WHO: Reducing The Burden Of NCDs

 

 

 

# 5850

 

Although we tend to focus on communicable diseases in this blog, in truth, in a normal year about 60% of all deaths are due to NCDs; Non Communicable Diseases.

 

The four biggest contributors to NCDs around the world are:

• cardiovascular disease
• cancer
• chronic lung diseases
• diabetes

Last week the World Health Organization released a detailed profile of the burden of NCDs on 193 countries, stating that (in 2008) more than 9 million of all deaths attributed to NCDs occurred in those under the age of 60. And the overwhelming majority (90%) occurred in low- and middle-income countries.

 

Individual country NCD Profiles may be downloaded and viewed at NCD country profiles: A-Z list of country profiles.

 

Each country’s profile is summarized on a single page as depicted below:

 

The entire global report is available at:

Noncommunicable diseases country profiles 2011

 

This week (Sept. 19th & 20th) the World Health Organization will convene an international meeting in New York City to consider the prevention and control noncommunicable diseases. 

 

Details on that meeting can be found at:

 

United Nations high-level meeting on noncommunicable disease prevention and control

Date: 19-20 September 2011
Place: New York, USA

Facts about NCDs

• 36 million people die annually from NCDs.
• 63% of all global deaths are due to NCDs.
• 9 million people die too young from NCDs, before the age of 60.

10 facts on NCDs

Fact sheets on chronic diseases

 

 

In an attempt to reduce the global burden of NCDs, the WHO has released a couple of studies to coincide with this meeting.

 

New WHO study details low-cost solutions to help curb the tide on noncommunicable diseases

Strategies to prevent and treat cancer, heart disease, diabetes and lung disease for just US$ 1.20 per person per year

News release

18 September 2011 | New York | Geneva - A new WHO study reveals that low-income countries could introduce a core set of strategies to prevent and treat cancer, heart disease, diabetes and lung disease for just US$ 1.20 per person per year.

 

"Noncommunicable diseases are the leading cause of death worldwide, killing ever more people each year. Nearly 80 per cent of these deaths occur in low- and middle-income countries," says Dr Ala Alwan, Assistant Director-General for Noncommunicable Diseases and Mental Health at WHO. "The challenge to these countries is tremendous, but this study proves that there are affordable steps all governments can take to address noncommunicable diseases."

(Continue . . .)

 

• Scaling up action against noncommunicable diseases: How much will it cost?
• From burden to "best buys": Reducing the economic impact of NCDs in low- and middle-income countries

 

 

The `Best Buys’ report above, prepared by the WHO, the World Economic Forum, and the Harvard School of Public Health states:

 

Under a “business as usual” scenario where intervention efforts remain static and rates of NCDs continue to increase as populations grow and age, cumulative economic losses to low- and middle-income countries (LMICs) from the four diseases are estimated to surpass US$ 7 trillion over the period 2011-2025 (an average of nearly US$ 500 billion per year).

 

This yearly loss is equivalent to approximately 4% of these countries’ current annual output. On a per-person basis, the annual losses amount to an average of US $25 in low-income countries, US$ 50 in lower middle-income countries and US$ 139 in upper middle-income countries.

 

By contrast, findings from the second study by the WHO indicate that the price tag for scaled-up implementation of a core set of NCD “best buy” intervention strategies is comparatively low.

 

Population-based measures for reducing tobacco and harmful alcohol use, as well as unhealthy diet and physical inactivity, are estimated to cost US$ 2 billion per year for all LMICs – less than US$ 0.40 per person. Individual-based NCD “best buy” interventions – which range from counselling and drug therapy for cardiovascular disease to measures to prevent cervical cancer – bring the total annual cost to US$ 11.4 billion.

 

On a per-person basis, the annual investment ranges from under US$ 1 in low-income countries to US$ 3 in upper middle-income countries.

 

To learn more about NCDs, and what can be done to reduce their impacts, the WHO provides the following links.

 

ABOUT NCDs

Four diseases

• Cancer
• Cardiovascular diseases
• Chronic obstructive pulmonary disease
• Diabetes

Four risk factors

• Tobacco use
• Unhealthy diet
• Harmful use of alcohol
• Physical inactivity

 

Aside from the humanitarian aspects, as with most health issues, prevention and early intervention are far more cost effective than ignoring the problem.

»» Read More

CDC Study: Risks Of High Sodium, Low Potassium Diets

 

 

# 5686

 

 

Photo Credit – CDC Grand Rounds

 

 

Another salvo in the excess-dietary-sodium wars was fired yesterday with the release of a study by the CDC, Emory University, and Harvard University on the effects of high sodium and low potassium diets on all-cause and coronary death rates.

 

As you may recall, last April I blogged on a CDC Grand Rounds presentation called Sodium Reduction: Time for Choice, and mentioned my own attempts to lower my sodium intake.

 

Last week, we looked at a conflicting and controversial Cochrane review called:

 

Reduced dietary salt for the prevention of cardiovascular disease

Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim SPlain Language Summary

Cutting down on the amount of salt has no clear benefits in terms of likelihood of dying or experiencing cardiovascular disease

 

Patients with congestive heart failure, they cautioned, who were on a sodium restricted diet saw an increase in all-cause deaths.

 

I discussed the all-too-frequent dilemma posed by conflicting scientific studies last week in A Decided Lack Of Scientific Certainty.

 

While the debate rages on (The Salt Institute is taking considerable umbrage over this latest research, calling it `Highly flawed’), today’s study – which appears in the Archives of Internal Medicine – strongly suggests that: 

 

Americans who eat a diet high in sodium and low in potassium have a 50 percent increased risk of death from any cause, and about twice the risk of death from heart attacks. - (Lede from CDC Press Release)

 

You can read the entire Press Release here, but a few excerpts include:

 

 

"The study's findings are particularly troubling because U.S. adults consume an average of 3,300 milligrams of sodium per day, more than twice the current recommended limit for most Americans," said Elena Kuklina, M.D., Ph.D., an investigator on the study and a nutritional epidemiologist with CDC's Division for Heart Disease and Stroke Prevention.

 

"This study provides further evidence to support current public health recommendations to reduce sodium levels in processed foods, given that nearly 80 percent of people's sodium intake comes from packaged and restaurant foods. Increasing potassium intake may have additional health benefits."

 

In general, people who reduce their sodium consumption, increase their potassium consumption, or do both, benefit from improved blood pressure and reduce their risk for developing other serious health problems.

 

The abstract to the study is available on the Archives of Internal Medicine site:

 

Sodium and Potassium Intake and Mortality Among US Adults

Prospective Data From the Third National Health and Nutrition Examination Survey

Quanhe Yang, PhD; Tiebin Liu, MSPH; Elena V. Kuklina, MD, PhD; W. Dana Flanders, MD, ScD; Yuling Hong, MD, PhD; Cathleen Gillespie, MS; Man-Huei Chang, MPH; Marta Gwinn, MD; Nicole Dowling, PhD; Muin J. Khoury, MD, PhD; Frank B. Hu, MD, PhD

Arch Intern Med. 2011;171(13):1183-1191. doi:10.1001/archinternmed.2011.257

 

 

This study basically followed 12,267 U.S. adults, tracking their sodium/potassium consumption, and correlated that with death rates (and their causes) over a 15 year follow-up period.

 

They found those who had the highest sodium intake combined with the lowest potassium intake were twice as likely to die from CVD (Cardiovascular Disease), and 50% more likely to suffer any any-cause death.

 

It should be noted that the study did not find a significant link between excess sodium consumption alone and CVD, stating:

 

“Sodium intake was not statistically associated with CVD or IHD mortality.” 

 

The go on to state, however, that:

 

"The non-significant associations between sodium intake and CVD mortality observed in our study do not undermine a well-established relationship between sodium intake and high blood pressure or the potential benefits of sodium reduction at the population level.”

 

 

Given the vehement protestations of the Salt Institute, and the lack of a smoking salt shaker in this study, how should the public regard this latest information?

 

Accepting that scientific certainty is often an elusive, and sometimes impossible goal – and that what may apply to the population as a whole may not apply to each and every individual . . .

 

. . . the preponderance of evidence right now suggests that excess sodium consumption poses a significant health risk.

 

Increasing your potassium intake may help mitigate some of those risks, but this study strongly suggests that the best strategy is probably to both reduce sodium and increase your potassium intake.

 

The CDC advises: 

 

Adults can improve their health by knowing recommended limits for daily sodium intake, choosing foods like fresh or frozen fruits and vegetables, and unprocessed or minimally processed fish, meat or poultry, low-fat milk or plain yogurt, asking for foods with no or low salt at restaurants, and reading the nutrition labels of foods before purchasing can improve health for all adults.

 

 

If you are still unsure, you should discuss it with your health care practitioner. But the odds are, they will side with the CDC on this issue, and advise you to take a step back from your salt shaker.

»» Read More

A Decided Lack Of Scientific Certainty

 

 

# 5680

 

 

Last April I blogged on a CDC Grand Rounds presentation called Sodium Reduction: Time for Choice. As the following presentation slide illustrates, it promoted the idea that as a society are endangering our health by consuming too much salt.

 

Or are we?

 

Well, not according to a recent Cochrane review called

 

Reduced dietary salt for the prevention of cardiovascular disease

Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim SPlain Language Summary

Cutting down on the amount of salt has no clear benefits in terms of likelihood of dying or experiencing cardiovascular disease

 

In fact, among patients with congestive heart failure (who are routinely advised to reduce salt intake), those on a sodium restricted diet saw an increase in all-cause deaths.

 

Confused?

 

Hang on . . .

 

Last year (see IOM Report On Vitamin D) the Institute of Medicine released a long-awaited report on the benefits of vitamin D supplementation.

 

While the IOM’s Food and Nutrition Board increased their daily recommendations for Vitamin D, they fell well short of endorsing the high daily doses that have become in vogue over the past decade.

 

The entire 999 page report is available online for free, or may be ordered as PDF files, or as a hardback from the National Academies Press.

 

Essentially, the IOM recommended an RDA (recommended dietary allowance) of 600 IU of Vitamin D for most Americans, and a maximum of 4000 IUs. 

 

They also concluded:

 

The IOM finds that the evidence supports a role for vitamin D and calcium in bone health but not in other health conditions. Further, emerging evidence indicates that too much of these nutrients may be harmful, challenging the concept that “more is better.”

 

Not exactly what the vocal proponents of this popular supplement wanted to hear. And as you can imagine, their reaction to this report has not been entirely positive.

 

But over the eight months since this landmark report was released, we’ve seen other studies that take issue with the IOM’s findings.   

 

Last month, The Endocrine Society – which consists of 14,000 clinicians and research scientists – released new guidelines that recommended higher doses than did the IOM (Endocrine Society Issues Practice Guideline on Vitamin D).

 

And just over a week ago, a study in the Journal of Bone & Mineral Research that looked at Vitamin D levels during pregnancy recommended:

 

"the current vitamin D EAR and RDA for pregnancy women issued in 2010 by the Institute of Medicine should be raised to 4,000 IU vitamin D per day so that all women regardless of race attain optimal nutritional and hormonal vitamin D status throughout pregnancy."

 

 

This week Nature News has two excellent in-depth articles on why these reports contradict one another, and how difficult it can be to draw firm conclusions from observational studies.

 

Nutrition advice: The vitamin D-lemma

Review adds salt to a familiar concern 

 

While both of these articles are highly informative, they can’t tell us which side of these two debates is correct. 

 

And neither can I.

 

For those who like their science neat and tidy, devoid of ambiguity, and rock solid . . .  dueling studies such as these are no doubt more than a little disconcerting.

 

And we’ve seen similar (unresolved) debates over the efficacy of Tamiflu, the value of surgical masks in preventing respiratory infections, and the effectiveness of flu vaccines.

 

A few previous blogs on these uncertainties include:

 

RCTs: All That’s Gold Standard Doesn’t Glitter

When Studies Collide (Revisited)

When Studies Collide

 

 

None of this is intended to suggest that scientific research is useless, or fundamentally flawed.

 

Only that gaining scientific knowledge is a process . . . one that evolves over time . . . and scientific certainty is an elusive, sometimes unobtainable goal.

 

So the next time you see a study cited here, or any place else for that matter, keep in mind that while it may be useful . . . and it may even be correct . . .  

 

Caveat lector should always apply.

»» Read More

Pandemic Field and Epidemiologic Investigations

 

 

 

# 5145

 

While not terribly severe, the pandemic of 2009 has been perhaps the most intently studied infectious disease outbreak in the history of medical science.

 

Although there is still much to learn, studies conducted over the past 18 months have helped to bring much needed insight to the field of influenza research.

 

Yesterday the CDC, in a press release, announced the availability of more than two dozen research articles in the January, 2011 supplemental issue of Clinical Infectious Diseases.

 

New Articles Highlight the Science Behind Government's Response to 2009 H1N1 Pandemic

For Immediate Release: December 14, 2010
Contact: CDC Media Relations
(404) 639-3286

WHAT

A series of studies published today in a supplement to the journal Clinical Infectious Diseases (CID) provide a unique look at the science that guided the Federal Government's response to the 2009 H1N1 pandemic.

Topics covered include the impact of the pandemic on society, disease transmission and the effectiveness of mitigation strategies, historical perspectives on the significance of the pandemic compared to prior pandemics, and assessments of preparedness efforts made prior to and following the pandemic.

(Continue . . .)

 

To view the table of contents, and to view the abstracts or complete full texts, follow this link:

 

The 2009 H1N1 Influenza Pandemic: Field and Epidemiologic Investigations

Volume 52 suppl 1 January 1, 2011

 

 

For an excellent overview, I can think of no better place to start than with last night’s report by  Lisa Schnirring at CIDRAP. 

 

Studies show science behind CDC pandemic response

Lisa Schnirring Staff Writer

Dec 14, 2010 (CIDRAP News) – The US Centers for Disease Control and Prevention (CDC) today published a detailed look at the early field and epidemiologic studies it used to guide its response to the 2009 H1N1 pandemic, such as spread among household contacts, disease severity, and the impact on high-risk groups.

 

The 29 reports, all of which are freely available, appear today in an early online supplement of Clinical Infectious Diseases (CID) that is sponsored by the CDC. Topics range from epidemiologic and surveillance methods used by the CDC to clinical characteristics and disease burden.

(Continue . . . )

 

 

 

Since the weather outside has been frightful, I fully expect to spend some quality time over the holidays catching up with my scientific reading – starting with these articles.

»» Read More

Eurosurveillance: The Temporary Immunity Hypothesis

 

 

# 5092

 

 

In September of 2009, news of an (at that time) unpublished Canadian study began to surface that suggested that those who had received a seasonal flu shot the previous year were more susceptible to the new pandemic virus than those who hadn’t.

 

Helen Branswell, science and medical reporter for the Canadian Press, was among the first to report on it (see Branswell On The Canadian Flu Shot Controversy).

 

This bombshell – which began to be known as `the Canadian problem’, sent shockwaves through public health circles.  Many agencies were just days away from starting up their seasonal flu vaccination campaigns as they waited for the arrival of the H1N1 pandemic vaccine expected later in the fall.

 

Suddenly, there was genuine concern that maybe  . . .  just maybe  . . .  with a pandemic virus on the way, that rolling out the seasonal vaccine was the wrong thing to do. 

 

The CDC and the World Health Organization both scrambled to look at their available data, and stated that they could find no correlation between the seasonal vax and susceptibility to the pandemic flu . . . but that they would continue to look.

 

Meanwhile, with concerns rising, a number of Canadian Provinces halted or announced delays in rolling out the seasonal flu shot, even though the study had yet to be published (see Ontario Adjusts Vaccination Plan).

 

October saw a number of new reports and studies that failed to corroborate the (still unpublished) findings, including a study published in the BMJ (British Medical Journal) that suggested exactly the opposite - that getting the seasonal flu vaccination may be slightly protective against the swine flu  (see When Studies Collide).

 

Which, admittedly, ran contrary to what we’d heard previously from the CDC, who maintained that the seasonal vaccine was not expected to offer any protection against the novel H1N1 swine flu virus.

 

By November, with no compelling corroboration of the `Canadian Problem’, Canada’s National Advisory Committee on Immunization (NACI) came out in favor of resuming seasonal flu jabs (see NACI: Canada Should Resume Seasonal Flu Vaccinations).

 

The controversy wasn’t over, however.

 

In April of this year these Canadian studies were finally published by PLoS Medicine. Writing for CIDRAP, Maryn McKenna   detailed their findings.

 

New Canadian studies suggest seasonal flu shot increased H1N1 risk

Maryn McKenna Contributing Writer

Apr 6, 2010 (CIDRAP News) – Despite a rapidly launched range of studies, investigators in Canada are still unable to say—or to rule out—whether receiving a seasonal flu vaccination in the 2008-09 season made it more likely that Canadians would become ill from 2009 pandemic H1N1 flu.

(Continue . . .)

 

Other studies continued to fail to show any correlation, leaving us with a bit of a mystery on our hands. 

 

Why were these Canadian findings so different than all the others?

 

Which bring us to today’s story regarding a hypothesis that appeared in yesterday’s Eurosurveillance journal, suggesting a mechanism that might explain the `Canadian Problem’.

Eurosurveillance, Volume 15, Issue 47, 25 November 2010

Perspectives

Seasonal influenza vaccination and the risk of infection with pandemic influenza: a possible illustration of non-specific temporary immunity following infection

H Kelly , S Barry, K Laurie, G Mercer

 

You’ll probably want to read the entire paper, but for those not inclined to wade through the whole article, I’ll attempt to summarize their hypothesis.

 

Unlike the Canadian researchers, Australian scientists could find no increased susceptibility to the pandemic H1N1 virus among those who had been vaccinated the previous year against seasonal flu.

 

The difference between the two findings, they suggest, comes from three separate factors:

• A theory regarding temporary immunity following any influenza infection
• The timing of the arrival of the pandemic virus in Canada
• And the protective effects of seasonal flu vaccination against seasonal - but not pandemic - flu.

 

We’ll take these one at a time.

 

It has been theorized that infection by any influenza (or perhaps, any respiratory) virus ramps up the body’s immune system for weeks or even months after the illness has passed, making that person temporarily less susceptible to infection by another virus.

 

Researchers, looking back at the infection patterns from the 1918 and 1957 pandemics, have used this theory to explain why pandemics come in waves.

 

And given that each year we usually see two A strains of influenza, a B strain, and a veritable rogues gallery non-influenza respiratory viruses circulating, this may also help explain why we all don’t endure non-stop ILI’s every winter.

 

Which bring us to the timing element.

 

In Canada, the first wave of the virus arrived on the heels of the 2008-2009 seasonal flu epidemic, which had peaked only 3 months earlier.

 

Australia, however, was nearing the end of their summer, and the peak of their flu season had occurred a full 9 months before.

 

If the temporary immunity theory is correct (`if’ being the operative word), Canadians who had contracted seasonal flu earlier in the year, may still have carried some generic immunity against infection.

 

Australians, on the other hand, saw the pandemic virus arrive long after any such temporary protective benefits would have decayed.

The third element is the protective benefits of the seasonal flu vaccine. 

 

The 2008-2009 vaccine was reasonably protective against seasonal flu, but offered little or no protection against the novel H1N1 virus.

 

Since those that eschewed the seasonal vaccine were more likely to catch the flu, it increased their opportunity to develop the (hypothesized) temporary generic immunity discussed above. 

 

The authors suggest that those who took the vaccine, lacking the `temporary protection’ from a recent bout with the flu, may have appeared to be more susceptible to the pandemic virus.

 

It’s an attractive solution, and many of the elements do seem to fit. 

 

But to make it work, you have to accept the temporary immunity hypothesis as being valid - and while gaining acceptance – it hasn’t been fully proven.

 

And if this explanation is correct, you would also expect to find a similar pattern in other vaccinated regions of the northern hemisphere where novel H1N1 arrived shortly after the peak of their flu season. 

 

So far, that hasn’t been demonstrated.

 

But good science takes time, which means that more research will be needed on several fronts before this theory can be accepted as a resolution to the `Canadian Problem’.

»» Read More

Haiti: Three Non-Cholera Health Threats

 

 

 

# 5052

 

 

While the world’s attention has been (at least briefly) focused on the Cholera epidemic in Haiti, it is worth noting that there are other serious health threats affecting the residents of that beleaguered nation.

 

I’ve selected three that were around before the cholera outbreak began (but have been greatly exacerbated by last January’s earthquake) to highlight.

 

Earlier this week I mentioned the abstract book from this past week’s American Society of Tropical Medicine and Hygiene (ASTMH) 59th Annual Meeting.   A search on the word `Haiti’ produced several studies on serious health problems endemic to that Caribbean nation.

 

 

A few excerpts from these abstracts along with some background.   You can find the entire abstract book here.

 

 

The first, like cholera, involves a serious diarrhea producing waterborne contaminant; cryptosporidium.

 

 

Although rarely fatal in healthy individuals, `Crypto’ can be deadly for the very young, the very old, and those with compromised immune systems. Cohorts that are common in Haiti.

 

The CDC  maintains a large Crypto Information Site.

 

Occasionally campers, swimmers, or those drawing water from untreated wells will contract Crypto here in the United States.  The largest outbreak occurred in Milwaukee in 1993, when Cryptosporidium entered the public water supply (exactly how, remains a mystery), and sickened 400,000 people and killed more than 100 who were immunocompromised.

 

Cryptosporidium is chlorine resistant, making it particularly difficult to eliminate from water sources.  The Milwaukee incident has led to increased water testing, and the use of ozone, filters, and other interventions across the nation to help make our water supply safer.

 

Measures that are pretty much unavailable for most of Haiti.

 

Crypto is spread via the fecal-oral route, and as the study below indicates, is abundant in water samples taken in Haiti.  

 

 

#440  CRYPTOSPORIDIUM CONTAMINATION OF SURFACE AND WATER SUPPLIES IN HAITI

Philippe M. Brasseur, Ketty Balthazard-Accou, Patrice
Agnamey, Evens Emmanuel, Michel Vaillant, Christian Raccurt

Cryptosporidiosis is one of the most frequent causes of diarrhoea in Haiti. Transmission in children less than five years-old, HIV-infected individuals, and people living in low socio-economic conditions is frequently due to consumption of water or food contaminated by Cryptosporidium oocysts.

<SNIP>

In the district of Port-au-Prince, 24/37 (65%) of water samples collected were contaminated by Cryptosporidium oocysts and the number of oocysts per 100L ranged from 4 to 1,274.

 

In the reservoirs used by people living in peripheral
areas, 10/11 (91%) of samples collected were contaminated with a mean number of 140 oocysts per 100L. In water samples from public standpipes
provided by Camep, the public company of water distribution in Port-au-Prince, 7/13 (54%) were contaminated.

 

All surface water 4/4 collected in Port-au-Prince or in peripheral areas was highly contaminated. In Les Cayes 8/15 (53%) samples contained ryptosporidium oocysts and the number detected varied from 5 to 100 (mean 29) / 100 L of water filtered.

 

In conclusion, a commitment to environmental improvement in Port-au-Prince and in Les Cayes is required to improve the quality of drinking water
and to limit the risk of human transmission of cryptosporidiosis.

 

Another common tropical parasite, Malaria, is also endemic in Haiti – and with hundreds of thousands of post-earthquake displaced persons living in tents and under tarps, exposure to malaria (Anopheles) mosquitoes has increased.

Once again you’ll find a comprehensive Malaria information site at cdc.gov.

 

In the wake of the January earthquake, the CDC, Save the Children, and the Ministry of Public Health in Port-au-Prince conducted a malaria surveillance program to determine just how prevalent the infection was among refugees.

 

# 778 MALARIA SURVEILLANCE IN HAITI, POST-EARTHQUAKE, 2010

David A. Townes, Ribka Amsalu, Roc Magloire, Michelle Chang, Meredith McMorrow, S. Patrick Kachur

<SNIP>

 

Plasmodium falciparum malaria is endemic in Haiti where the principal vector is the Anopheles albimanus mosquito, which frequently bites outdoors. Thus, displaced persons living outdoors or in temporary shelters in Haiti are at substantial risk for malaria.

 

We conducted a survey of 1,629 consecutive suspected malaria patients presenting to medical clinics managed by Save the Children in the earthquake affected areas of Leogane and Jacmel from March 4 to April 9, 2010. Suspected malaria accounted for 3.0% of all consultations.

 

Females accounted for 59% of suspected malaria
consultations. A malaria rapid diagnostic test (RDT) was performed on 96% (1,564/1,629) of these patients with an overall positivity rate of 20.3% (317/1,564).

 

Among 341 children less than five years of age, 7.6% were RDT positive, 87.7% were RDT negative, and 4.7% had no RDT result recorded.

 

<SNIP>

 

Of the 317 patients with a positive RDT, 87.7% received chloroquine, 2.5% received quinine, and 9.8% had no anti-malarial documented.

 

Malaria is an important public health problem in Haiti post-earthquake with the potential for an increase in cases given the large number of displaced individuals and the onset of the rainy season. Continued malaria surveillance is essential to monitor prevalence, identify areas of potential increased transmission, detect epidemics should they occur, and help direct and monitor interventions and response.

 

 

A third surveillance study, again by Save The Children, indicates that ARIs (acute respiratory infections) constitute the most common health threat to children under the age of five in post-earthquake Haiti.

 

You may recall that earlier this week I highlighted the World Lung Foundation’s Acute Respiratory Infection Atlas, which details the global impact of ARI’s and in particular, childhood pneumonia.

 

Even in 2008, the death rate in children under 5 from pneumonia was more than twice that of neighboring Dominican Republic (72 vs. 33  per 100K).

 

# 1135  ACUTE RESPIRATORY INFECTION, MAIN CAUSE FOR MORBIDITY FOR CHILDREN 0-5 YEARS OF AGE, IN POST-ARTHQUAKE, HAITI, 2010

Ribka Amsalu Tessera

Save the Children , Wahington, DC, United States

<SNIP>

Disease surveillance is one of the key tasks of the medical team to prioritize health action and determine the occurrence of disease outbreaks. From January 31st  - April 4th, 21 Mobile Medical team of Save the Children  composed of medical doctors, midwife and nurses, had 52,761 consultations in Port-au-Prince and Jacmel, out of which 22% were due to Acute Respiratory Infections (ARIs).

 

ARI accounted for 48.4% of consultations among children 0-5yr of age, and 12.5% among those over the age of 5yrs. The total consultation due to ARIs was four fold higher than the total number of consultations due to diarrhea and suspected malaria among children 0-5yr of age.

 

The World Health Organization (WHO), estimates that prior to the earthquake pneumonia accounted for 20% of mortality among children in Haiti, much higher than diarrhea (16%) and malaria (1%).

 

Crowded leaving conditions, low vaccination coverage, and poor nutritional situation have exacerbated the risk for pneumonia among children in post-earthquake Haiti.

 

 

All of this means that once the furor and media attention over the cholera outbreak fades away, Haiti will still face huge public health and humanitarian challenges.

 

So if you can find a way to help support the relief efforts in Haiti through a donation to one of the reputable NGOs working on the ground there (ie. Red Cross, CARE.ORG, SAVE THE CHILDREN), I’m certain they - and the people of Haiti - will be grateful for your generosity.

»» Read More

RCTs: All That’s Gold Standard Doesn’t Glitter

 

 

# 4717

 

 

Over the next couple of days I’ll be highlighting some of the interesting abstracts of slide presentations to the ICEID 2010 conference going on in Atlanta this week.

 

Academic conference presentations are not in the same league as peer-reviewed journal articles  – but they do give us an important and early look at research being conducted around the world.

 

Many of these presentations will eventually end up in peer-reviewed journals, however.  But that can take a year or longer.

 

Meanwhile, important information and avenues of research may languish. These presentations are therefore of keen interest, even if they haven’t been subjected to peer-review.

 

So as you read these abstracts, and follow news reports from this conference, I’d recommend a bit of caution. 

 

But even peer-reviewed RCTs (Randomized Controlled Trials)  (long considered the `gold standard’ for scientific research)  published in prestigious journals - deserve a dash of skepticism on the part of the reader.

 

Today a cautionary note from Johns Hopkins Medicine on RCTs. From the press release below, here is the `money quote’, but follow the link to read the whole thing (emphasis mine).

 

Overall, 41 percent of the 146 trials in the review had improper or poorly described randomization techniques. Industry-funded trials were six times more likely to have high risk for biased randomization than government-funded trials or those funded by nonprofit organizations.

 

 

First, this press release from Johns Hopkins (hat tip @Lizsherer) on potentially flawed RCT pediatric studies, followed by a few words on my part.

 

 

Pediatric Clinical Studies Appear Prone to Bias

Released: 7/9/2010 8:00 AM EDT
Embargo expired: 7/12/2010 12:05 AM EDT
Source: Johns Hopkins Medicine

-Better design, reporting urged to ensure accurate results

Newswise — A Johns Hopkins review of nearly 150 randomized controlled trials on children — all published in well-regarded medical journals — reveals that 40 to 60 percent of the studies either failed to take steps to minimize risk for bias or to at least properly describe those measures.

 

A report of the team’s findings in the August issue of Pediatrics shows that experimental trials sponsored by pharmaceutical or medical-device makers, along with studies that are not registered in a public-access database, had higher risk for bias. So were trials that evaluate the effects of behavioral therapies rather than medication, the report states.

 

“There are thousands of pediatric trials going on in the world right now and given the risk that comes from distorted findings, we must ensure vigilance in how these studies are designed, conducted and judged,” says lead investigator Michael Crocetti, M.D., M.P.H., a pediatrician at Johns Hopkins Children’s Center. “Our review is intended as a step in that direction.”

 

Considered the gold standard of medical research, the hallmark of double-blind randomized controlled trials (RTC) is a design that rules out or accounts for actual or potential bias. Results of such studies, when peer-reviewed and published in reputable medical journals, can influence the practice of medicine and patient care. A poorly designed or executed trial can therefore lead researchers to erroneous conclusions about the effectiveness of a drug or a procedure.

 

Citing the degree of bias risk in the studies they reviewed, the researchers caution pediatricians to be critical readers of studies, even in highly respected journals.

(Continue . . . )

 

 

First and foremost, science is messy, and scientists are far from infallible.

 

Which is why I am always a little bit skeptical when I read the conclusions of the latest whiz-bang scientific study or a press release announcing an exciting new advance in medicine. 

 

Not because I harbor conspiratorial beliefs, or a deep suspicion of the motives of scientists . . . but because I view scientific discovery as a journey. . . a learning process . . . not a destination.

 

Advances in science are anything but linear, and very often we find ourselves sidetracked or detoured down some flawed alley of investigation along the way.   

 

What we know, or what we think we know, is constantly changing.  This is particularly true in medicine.

 

When I was a young paramedic, 35 years ago (back when dinosaurs roamed the earth), every doctor knew that the very first thing you did for someone in cardiac arrest (after initiating CPR) was to give them a bolus of 1 or 2 amps of Sodium Bicarb to reverse the inevitable acidosis brought on by respiratory arrest.

 

You did this even before attempting to defibrillate, since conventional wisdom said that you couldn't cardiovert an acidotic heart.

 

And so 2 amps of bicarb went in as a matter of course.  Because everyone knew that was the right thing to do.

 

Trouble is, even with our cardiac meds and defibrillators and advanced training, we were losing a lot of patients.   By the mid-1980's it became apparent that the bolus of bicarb wasn't helping, and in fact, was probably hurting patients.

 

By 1986 several scientific studies had demonstrated that rapid provision of effective ventilation and artificial circulation were entirely adequate means of managing the small amount of respiratory- (or metabolic-) acidosis that accompanied common cardiac arrests.

 

Administration of even 1 amp of Bicarb was linked to poorer outcomes, and so the automatic administration of it was removed from the ACLS protocols in 1986.

 

How could we have gotten it so wrong?

 

 

(Note: Use of Bicarb (NaHCO3), while controversial, may still be considered in some cases of prolonged cardiac arrest, particularly in cases of asystole). 

 

 

 

What seemed like a perfectly good idea in 1975 had become obsolete (indeed, regarded even as dangerous) by 1986.  Studies were conducted, and while initial survival rates increased with bicarb administration, long-term survival rates were lower.

 

 

A result not unlike that which was found a few years ago with the use of high-dose steroid treatment for SARS. It increased short-term survival, but long-term it turned out to be detrimental.

      

 

No doubt, some of what we believe to be true or prudent today may be disproved or abandoned five or ten years from now.

 

Absolutes in science are hard to find.  And the process of determining scientific `fact’ can be both arduous and prolonged.

 

While I try to highlight only reputable studies, I offer the admonition of Caveat Lector for anything you read here (or anyplace else for that matter).

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NEJM: Enrolling Pregnant Women In Clinical Trials

 

 

# 4654

 

 

 

One of the more worrisome aspects going into pandemic of 2009 was the sheer lack of data on the safety of using antivirals on women who were pregnant.  

 

Public Health officials very early on had to weigh the benefits of their use during pregnancy against largely unknown risks.  Since that time, we’ve seen studies that have shown these drugs were used to good effect (see Study: Antivirals Saved Lives Of Pregnant Women)

 

In truth, the same situation exists for a wide range of drugs, since clinical trials often exclude pregnant women altogether.  

 

Clinicians are often put in the uncomfortable position of having to assume that these drugs will work in the same way, and at the same dosage, in pregnant patients.

 

Yet we know that pregnancy alters a woman’s metabolism, and down regulates her immune system.  Changes that conceivably could change the way some medications work in their bodies.

 

From the New England Journal of Medicine today we get a Perspective article on the need to enroll more women in clinical trials.  

 

This is a good article, and well worth reading.

 

Enrolling Pregnant Women in Research — Lessons from the H1N1 Influenza Pandemic

Sara F. Goldkind, M.D., Leyla Sahin, M.D., and Beverly Gallauresi, M.P.H.

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Tip-Toeing Through The Minefield

 

 

# 4398

 

 

There was a sardonic one-liner back in the 1970s, after a decade of media `scare stories’ about the dangers of everything from butter, to coffee, to artificial sweeteners, that said; `Face it . . everything gives lab rats cancer’.

 

While probably not true, it sprang to mind this morning when I saw this little tidbit that appears into a recent edition of PNAS.

 

“Control” laboratory rodents are metabolically morbid: Why it matters

1. Bronwen Martin, Sunggoan Ji, Stuart Maudsley, and Mark P. Mattson

Abstract

Failure to recognize that many standard control rats and mice used in biomedical research are sedentary, obese, glucose intolerant, and on a trajectory to premature death may confound data interpretation and outcomes of human studies. Fundamental aspects of cellular physiology, vulnerability to oxidative stress, inflammation, and associated diseases are among the many biological processes affected by dietary energy intake and exercise.

 

Although overfed sedentary rodents may be reasonable models for the study of obesity in humans, treatments shown to be efficacious in these animal models may prove ineffective or exhibit novel side effects in active, normal-weight subjects.

 

I suppose the good news here is that with the proliferation of fast food, Playstations, a ubiquitous Internet, and 500 cable channels streaming into every home – soon mankind’s metabolism will match that of lab rats and it will all balance out.

 

Scientific experimentation with lab rats isn’t wrong, you see. It is just a little ahead of its time.

 

I am, admittedly, always a little bit skeptical when I read the conclusions of the latest whiz-bang scientific study or a press release announcing an exciting new advance in medicine.  Even the ones that don’t employ rodents.

 

Not because I harbor conspiratorial beliefs, or a deep suspicion of the motives of scientists . . . but because I view scientific discovery as a journey  . . . not a destination.

 

Advances in science are anything but linear, and very often we find ourselves sidetracked or detoured down some flawed alley of investigation along the way.   

 

What was conventional scientific wisdom five years ago may be debunked today, and what we replace that old knowledge with now may be obsoleted in short order as well.

 

Absolutes in science are hard to find.  And the process of determining scientific `fact’ can be messy and prolonged.

 

Which is why you’ll often see cautions in my blogs about the latest research, and an avoidance of self-serving `medical miracle’ press releases about innovations that may never get out of the laboratory.

 

Over the past year, I’ve highlighted some of the conflicting studies on the efficacy of face masks vs. respirators for infection control, on the usefulness of hand washing as a flu preventative, and numerous studies on exactly how influenza is transmitted.

 

If you are looking for a consensus among scientists on these matters, I’m afraid you’ll have to keep looking.

 

What you probably can find, however, is a study that will support practically any scientific, personal, religious or economic bias or agenda you might happen to favor. 

 

And barring that, you can most certainly find a study that conveniently questions the methods of any study you might oppose. 

 

It’s a contrarian’s delight.

 

Scientific research can be a bit of a minefield through which one must tread carefully.  But rather than being distressed by the confusion or ambiguity that conflicting research sometimes promotes, I’m intrigued by it. 

 

 

Which is why I try to put links to the original study (or abstract) whenever I write about a journal article, so that the reader can look beyond the press release or the media hype and hopefully weigh the merits of the research themselves. 

 

As a non-scientist, I also rely heavily on the opinions and reviews of reputable scientists and (science) journalists whom I trust for guidance, particularly in those areas where I have little or no expertise.  

 

Although it usually comes at a great price, pandemics . . .  like wars, often result in a significant surge in scientific and medical knowledge.   

 

Our understanding of how influenza mutates, evolves, and spreads will no doubt grow tremendously over the next couple of years as the data gathered during this pandemic is examined and analyzed. 

 

While I try to highlight only reputable studies, the admonition of Caveat Lector remains for anything you read here (or anyplace else for that matter).   

 

Novel H1N1 has already re-written much of what we thought we knew about influenza virology. And some of the things we will think we learned from this virus may be overturned by the next pathogen to come down the pike. 

 

That’s simply the nature of science.   Our knowledge, like the influenza virus, is constantly evolving.  

 

Which is why, after more than 4400 essays in this space, there will always be something new to write about tomorrow.

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