Dr. Buttery's Public Health BLOG

The findings from Rwanda and Ethiopia are the first to show a greater than 50 percent reduction in malaria mortality nationwide in "high burden" countries.
Malaria is responsible for 2 percent of all deaths worldwide and 9 percent of deaths in Africa. Each year, about 1.1 million deaths -- almost all in children -- are directly attributable to the disease, and at least a million more occur from complications such as severe anemia. In Africa, where most cases occur, malaria costs $12 billion a year in medical expenses and lost productivity.
Two key items in the current "tool kit" are bed nets treated with insecticide that lasts as much as five years, and treatment with at least two drugs, one of them artemisinin, a compound derived from a Chinese herbal medicine.

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Editorials in several journals today: Global health is too important to be left to global health experts. That is why a new initiative announced by the Bill & Melinda Gates Foundation in Cape Town on Oct 9 is welcome. The initiative, a 5-year US$100 million grant programme called Grand Challenges Explorations, will provide hundreds of small start-up grants to researchers who come forward with promising new ideas to tackle key problems in global health. The initiative is modelled on the investment strategies favoured by venture capitalists. Initial grants will be about $100 000 but more funds will become available if projects show progress.

Posted by at 9:56 AM | Permalink | Comments (13)

The renewed worldwide commitment to the reduction of maternal and child mortality, if translated into effective action, could help to provide the systemic changes needed for longterm elimination of maternal and neonatal tetanus. These are the conclusions of authors of a Seminar published early Online and in an upcoming edition of The Lancet. Dr Jos Vandelaer, World Health Organisation, Geneva, Switzerland, and colleagues, say: "Although easily prevented by maternal immunisation with tetanus toxoid vaccine, and aseptic obstetric and postnatal umbilical-cord care practices, maternal and neonatal tetanus persist as public-health problems in 48 countries, mainly in Asia and Africa."

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The World Health Organization (WHO) today issued new global guidance for the use of insecticide-treated mosquito nets to protect people from malaria. For the first time, WHO recommends that insecticidal nets be long-lasting, and distributed either free or highly subsidized and used by all community members. The long-lasting insecticidal nets (LLINs) are designed to be effective without re-treatment for the life of the net. At around US$ 5 per net, LLINs are a simple and cost-effective intervention against malaria. “This data from Kenya ends the debate about how to deliver long-lasting insecticidal (or just mosquito nets) nets,” said Arata Kochi, head of the WHO’s Global Malaria Programme. Malaria, which is preventable and treatable, still kills more than one million people each year, mainly African children under five years of age.

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Another genetic breakthrough is detailed in the journal Science, this week, The complete geneome of of Ae. aegypti. With this information a step forward in prevention of malaria, a medical goal for well over 50 years, may take a step forward. [Science 22 June 2007: Vol. 316. no. 5832, pp. 1703 - 1704]

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From the WHO today new data show that 13 million deaths worldwide could be prevented every year by making environments healthier. In some countries, more than one third of the disease burden could be prevented through environmental improvements. In 23 countries worldwide, more than 10% of deaths are due to just two environmental risk factors: unsafe water, including poor sanitation and hygiene; and indoor air pollution due to solid fuel use for cooking. Around the world, children under five are the main victims and make up 74% of deaths due to diarrhoeal disease and lower respiratory infections.

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While policy makers talk about lack of primary care in the U.S. an international comparison showed patient-physician time in the US is about half the average of New Zealand and one-third of Australia. Such a severe shortfall impacts preventive care and management of chronic conditions in the US and could explain why the US does not achieve health outcomes that correspond to its higher level of investment in health care,” said study lead author Andrew Bindman, MD, of the University of California, San Francisco. Published on-line in the BMJ this week.

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From Brown University the first study in the developing world of directly observed antiretroviral therapy for HIV-infected children shows this form of treatment is an inexpensive, effective way to ensure that children take life-saving medications. Researchers at The Warren Alpert Medical School of Brown University, together with Maryknoll, the international Catholic charity, conducted the study. Results are published in the June issue of the American Journal of Public Health. A good example of transferring lessons learned in the U.S. to the international arena

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MVP, a partnership between the World Health Organization (WHO) and the Seattle-based nonprofit, PATH, is collaborating with a vaccine producer, Serum Institute of India Limited (SIIL), to produce the new vaccine against serogroup A Neisseria meningitidis (meningococcus). The preliminary results of their study, a Phase 2 vaccine trial, reveal that the vaccine could eventually slash the incidence of epidemics in the “meningitis belt,” as 21 affected nations of sub-Saharan Africa are collectively known. The vaccine is expected to block infection by the serogroup A meningococcus, and therefore extend protection to the entire population, including the unvaccinated, a phenomenon know as “herd immunity.”

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Another major initiative of the Gates Foundation The Health Metrics and Evaluation Institute will be sited at the University of Washington in Seattle with a US$105 million core grant from the Gates Foundation over 10 years. The new institute fills a critical gap. The enormous political and financial attention now being paid to global health has not been matched by improved sources of information on the performance of health systems and new health programmes. This shortfall in knowledge is hampering efforts to create a favourable environment for investments in health. Worst of all, the evidence gap is harming work to improve the health of the most vulnerable populations in the world.

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When meeting 2 years ago in Gleneagles, Scotland, the G8 leaders predicted that if their plan for Africa were implemented it would make it possible to deliver free basic health care and primary education for all and to provide near-universal access to treatment to people with HIV/AIDS by 2010 and to double the size of Africa's economy and trade by 2015. An editorial in the Lancet this week [Volume 369, Issue 9576, 2 June 2007-8 June 2007, Page 1833] states that Oxfam has calculated that over the past 2 years, 21 million children have died as a result of poverty, the equivalent of every child under 5 years in Canada, France, Germany, Italy, Japan, and the UK combined.

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The WHO's 'Stop TB Partnership' announced today that its drug supply arm, the Global Drug Facility, has provided anti-TB drug treatments for 10 million people to 78 countries in the past six years. "This is an important milestone, because getting anti-TB drugs to people who need them and making sure they complete their treatment is the only way to break the back of the epidemic. It is also the best weapon we have for preventing a potentially massive new epidemic of drug-resistant TB", said Dr Marcos Espinal, Executive Secretary of the Stop TB Partnership. "Together with countries and partners we are moving steadily towards our target of treating 50 million TB patients between 2006 and 2015."

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On World Tobacco Day the WHO emphasizes the need for countries to make all indoor public places and workplaces 100% smoke-free with the release of its new policy recommendations on protection from exposure to second-hand tobacco smoke. "The evidence is clear, there is no safe level of exposure to second-hand tobacco smoke," said the WHO Director-General Dr Margaret Chan. "Many countries have already taken action. I urge all countries that have not yet done so to take this immediate and important step to protect the health of all by passing laws requiring all indoor workplaces and public places to be 100% smoke-free."

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Unsurprisingly XDR-TB has finally made its way into the US by means of an air flight. The infected individual had travelled through Europe recently. The main issue is that he spent a number of hours in an evironment where the cabin air was recirculated. The CDC and other health authorities are tracking down potential contacts for follow-up. While indivdual risk may be low, a lot depends on the state of health of other passengers in the plane. We have seen TB spread on ships where crew were exposed to recirculated air, although often for days or weeks, not just a few hours.

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When I was at medical school more than 50 years ago I was told to expect the end of syphilis with the advent of Penicillin. Now from New South Wales in Australia we learn of a doubling of Syphilis between 2002 and 2005. Ocular syphliis which used to be rare is becoming more commonplace, particularly in the Gay Community, where prevention of STDS occurs rarely, Reported at http://www.promedmail.org

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From the Commonwealth fund today: despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance. This report, which includes information from primary care physicians about their medical practices and views of their countries' health systems

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An Ediorial in the Lancet This week [V.369, Issue 9566, 24 March, Page 965] states that comorbidity with tuberculosis and HIV/AIDS affects around 11 million people and killed nearly 200 000 in 2005. Yet, less than 0·5% of HIV-positive people were screened for tuberculosis that year.

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In "Science" today is an article on potential population overgrowth in Niger [Science 315, 1501 (2007); Martha Campbell, et al.] which should cause all of us in public health to think about the unintended consequences of interfering in disease without looking at the population effects of such interference. If we wipe out a disease so that the resulting population overgrowth results in deaths from famine, did we do well?

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From the WHO today, governments, donors and international agencies leading the drive to eradicate polio fully supported the planned final attack on the poliovirus. Indigenous wild poliovirus survives in only parts of four countries – Nigeria, India, Pakistan and Afghanistan – where transmission has never been stopped. Today's high-level Consultation on polio eradication agreed to raise within 12 months - and then sustain for as long as needed - the levels of vaccination coverage and child immunity in the areas with endemic polio to levels that stopped the disease altogether in the polio-free parts of these countries. Ten other countries are currently fighting the tail-end of outbreaks caused by importations of poliovirus.

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HEALTHmap is an internet site that shows location of significant disease incidents around the world,

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WHO has just released a statement about women's health which should be read by all of us in public health.
Globally, inadequate sexual and reproductive health services have resulted in maternal deaths and rising numbers of sexually transmitted infections (STIs), particularly in developing countries. WHO estimates that 340 million new cases of sexually transmitted bacterial infections, such as chlamydia and gonorrhoea occur annually in people aged 15 - 49. Many are untreated because of lack of access to services. In addition, millions of cases of viral infection, including HIV, occur every year. The sexually transmitted human papilloma virus (HPV) infection is closely associated with cervical cancer, which is diagnosed in more than 490 000 women and causes 240 000 deaths every year.
While this may be true globally, it is just as true in the US and other 'advanced' countries which give little support to prevention of STDs and prefer to focus on treatment.

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From today's Telegraph (UK) we find that British travellers are more at risk of contracting the most deadly form of malaria now than they were 20 years ago, leading medical authorities reported this week.

According to figures from the Health Protection Agency (HPA), about 1,300 British travellers last year contracted Plasmodium falciparum, a potentially fatal strain of malaria. This is more than twice the number of cases reported in 1985.

Travellers need to be more careful about proectection against infectious diseases.

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Global deaths due to measles fell by 48%, from 871 000 in 1999 to an estimated 454 000 in 2004, thanks to major national immunization activities and better access to routine childhood immunization, the agencies said. These measles mortality data, calculated by WHO, are the latest available.
"Measles remains a major killer of children in the developing world, but it doesn't have to be," UNICEF Executive Director Ann M. Veneman said. "Just two doses of an inexpensive, safe, and available measles vaccine can prevent most, if not all, measles deaths."
WHO and UNICEF have concentrated measles mortality reduction activities in 47 countries that account for about 98% of global measles deaths, working primarily to improve routine immunization as well as providing treatment to children with measles and strengthening disease surveillance. Supplementary immunization activities (SIAs) have also proven to be especially effective: from 1999 to 2004, nearly 500 million children were immunized against measles.

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While we worry about AIDS we tend to forget the toll of TB and Malaria in developing countries. A news extra in the BMJ today referrences data from the Feb 28 Issue of the International Journal of Epidemiology noting that:
Between 700 000 and 900 000 children in sub-Saharan Africa aged under 5 years died of the disease in 2000, accounting for 16% to 20% of deaths in that age group, the report estimates. The authors said the results suggest that malaria mortality increased during the 1980s and 1990s, and they cited previous studies that blame the increase on growing resistance to the commonly used antimalarial drug chloroquine. Malaria is directly accountable for around 18% of deaths among children in sub-Saharan Africa

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The March 6 issue of Lancet-Infectious Diseases refers to the WHO Stop TB Goals and should be read by all interested in public health, as well as the WHO Stop TB strategy

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This research from the University of Liverpool, in the UK, discusses a method to predict Malaria, which is one of the world’s deadliest diseases, killing more than one million people every year, as well as infecting a further 500 million worldwide. The mosquito-borne illness is endemic in several regions globally, but is most acute in Africa, home to an estimated 90 per cent of all cases.

Dr Andy Morse from the Department of Geography and colleagues from the European Centre for Medium Range Weather Forecasting; Columbia University, New York and the Ministry of Health in Botswana, based their early-warning model on population vulnerability, rainfall and health surveillance data and then used forthcoming season forecasts for rainfall to predict unusual changes in the seasonal pattern of disease in Botswana. The team based their study on Botswana as its climate makes it susceptible to malaria epidemics.

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When it started, I must admit that I never believed the Rotary Foundation had a prayer of succeeding, but the results are outstanding and show what private philanthropy can do. The Gates Foundation carries the activities of private foundations further on the world stage.

The WHO announces that the number of countries with indigenous polio has dropped to an all-time low of four, as polio eradication efforts enter a new phase involving the use of next-generation vaccines targeted at the two surviving strains of virus.

In 2006, monovalent vaccines, aimed at individual virus strains, will be the primary platform for eradication in all remaining polio-affected areas, announced the core partners in polio eradication – the World Health Organization (WHO), Rotary International, the US Centers for Disease Control (CDC) and Prevention and UNICEF – enabling the eradication drive to hone in on poliovirus types 1 and 3.

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We rarely think about this scourge in the U.S.A. The latest review by the WHO shows remarkable progress.
Europe was so badly affected during the 13th century that by 1225 there were around 19 000 leprosaria—hospitals to house lepers. By 1350, the disease started to wane in Europe, possibly because the black death killed so many of Mycobacterium leprae's hosts. But today M leprae's effects are still seen worldwide, especially in India where 260 000 of the 408 000 people diagnosed in 2004 reside.

In 1991, the World Health Assembly adopted a resolution to eliminate leprosy by 2000, defining elimination as reducing the prevalence to below one case per 10 000 population. By 2005, the goal had not been met, despite the provision of free multidrug therapy by Novartis from 2000 onwards. Despite these failures, there will be a great deal to cheer about on World Leprosy Day on Jan 29. In 1985, 122 countries had prevalence rates above one case per 10 000. Now, only nine do: Angola, Brazil, Central African Republic, Democratic Republic of Congo, India, Madagascar, Mozambique, Nepal, and Tanzania.

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An Editorial in the BMJ this week states that "Russia is one of the few developed countries where life expectancy has fallen in recent years. Russia's total life expectancy of 66 years lags behind that of Japan by 16 years, the European Union by 14 years, and the United States by 12 years. High mortality and morbidity from non-communicable diseases, along with a low birth rate, mean that Russia's overall population is rapidly becoming smaller and sicker."

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