaccine hesitancy

Vaccine hesitancy – the reluctance or refusal to vaccinate despite the availability of vaccines – threatens to reverse progress made in tackling vaccine-preventable diseases. Vaccination is one of the most cost-effective ways of avoiding disease – it currently prevents 2-3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccinations improved.

Measles, for example, has seen a 30% increase in cases globally. The reasons for this rise are complex, and not all of these cases are due to vaccine hesitancy. However, some countries that were close to eliminating the disease have seen a resurgence.The reasons why people choose not to vaccinate are complex; a vaccines advisory group to WHO identified complacency, inconvenience in accessing vaccines, and lack of confidence are key reasons underlying hesitancy. Health workers, especially those in communities, remain the most trusted advisor and influencer of vaccination decisions, and they must be supported to provide trusted, credible information on vaccines.

In 2019, WHO will ramp up work to eliminate cervical cancer worldwide by increasing coverage of the HPV vaccine, among other interventions. 2019 may also be the year when transmission of wild poliovirus is stopped in Afghanistan and Pakistan. Last year, less than 30 cases were reported in both countries. WHO and partners are committed to supporting these countries to vaccinate every last child to eradicate this crippling disease for good.

Dengue

Dengue, a mosquito-borne disease that causes flu-like symptoms and can be lethal and kill up to 20% of those with severe dengue, has been a growing threat for decades.

A high number of cases occur in the rainy seasons of countries such as Bangladesh and India. Now, its season in these countries is lengthening significantly (in 2018, Bangladesh saw the highest number of deaths in almost two decades), and the disease is spreading to less tropical and more temperate countries such as Nepal, that have not traditionally seen the disease.An estimated 40% of the world is at risk of dengue fever, and there are around 390 million infections a year. WHO’s Dengue control strategy aims to reduce deaths by 50% by 2020.

HIV

The progress made against HIV has been enormous in terms of getting people tested, providing them with antiretrovirals (22 million are on treatment), and providing access to preventive measures such as a pre-exposure prophylaxis (PrEP, which is when people at risk of HIV take antiretrovirals to prevent infection).

However, the epidemic continues to rage with nearly a million people every year dying of HIV/AIDS. Since the beginning of the epidemic, more than 70 million people have acquired the infection, and about 35 million people have died. Today, around 37 million worldwide live with HIV. Reaching people like sex workers, people in prison, men who have sex with men, or transgender people is hugely challenging. Often these groups are excluded from health services. A group increasingly affected by HIV are young girls and women (aged 15–24), who are particularly at high risk and account for 1 in 4 HIV infections in sub-Saharan Africa despite being only 10% of the population.This year, WHO will work with countries to support the introduction of self-testing so that more people living with HIV know their status and can receive treatment (or preventive measures in the case of a negative test result). One activity will be to act on new guidance announced In December 2018, by WHO and the International Labour Organization to support companies and organizations to offer HIV self-tests in the workplace.


Female genital alteration: a compromise solution

Arora KS, Jacobs AJ. J Med Ethics 2016;00:1–7. doi:10.1136/medethics-2014-102375

Journal of Medical Ethics

“…… In order to better protect female children from the serious and longterm harms of some types of non-therapeutic FGA, we must adopt a more nuanced position that acknowledges a wide spectrum of procedures that alter female genitalia. We offer a revised categorisation for nontherapeutic FGA that groups procedures by effect and not by process. Acceptance of de minimis procedures that generally do not carry long-term medical risks is culturally sensitive, does not discriminate on the basis of gender, and does not violate human rights. More morbid procedures should not be performed. However, accepting de minimis non-therapeutic f FGA procedures enhances the effort of compassionate practitioners searching for a compromise position that respects cultural differences but protects the health of their patients…..”

 

NPR

“…..The new traditions are taking hold in Maasai and Samburu communities in Kenya and Tanzania. After two or three days of preparatory sessions for the girls, the celebration culminates with communal singing and dancing and blessings by the village elders, who pour a mixture of milk and honey and water over the heads of the girls. Goats and cows are slaughtered for specially prepared stews or roasts. Traditional beer is brewed for the men to drink. The young women don multi­colored clothing and decorative beads that dangle from their heads and hang around their necks.

Such ceremonies have included from 200 to over 1,000 girls….. with several communities often coming together for the celebration. Usually, the elders also make a public declaration abandoning FGM, and the young men will similarly make public assurances that they will marry women who did not undergo FGM. That’s important because any girl who refused to be cut was shamed and shunned, subjected to a life of isolation, without marriage or children.

And at the center of the celebration are the girls themselves. During the two to three days preceding the celebration, participating girls in the alternative rites of passage are secluded, in a school dormitory or village hut, where they learn about womanhood: lessons which now include sex education, information about STDs and violence against women, and presentations emphasizing the importance of continuing education for girls and women’s rights. The traditional cutters who had in the past performed the cut also are usually present, discussing their role in the past — and explaining the health reasons for abandoning the practice…..”


WHO: All about measles

WHO

Key facts

  • Even though a safe and cost-effective vaccine is available, in 2017, there were 110 000 measles deaths globally, mostly among children under the age of five.
  • Measles vaccination resulted in a 80% drop in measles deaths between 2000 and 2017 worldwide.
  • In 2017, about 85% of the world’s children received one dose of measles vaccine by their first birthday through routine health services – up from 72% in 2000.
  • During 2000-2017, measles vaccination prevented an estimated 21.1 million deaths making measles vaccine one of the best buys in public health.

Measles is a highly contagious, serious disease caused by a virus. Before the introduction of measles vaccine in 1963 and widespread vaccination, major epidemics occurred approximately every 2–3 years and measles caused an estimated 2.6 million deaths each year.

Approximately  110 000 people died from measles in 2017 – mostly children under the age of 5 years, despite the availability of a safe and effective vaccine.

Measles is caused by a virus in the paramyxovirus family and it is normally passed through direct contact and through the air. The virus infects the respiratory tract, then spreads throughout the body. Measles is a human disease and is not known to occur in animals.

Accelerated immunization activities have had a major impact on reducing measles deaths. During 2000– 2017, measles vaccination prevented an estimated  21.1 million deaths. Global measles deaths have decreased by  80% from an estimated  545 000 in 2000* to  110 000 in 2017.

Signs and symptoms

The first sign of measles is usually a high fever, which begins about 10 to 12 days after exposure to the virus, and lasts 4 to 7 days. A runny nose, a cough, red and watery eyes, and small white spots inside the cheeks can develop in the initial stage. After several days, a rash erupts, usually on the face and upper neck. Over about 3 days, the rash spreads, eventually reaching the hands and feet. The rash lasts for 5 to 6 days, and then fades. On average, the rash occurs 14 days after exposure to the virus (within a range of 7 to 18 days).

Most measles-related deaths are caused by complications associated with the disease. Serious complications are more common in children under the age of 5, or adults over the age of 30. The most serious complications include blindness, encephalitis (an infection that causes brain swelling), severe diarrhoea and related dehydration, ear infections, or severe respiratory infections such as pneumonia. Severe measles is more likely among poorly nourished young children, especially those with insufficient vitamin A, or whose immune systems have been weakened by HIV/AIDS or other diseases.

Who is at risk?

Unvaccinated young children are at highest risk of measles and its complications, including death. Unvaccinated pregnant women are also at risk. Any non-immune person (who has not been vaccinated or was vaccinated but did not develop immunity) can become infected.

Measles is still common in many developing countries – particularly in parts of Africa and Asia. The overwhelming majority (more than 95%) of measles deaths occur in countries with low per capita incomes and weak health infrastructures.

Measles outbreaks can be particularly deadly in countries experiencing or recovering from a natural disaster or conflict. Damage to health infrastructure and health services interrupts routine immunization, and overcrowding in residential camps greatly increases the risk of infection.

Transmission

Measles is one of the world’s most contagious diseases. It is spread by coughing and sneezing, close personal contact or direct contact with infected nasal or throat secretions.

The virus remains active and contagious in the air or on infected surfaces for up to 2 hours. It can be transmitted by an infected person from 4 days prior to the onset of the rash to 4 days after the rash erupts.

Measles outbreaks can result in epidemics that cause many deaths, especially among young, malnourished children. In countries where measles has been largely eliminated, cases imported from other countries remain an important source of infection.

Treatment

No specific antiviral treatment exists for measles virus.

Severe complications from measles can be avoided through supportive care that ensures good nutrition, adequate fluid intake and treatment of dehydration with WHO-recommended oral rehydration solution. This solution replaces fluids and other essential elements that are lost through diarrhoea or vomiting. Antibiotics should be prescribed to treat eye and ear infections, and pneumonia.

All children diagnosed with measles should receive two doses of vitamin A supplements, given 24 hours apart. This treatment restores low vitamin A levels during measles that occur even in well-nourished children and can help prevent eye damage and blindness. Vitamin A supplements have been shown to reduce the number of deaths from measles by 50%.

Prevention

Routine measles vaccination for children, combined with mass immunization campaigns in countries with high case and death rates, are key public health strategies to reduce global measles deaths. The measles vaccine has been in use for over 50 years. It is safe, effective and inexpensive. It costs approximately one US dollar to immunize a child against measles.

The measles vaccine is often incorporated with rubella and/or mumps vaccines. It is equally safe and effective in the single or combined form. Adding rubella to measles vaccine increases the cost only slightly, and allows for shared delivery and administration costs.

In 2017, about 85% of the world’s children received 1 dose of measles vaccine by their first birthday through routine health services – up from 72% in 2000. Two doses of the vaccine are recommended to ensure immunity and prevent outbreaks, as about 15% of vaccinated children fail to develop immunity from the first dose. In 2017, 67% of children received the second dose of the measles vaccine.

Of the estimated 20.8 million infants not vaccinated with at least one dose of measles vaccine through routine immunization in 2017, about 8.1 million were in 3 countries: India, Nigeria and Pakistan

WHO response

In 2010, the World Health Assembly established 3 milestones towards the future eradication of measles to be achieved by 2015:

increase routine coverage with the first dose of measles-containing vaccine (MCV1) by more than 90% nationally and more than 80% in every district;

reduce and maintain annual measles incidence to less than 5 cases per million;

reduce estimated measles mortality by more than 95% from the 2000 estimate; and

In 2012, the Health Assembly endorsed the Global Vaccine Action Plan, with the objective of eliminating measles in four WHO regions by 2015 and in five regions by 2020.

By 2017, the global push to improve vaccine coverage resulted in an  80% reduction in deaths. During 2000– 2017, with support from the Measles & Rubella Initiative and Gavi, the Vaccine Alliance, measles vaccination prevented an estimated  21.1 million deaths; most of the deaths averted were in the African region and in countries supported by the Gavi Alliance.

But without sustained attention, hard fought gains can easily be lost. Where children are unvaccinated, outbreaks occur. Because of low coverage nationally or in pockets, multiple regions were hit with large measles outbreaks in 2017, causing many deaths. Based on current trends of measles vaccination coverage and incidence, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) concluded that measles elimination is greatly under threat, and the disease has resurged in a number of countries that had achieved, or were close to achieving, elimination.

WHO continues to strengthen the global laboratory network to ensure timely diagnosis of measles and track international spread of the measles viruses to allow more coordinated country approach in targeting vaccination activities and reduce measles deaths from this vaccine-preventable disease.

The Measles & Rubella Initiative

Launched in 2001, the Measles & Rubella Initiative (M&R Initiative) is a global partnership led by the American Red Cross, United Nations Foundation, Centers for Disease Control and Prevention (CDC), UNICEF and WHO. The Initiative is committed to ensuring that no child dies from measles or is born with congenital rubella syndrome. We help countries to plan, fund and measure efforts to stop measles and rubella for good.

 


1/20/1980: Bleachers at a bullring in Sincelejo, Colombia, collapse, resulting in 222 deaths

HxC

 


Tuyuksu Glacier in Central Asia: In 6 decades it has lost more than 1/2 mile

NYT

“….The world’s roughly 150,000 glaciers, not including the large ice sheets of Greenland and Antarctica, cover about 200,000 square miles of the earth’s surface. Over the last four decades they’ve lost the equivalent of a layer of ice 70 feet thick…..”

 


About 170 people are feared to have died in two separate Mediterranean shipwrecks

BBC

UNHCR

“UNHCR is deeply saddened at emerging reports of an estimated 170 people who either died or went missing in two separate shipwrecks on the Mediterranean Sea.

Some 53 people have died on the Alborán Sea, western Mediterranean, according to recent information from NGO sources. One survivor is understood to have been rescued by a passing fishing boat after being stranded for more than 24 hours at sea and is receiving medical treatment in Morocco. Moroccan and Spanish rescue vessels have been searching for the boat and survivors for several days to no avail.

The Italian Navy are also reporting an additional shipwreck on the central Mediterranean. Three survivors were taken for treatment on Lampedusa, and reported that 117 people, who are currently dead or missing, were on board with them when they departed from Libya.

UNHCR has been unable to independently verify the death tolls for both shipwrecks.

“The tragedy of the Mediterranean cannot be allowed to continue,” said Filippo Grandi, UN High Commissioner for Refugees. “We cannot turn a blind eye to the high numbers of people dying on Europe’s doorstep. No effort should be spared, or prevented, from saving lives in distress at sea.”

In 2018, 2,262 people lost their lives attempting to reach Europe via the Mediterranean Sea. UNHCR is concerned that actions by States are increasingly deterring NGOs from conducting search and rescue operations, and is calling for these to be lifted immediately.

At the same time, greater efforts are needed to prevent refugees and migrants from taking these desperate journeys in the first place. More safe and legal pathways to access asylum in Europe are needed for those fleeing war and persecution so that no one feels they have no other choice than to put their lives in the hands of unscrupulous traffickers and smugglers. ”


Pipeline explosion: 73 dead so far (‘People’s skin came off’)


M 6.7 – 15km SSW of Coquimbo, Chile 2019-01-20 01:32:51 (UTC)

DYFI intensity map

Estimated Fatalities Histogram

Estimated Economic Losses Histogram

Population Exposure Map


Somalia: Pediatric Surgical Conditions

JAMA

Prevalence of Pediatric Surgical Conditions Across Somaliland

JAMA Netw Open. 2019;2(1):e186857.
“…..The most common conditions encountered were congenital anomalies (33.8%) and wound-related injuries (24.6%)…  Nationally, an estimated 256 745 children have surgical conditions, with an estimated 88 345 to 199 639 children having unmet surgical needs.…”

A Typhoid Fever Outbreak — Harare, Zimbabwe, October 2017–February 2018

MMWR

The figure is a histogram showing suspected cases of typhoid fever (N = 3,187) in Harare, Zimbabwe, during October 1, 2017–February 24, 2018, by date of symptom onset.

“……Among 583 patients admitted with a diagnosis of suspected typhoid, complications occurred in 79 (14%), the most common being acute kidney injury (26), anemia (10), peritonitis (nine), and electrolyte abnormalities (nine). One patient experienced intestinal perforation. Five patients with suspected typhoid died; …….”

 


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