MSF in Haiti: Managing the risk of communicable disease outbreaks

Posted on February 8, 2010 by Guest Blog

Guest blog by Dr. Greg Elder, Deputy Operations Manager, Médecins Sans Frontières/Doctors Without Borders (MSF), New York

Now in the fourth week after Haiti’s catastrophic January 12th earthquake, approximately 700,000 internally displaced people (IDPs) in Port-au-Prince are living in temporary shelters at nearly 600 relief sites. Displaced populations are also living in resettlement camps just outside Port-au-Prince and in other affected areas such Léogâne and Jacmel.

Understanding the epidemiology of mass displacement, including strategies to control disease spread among displaced and migrant populations, has been a cornerstone of MSF’s work in IDP (and refugee) health. IDP settlements are often overcrowded with inadequate sanitation, potentially leading to poor hygiene among the population. These environmental factors can multiply the risk of outbreaks of communicable diseases such as acute diarrhea and respiratory tract infections, or vaccine-preventable diseases like measles, in a population already exhausted and vulnerable.

Outbreak risk is not linked directly to the earthquake itself but rather to the overcrowded, unsanitary conditions of large, displaced populations living in makeshift camps. Indeed historically, major disease epidemics have not been seen after natural disasters like the earthquake in Haiti.

Most of the medical attention during the first weeks focused on the immediate trauma care, enormous surgical needs, and huge burden of follow-up and post-operative wound management to prevent long-term disability due to poorly managed injuries. However we cannot now neglect the large populations resettled in poor and overcrowded camps. As is common in such situations, in recent days our clinics have started to see cases of acute diarrhea and respiratory infections in younger age groups in the resettlements. A small number of measles and varicella (chickenpox) cases have been reported in Port-au-Prince, Léogâne, and Jacmel.

In response, health organizations led by the Haitian Ministry of Health and PAHO/WHO have set up a surveillance system with 52 sentinel sites across Port-au-Prince. This involves standardized reporting of communicable diseases of epidemiologic importance into a centralized system to inform response interventions. On February 2, UNICEF launched a vaccination campaign against diphtheria, tetanus, and pertussis in Port-au-Prince, targeting more than 500,000 children <7 years old overall, including 250,000 in the displacement camps.

MSF is following up on the suspected cases of measles reported in Léogâne and has sent a team of epidemiologists from Epicentre (epidemiology and research division of MSF) to develop data management systems across our health facilities and to link our outreach health activities to this surveillance system. This team is mapping the camps around our fixed clinics, while other teams try to support the population through water and sanitation activities and distribution of relief items in these areas.

Health assessment, provision of water and sanitation, measles vaccination, and surveillance are among the top 10 priorities for health interventions in such a setting, learned from years of experience in similar emergencies. Improvements in water, sanitation, food, and nutrition support, as well as strengthening basic primary health care and obstetric care, are among the priorities for the next phases of this emergency response.

Updates on MSF’s response to the earthquake can be found here.

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This week in PLoS Medicine: HIV-associated morbidity in adolescents; Policy prohibiting ghostwriting; Measuring hsCRP – Important or clinically redundant?

Posted on February 5, 2010 by darcygill

Read the new papers published in PLoS Medicine this week, including a Research Article that finds nearly half of adolescents admitted to two public hospitals in Zimbabwe were HIV positive and its related Perspective that discusses the implications of this study.

Also published this week, an Essay that discusses whether measuring hsCRP is an important part of a comprehensive risk profile or a clinically redundant practice and a Policy Forum that finds of the 50 top US medical schools, as defined by the 2009 US News and World Report’s research ranking, only 13 (26%) have publicly available policies in place that strictly prohibit ghostwriting.

You can comment on, annotate, and rate this week’s PLoS Medicine articles and any of the others in the archive.

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What does it mean to deidentify data?

Posted on February 4, 2010 by eveitch

Many journals, including PLoS Medicine, have policies regarding the availability of datasets underpinning published research findings. For example, PLoS journal policies require the “…agreement of authors to make freely available any materials and information described in their publication that are reasonably requested by others for the purpose of academic, non-commercial research…”. And the Annals of Internal Medicine publishes a statement with each paper declaring the willingness of authors to share study protocols, statistical code, and underlying datasets.

However, when those datasets result from clinical or public health research, the question of patient confidentiality arises. Although attempts have been made to define what’s meant by “reproducible research” in epidemiology, such attempts have led some authors to state that “Under our definition, it would seem impossible to simultaneously honor those promises [of confidentiality] and make one’s research reproducible”. (eg, http://aje.oxfordjournals.org/cgi/content/full/163/9/783).

A recently published paper in the journal Trials attempts to set out a standard for deidentifying datasets (mainly for clinical trials) so that they can be freely published alongside articles. The authors “define a dataset as that containing the minimum level of detail necessary to reproduce all numbers reported in the paper”. In addition, they collate a set of 28 datatypes which are directly, or potentially, identifying. In the paper the authors propose that if a dataset contains three or more “indirect identfiers”, researchers seek advice from an appropriate oversight body (such as their ethics committee) before releasing the dataset.

Although this guidance offers a clear starting point to researchers, a field of “de-identification science”  seems to be rapidly emerging — as highlighted in a recent Guardian article and PNAS paper — whereby researchers attempt to tie together public data sources in an effort to see whether they can identify the individuals within datasets. These efforts suggest that even an attempt to remove obvious identifiers may not be enough to protect individuals. One possible way forward may be to ask participants in research studies to consent prospectively to release of the dataset, although even this approach has limitations.

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How neglected are neglected diseases?

Posted on February 4, 2010 by Susan Jones

The World Health Organization uses the disability-adjusted life year (DALY), a time-based measure that combines years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health,  to measure the burden of diseases and health-related conditions. Estimating DALYS for neglected tropical diseases is problematic as the full data necessary for accurate DALY calculations are not always available in resource-limited settings. So, it’s possible NTDs suffer from a double-whammy: the DALYs attributable to an NTD may be underestimated owing to a lack of sufficiently robust data but because DALYs are taken into account when allocating funds for prevention and healthcare, funding for research into, and treatment of,  NTDs suffers more than it should.

To probe whether this is a real problem, Dieter Vanderelst and Niko Speybroeck  carried out a case-control study comparing the number of publications for 13 NTDS with 13 non-NTDs that have comparable DALYs.   The study has just been published in PLoS Neglected Tropical Diseases. They  searched for publications in PubMed and the Web of Science and found that NTDs were less-researched than their matched non-NTD controls. The discrepancy was larger in the Web of Science, and the authors attribute this to the Web of Science featuring more traditional journals that may have tended to publish less NTD research. One limitation of this study is the significant variance in the data. Querying Google provided a similar result – more people search for information on non-NTDs with matched DALYs compared with NTDs.  There are some positive findings, as the discrepancy in research published between the two matched sets of papers peaked in 2003-2004 and now seems to be on the decrease. The authors call for better estimates of the burden of disease due to NTDs, as more accurate DALYs might provoke direction of more resources into tackling the problems caused by these diseases.

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My 12 Minutes Speaking in the House of Commons

Posted on February 2, 2010 by Guest Blog

Guest blog by Gavin Yamey, San Francisco Lead, Evidence to Policy initiative (E2Pi), Global Health Group, University of California San Francisco.

PLoS Medicine recently published an editorial about the rise of “malaria activism,” and particularly the need for a new wave of advocacy to raise awareness about the crisis of malaria drug stock-outs in Africa. I did the background reporting and interviews for the piece in Kenya during my 2009 Kaiser Family Foundation Mini-Fellowship in Global Health Reporting. The piece caught the attention of the All Party Parliamentary Group on Malaria and Neglected Tropical Diseases (APPMG), and they kindly invited me to talk to the group at their Tuesday 26th January 2010 meeting in the House of Commons in London. The theme of the meeting was, “Are we delivering effective treatments to malaria patients?”

It isn’t every day that you get an invite from your elected representatives to come and give a presentation inside a truly beautiful, historic, and iconic building. It was an exciting opportunity to play a very small part in shaping the UK parliamentary debate on the ongoing global malaria crisis and the political opportunities for supporting malaria control.

The occasion called for a haircut and a new suit. It may seem a bit frivolous to mention fashion and malaria in the same breath – but that link is actually one of the cornerstones of the high profile advocacy work by Malaria No More UK . They’re one of the charities I mentioned in my talk, and their key strategy is to involve fashion and sports icons in raising awareness and money (Victoria Beckham recently wore a specially commissioned piece of jewellery, a silver mosquito ring, that sold out instantly, raising cash to buy insecticide-treated bed nets and other control tools).

The group’s coordinator, Susan Dykes, met me and one of the other speakers, Paul Newton, at the St Stephen’s Gate to usher us quickly through security, get us a cup of House of Commons tea (I was delighted to see that it was Fair Trade), and brief us on what to expect. Paul lives and works in Lao, as the Director of the Wellcome Trust-Mahosot Hospital-Oxford University Tropical Medicine Research Collaboration, and has been a regular PLoS Medicine author. Then it was through the gigantic entry hall and up the stone stairs to the committee room, where the parliamentarians were gathered—together with the two other speakers, Cally Roper (London School of Hygiene and Tropical Medicine) and Hans Rietveld (Director, Global Access and Marketing, Novartis) and a packed room of malaria experts and public health students (mostly from the London School of Hygiene Tropical Medicine and Imperial College London).
The APPMG is chaired by Stephen O’Brien, shadow health minister. Many malaria experts tell me they have been very impressed with his advocacy for malaria control. In the current economic climate, I can’t imagine that it’s an easy task to persuade the British public to care about a disease of poverty in distant lands, yet through his work as Chair of the Board of Trustees of the Malaria Consortium (one of the NGOs that hosted me during my fellowship) and of the APPMG, he has helped to maintain British commitment to malaria control. It’s good to know that if the Conservative party prevail at the next UK General election,  there should be some high level political commitment to global health.

Stephen ran a lively, tightly chaired meeting (each of us had just 12 minutes for our presentations). Paul kicked off with an alarming talk about fake and sub-standard artesunate. The topic of fake drugs, he said, has been a “Cinderella subject in health research,” despite the fact that distribution and treatment with fake and sub-standard medicines result in major morbidity and mortality, economic losses, loss of faith in genuine medicines, and drug resistance.
Cally discussed the value of mapping such malaria drug resistance. It’s deeply worrying that artesunate resistance has now been documented on the Thai/Cambodia border, and Cally discussed strategies that could be adopted to contain the spread of such resistance to Africa. Hans discussed Novartis’s work in malaria (the company manufactures artemisinin-based combination therapy, a cornerstone of malaria control in Africa). He also gave his views on some of the opportunities for improving the global response to malaria (such as greater political support and improved ACT procurement practices and inventory management). I was the final speaker, and I discussed the power of malaria activism and advocacy in highlighting failures and deficiencies in malaria control. A large focus of my talk was on ACT stock-outs and how these could be prevented. The APPMG will be posting the talks to its website shortly, and in the mean time I’d also be happy to send anyone interested a PDF of my slides (please e-mail YameyG@globalhealth.ucsf.edu).

Competing interests: E2Pi is funded by the Bill and Melinda Gates Foundation, a major funder of malaria control. The Global Health Group at UCSF is directed by Sir Richard Feachem, founding Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. GY is a former Senior Editor at PLoS Medicine.

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This week in PLoS Medicine: Call for better global health data; Pregnancies at risk of malaria in 2007; Lessons for a stronger institutional framework; and more!

Posted on January 29, 2010 by darcygill

Read the new papers published in PLoS Medicine this week, including a Research Article that finds at least 125.2 million women at risk of malaria become pregnant each year, a Health in Action that discuss how Médecins Sans Frontières has addressed the issue of maintaining quality control for laboratory testing, and an Essay in which eight global health agencies call for a concerted global effort to collect better health data.

Also published this week is a Policy Forum – the last in a four-part series on the changing nature of global health institutions – that argues an effective global health system must accomplish at least five core functions: agenda-setting; financing and resource allocation; research and development; implementation and delivery; and monitoring, evaluation, and learning and the January Editorial in which the PLoS Medicine Editors discuss how collisions between science and politics slow progress in public health.

You can comment on, annotate, and rate this week’s PLoS Medicine articles and any of the others in the archive.

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Water and Sanitation in Humanitarian Emergencies

Posted on January 29, 2010 by maggiebrown

Maggie Brown, MS, ELS is Senior Production Editor at PLoS

In a humanitarian crisis a population’s needs are great and many–for medical attention, shelter, safe water and adequate sanitation, food, and security. Disasters that occur in places that are already resource-poor and underserviced are more devastating than they might otherwise be.  The catastrophic January 12 earthquake in Haiti is currently in the spotlight, but other disasters, such as the 2008 earthquake in China, Hurricane Katrina and the northern Pakistan earthquake in 2005, and the Indian Ocean tsunami in 2004 also remain clear in recent memory. Armed conflict–ongoing in Somalia, Afghanistan, and Democratic Republic of Congo among other places–is another cause of immediate injury and loss of life and results in misery, illness, and mortality due to displacement of refugees to areas that are often ill-equipped to provide basic services (see http://www.icrc.org/web/eng/siteeng0.nsf/html/p1014).

When large numbers of people are internally displaced, water and sanitation become immediate and urgent issues (see http://www.who.int/water_sanitation_health/emergencies/en/). As a given displacement persists, clean water and adequate sanitation become ever more important in the control of disease transmission. The list of possible epidemic diseases that can occur in concert with natural disasters and conflict situations is long, but the among the commonest are infectious causes of diarrhea, leptospirosis, hepatitis, intestinal helminths, meningitis, and trachoma (http://www.bt.cdc.gov/disasters/disease/infectious.asp).

WHO recommendations for water and sanitation in a humanitarian emergency include :

  • At least 15-20 liters of water daily per person for drinking, washing, and food hygiene.
  • Latrines or, at least, designated defecation areas. These areas should preferably be segregated by sex and attention paid to possible security issues in their use.
  • Promotion of adequate hygiene, such as hand washing after toileting or changing babies and before food preparation and eating.

In Haiti the situation is evolving quickly, and prospects for a communicable disease outbreak are serious but still unclear. Blogs and internet news sources, as well as WHO, are monitoring the situation.

Other SoM entries on water and sanitation:

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Improving nutrition highlighted by SciDevNet article collection

Posted on January 28, 2010 by Susan Jones

Problems with nutrition range from a lack of food to an imbalanced or inadequate diet. Being underweight is a major risk factor for both mortality and disease and poor nutrition affects long-term productivity and socioeconomic development. To highlight the problems of malnutrition and poor nutrition, and to spotlight some of the solutions that might help to improve nutrition in the developing world, SciDevNet have put together a selection of articles on topics ranging from the causes of malnutrition to advice for policymakers on how to improve nutrition.

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MSF in Haiti: Treating and managing infected wounds

Posted on January 27, 2010 by Guest Blog

Guest blog by Dr. Richard Murphy, Infectious Diseases Referent, and Oliver Yun, Medical Editor, Médecins Sans Frontières/Doctors Without Borders, New York, NY

A major challenge in Haiti in the aftermath of the January 12th earthquake has been, and will continue to be, the management of infected wounds. Untreated wounds have progressed to gangrene and sepsis among some patients who have received inadequate or late initial care. After the earthquake, we sent additional guidance to our medical staff in Haiti for recognizing and treating infected wounds.

Opportunities to prevent wound infections were likely missed in many patients who could not access care or received delayed care after the earthquake. This is unfortunate because it is known that some common types of injuries seen after the earthquake, including open fractures, benefit from early aggressive management. Open fractures, which are fractures in which the skin and soft tissue have also been compromised, have far better outcomes when early antibiotic prophylaxis and surgical wash-out (debridement) are delivered. We expect to see many patients in the weeks and months to come with infectious complications of open fractures and other contaminated injuries.

Past earthquakes have provided some important lessons about the types of infections to expect. After the 2005 earthquake in Pakistan, polymicrobial infections were observed with a prominence of difficult-to-treat pathogens such as Pseudomonas aeruginosa and Acinetobacter spp. The same was true after the 2008 Wenchuan earthquake in China. Oddly, the classic pathogens in skin and soft tissue infections, Staphylococcus aureus and Streptococcus spp, were rarely encountered after the earthquakes in Pakistan and China.

What are the implications? Since we will not have the benefit of a microbiology laboratory to guide our antibiotic choices in Haiti, we will have to base our initial treatment strategies on our best predictions, making use of the experiences from Pakistan and China. In addition to antibiotics, other steps are critical in the management of infected wounds including debridement and tetanus prophylaxis.

We prioritized tetanus vaccine and immunoglobulin in our initial medical-supply shipments to the earthquake zone. Tetanus is a potentially deadly complication of contaminated wounds that we expect to see in Haiti. The existing level of protection to tetanus in the general population is inadequate with only about half of Haitians appropriately vaccinated.

In unvaccinated persons, wound contamination with dirt, saliva, or faeces brings a high risk of infection with tetanus bacteria. Clostridium tetani spores are ubiquitous in the environment and germinate under low oxygen tensions, which are present in closed wounds. As the disease develops, patients develop lockjaw or stiff neck. The syndrome can quickly progress to critical illness requiring intensive medical support.

Prevention is clearly the preferred option and we have urged our staff to ensure that all patients with tetanus-prone wounds receive, at minimum, tetanus toxoid vaccine, with the addition, in some cases, of tetanus immunoglobulins. Because the median incubation period is about a week to 10 days after exposure, we are concerned that a spike in tetanus could occur any time now in Haiti.

Updates on MSF’s response to the earthquake can be found here. The first post on SpeakingofMedicine reporting on MSFs activity in Haiti  is here.

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NIH responds to PharmedOut open letter calling for more research on ethics

Posted on January 27, 2010 by ginnybarbour

The following was received in response to this letter, which PLoS was one of the co-signers of:

Dear Dr. Fugh-Berman:

Thank you for your November 17, 2009 letter requesting that the National Institutes of Health (NIH) promote the highest ethical standards and practices in the translation of biomedical advances from bench to bedside through its funding of ethics-oriented research.  I appreciate your concerns and share your commitment to research and clinical environments that place public safety, trust, and well-being before personal gain.

The NIH has a long history of promoting the highest ethical standards and practices through its funding mechanisms, in addition to its role in  promoting management of conflicts of interest and assuring Federal requirements associated with receipt of NIH awards.  The NIH regularly supports a variety of research and training opportunities related to identifying and resolving bench-to-bedside ethical issues.  Among the many on-going programs, some examples include: the Clinical Research Ethics component of the Clinical and Translational Science Awards (CTSAs), Fogarty International Center’s “International Research Ethics Education and Curriculum Development Awards”, and the National Human Genome Research Institute’s “Ethical, Legal, Social Implications of the Human Genome Project” Program.  Also, the “Ruth L. Kirschstein

National Research Service Award (NRSA) Institutional Research Training Grant” (T32), which trains scientists and shapes the next generation moving through the scientific pipeline, requires that participants receive training in the responsible conduct of research. In addition to these programs, NIH has issued funding opportunity announcements (FOAs) to support bioethics research.

Examples of these include:

*        The NIH Challenge Grants in Health and Science Research (RC1). This FOA included Bioethics as a Challenge Area and specifically identified commercialization and conflict of interest, and blurring between treatment and research as areas of concern.

*        The NIH periodically issues FOAs as part of a series focused on “Research on Research Integrity”, the most recent of which was RFA-RR-09-004 (an Exploratory/Developmental Grant R21).

*        The NIH currently has three FOAs as part of a series active since 1999 that specifically focus on “Research on Ethical Issues in Human Subjects Research”, including research on conflicts of interest:

o       PA-07-277 (a Research Project R01)

o       PA-06-367 (a Small Research Grant R03)

o       PA-06-368 (an Exploratory/Developmental Grant R21)

These FOAs exemplify the NIH’s on-going commitment to funding research that enhances interpretation and application of ethical principles and regulatory requirements. While NIH has a long history of promoting bioethics research, we recognize that we must be continually vigilant and responsive to the evolving context of science and clinical practice.  The NIH convened a Task Force on NIH’s Role and Investment in Bioethics Research, Training and Translation in May 2009.  The Task Force is completing its proposal to further strengthen the NIH investment in bioethics research and training.  I look forward to receiving their recommendations in the near future, and to furthering the NIH’s commitment to fundamental research promoting the highest ethical standards in the translation of research from bench to bedside.

Sincerely,

*SALLY J. ROCKEY, Ph.D.*

Acting Deputy Director for Extramural Research National Institutes of Health

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