Why there’s no Ebola treatment or vaccine yet, in one chart

This is the second of two posts this week on Ebola. Read yesterday’s here: Why here, why now, and why so deadly?

I didn’t make a mistake in the chart above. Ebola’s 1,323 cases barely register when lined up next to killers like AIDS and cancer.

Drugs and vaccines have been in the works for a while, but drug companies aren’t interested in something that infects a handful of people each year in poor countries. (They, like the fictional Samuel Gall, are perhaps happiest specializing in “diseases of the rich”).

Treatments and vaccines in the pipeline

A better source of funding would be governments concerned about Ebola being used as a bioterror weapon. That’s how BioCryst is positioning its antiviral drug, currently known as BCX4430, which seems to be effective in monkeys but hasn’t been tested in humans yet. A Canadian company, Tekmira, is taking a similar approach with their RNA-based treatment; their studies were funded by the US Department of Defense.

Antibody treatments are another possible option, and Kent Brantly, a doctor who contracted Ebola, is reportedly being given antibodies from a boy he treated, who survived the disease.

Inspired by the recent outbreaks, the US’s NIH and FDA are working together to fast-track a Phase 1 clinical trial of an Ebola vaccine that works in animals and could be given to humans as soon as next month.

What we’re doing in the meantime

Ebola patients receive basic supportive care, for example to maintain hydration, but there’s no treatment that can make the disease go away. Antibiotics don’t work because it’s a virus; the antiviral treatment Ribavirin that works on some other hemorrhagic fevers isn’t effective against Ebola.

The only public health tools we have to prevent spread of the disease are good old fashioned isolation (for sick people) and quarantine (for those who have been exposed and may be sick). To find people who have been exposed, health workers track down people who have been in contact with someone who has the disease.

“None of us would be thrilled about the prospect of being admitted to an isolation ward,” says Daniel Bausch, the Ebola expert I spoke with for yesterday’s post. NPR reports that some families are choosing to hide a loved one’s infection rather than risking the “panic and ostracism” that may come from seeking treatment.

Health workers are seeing serious resistance to medical care in some areas. Another NPR report explains:

A plague hits, and then a bunch of foreigners in spacesuits come and whisk away the corpses in shiny white body bags. There have been stories that this is all a scheme to harvest organs from the locals. … Dr. Tim Jagatic of Doctors Without Borders says the misperceptions are understandable: “We created a hospital, and a lot of people started to get sick and die.”

Bausch says that a good treatment or vaccine could reverse that trend: instead of tracking down patients and contacts who believe they have a good reason to hide from health workers, people “would be knocking on the door: ‘I think I have Ebola, could you please give me that treatment?’”

 

Epilogue: The three big questions

I asked Daniel Bausch what big questions still remain in Ebola research. He named three broad areas:

  1. As reported above, we don’t know any good treatments to offer patients and their contacts–just supportive care, quarantine and isolation.
  2. We don’t know enough about how the virus works in the human body. There are animal models that provide some glimpses, but to study humans you have to be able to do research in the middle of a raging outbreak of a rare disease. That’s tough. We have recently learned, for example, that it doesn’t always cause extensive bleeding. That’s why its name was changed from “Ebola hemorrhagic fever” to the simpler “Ebola virus disease.”
  3. We don’t know enough about how the virus spreads. Probably it circulates in bats and is occasionally transmitted to other animals, including humans, as a dead-end host–but the disease is so rare we don’t have a good way of studying it in the wild. Bausch says that while he was in Guinea recently, a group of ecologists started collecting bats from the local population, but their results are not yet published.
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Ebola: Why here, why now, and why so deadly?

This is the first of two posts on Ebola this week. Tune in tomorrow for a look at the big questions facing Ebola researchers.

You’ve probably heard that the current outbreak of Ebola virus is the largest ever, and thus the deadliest. Today’s death toll is 729 out of 1,323 infected since the outbreak began late last year.

Unlike other diseases, Ebola is not always around. Measles infects twenty million people a year; Ebola, outside of outbreaks, infects (as far as we know) zero. Before the current outbreak, the previous infection was more than a year earlier. In between outbreaks, the disease doesn’t exist at a baseline level in the population; it is simply gone.

So why is a huge outbreak occurring now? Why in western Africa, thousands of miles from the place this strain of virus was last seen, in 2009? And why has it gotten so large? Those are the questions Daniel Bausch discusses in an article published today in PLOS Neglected Tropical Diseases. Bausch is an expert in infectious tropical diseases who has been part of the response to the current outbreak, treating patients and training medical staff.

Doctors and scientists know precious little about Ebola virus: how it travels, how it kills, why it emerges when it does. Ebola is suspected to circulate among fruit bats, but nobody has yet isolated the virus in a wild bat.

What’s a deadly little virus like you doing in a place like this?

There’s more than one kind of Ebola virus. Analysis of the genome of the virus in the current outbreak shows that it isn’t related to the Tai Forest virus from nearby Cote d’Ivoire, but rather to the Zaire ebolavirus whose stomping grounds are half a continent away.

How did the virus travel so far without any human cases detected in the meantime? Bausch thinks it wasn’t due to a human traveler. Getting to Gueckedou, where the outbreak seems to have started, requires 12 hours of driving just for the last leg of the trip from any of the nearby capital cities, hardly something you’d do if you were suffering from Ebola. I asked Bausch if an asymptomatic carrier could be the culprit in a Typhoid Mary-like situation, but he says that a person’s ability to shed the virus seems to correlate strongly with how severe their symptoms are. “The likelihood of this being introduced by a sick human is very low,” he says, and by an asymptomatic human even lower.

That leaves the bats. Bats do migrate, and if the virus is in regular circulation among bats it may be less severe, letting a sick bat make the trip more easily than a sick person.

When did the virus make its trip? A recent analysis of blood samples collected from the area over the last 18 years (when they were collected from patients suspected of having Lassa fever) shows that years before the current outbreak, the Ebola virus may have been popping up occasionally in humans in this part of Africa.

Why now?

The current outbreak started in December 2013, at the beginning of the dry season; based on previous outbreaks Bausch believes there may be a connection with the weather, but without knowing more about the ecology of the virus, it’s hard to say if that’s a factor or just a coincidence.

We don’t know how many places in Africa may have Ebola virus circulating in bat populations and occasional Ebola cases in humans that miss diagnosis. But the key factor that sustains an outbreak may not be biological at all.

Why is this outbreak so bad?

Bausch traveled to Guinea every year for a decade while investigating other diseases in the area, and writes that every time he traveled from the capital Conakry to the forest region, “the once-paved road was worse, the public services less, the prices higher, the forest thinner.”

That area where the outbreak started, around Guéckédou, is in a pocket of forest where the borders of three countries converge: Liberia, Sierra Leone, and Guinea. They rank 174, 177, and 178, respectively, on the UN’s Human Development Index; in other words, they are three of the poorest countries in the world. Sierra Leone and Liberia were embroiled in civil war until the early 2000s; Guinea has suffered from a devastatingly corrupt government. None of the countries are in a good position to respond quickly and efficiently to a disease outbreak, and health centers in the region are not always equipped with necessities like gloves and clean needles.

Another complication is that the outbreak area covers three countries. In this area, Bausch says, people identify more with their ethnic group than with their country; borders aren’t much of a dividing line in everyday life. If you live in the area you might cross a border to go to the market or attend school, and you may speak your local language rather than the national language of French (Guinea) or English (Liberia and Sierra Leone).

This all adds up to a situation where a health worker in one country can’t just call up the other side to say hey, this patient had contacts on your side of the border, can you follow up? Even when language is not a barrier, there may not be a phone line to deliver that message nor the organization and resources to do the job.

As the virus spreads–it’s now in Nigeria–socio-economic factors like these will likely determine where an outbreak will catch fire and where it will fizzle out. “I think a military analogy is appropriate here,” Bausch says. “How many fronts can you fight on?”

Correction: A previous version of this post stated that Liberia and Sierra Leone were “embroiled in civil war.” This isn’t currently true, and I’ve corrected the statement above. Thanks to Adia Benton for pointing out the error.

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Immigrant youth to Canada are less active than Canadians, but only for a little bit

Regular readers of the blog and my Twitter profile will know that my PhD dissertation is focused on the health of young people to Canada. In particular, I’m interested in how their health changes over time – does it get better? Does it get worse? Does it stay the same? And in particular, I’m interested in how they compare to peers born in Canada, and whether this is the same between different ethnic groups.

So, for example, if you took two South Asian kids, one born in Canada and one born abroad, what happens to their health? Is the one born abroad healthier? The same? What about after they move to Canada – if the one born abroad starts off healthier, does that persist, or does that benefit disappear with time?

I did a few interviews for this study with the media, and I’ve embedded them throughout the piece. So if you don’t want to read anymore, just hit play on the video below.

(Note: The video should be 16:9, but Vimeo made it 4:3 and I can’t figure out how to change it. Sorry about that).

Now, there’s been a lot of research on this in the US. But the research in the US has focused on the ethnic groups that are of interest to the US – Black, Hispanic and Asian Americans. In Canada though, the major immigrant groups are from East and South East Asia and South Asia. Combine that with two different views on immigration (melting pot vs multiculturalism), and there’s not much evidence out there for what happens to kids once they move to Canada in terms of their physical health.

And that’s where I come in.

We just had a study published in PLOS ONE that looked specifically at the physical activity of young immigrants to Canada, and how their physical activity changes over time.

What did we do?
The Health Behaviour in School Aged Children Survey (HBSC) is an international survey coordinated by the World Health Organization in 43 countries in Europe and North America. We used data from Cycle 6 of the Canadian HBSC, which had data on approximately 26,000 youth in all provinces and territories in Canada, except PEI and New Brunswick. We categorized kids by ethnic group: Canadian, Arab, African, South Asian, East and South East Asian, Latin American and Other. We also categorized them by how long it had been since they moved to Canada: “1 to 2 years,” “3 to 5 years” “6+ years” and then “born in Canada.”

We then were interested in their physical activity levels, and put them into one of three groups based on the number of days of 60+ minutes of physical activity they reported. The first group was 1-3 days, the second was 4-6 days, and the third was 7 days a week. Only the last group met the Canada Physical Activity Guidelines, but then we were also interested in kids who were close (the 4-6 days a week group).

I was interviewed by Wei Chen for CBC Ontario Morning – take a listen here!

What did we find?
As we expected, kids born outside of Canada were less active than those born in Canada. In fact, only 11% of those born abroad got 7 days a week of 60+ minutes of physical activity compared to 15% among those born in Canada. However, the longer you were in Canada, the higher your physical activity was. For example, while kids who moved here 1-2 years before were much less likely to meet the physical activity guidelines, those who moved here 3-5 or 6+ years ago were just as likely as those born in Canada to meet the guidelines. This is a really positive finding – while their initial levels of physical activity might be low, they correct this really soon after immigrating.

But here’s where things got interesting. When you start looking at this by ethnic group, certain trends emerge. We found that East and South-East Asian youth were less active, regardless of time since immigration. They were less likely to be active on 4–6 days/week (0.67; 0.58–0.79) and 7 days/week (0.37; 0.29–0.48), compared to (White) Canadian peers. So whether they were born in Canada, or whether they just moved here, their physical activity levels were consistently lower than other kids.

What is the take home message?
There a few things you can take from this. We found that immigrant kids were less active than Canadian-born peers, although this difference disappears over time. However, this is impacted by ethnicity, with some groups reporting higher levels of physical activity than others. Perhaps most interesting was how East and South East Asian youth have lower levels of physical activity levels regardless of where they were born or how long they have lived in Canada.

Below is an interview that I did with Philip Till from CKNW Radio in Vancouver.

Throughout the piece, I’ve embedded clips of me talking about the study. Take a listen, and I’d love to hear your thoughts! Does this resonate with your experiences/what you’ve seen? And for my international readers, how does this compare to your countries?

Finally, this study wouldn’t be possible with our funders and the respondents to the HBSC Survey. Thank you all for your support!

References:
Kukaswadia, Atif, William Pickett, and Ian Janssen. “Time Since Immigration and Ethnicity as Predictors of Physical Activity among Canadian Youth: A Cross-Sectional Study.” PloS one 9.2 (2014): e89509. Link: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0089509

Category: Determinants of health, Epidemiology, Nutrition, Running, Time trends | Tagged , , , , , , , , , | Leave a comment

“Oh no! What happened?” “W220.2XD: Walked into lamppost, subsequent encounter.”

Last week, I ran across this very entertaining piece over in Healthcare Dive about the new ICD-10 codes. The International Classification of Diseases (ICD) is an incredibly useful tool in public health that basically can reduce an injury to a series of numbers. As you can imagine, this is very powerful when it comes to determining if something is on the rise. Researchers can easily count the number of times something occurs, and if it’s up from previous years, there might be something there.

Part of the beauty of the ICD-10 codes is how specific they are. The previous system, ICD-9 (creative, I know) wasn’t nearly as specific as they only had 13,000 codes compared to the 68,000 in ICD10. With the advent of ICD-10, The Powers That Be have gone into painstaking detail breaking down injuries, diseases and other maladies into incredible precise codes that can be used by researchers and public health professionals.

Today, we’re going to go through my favourite ones.

Do you know what code it is if you get hit by a Macaw? Because one exists. | Photo via National Geographic

Do you know what code it is if you get hit by a Macaw? Because one exists. | Photo via National Geographic

W55.89XA: Other contact with other mammals
There are many codes for contact with mammals. Raccoons, cows, pigs and cats are all represented. However, the mighty seal is not covered, which made Buster Bluth very sad. He would have suffered from W55.89XA.

 

W61.12XA: Struck by macaw, initial encounter. ​

Look like our patient
*puts on sunglasses*
Is a little Macaw-struck
YEAHHHHHHHHHHHHHHHHHHHHHHHHHHH

(The other option here was for an AC/DC reference…)

 

V97.33XD: Sucked into jet engine, subsequent encounter.
Now, I’m not an MD. But, if you are getting sucked into a jet engine on more than one occasion, you may want to re-evaluate your life choices.

Lamp posts are sneaky, and when you're not looking will clock you over the head. | Photo via Wikipedia

Lamp posts are sneaky, and when you’re not looking will clock you over the head. | Photo via Wikipedia

 

W22.02XD: Walked into lamppost, subsequent encounter.
I don’t really know if going to see a doctor is the best solution here, or just looking where you’re going. I do imagine this being on the rise as the epidemic of texting and walking continues to rise.

(Ed note: Subsequent encounter here means they have seen the doctor previously for the same complaint, not that they have done it several times, even though the latter does make it funnier).

 

Y93.44: Activity, trampolining
When searching for “trampoline fail” yields a 5 minute montage on YouTube, you know this is a necessary code.

 

I also looked at some and realized they could be for superheroes…

T63.301A: Toxic effect of unspecified spider venom, accidental (unintentional), initial encounter
Spiderman, spiderman, does whatever a T-63-301-A can!

 

T75.01XA: Shock due to being struck by lightning, initial encounter
When he was hit by lightning, Barry Allen turned from a police scientist to become The Flash! One of the greatest superheroes of the Silver Age!

 

W88.1: Exposure to ionizing radiation
HULK NO LIKE BAD CODES. HULK LIKE WELL CATEGORIZED DATA. HULK LIKE PUBLIC HEALTH.

 

And my favourite code in the ICD10 manual:

V91.07XA: Burn due to water-skis on fire, initial encounter
Frankly, if you manage to set water-skis on fire, I’m not sure whether I want to give you a hi-five, a Darwin award, or video the whole thing for YouTube. I’m not even mad, that’s amazing.

 

====

While I make fun of the codes, they’re incredibly useful for public health and for collecting data. Knowing person, place and time, i.e. this idea of who is getting injured, where they’re hurting themselves and how can make all the difference when it comes to analyzing data and creating programs to prevent these injuries and illnesses from occurring. Whenever you present to a doctor, if they record the information that will allow for your ailments to be categorized using the ICD10 system, it goes a long way to helping researchers figure out what is going on at a macro, population level.

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1 weird tip to not die of smallpox

Cartoon about vaccination ("The Cow Pock") from http://en.wikipedia.org/wiki/File:The_cow_pock.jpg

How weird is vaccination? So weird they’re putting cow disease juice under your skin. Ew.

Sawbones is a hilarious podcast about the ways medicine has, historically, gone wrong. On long drives with nerdy friends, I whip out my phone and we consider which episode to listen to and laugh at: Leprosy? Trepanation? Bloodletting? Plague?

The hosts, Justin and Sydnee McElroy, offer a “marital tour of misguided medicine.” Dr. Sydnee, who is an actual doctor, provides the medical and historical knowledge. Meanwhile her husband, Justin, plays dumb—for example, thinking he’s got leprosy, or positing that menstruation is a disease that needs to be cured.

But last week, Sawbones released a Very Special Episode about vaccines. It was their most requested topic, the hosts said, and they really, really didn’t want to do it. The show is supposed to be light entertainment, and they’ve avoided taking sides on any controversy—even, in the episode on homeopathy, going easy on modern-day adherents of the practice. What made them jump into the fray for vaccines? In Justin’s words: “It’s 2014, and kids are getting the measles.”

You can listen to the episode here:

The other problem with featuring vaccines on Sawbones was simply that medicine got it right. While most of the treatments they lampoon on the show are ones that sort of sound plausible, but were wrong, vaccines sound totally weird (give my kid a sick person’s pus?!) but actually work. So it’s not a history of mistakes, but for the most part a string of successes.

It is also, touchingly, at many times a story of parents trying to save their children from death. I saw in the story of Lady Mary Wortley Montagu a reflection of today’s “mommy wars” over vaccines. She was a young mom who had lost her brother to smallpox. Her husband was the English ambassador to Turkey, and while she lived there she learned about variolation, in which a healthy person is given liquid from a smallpox pustule. (If the virus involved is Variola minor, you’ll gain immunity to both that and the more serious Variola major.)

Lady Mary had her 5-year-old son inoculated in Turkey, and after returning to England, had her daughter inoculated in the midst of a smallpox epidemic. She encouraged others to try variolation, but it didn’t catch on (too foreign) until Princess Caroline allowed it for her children. And she didn’t try it until after it had been tested, first on a group of death row prisoners, and later (for good measure) on a half-dozen orphans.

OK, so they got the science right, but the ethics way, way wrong. Several times.

When Edward Jenner famously made the first vaccine—from vacca for cow—he gave it to James Phipps, the son of a poor worker. Dr. Sydnee and Justin speculate that money may have changed hands (would YOU volunteer your son to catch a cow disease?), but there’s no record of a payoff at the time (he did give Phipps a free lease on a house, later in life). Jenner then attempted to infect the child with smallpox twenty more times in his life. Fortunately for the kid, the vaccine had worked.

Worse yet, to provide colonies with the vaccine, cowpox was given to five orphans who were then shipped across the ocean.

Throughout the story, our Sawbones hosts marvel at how weird the techniques were. And yet, they worked. Weirder still, they caught on. Vaccination was such a success that smallpox was, in 1977, officially eradicated. Dr. Sydnee recalls learning the progression of smallpox lesions in medical school: “macule to papule to vesicle to pustule,” she recites, and adds that, fingers crossed, she should never have to use that knowledge.

But you know what comes next. As soon as they released that episode, mentioning in an offhand way that smallpox now only exists in two labs in the world (one in the US, one in what is now Russia), a third stash of smallpox virus was found in the back of a fridge in Bethesda.

Still, the World Health Organization keeps stockpiles of smallpox vaccine and recommends that the existing virus stocks not be destroyed, an idea that is floated from time to time. We don’t know what other refrigerators smallpox might lurk in; best to be prepared.

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Why young Americans aren’t using Obamacare

gotinsurance

You’re going to need insurance if you break your neck doing a keg stand…

The first open enrolment period for Obamacare ended this March. Despite the cringe-worthy ads, it was a success. 9.5 million Americans now have health insurance through the Affordable Care Act – a huge step forward for President Obama’s vision of universal healthcare for the country. The rate of uninsured adults has dropped from 20% last year to 15% this year (1).  Given the disastrous roll-out phase of the program, this surge in enrolment is encouraging to those who view Obamacare with a glass half-full attitude. However, there are still roadblocks on the path to equitable and affordable health care for Americans. One of these is the fact that young Americans simply aren’t signing up for health insurance as much as they should.

According to the just-released Commonwealth Fund poll, 18% of young adults (ages 19-34) are currently uninsured (1). This figure is much lower than last year, but is still higher than the nationwide-average of 15%. It’s strange, because the idea of universal healthcare was likely a big draw for young democratically-minded Americans hoping for a more equal society under Barack Obama. So why aren’t we buying in?

Being young, we feel invincible. And rightly so – young people enjoy the best health.  In fact, as a young person, it can be more expensive to visit the ER if you are insured versus not. A recent study estimated that an uninsured young adult visiting the ER once in 2014 will pay an average of $2,022 in out-of-pocket costs (2). On the other hand, the average insured young adult visiting the ER once will pay $2,791 in the 2014 year for their insurance premium and the remaining out-of-pocket cost of the ER visit.  This example is a bit extreme, since it assumes that the only healthcare used in one year would be one ER visit. More realistically, the insured person would win out in the end if he or she uses other healthcare services as well.  But, it exemplifies how you wouldn’t necessarily save money as a young person if you have a medical emergency. Even with the cost of the penalty for not buying insurance (which will go significantly up in future!), it can still be cheaper to go uninsured.

The question of whether or not to buy health insurance as a young person is a game of risk, and how much of it we’re willing to bear.

Another issue is that we don’t bother to educate ourselves about health insurance, and the government doesn’t do much to help us. Over one-quarter of Americans aged 19 to 29 didn’t even know that the ‘Health Insurance Marketplace’ – the online portal for getting information, comparing plans, and purchasing health insurance – even exists. That’s a huge problem. But, it’s not entirely our fault. Even for highly educated young adults, the HealthCare.gov website can be remarkably difficult to navigate. A study recently published in the Annals of Internal Medicine recorded the following problems with the website (3):

-          Poor explanations of technical health insurance terms

-          An overwhelming amount of information

-          It’s not clear that preventive health services like cancer screenings are always free (they are!)

-          It’s difficult to figure out which plan is best suited to you and your needs

-          The ‘catastrophic’ insurance category sounds scary

If young, highly-educated people encounter these seemingly basic problems, then that’s a scary thing. Think about how older adults with lower education, or whose first language isn’t English might do when trying to make a good decision when buying health insurance. It’s really difficult to communicate complex risk information, and as a result most people (even young, highly educated people!) have low ‘risk literacy’. Check out this 3-minute Risk Literacy to see how well you do – you might be surprised.

gotinsurance2

So, what’s the take-home message? As always, no matter whether you are old or young, or whether you have health insurance or not, take the time to educate yourself so that you can make the best decisions and be in control of your own health and how it’s taken care of. The benefit of Obamacare to the country is obvious now after this open enrolment period. The new Commonwealth Fund report states that:

By June [2014], six of 10 adults with new marketplace or Medicaid coverage said they had used their insurance to go to a doctor or hospital or to fill a prescription. A majority said they would not have been able to access or afford this care before enrolling.

If you are a young American and don’t have health insurance, you really should look into getting some. You might find that it’s not worth it for you, and that’s fine. It’s a politicized issue too, so it’s good to decide what stance you take on it. Every citizen plays a role in the future of Obamacare, and be extension, the future of equality and the welfare state in America. And, the penalty fee is going to be quite hefty in the next few years if you don’t sign up (4).

Image source: http://doyougotinsurance.com/

References

1)      Collins SR, Rasmussen PW, Doty MM. Gaining Ground: American’s health insurance coverage and access to care after the Affordable Care Act’s first open enrolment period. Commonwealth Fund. Report number: 1670, 2014.

2)      Pratini N. The $1000 mistake? Why getting insured is 5x more costly for healthy young adults in 2014. http://www.nerdwallet.com/blog/health/2014/01/14/cost-health-insurance-young-adults/ (accessed 13 July 2014).

3)      Wong CA, Asch DA, Vinoya CM, Ford CA, Baker T, Town R, et al. The experience of young adults on HealthCare.gov: suggestions for improvement: a case report. Ann Intern Med 2014; doi:10.7326/L14-0287

4)      Patton M. Obamacare: Penalties and exemptions. http://www.forbes.com/sites/mikepatton/2013/10/28/obamacare-penalties-and-exemptions/ (accessed 13 July 2014).

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The worm turns no more…

Public Health Perspectives is pleased to welcome Charles Ebikeme to the blog this week. For more information about Charles, see the end of this post.

Bandaged children read about the guinea worm.

Bandaged children read about the guinea worm.

John Stavely, age 24 and unassuming, arrived at Cape Coast Castle on the coast of Ghana in June of 1842. He spent no more than 65 days on the gold coast, stowing and moving palm oil casks in the holds of the sailing ladies that came and went.

It was not until May of the next year that he began to suspect something was seriously wrong – a sore on his left instep. It caused him little pain at the time. After a while his sore had grown – a worm the width of a violin string was searching for its way out, migrating through his subcutaneous tissue. His leg became inflamed and many abscesses formed. It turned out that there were three of those little worms – or filaria – wriggling inside his body; one in his left leg, one in his left forearm, and the other in his right foot. All were over two feet long. The disease was Dracunculiasis, and is caused by the parasitic worm Dracunculus medinensis.

It took two weeks for his physician to finally take out the worm in his foot, extracting it, little by little, wrapping it around a small piece of rag.

John Stavely’s case of guinea worm was an early documented case of dracunculiasis, but was in no way the earliest. The Ghanaians that worked with him on the ships bound their legs with leaves to cover the marks, blisters and ulcers caused by the worms. Guinea worm has been documented in Egyptian medical texts as early as the 15th century BC. In the book of Numbers, when the Israelites spoke out against their god, the Lord sent fiery serpents among the people, biting and killing them. These “fiery serpents” referenced are thought to be guinea worm.

The case of guinea worm eradication is one of the more under-reported global health stories. A completely non-revolutionary tale made even more remarkable if you think that there is no treatment or vaccine for the disease.

The only way to eliminate the disease is to avoid its playground: sources of water that are contaminated with the tiny crustaceans that act as hosts for the worm’s larvae.

From an estimated 3.5 million cases in 1986, there has been a dramatic reduction, with only 1058 cases reported in 2011. The majority of these cases occurred in South Sudan, and a few cases in Mali, Ethiopia and Chad. It is very probable that zero cases will be achieved in the coming years.

Eradication programmes have been multi-pronged and old-fashioned, a far cry from the technological revolution that inspired much of the global health revolution with former US President Jimmy Carter leading the charge. Eradication depends almost entirely on education – teaching people how to avoid contaminating water sources and how to avoid infection. This together with filtering drinking water with straws with cloth filters and treating water sources with larvicide, form a concerted eradication effort.

In many remote villages in Mali, people get their water from rivers and ponds nearby. Water potentially contaminated with the larvae of the guinea worm. It is usually the children’s job to fetch the water. If a child who is infected is in charge of collecting the water, as is often the case, they could go on to transmit the disease and contaminate a further 300 people. In Mali, UNICEF go to great lengths to isolate those already infected – placing them in makeshift clinics for the duration of their treatment. Local health authorities financially reward anyone who informs them of the presence of infected cases and those infected are also rewarded for coming in for treatment.

The safe and effective solution comes from the provision of safe supplies of water, ensuring that villagers are able to filter the water they collect. If no filter is present then people simply pour water through large pieces of clothing or fabric (another low-tech solution).

When an eradication effort comes down to the last quarter of an inch — from a global agreement across countries, fierce political will, and from an effort that spans many decades — the last remaining piece of the puzzle is that you need to be able to get to people (and to that last individual). This often proves a huge logistical challenge, and has seen some efforts fall at the final stage (the global effort to eradicate malaria is one example). But the signs of progress are in the numbers.

In January of this year, the Carter Center announced that only 148 cases of guinea worm disease remain worldwide, with South Sudan reporting 76% of total cases in 2013.

Very early on, global disease eradication campaigners understood that Sudan would likely be a last bastion of dracunculiasis. From independence in 2011, South Sudan has continued to face deteriorating humanitarian and health conditions.

With South Sudan a pastoralist community, population movements in cattle camps and continued low safe water coverage in endemic villages posed daunting operational challenges for the country eradication programme coordinated by the WHO. The WHO South Sudan report wrote in 2012 that ”there are also uncertainty and concerns in achieving good surveillance in parts of Jonglei because of poor road network and high insecurity.” Former US President Jimmy Carter said,

“As we near the finish line in this eradication campaign, The Carter Center and its partners remain committed to ending the devastating suffering caused by Guinea worm disease, recognizing that the final cases of any eradication campaign are the most challenging and most expensive to eliminate,”

Countries only enter the WHO precertification stage of eradication after completing one full calendar year of reporting no cases. South Sudan is currently some way off from this (2 new cases were reported in April) although it is a much improved situation compared to last year when 31 cases were reported during the same period.

The one year incubation period leaves little room for mistakes, and makes declaration of elimination tricky. Currently, there are nine people walking around with the little worms wriggling inside. Perhaps the worms are in the leg, the foot, or the forearm; all probably quite large. But most certainly, this will definitely be the last of the disease.

About Charles

charles_ebikeme (1)

Charles Ebikeme is a science journalist with a PhD in parisitology who serves as a Science Officer with the International Social Science Council of UNESCO and writes frequently on global health, health policy, neglected tropical diseases and infectious diseases for The Huffington Post, The Guardian, Scientific American, and Think Africa Press. He is based in Paris. You can find him on Twitter @CEbikeme.

 

Image Credit: The Carter Center/L. Gubb

 

References

Case of Filaria Medinensis, or Guinea Worm.

Oke WS.

Prov Med J Retrosp Med Sci. 1843 Aug 26;6(152):446-7.

 

Logistics of Guinea Worm Disease Eradication in South Sudan

Alexander H. Jones et al.

Am. J. Trop. Med. Hyg., 90(3), 2014, pp. 393–401

doi:10.4269/ajtmh.13-0110

 

Dracunculiasis eradication – Finishing the job before surprises arise

Benjamin Jelle Visser

Asian Pac J Trop Med. 2012 Jul;5(7):505-10. doi: 10.1016/S1995-7645(12)60088-1.

 

Dracunculiasis eradication and the legacy of the smallpox campaign: What’s new and innovative? What’s old and principled?

Frank O Richards et al.

Vaccine. 2011 Dec 30;29 Suppl 4:D86-90. doi: 10.1016/j.vaccine.2011.07.115.

Category: Epidemiology, Guest Posts, Health systems, History of Public Health, Infectious disease | Tagged , , , , , , , | Leave a comment

Do older mothers really live longer? And what does it mean if they do?

Photo by Chris Zielecki via Flickr. CC-BY-NC-SA.

Photo by Chris Zielecki via Flickr. CC-BY-NC-SA.

You may have seen the headlines: “Older mothers tend to live longer,” was how TIME put it. NPR chose a more careful but similar phrasing: “Older moms take heart: You may be more likely to live longer.” But the study didn’t show what you might expect.

(Disclaimer: I wrote one of the many news briefs on this, though not the ones linked above. That’s why I had occasion to read the paper so closely.)

First of all, the older moms weren’t that old when they had their last child (which is the date the researchers counted: age at the last child’s birth, regardless of when or whether earlier siblings may have been born). Women who are older when they have their last child are likely to be older at menopause, but those dates are often separated by a decade, and clearly there are a lot of different factors at play in their social lives, not just their biology, in determining whether they have a child at a later age.

The women in this study were born on the order of 70 to 100 years ago, so we’re looking at women making decisions about family planning from roughly the 1940s through the 1970s. That’s nearly a generation of difference between subjects in the same study, although the researchers say they were only looking at women over 70 because going any younger would be too drastic of a difference in social factors.

But the biggest thing that didn’t always get reported about this study was that the controls—the women who were judged as NOT living to extremly old ages—were also very old. The median age of the extremely old women was 100; in the group of deceased women used as controls, the median was 92. So if a woman finished having kids (for any reason) before the age of 33, she was more likely to end up in the group that “only” lived, on average, to 92.

As a study to tell us about the health of the average woman who has babies late in life, this stinks. But that’s not what the study was meant to do. It’s one of the analyses that comes out of the Long Life Family Study, which enrolls not just individuals, but families in which several siblings live to exceptional old ages. The idea is that if there are genes for super-longevity, these families would have them.

So it was within this population that the researchers looked for links to fertility. Some historical studies had shown that women who finished having children later in life were likely to live longer. Women from those times didn’t have the same contraception options that we (well, some of us) do today, so the factors involved may be more biological.

The researchers were considering some evolutionary hypotheses that would link fertility and longevity: perhaps women that are fertile longer are somehow better able to conserve energy in a way that would help them live longer. And they admit (for example, in quotes in the NPR article) that studying the women’s actual age of menopause would be more useful in the quest for genes that can confirm their hypothesis. That data, they say, isn’t available yet.

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Bullet Points: This article has no waiting period

In December of 2012, I was asked my thoughts on the Sandy Hook shooting on Twitter, and if I was going to write about it through a public health lens. I said no – I didn’t want to weigh in so soon, and I didn’t really know where to start. Sandy Hook capped off a year where 130,437 people were shot by firearms. Of these, 31,672 people died, with almost 60% listed as suicides. Since that exchange, there have been several more mass shootings (defined as 4 or more fatalities in one instance - not including the shooter), and I kept surfing the internet to explore the arguments on both sides of the gun control debate. As pointed out by Kathleen Bachynski over on The 2×2 Project’s series on gun violence, aptly titled “Fully Loaded“, if “measles or mumps killed 31,672 people a year, we would undoubtedly consider the situation to be a public health emergency.”

Smith_&_Wesson_Model_29_retouched

The Smith & Wesson Model 29 became a classic after the Dirty Harry movies starring Clint Eastwood were released

The issue is, I’m not inherently against owning firearms. Sure, I don’t understand it, and it makes little to no sense to me how owning a gun makes you feel safer given how every other country in the Western world doesn’t and they seem to be getting along just fine, but that’s not the point. Many gun owners own firearms for self-defence, but use them mainly for fun and recreation – shooting targets and hunting are two of the major uses. More importantly though, Americans don’t want to give up their firearms, and that attitude isn’t going away any time soon: Anyone who thinks advocating for a universal ban on firearms in the US is wasting their time.

The support for firearms is highlighted by the NRA and their attitude following any mass shooting. When the NRA can stand up and brazenly declare that this would never have happened if everyone else was armed, and, more importantly, have people believe them, the mere idea that firearms are the problem is a non-starter. The whole idea that “the only thing that can stop a bad guy with a gun is a good guy with a gun” is unbelievably foreign and alien to me. It sounds like a cheesy line in a 1980s action movie, where the city has been overrun by crime and the only thing between civilization and chaos is one lone officer who doesn’t care for regulations – not the speech you give following a mass shooting where 20 children and 6 teachers died. It all feeds into a belief that we’re all fighting against each other rather than being on the same side, which is exactly what the NRA and gun manufacturers want.

Wayne_LaPierre_by_Gage_Skidmore_2

Wayne LaPierre took to the stage following the Newtown Massacre to promote a plan where armed guards would patrol schools around the country. That’s his “solution.”

Divisive Politics

While exploring this issue further, the biggest obstacle I found in reducing gun violence is how much of a hot button issue this is. The issue is often painted as an “us vs them” battle, with strong militaristic language, and hyperbole in spades, exacerbated by the fact that one side is literally pointing guns at the other. When a discussion around gun control is met with “I’ll give you my gun when you take it from my cold, dead hands,” there’s no sense in engaging. And politicians aren’t going to either – the NRA donated $650,000 to congressional candidates in the 2012 election, effectively ensuring that no real change happens, and any objections to current policies are met with swift and immediate condemnation. In fact, the only major federal piece of gun legislation that has been enacted in the past 10 years was the Protection of Lawful Commerce in Arms Act, which, I kid you not, prevents gun manufacturers and dealers from being held liable if their products were used in crimes. Now while this makes sense (you’d never sue Chevrolet if you were hit by an Impala), the fact that this is the only piece of federal legislation that has been passed is a telling indication of the priorities that exist at the highest levels of government. Even something as simple as forcing mandatory background checks is met with resistance at the Senate, being voted down 54-46, despite 91% of Americans being in support of criminal background checks.

But is polarization this the only way forward? Are we truly okay with the status quo as it stands right now? We don’t need or want extreme solutions – arming everyone or removing all guns are not feasible options. However, there has to be a middle ground, where rational minds sit down and determine how can we best approach this problem, and what would be a viable solution.

Quality of the data

A major issue in the discussion of gun violence is that we simply don’t know what works as the data on gun violence is sorely lacking. This is largely driven by the fact that the CDC hasn’t been allowed to conduct research on firearms since 1993. The fascinatingly titled Omnibus Consolidated Appropriations Bill states on page 245 “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” So we have very little data available about firearms, and the largest organization in the US that could research it was effectively muzzled from being able to explore this issue and provide us with (any) options. Now, some stats do remain, such as those collected by the FBI, or by private citizens. However, the elimination of a whole area of public health from the CDC’s mandate is a decision that is almost Machiavellian in nature. My colleague Margaret Winker at Speaking of Medicine weighed in on this last January, and summed the practicalities of the situation up well:

“Research that had been conducted to date found that a major argument for gun ownership, protecting oneself at home, was not effective, and gun ownership was in fact associated with an increased risk of homicide. This threat to pro-gun lobbyists was blocked through NRA lobbying Congress, preventing research on a public health threat that claims 30,000 lives a year in the United States. Lifting the ban will reinvigorate this critical area of research; unfortunately, few researchers would pursue a career path with essentially no steady source of funding, so much-needed gun research will not happen overnight.” (Emphasis mine, from Speaking of Medicine)

Without good data, how can we possible make good decisions?

Bringing people together

Finally, if there was an easy solution to the gun violence epidemic, it would have come about by now. But the solution requires us to sit down at a table together and discuss what is going on, and if there’s a way to stop these senseless deaths from occurring. This doesn’t just refer to the mass shootings – most gun-related fatalities are suicides. How can we prevent these deaths from happening, and how can we get these people the help they might need? This isn’t a “new” problem by any stretch – the number of deaths due to firearms has stayed relatively constant at 10.3 per 100,000 every year since 1999. Solving the gun violence epidemic will require leadership, commitment from those from both the pro-gun and pro-regulation sides, and above all, putting petty politics aside to prevent these senseless deaths from occurring. Part of the issue here will require investing money into research as to why people are using guns in this manner, and if there are ways we can get them help before they decide to use them to kill themselves and others. The role of public health in the gun violence sphere is really in figuring out why, creating interventions that will ensure that it never gets to the point of a gun being used.

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Thanks to @Crommunist and @ryanclassic for the title suggestion!

Category: Determinants of health, Preventable Deaths, Time trends | Tagged , , , , , , , , | 5 Comments

Exercise is safe during pregnancy, but not enough docs know that.

Pregnant women are getting the wrong messages on exercise—often because their doctors cling to old-fashioned ideas.

I was inspired to write about this after reading a post from another PLOS blog, Obesity Panacea, discussing whether exercise is safe for pregnant women. (Short answer: yes.) It’s a topic I’m quite familiar with, having taken a lot of grief about it myself: I ran a marathon while I was pregnant with my second child.

Yes, the kid turned out fine.

pregnant_5k

I was lucky to be working with midwives who recognize the evidence base supporting exercise in pregnancy, but a 2010 survey of providers suggests that’s a rare situation. Although 99% of the doctors and midwives said that they believed exercise in pregnancy is beneficial, a whopping 64% of them still gave patients the outdated advice to keep their heart rate below 140 beats per minute.

The rule, proposed in 1985, was meant to restrict pregnant women to light to moderate exercise For some of us, a brisk walk gets us up to 140, though it would allow some women to do light jogging. There is, in fact, no reason why women should keep their heart rate below any particular number; the scientist who came up with it explained to ESPN that it was a “guesstimate” based on zero empirical evidence. And so the group that first issued the rule, the American Congress of Obstetrics and Gynecology, removed it from their next set of guidelines.

That means that in the 2010 survey, those providers were giving out a 25-year-old rule that had been retracted since 1994. Worse, 60% of the MD’s in the study had no idea that the rule had been changed.

This is a small taste of what exercising pregnant women are up against.

While exercise is helpful during pregnancy to manage weight gain and blood sugar, and to keep the mom-to-be from going stir crazy, publicizing it as a public health message is sort of unfair when it’s given alongside draconian restrictions. Pregnant women who take to the gym for anything more than a gentle yoga class (full disclosure: I sprained my pelvis in a gentle yoga class) are met with stares and that classic, infuriating question:

“Does your doctor let you do that?”

A doctor, or midwife, doesn’t have the authority to “let” a pregnant woman do something—which also implies that everything is prohibited until the doctor says it’s OK. Rather, evidence should be used to weigh risks and benefits, and ultimately the choice is up to the woman herself.

My midwives asked about my training and race-day plans for hydration and fueling (pregnant women are prone to low blood sugar while exercising, and overheating, while rare, can be dangerous to the fetus) and advised me on some warning signs that could indicate trouble with my pelvic ligaments: if you feel this, stop. Otherwise, they encouraged me to keep exercising as long as I was “listening to my body,” which may sound like woowoo advice but is solidly backed by evidence—absent other problems, pregnant women voluntarily slow down or stop when their temperature rises, for example (thus making obsolete the oft-repeated and probably never-followed advice to stick a thermometer in your vagina mid-workout).

Even though it seems intuitively right, somehow, to advise a pregnant woman that her choices for exercise are walking, yoga, and swimming (or, as I like to put it, “walking gently in a field of pillows”), studies repeatedly fail to find any detriment to mom or baby from even vigorous exercise.

If you can’t imagine wanting to exercise while pregnant, it could be you just don’t have a vivid imagination. I went running 3-4 times per week during the height of my morning sickness, because I knew from experience that I would feel even worse if I stayed in bed. Although I met women who cheered me on, including one who had been out for a run at 40 weeks the day before she delivered her daughter, I had to stop running around 6 or 7 months (shortly after the above picture was taken) but completed a grueling 18-mile hike just so I would have something else to do. Some women can stay motivated to exercise by a goal of “staying healthy for baby” or “training for the birth,” but not all of us. I’m in the camp that needs goals and challenges.

When hiking got too hard, I went to my air-conditioned local gym and lifted weights, including endless kettlebell swings with 35 pounds because that was the biggest bell my gym had, and barbell squats with ever-lightening weight, maybe 85 pounds on a good day. That came to a sudden but temporary stop after I mentioned my routine to a midwife who told me that pregnant women “shouldn’t lift more than 25 pounds.”

Lift 25 pounds how? I said. There’s a big difference between a 25 pound deadlift and a 25 pound bicep curl.

“Just, you shouldn’t lift more than 25 pounds. That’s the rule.”

None of the midwives could tell me where the rule came from, or whether it applied to people who were experienced at weightlifting and were using proper form and breathing appropriately. Finally, one midwife sighed over the phone and said, Look, there are pregnant women who run marathons but it’s not like we recommend that to everybody.

“I ran a marathon back in May,” I told her.

“Oh!” she said. “Oh! I remember you now.” In the end, she agreed that I could go ahead with the same type and intensity of exercise I’d been doing before pregnancy, easing up on the weight depending on how I feel.

I did some further research and found that the 25-pound limit comes from studies of women who had to lift heavy objects at work. The studies found that this correlated with a small increase in risk of miscarriage and preterm birth, which may or may not have been due to the lifting; another school of thought simply holds that the weight you lift while pregnant should be a little bit less than you would lift otherwise. My midwife admitted that while the evidence on cardio exercise (like running) in pregnancy comes from a small pool of research, the evidence on the risks and benefits of lifting is nearly nonexistent.

And so, as in the case of drugs for pregnant women, we need better research. Pregnant women are exercising anyway; researcher James Clapp admits in Exercising Through Your Pregnancy that many of his studies followed women who chose to disregard guidelines, since he couldn’t ethically randomize them to follow the guidelines or not.

Spoiler alert: the babies pretty much all turned out fine.

 

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