#Polio eradication in @CDCMMWR: Are we finally on the cusp of that elusive dream?

Note: This was cross-posted to my own blog.


I came across a very encouraging article in last week’s MMWR (the CDC’s Morbidity and Mortality Weekly Report) this morning about polio eradication. After several reappearances in 2013, cases are down again this year and, if things continue to go well, the end may be in sight:

Four of six WHO regions have been certified as free of indigenous WPV, and endemic transmission of WPV continued in only three countries in 2014. In 2013, the global polio eradication effort suffered setbacks with outbreaks in the Horn of Africa, Central Africa, and the Middle East; however, significant progress was made in 2014 in response to all three outbreaks. Nonetheless, the affected regions remain vulnerable to WPV re-importation from endemic areas and to low-level, undetected WPV circulation. Continued response activities are needed in these regions to further strengthen AFP surveillance and eliminate immunity gaps through high-quality SIAs and strong routine immunization programs.

Progress in Nigeria since 2012 has brought the goal of interrupting the last known chains of indigenous WPV transmission in Africa within reach. Elimination of all poliovirus transmission in Nigeria in the near term is feasible, through intensified efforts to 1) interrupt cVDPV2 transmission, 2) strengthen routine immunization services, and 3) increase access to children in insecure areas. Similar efforts should be implemented in all countries in Africa, where 9 months have passed without a reported WPV case, and 6 months have passed since the last reported cVDPV2 case.

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Number of cases of wild poliovirus type 1 in countries with recent polio outbreaks, by territory* — January 1, 2013–March 30, 2015

*Central Africa (Cameroon and Equatorial Guinea), Horn of Africa (Ethiopia and Somalia), and Middle East (Iraq and Syria).

The eradication push has suffered major blows in the last two years. In 2013, after six years of being polio-free, a major outbreak in Somalia contributed more polio cases to the year’s tally than the rest of the world combined; meanwhile, the virus made its way back into Syria that same fall after a 14-year hiatus. Luckily, extraordinary efforts in the midst of conflict zones on the part of health workers were able to beat the virus back to the heart of the fight – the final three countries in which it remains endemic.

Number of cases of wild poliovirus type 1 among countries with endemic poliovirus transmission, by country — January 1, 2013–March 30, 2015

Number of cases of wild poliovirus type 1 among countries with endemic poliovirus transmission, by country — January 1, 2013–March 30, 2015

Most (86%) WPV cases in Afghanistan in 2014 resulted from importation from Pakistan; however, the detection of orphan viruses highlights the need to strengthen the quality of both polio vaccination and AFP surveillance (10). Efforts are also needed to increase population immunity by intensifying routine polio immunization activities to ensure high coverage among infants with at least 3 OPV doses.

Recent challenges to the secure operation and public acceptance of the polio eradication program in Pakistan are unprecedented (10). Although poliovirus transmission has been concentrated primarily in the FATA region of northwest Pakistan, transmission has continued in the greater Karachi area, and WPV cases have been reported from all major Pakistan provinces. Successful efforts to enhance security to protect health workers and increase public demand for vaccination are urgently needed.

The recent gains in control and elimination of poliovirus transmission globally must be maintained and built upon through innovative strategies to access populations during SIAs in areas with complex security and political challenges, improve AFP surveillance, and strengthen routine immunization. With the progress achieved in 2014 to interrupt endemic WPV transmission in Nigeria and polio outbreaks in Africa and the Middle East, permanent interruption of global poliovirus transmission appears possible in the near future, provided that similar progress can be made in Afghanistan and Pakistan; progress there would also reduce the risk for future importation-related outbreaks in polio-free countries.

While there have been several cases of circulating vaccine-derived poliovirus in northern Nigeria, the fact that no wild poliovirus has been seen in the country since last July is extremely encouraging – eradication in Africa may be in sight. The final stronghold will be Pakistan and Afghanistan (primarily its regions that border Pakistan) – where, as the global health community has discussed ad nauseum, militants take advantage of the lack of public trust in eradication owing to bad intelligence schemes, among other things.

Obviously, it is still too early to tell. Gaps in surveillance mean incomplete data; there are most likely more cases that have not been reported. Furthermore, ongoing conflict (not to mention the recent Ebola outbreak) has left the health systems of many countries devastated, so vulnerabilities are everywhere. Nevertheless, with continued dedication (and a little luck), we may very well get there. Here’s hoping.

World Human Right Cities Forum Advances Interdisciplinary Rights Dialogue

Gwangju, the “City of Light” and capitol of Jeollanam-do province in South Korea, is also the country’s historical epicenter of democratic activism and civil disobedience. In addition to being known for its flavorful food and spicy kimchi, the city has made a name of itself as a champion of human rights. Aung San Suu Kyi accepted an award for democracy there in 2013 (that had been awarded to her in 2004, while she was still under house arrest), and the city hosts an Annual World Human Rights Cities Forum. I am so proud of the fact that my own time in Korea was there, and that I became actively involved in the Gwangju International Center – a non-profit organization focused on cultural exchange that organizes and co-hosts the forum – while I was there. My husband and I both still have a strong affinity for Gwangju, which is why he chose to do his internship for his Master of Global Policy Studies program at the GIC. He had the good fortune of attending this year’s forum and even had the opportunity to speak with several panelists. He graciously agreed to share his experience and observations – even those that relate to public health – so that I could feature them here. What follows is his coverage (and photos!).

Note: This was cross-posted to my own blog.


Gwangju, South Korea – From May 15th to May 18th Gwangju, South Korea played host to the 5th Annual World Human Rights Cities Forum. Begun in 2011, the World Human Rights Cities Forum (WHRCF) has grown into a premier forum for human rights advocacy and policy with an emphasis on community-level programming. The foundational concept for the forum is that of the “human rights city,” which, according to the Gwangju Human Rights Charter, is a city built on “the historical assets and the infrastructure of democracy and human rights the city has, a democratic administration of participatory autonomy, and civic consciousness that functions as a catalyst in implementation of the human rights.” Gwangju’s interest in human rights stems from its history as the site of the May 18 Democratic Uprising, a popular revolt that played a key role in South Korea’s transition to democracy in the 1980s.

The WHRCF aims to draw activists, community organizers, and city government officials together in order to encourage the exchange of policies and ideas involving human rights advocacy and implementation. While acknowledging that city-level government is often unable to set a national tone for human rights policy, the role of municipal governments in implementation of human rights policies is key. Sessions at the 2015 WHRCF covered a variety of different themed sessions including topics of state violence and torture, gender, disability, education, and social economy. In total, over one hundred speakers from twenty-three countries presented or participated in panel sessions.

Public health interests were well represented among the panelists. The thematic session on disability placed a significant focus on self-determination in access to care, particularly for patients with mental disabilities. Discussions involved the rights of the disabled to humane treatment when institutionalized in long-term facilities, and how municipal and provincial policies can encourage proper oversight and legal protection for long-term patients at psychiatric facilities. Areas of additional concern were policies protecting the disabled from involuntary sterilization and strategies to advance public education capabilities for developmentally disabled children. Many of these are areas where local ordinances or regional organizations can have a major effect on at-risk populations, even in situations where national healthcare and education policies are lacking in their protections for the disabled.

Panelists and audience members listen to a speaker at the special session on psychological support for torture victims participating in legal proceedings.

Panelists and audience members listen to a speaker at the special session on psychological support for torture victims participating in legal proceedings.

A topic of particular relevance in many countries, including even the United States given the ongoing racial tensions and unrest in places like Baltimore or Ferguson, was the thematic session on assisting victim of state violence and torture. In an interview following the session, panelist Pinar Onen, a clinical psychologist working with the Human Rights Foundation of Turkey, spoke about the need for psychological treatment for victims of state violence, and the difficulty of finding treatment for victims who distrust state authority and state-operated healthcare system due to their association between oppressive violence and state authority. Other speakers talked about the challenges facing legal activism in support of victims of state violence, particularly re-traumatization associated with the legal challenges needed to get redress for state violence or torture. An additional concern is the need to relax or eliminate statute of limitations laws for state violence and torture, as they prevent accountability of government figures and represent an inherent conflict of interests when the body instituting the statute of limitations stands to directly benefit from the inability to hear legal action involving state violence and oppression.

Assembled dignitaries and representatives at the closing of the 2015 World Human Rights Cities Forum on May 17th, 2015.

Assembled dignitaries and representatives at the closing of the 2015 World Human Rights Cities Forum on May 17th, 2015.

The WHRCF is particularly valuable as a platform for coordinating research and policies involving human rights across a variety of different fields and locations. The opportunity for dialogue and discussion helps activist gain insight on how to institute local government policies or to effectively run advocacy organizations working to increase access to human rights protections across the world. More recognition needs to be given to worker on the regional and municipal levels who are actually involved in policy implementation and development, as broad, national directives can make a statement about human rights but cannot actually benefit citizens without effective implementation on the ground. It is absolutely essential for those in need of assistance and expertise in implementing these policies to have platforms such as these to gain knowledge and information on managing and implementing the desired programs.

As the WHRCF continues in the future, there is great need for further participation of researchers, policy-makers, and professionals in related fields to continue this dialogue regarding methods for ensuring human rights protections. Public health plays a crucial role in this endeavor, as evidenced in the Universal Declaration of Human Rights Article 25, which establishes access to medical care and social services as a basic human right. When protections are needed for children, elderly, infirm, or disabled persons, public health professionals are best equipped to provide input on the needs and challenges of these at-risk populations, and their input is absolutely necessary for administrators and policy-makers to be able to craft the laws and regulations necessary to realize human rights protections for all.

Two countries, opposite approaches: HIV on the rise in Russia and the Philippines

Note: This was cross-posted to my own blog.


Two different articles on rising HIV rates in two different countries crossed my social media news feeds today; I though I would juxtapose them here because they embody very different approaches to a problem (embedded within two very different sociopolitical environments, of course).

The first piece from the BBC focuses on an alarming rise in HIV rates in Russia:

For years Russia has remained remarkably silent on the challenge it faces from HIV and Aids. Now that silence has been broken by an epidemiologist who has been working in the field for more than two decades – and he calls the situation “a national catastrophe”.

Vadim Pokrovsky, the softly spoken head of the Federal Aids Centre in Moscow, has watched as the figures have climbed remorselessly upwards.

There are about one million people living with HIV today in Russia and year on year the rate of infection is rising, unlike sub-Saharan Africa where the rate of increase is slowing. This is according to Russia’s official figures, which almost everyone agrees are a substantial underestimate of the true position.

The epidemic in Russia, argues Mr. Pokrovsky, has been driven by ideological (rather than evidence-based) policies on sex education and injection drug therapy that have been pushed by the Russian Orthodox Church and a conservative government. Education officials argue that comprehensive sex education will encourage kids to have sex (despite plenty of evidence to the contrary), while the use of methadone replacement as a harm reduction strategy for injection drug users is ridiculed and banned (despite the method’s success in reducing HIV transmission through injection drug use in Europe and Australia). HIV infections have predominantly been driven by injection drug use in the past, but sexual transmission is on the rise. Apparently Russia is not on the evidence-based health policy bandwagon.

According to Al Jazeera, meanwhile, the picture of rising HIV rates in the Philippines looks quite different:

In the last five years, HIV cases have gone up 277 percent in the Philippines. While the total number is less than one percent of the 100 million population, it continues to rise. From one reported case every three days in 2000, there are now 21 new cases recorded every day, according to the latest government report.

A separate UN study ranks the Philippines as among the seven countries with over 25 percent or more increase in HIV cases annually from 2001 to 2009, even as the worldwide trend continues to fall.

“Unlike in other parts of the world, the AIDS Epidemic in the Philippines has been growing rapidly,” the Philippine National AIDS Council said.

Danton Remoto, university professor and gay rights activist, however, said that the real number could be 10 to 20 times higher. And he attributed the underreporting to the stigma associated with the disease, particularly among the gay community, the section of the Philippine society worst hit by the disease.

In the case of the Philippines, it has largely been government inaction (rather than counterproductive policies) and social stigma surrounding homosexuality and safer sex practices in the overwhelmingly Catholic country that have driven the epidemic. There is a silver lining here, however, as governments have begun to move (albeit slowly):

Cortes said that only a handful of the 1,634 cities and towns in the country, have programmes related to HIV prevention. She also said that a “very low condom use and low overall knowledge” about reproductive health has contributed to Filipinos engaging in risky sexual behaviours.

It was only in 2014, when the country’s reproductive health law was given a greenlight by the Supreme Court, after it was challenged by the Catholic Church as unconstitutional. The law mandates sex education and access to artificial birth control methods, including condom use.

It also includes provisions on HIV-AIDS awareness and treatment.

What is sustainability?

By Abbhirami Rajagopal, PhD MPH
This was cross-posted to my own bog

Sustainability is the ability of a system or a process to endure. And for a process to endure, we have to build it in such that it remains flexible and adaptable in many contexts.

The health program that comes to mind when you think about sustainability is the eradication of smallpox. The smallpox eradication effort was continually adapted to fit the changing needs and goals of the disease eradication program. Over time, with decreasing number of smallpox cases, the emphasis shifted from routine vaccination to surveillance.

Far too often, public health policies and programs are implemented on small scales and with limited funds and risks being discontinued when funding runs out – even if it was successful. There is a mismatch between the expectation of long-lasting effects of large-scale interventions and reality. Trying to scale up health innovations or even continuing a program when the funding runs out or political landscape changes is challenging.

In the last decade, there has been a big push toward creating programs and interventions that are sustainable. More and more donors are recognizing the importance of the sustainability of evidence-based health interventions and favor programmatic approaches that include long-term maintenance. All of this recognition has culminated in the adoption of Sustainable Development Goals (SDGs) by the United Nations earlier this year.

The SDGs differ from the Millennium Development Goals (MDGs) by virtue of being much more comprehensive with 12 goals and 17 focus areas. The SDGs set zero-oriented goals: getting to zero cases of hunger, child and maternal deaths and poverty. This lofty goal cannot be achieved by relying solely on the ever-shrinking development assistance from rich donors, as was the case with the MDGs. This is why the SDGs put sustainable, economic development right at the core of the strategy. The goals have been developed through consultation with nearly 100 member states and millions of citizens—probably the largest and most inclusive and participatory process we have ever seen. This allows for adaptable goal setting by countries that would then allow them to assess their own strengths and leverage their assets to meet the targets. To me, some of the most significant changes that we see in the SDGs are the emphasis on accountability, the separation of the issues of poverty from issues of food and nutrition security and the stronger goals with respect to women’s empowerment.

To strategically include sustainability in health programs and policies requires a “clear understanding of the concepts of sustainability and operational indicators to monitor sustainability” (1). The first step in designing sustainable health programs is to define the program elements that need to be sustained. It is also essential to build and effectively leverage partnerships for a program to be sustainable. This would imply that if you are planning a large scale program or intervention, you need to start early by planning, engaging the partners, using appropriate frameworks that conceptualize sustainability and incorporating outcome/success measures for your sustainability approach.

To go from theoretical frameworks to successful sustainability, there has to be more research with regards to how sustainable existing programs are, especially the ones that have incorporated “sustainability” into their programmatic approach. We need to know what works and what does not. We need to know what are the stumbling blocks that prevent programs from becoming sustainable. In doing so, in the future, we can design better plans for sustainable health programs, especially in settings where resources are becoming more and more limited.

Sustainability has been a huge challenge in programs designed to address micronutrient (vitamin and mineral) deficiencies. Micronutrient deficiencies impact a large number of children under-5 years of age worldwide. Many of these deficiencies co-occur with infections can exacerbate other infections that may be present (2-4).

One such micronutrient is Vitamin A; globally, nearly one-third of children under the age of 5 are deficient. We know vitamin A supplementation (VAS) works; a meta-analysis of 43 studies published in 2011 showed that VAS in children at risk for deficiency reduces mortality by about 24% (5). Despite large-scale efforts for VAS in children since the 1990s, as of 2013, the coverage rate is anywhere between 10-90% (6).

Nutrition interventions often rely on aid dollars and fortified foods or supplements from wealthy countries or private donors (for e.g. Vitamin A products for supplementation are obtained from the Micronutrient Initiative which is supported by Canadian International Development Agency). Both lack of support from the local Ministries of Health (since these programs may not align with their top priorities) and lack of policy initiatives to address micronutrient deficiencies contribute to the problems that dietary interventions encounter. The issues mentioned above point to one major theme— SUSTAINABILITY—that we as public health practitioners have to take into account when planning programs both at local and global levels.

References:

1) Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998 Mar;13(1):87-108. Review.

2) de Gier B, Campos Ponce M, van de Bor M, Doak CM, Polman K. Helminth infections and micronutrients in school-age children: a systematic review and meta-analysis. Am J Clin Nutr. 2014 Jun;99(6):1499-509. doi: 10.3945/ajcn.113.069955.

3) Amare B, Moges B, Mulu A, Yifru S, Kassu A. Quadruple burden of HIV/AIDS, tuberculosis, chronic intestinal parasitoses, and multiple micronutrient deficiency in ethiopia: a summary of available findings. Biomed Res Int. 2015;2015:598605. doi: 10.1155/2015/598605. Epub 2015 Feb 12.

4) Bhutta ZA. Effect of infections and environmental factors on growth and nutritional status in developing countries. J Pediatr Gastroenterol Nutr. 2006 Dec;43 Suppl 3:S13-21.

5) Imdad A, Herzer K, Mayo-Wilson E, Yakoob MY, Bhutta ZA. Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD008524. DOI: 10.1002/14651858.CD008524.pub2.

6) Vitamin A supplementation coverage rate (% of children ages 6-59 months). Available at http://data.worldbank.org/indicator/SN.ITK.VITA.ZS

Abbhirami Rajagopal, PhD MPH: I am currently a postdoc at Baylor College of Medicine transitioning to a career public health. My graduate work involved identifying genes involved in heme homeostasis and for my postdoctoral work, I have worked on phosphate homeostasis and understanding pathogenesis skeletal dysplasias. During my postdoc, my drive for large-scale sustainable impact led me to an MPH degree from Johns Hopkins School of Public Health. I am interested in health equity, environmental issues, sustainable food, nutrition security and social justice. I love to write and I love to volunteer! Find me on Twitter @abbhi_515 LinkedIn and Facebook

Growth and challenges of health research in the WHO Africa Region: new analysis in the BMJ

This was cross-posted to my own blog.


I have always been devoted to the principle of evidence-based policy and decision making in public health, but I have taken a keen interest in the finer points of research and methodology since taking my current position as an epidemiologist (and contemplating the pursuit of a doctorate more seriously). Earlier this month, I spotted an article from BMJ examining the output of health research in the WHO Africa region from 2000 to 2014 (h/t to Dr. Ron LaPorte, professor of epidemiology at the WHO Collaborating Center at the University of Pittsburgh and co-founder of the Supercourse project). The article, entitled “Increasing the value of health research in the WHO African Region beyond 2015,” is a bibliometric analysis of the health research publications from the WHO Africa region indexed on PubMed; it analyzes the influence of various factors, including GDP, population, and health spending on the number and growth of published papers by country over the time period. The abstract reads:

Objective To assess the profile and determinants of health research productivity in Africa since the onset of the new millennium.

Design Bibliometric analysis.

Data collection and synthesis In November 2014, we searched PubMed for articles published between 2000 and 2014 from the WHO African Region, and obtained country-level indicators from World Bank data. We used Poisson regression to examine time trends in research publications and negative binomial regression to explore determinants of research publications.

Results We identified 107 662 publications, with a median of 727 per country (range 25–31 757). Three countries (South Africa, Nigeria and Kenya) contributed 52% of the publications. The number of publications increased from 3623 in 2000 to 12 709 in 2014 (relative growth 251%). Similarly, the per cent share of worldwide research publications per year increased from 0.7% in 2000 to 1.3% in 2014. The trend analysis was also significant to confirm a continuous increase in health research publications from Africa, with productivity increasing by 10.3% per year (95% CIs +10.1% to +10.5%). The only independent predictor of publication outputs was national gross domestic product. For every one log US$ billion increase in gross domestic product, research publications rose by 105%: incidence rate ratio (IRR=2.05, 95% CI 1.39 to 3.04). The association of private health expenditure with publications was only marginally significant (IRR=1.86, 95% CI 1.00 to 3.47).

Conclusions There has been a significant improvement in health research in the WHO African Region since 2000, with some individual countries already having strong research profiles. Countries of the region should implement the WHO Strategy on Research for Health: reinforcing the research culture (organisation); focusing research on key health challenges (priorities); strengthening national health research systems (capacity); encouraging good research practice (standards); and consolidating linkages between health research and action (translation).

In the discussion, there is some fascinating commentary on the challenges facing researchers in the research and the barriers to publication, as well as to making those publications available to other researchers in the field. Some of them are familiar and strike me as a common symptom of the complicated relationship between politics and (especially evidence-based) policy making:

Although there is clearly a need for improving the performance of health researchers on the continent, African health decision makers should use the available research evidence to guide policy, strengthen practice and maximise the use of resources in order to improve the welfare of their citizens. However, there appears to be a failure to apply available research evidence to improve the health of populations on the continent. This unfortunate situation may be related to the lack of sharing of research evidence for translation into policy and practice, a non-alignment of research conducted in African countries to national research policies and/or the non-existence of national health research policies with clearly defined priorities.

However, others are somewhat unique to Africa. Not of them are economic (though funding plays a major role), and the paper goes so far as to describe some of the challenges as “intractable”:

The difficulties in research, publication, editorial bias and information access facing Africa are profound and seem almost intractable. Another difficulty facing African researchers is dissemination of findings to other parts of the world. Most of the information published in African journals is largely not included in major databases. Access to technological tools, information access and other equipment and supplies to ease research work is not always possible.

I hope this will influence the wider debate on the future of aid and health spending in Africa. The call for a shift in funding and emphasis from technologically-focused solutions to health-systems strengthening and sustainability has gained momentum, and research and academic exchange is a crucial part of the latter.

White House Takes a Stand on Climate Change and Public Health

“Climate change is making an impact on our public health.”
-President Obama

We know that climate change threatens our air, food, water, and homes but earlier this month at a round table discussion, President Obama spoke about the effects of climate change on public health. In this video he says the temperature of the planet is rising and that not only comes with adverse weather and environmental consequences, but also a “whole host of public health impacts.”

Accompanied by Surgeon General Dr. Vivek Murthy, President Obama put a spotlight on increased heat-related deaths, severe asthma, extended allergy seasons, and the spread of tropical or insect-borne diseases as some possible consequences of climate change. He also spoke about the need to focus on prevention and action and the costs associated with inaction.

This is the beginning of a big push from the White House to better understand and deal with the health effects of climate change and this statement outlines their plan to do so. This is such a great step in the right direction and a big win for the public health field. Here’s to hoping it all leads to a long-term commitment with the necessary funding and policies to make significant changes!

HUMANITY OF GENDER EQUALITY BY MARY LOUISE TATUM

“Girls must be told at an early age that they have the potential to become influential leaders before they fall victim to their own self-doubt”. These are the insightful words of Malala Yousafzaia, a Pakistani activist for female education and the youngest Nobel Prize laureate.

These words continue to ring true regardless of one’s geographical location. Girls and women from around the world continue to be marginalized.  For example, more high-income countries face challenges, such as, equal pay, maternity leave policies that allow women enough time to nurture their infants, and job security to continue in their careers.

It is reprehensible that females around the world are forced into marriage at ages as young as nine,  punished for “immodest behavior or dress”, not allowed to drive, denied an education,  excluded from politics, gang raped with no retribution, coerced into female genital mutilation (look out for  my June blog), and the list goes on.

Females are approximately half of the world’s population (http://data.worldbank.org).  Thus, women have to be allowed equal rights for human survival. Not to mention, we all have the basic human right to choose our own destiny.

However, supporters of female rights must be empathetic and meet those who desire or need support where they are. As public health professionals, we cannot force values and beliefs because we think they are superior or imagine a clear path to their implementation. We have to be empathetic, willing to learn, and understand the values of the community we are involved. We can provide education on evidence-based health practices and provide availability to health care, education, financial training, etc. These changes will come from within the community, so we have to develop partnerships within the community and provide the necessary tools that will build capacity and self-reliance. Let’s encourage the enhancement of inherent positive cultural attributes, increase self-esteem and self-awareness with financial resources and training to optimize the quality of life.

All persons have the right for their basic needs to be met and to feel confident and empowered. All persons deserve the opportunity to realize their potential.  Education and opportunity is the key for making the world better. The survival of humanity depends on the synergy of women and men.