Posts or Comments 15 June 2024

Archive for "poverty"



Environment &Epidemiology &Health Systems &Indigenous Medicine &Lassa Fever &NTDs &poverty &Zoonoses Bill Brieger | 30 Apr 2024

Challenges of Lassa Fever in the 21st century: the need for health system accountability

Anthony AHUMIBE is a staff member of Nigeria CDC and presently a doctoral student at the Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan. Herein he examines the challenges posed by Lassa Fever to the West African region.

Following the West Africa Ebola epidemic of 2014, the global community has been preoccupied with Lassa fever, a zoonotic viral infection that has caused sickness and death in some communities in Nigeria, Liberia, Sierra Leone, and Guinea. Familiar challenges like absence of vaccine and point of care diagnostics are being handled through investments in research and development. There are, however, some imperceptible yet weighty challenges along the path of Lassa fever control.

The recent finding by Happi and colleagues shows that several species of household rodents, nonspecific to the familiar multimammate rats and other peri-urban small animals carry the Lassa virus and demonstrate that the virus is adapting. Conversely the economic turn of events in the endemic countries indicates that more people are moving into poverty and are unable to make proper hygiene choices. Furthermore, the expansion of city slums, and poor structured housing increases the opportunity for human contact with these rodents, thereby increasing rodents to human virus transmission.

The table derives from weekly reports published by NCDC. Nigeria Lassa fever data summary for Epi week 15, 2024 is compared with Epi Week 15 cumulative data in 2023 and 2024 (Courtesy: Nigeria CDC Situation report).

Related to the issue of homestead hygiene is the ineffective management of hospital waste in most of these communities. Many cases of Lassa fever slip through the cracks as malaria fever in health centres with limited capacity for molecular diagnosis.  After treatment, body fluid-stained dressings and disposables as well as serum and other body fluids are disposed as waste. The ineffectual medical waste management, so unsupervised, promotes fomite-rodent transmission and genetic spill-over to other species of household animals.

Citizens in the endemic countries share the same burden of poor health infrastructure and limited access to healthcare. For instance, only about 3% of adults aged 15-49 years have a form of health insurance. The high out-of-pocket expenditure required has caused increased hesitance in visiting hospital. As an alternative, many persons become victims of charlatans while genuine traditional healers who approach medical care blindly and without protective equipment become targets of infection and sources of transmission.

The photo (by author) shows the traditional sun drying of grated cassava for fufu meal. This exposure increases potential for Lassa fever transmission through contamination with rodent excreta.

The large trust deficit between the citizens and the political leaders owing to the several years of perceived economic and social mismanagement is also a great source of concern. Trust in the system by the people has been affirmed as necessary in advancing the cause of public health. Marcia McNutt and Michael Crow wrote in their op-ed, published in Issues in Science and Technology magazine that scientists and elected leaders need to earn citizens’ trust to win the war against misinformation and disinformation. Hesitancy in uptake of available countermeasures, appropriate risk perception and required behavioural change, seem imperiled in these communities due to the lack of trust in government and government institutions.

Finally, it is often assumed that every new infection cycle is initiated by human contact with rodent or rodent fluid. This does not consider however that the reinfection cycle could have started from a lab leak. Pathogen escape pathways are preponderant with many vials of remnant serum held unaccounted for in many public and private care institutions, some in community hospitals. This can only change if these countries develop a national system for accountability and repository of high-consequence pathogens.

Elimination &MDA &NTDs &poverty &Schistosomiasis &Trachoma &Vector Control Bill Brieger | 13 Jun 2023

Eliminating NTDs as a Public Health Problem May Not Be Enough

The concept and goal of eliminating a disease appears simple on the surface, but complications ensue when the words “as a public health problem” are added.  We know that the distinction exists between eradication and elimination with the former being globally and the latter being nationally or regionally. The sum total action of eliminating a disease from all endemic countries therefore results in total global eradication.

The challenge comes when we try to qualify the concept of elimination. The US CDC defined elimination of disease as, “Reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate efforts; continued intervention measures are required.” Thus, there is no more transmission.  Following from this eradication is defined as, “Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed.” Penn Medicine summarized this as, “Elimination means stopping the transmission of a disease in a specific geographic area or country, but not worldwide. Elimination is a crucial step in the path toward eradication, requiring constant monitoring and interventions to keep serious diseases at bay.”

The foregoing definitions seem straightforward, but what does elimination as a public health problem or a disease of public health concern mean? The World Health Organization recently “congratulate(d) Benin and Mali for eliminating trachoma as a public health problem. Concerning another neglected tropical disease (NTD), lymphatic filariasis (LF), global control programs are aiming “to reduce the prevalence of infection below target thresholds and to alleviate the suffering of people affected by lymphoedema and hydrocele.” Wiegand and colleagues in The Lancet Global Health note that, “For schistosomiasis, the criterion for elimination as a public health problem (EPHP) is defined as less than 1% prevalence of heavy-intensity infections (ie, ?50 Schistosoma haematobium eggs per 10 mL of urine or ?400 Schistosoma mansoni eggs per g of stool).” They take issue with the fact that such definitions mean that morbidity still exists, though at very levels, so elimination of transmission has not really occurred for any of these NTDs.

Because the social, environmental, and behavioral conditions that favor transmission may still exists, one cannot guarantee that incidence such diseases may not increase again. All three diseases, LF, Schistosomiasis, and Trachoma have been tackled primarily through preventive chemotherapy, is simply put, using mass drug administration (MDA) over a period of years until active surveillance determines that “infection (is) below target thresholds.” Trachoma does have its SAFE strategy which includes water, sanitation and hygiene interventions, but drugs can reduce the disease without long term achievements in such activities have become sustainable.

Prada et al. in the Journal of Infectious Diseases warn that there can be resurgence of a disease that was documented to be eliminated as a public health problem. They explain that the transmission assessment survey held after several MDA rounds for LF may not be enough to guarantee that low levels of transmission and eventual elimination are achieved. They conclude that, “The risk of resurgence after achieving current targets is low and is hard to predict using just current prevalence. Although resurgence is often quick (<5 years), it can still occur outside of the currently recommended post-intervention surveillance period of 4–6 years,” and recommend monitoring beyond this period.

Toor and co-researchers suggest for NTD programs that, “as case numbers drop and elimination comes into prospect, transmission reduction through other interventions, such as vector control and sanitation, becomes crucial in reducing the probability and speed of resurgence, particularly when MDA or screening programs are halted. Surveillance activities for detecting elimination and resurgence become increasingly important to ensure that successes are maintained.”

Ultimately, unless the context of NTD transmission is addressed, elimination will be an elusive goal. Therefore, as WHO advocated on the recent World NTD Day, “Everybody, including leaders and communities, to confront the inequalities that drive NTDs and to make bold, sustainable investments to free the world’s most vulnerable communities affected by NTDs from a vicious cycle of disease and poverty.”

Development &poverty &Vaccine Bill Brieger | 28 Apr 2022

African Immunization Week Press Briefing: Reducing Poverty, Saving Lives

The World Health Organization’s African Regional Office held a press briefing to mark World Immunization Week/African Immunization Week. Three experts shared their observations of developments and trends and responded to questions over the course of an hour on Thursday 28th April. The panelists included Dr Benido Impouma, Director, Communicable and Noncommunicable Diseases, WHO Regional Office for Africa, Professor Helen Rees, Executive Director, Wits Reproductive Health and HIV Institute, University of Witwatersrand, South Africa, and Hon. Dr Kailash Jagutpal, Minister of Health and Wellness, Government of Mauritius. In addition, Dr. Mory Keita answered questions about the latest Ebola Virus Disease (EVD) in the Democratic Republic of the Congo (DRC).

Concerns about COVID-19 featured in this immunization briefing for several reasons. First was the low coverage of COVID vaccines on the continent. Second was the way that COVID put demands on health workers’ time as well as on precautions to be undertaken, which limited the reach and coverage of immunization services for other vaccine preventable diseases (VPDs). Also, the resulting reduction in immunization coverage was responsible for other deadly outbreaks, notably measles. Between January and March 2022, for example, there was a 400% increase in measles cases compared to the same period last year.

Dr. Impouma that COVID ‘taught the lesson’ that catch-up campaigns for VPDs were not only necessary but could be handled successfully. Finally, health services learned the importance of integration, whether joining COVID and Yellow Fever vaccination efforts in Ghana or integrating COVID with maternal and child services and immunizations. Ultimately, health workers learned that by strengthening ‘routine’ immunization, health systems overall could be strengthened thus, making progress on achieving Health For all through Universal Health Coverage.

Dr. Jagutpal shared key considerations for successful life-course immunization programs. Mauritius offers free, universal vaccination from birth. Thirty VPDs are addressed ranging from Human Papilloma Virus to flu and not of course, COVID-19. Success is based on involvement of all stakeholders through regular meetings where real time decisions can be made. Mauritius in one of the first to formalize the COVID Vaccine Pass Card and has achieved 60% full vaccine coverage including booster shots.

Prof Rees noted that the term ‘routine services’ makes vaccines seem boring and less important, when in fact, they should be seen as “Core Services”. This central role of vaccines goes beyond preventing specific diseases. By saving children’s lives and reducing the time demands on parents who care for children suffering VPDs, immunization promotes human development, reduces poverty, enhances the economy, and strengthens employment. There remain children who have had no vaccines. Identifying these ‘zero dose’ children and the communities in which they cluster can help us focus on ameliorating the vulnerabilities of their families and bring multi-sectoral resources to bear on strengthening poor communities.

Dr Keita reviewed the two recent cases, now deaths from Ebola in Équateur Province in DRC, its third EVD outbreak. Ebola vaccine teams have started working, reaching 78 contacts. He lamented that much of the DRC has a natural ecological predisposition for the animal reservoirs of Ebola, so more effort on making regular vaccines and treatment available is required. As Prof Rees pointed out, this setting is a perfect example of the need for a One Health approach to many of our health challenges which are zoonotic in nature. Even with coronaviruses, animal reservoirs are a central element of transmission.

Additional research is recommended in several areas. The slowly increasing laboratory capacity in Africa was mentioned. It contributed to finding Omicron and its variants. Potential new ones may have been identified recently. Seropositivity analysis has found that 80-90% of people tested may already have COVID antibodies. Research can clarify the role of vaccines in these circumstances. Research as well as regular program monitoring is still needed to determine the factors that may cause children to miss vaccines. It is often not the case that parents are ‘hesitant’, but that system and community factors combine to prevent them from seeking care. Research can also assist in finding vaccines and tools for tackling other deadly pathogens such as Lassa Fever.

Vaccines save lives from endemic diseases, but in the long-term vaccinated families and communities can fight poverty which itself is a leading factor in illness and death. This will accomplish the theme of this year’s observance, “Long Life for All.

Economics &poverty Bill Brieger | 16 Aug 2021

With all its recent troubles, Haiti is still challenged by malaria

In the past month Haiti has experienced a political assignation, a magnitude 7.2 earthquake and a flood-threatening tropical storm. Add to these are endemic health problems like malaria. The Pan American Health Organization reported that in 2019 Haiti suffered more than 4,600 cases of the disease.

The difficulties responding to the above mentioned challenges is deep seated in efforts to suppress the country since it won its independence in 1804. The rest of the world, particularly Europe and the United States have been responsible for destabilization over the past two centuries.

As part of the online roundtable on Brandon R. Byrd’s book, The Black Republic, Leslie M. Alexander noted that, “We Have Not Yet Forgiven Haiti For Being Black”. He explains that, ” few are willing to ask the hard questions about how and why Haiti perpetually appears to teeter on the brink of economic and political disaster,” and might we add health disasters to the list.

Alexander points out that, “The painful truth is that Haiti’s decision to declare its independence from France and to establish itself as a sovereign Black nation caused most Western nations to declare Haiti as public enemy number one. From the birth of Haitian independence in 1804 until the present day, the United States and other western European nations have used their economic and diplomatic strength in an effort to isolate and impoverish Haiti. ”

Malaria persists where there is poverty and conflict. The solution to malaria in Haiti must account for political and economic interventions that address the injustices of the past.

Equity &Gender &Health Systems &Migration &Nomadic People &poverty Bill Brieger | 05 Mar 2021

Nomads in Mali Face Barriers to Health Care

We are sharing the abstract of a just published article by Moussa Sangare and colleagues entitled, “Factors hindering health care delivery in nomadic communities: a cross-sectional study in Timbuktu, Mali,” that appears in BMC Public Health. As COVID-19 has been disrupting health services generally, we need greater awareness of the serious barriers faced by more vulnerable populations even in better times.

Background: In Mali, nomadic populations are spread over one third of the territory. Their lifestyle, characterized by constant mobility, excludes them from, or at best places them at the edge of, health delivery services. This study aimed to describe nomadic populations’ characteristics, determine their perception on the current health services, and identify issues associated with community-based health interventions.

Methods: To develop a better health policy and strategic approaches adapted to nomadic populations, we conducted a cross-sectional study in the region of Timbuktu to describe the difficulties in accessing health services. The study consisted in administering questionnaires to community members in the communes of Ber and Gossi, in the Timbuktu region, to understand their perceptions of health services delivery in their settings.

Results: We interviewed 520 individuals, all members of the nomadic communities of the two study communes. Their median age was 38?years old with extremes ranging from 18 to 86?years old. Their main activities were livestock breeding (27%), housekeeping (26.4%), local trading (11%), farming (6%) and artisans (5.5%). The average distance to the local health center was 40.94?km and 23.19?km respectively in Gossi and Ber. In terms of barriers to access to health care, participants complained mainly about the transportation options (79.4%), the quality of provided services (39.2%) and the high cost of available health services (35.7%). Additionally, more than a quarter of our participants stated that they would not allow themselves to be examined by a health care worker of the opposite gender.

Conclusion: This study shows that nomadic populations do not have access to community-based health interventions. A number of factors were revealed to be important barriers per these communities’ perception including the quality of services, poverty, lifestyle, gender and current health policy strategies in the region. To be successful, future interventions should take these factors into account by adapting policies and methods.

Advocacy &COVID-19 &Insecticide &Mosquitoes &poverty &Resistance &Severe Malaria Bill Brieger | 22 Oct 2020

Malaria News Today 2020-10-22

The search for adjunctive therapy to aid in recovery from cerebral malaria is explored in Malaria Journal. A faster acting crystalline form of an insecticide is studied. In Nigeria the National Malaria Elimination Program advocates for equal footing with COVID-19 action. Links to full stories and abstracts are found below.

Dimethyl fumarate reduces TNF and Plasmodium falciparum induced brain endothelium activation in vitro

Neida K. Mita-Mendoza, and colleagues studied Cerebral malaria (CM) which is associated with morbidity and mortality despite the use of potent anti-malarial agents. Brain endothelial cell activation and dysfunction from oxidative and inflammatory host responses and products released by Plasmodium falciparum-infected erythrocytes (IE), are likely the major contributors to the encephalopathy, seizures, and brain swelling that are associated with CM. The development of adjunctive therapy to reduce the pathological consequences of host response pathways could improve outcomes.

To accurately reflect clinically relevant parasite biology a unique panel of parasite isolates derived from patients with stringently defined CM was developed. The effect of TNF and these parasite lines on primary human brain microvascular endothelial cell (HBMVEC) activation in an in vitro co-culture model was tested. HBMVEC activation was measured by cellular release of IL6 and nuclear translocation of NF?B. The transcriptional and functional effects of dimethyl fumarate (DMF), an FDA approved drug which induces the NRF2 pathway, on host and parasite induced HBMVEC activation was characterized. In addition, the effect of DMF on parasite binding to TNF stimulated HBMVEC in a semi-static binding assay was examined.

The findings provide evidence that targeting the nuclear factor E2-related factor 2 ( NRF2) pathway in tumour necrosis factor (TNF) and parasite activated human brain microvascular endothelial cell (HBMVEC) mediates multiple protective pathways and may represent a novel adjunctive therapy to improve infection outcomes in CM.

Fast-acting insecticide polymorph could boost malaria-control efforts

Chemistry World reports on a faster-acting version of a common insecticide could boost malaria control efforts. The new crystalline form of deltamethrin is absorbed by mosquitoes 12 times faster than commercial forms and could help to limit malaria transmission despite growing rates of insecticide resistance.

Microcystals of contact insecticides like deltamethrin are crucial ingredients in indoor sprays and treated bed nets used to combat malaria-spreading mosquitoes. But many mosquito populations are developing resistance to these compounds, which is harming efforts to control the disease.

Treat Malaria as National Health Emergency, NEMP tells Federal Government

The Coordinator of National Malaria Elimination Programme (NEMP), has asked the federal government to tackle malaria as a national health emergency in the same manner COVID-19 pandemic is being handled. Against the background of increasing poverty in the country, Civil Society in Malaria Control, Immunisation and Nutrition (ACOMIN) has said there is a direct linkage between malaria scourge and the level of poverty in communities.

Speaking at a meeting with the civil society group involved in anti malaria advocacy, Coordinator of NEMP, said the current level of funding of the health sector by government is unacceptably low.