Birth defect fears deepen as Zika spreads

Evidence linking the rapidly spreading Zika virus to birth defects is mounting, adding to the urgency of efforts to develop a vaccine and underlining calls for co-ordinated international efforts to control its spread.

A recent spate of microcephaly cases involving women who were infected with Zika while pregnant – including one where the virus was found in a newborn’s brain tissue – has strengthened suspicions the disease is responsible for severe abnormalities.

Thirty-four countries have been hit so far in the current outbreak, most of them in Latin America, according to the World Health Organisation. In Brazil alone, around 1.5 million cases have been reported, and a further 25,000 are suspected in Colombia.

But the disease has also spread to the Pacific. Ongoing transmission has been reported in Tonga, where 542 suspected cases have been identified, and Samoa.

Though there is no evidence of Zika virus transmission in Australia, Chief Medical Officer Professor Chris Baggoley has warned there is a “continuing risk” of the disease being imported into the country from infected areas – so far this year, seven cases have been confirmed, all involving returning travellers.

Disturbingly, two pregnant women who recently travelled to Zika-prone regions have tested positive to the virus – one if Victoria, the other in Queensland.

Health authorities have convened a Communicable Disease Network Australian working group to monitor the international outbreak and advise on public health measures.

Though the effects of the disease are considered relatively mild in adults, the WHO has declared the outbreak a public health emergency of international concern because of mounting fears it is causing serious birth defects.

WHO Director-General Dr Margaret Chan said last week that although a causal relationship between Zika virus infection in pregnancy and microcephaly (babies born with abnormally small heads) was not yet scientifically proven, it was “strongly suspected”.

Evidence of a causative link between the virus and severe congenital abnormalities is strengthening.

Last month, a mother in Hawaii who was infected with the Zika virus during her pregnancy gave birth to a baby with microcephaly, and the US Centers for Disease Control reported on 10 February the Zika infection was evident in the case of two babies born with microcephaly who subsequently died, and two instances of miscarriage. In addition, the New England Journal of Medicine reported the case of a Slovenian woman who suffered a Zika-like illness while pregnant in Brazil. Her baby developed microcephaly, and the Zika virus was found in its brain tissue.

“The level of alarm is extremely high,” Dr Chan said. “Arrival of the virus in some places has been associated with a steep increase in the birth of babies with abnormally small heads and in cases of Guillain-Barre syndrome.”

In declaring a health emergency, the WHO has urged a coordinated international response to the virus threat, including improved surveillance of infections and the detection of congenital malformations, intensified mosquito control measures, and the expedited development of diagnostic tests and vaccines.

There is currently no treatment or immunisation for Zika, and although 15 companies or groups are working on a vaccine, the WHO has warned it is likely to be 18 months before one is ready for trial.

Their task is complicated by uncertainty about how the virus is spread. Though mosquitos are considered the prime culprit, there are suspicions it may also be spread though bodily fluids, particularly blood and semen.

As a precaution, the Australian Red Cross Blood Service has deferred collecting blood from donors who have travelled to countries with mosquito-borne viruses such as dengue and malaria.

The virus, which is closely related to the dengue virus, was first detected in 1947, and since 2012 there have only been 30 confirmed cases in Australia, all of them involving infection acquired overseas.

Members of the European Society of Clinical Microbiology and Infectious Diseases have warned that the next stage of the epidemic may involve the re-emergence of Zika in sub-Saharan Africa and, from there, southern Europe.

The Department of Foreign Affairs and Trade has advised pregnant women considering travelling to countries where the Zika virus is present to defer their plans.

All other travellers are advised to take precautions to avoid being bitten by mosquitos, including wearing repellent, wearing long sleeves, and using buildings equipped with insect screens and air conditioning.

Adrian Rollins

A good nanny makes a difference

The health gap: the challenge of an unequal world. Michael Marmot. London: Bloomsbury Publishing, 2015 (400 pp, $35). ISBN 9781408857991.

Any person proposing interventions that change the lived environment, with the intention of improving health, will encounter the “nanny state” argument. This is the case be it John Snow removing the pump-handle from a cholera-infected water source in Victorian London or Nicola Roxon proposing plain packaging of cigarettes in modern Australia. Similarly, most general practitioners have experienced that sinking feeling on seeing the patient whose health issues arise from home or work environments over which the hapless GP has little sway. This book provides ammunition to defend the former and food for thought for responding to the latter. At the same time, Michael Marmot manages, in his inimitable style, to make his case both entertaining and accessible.

Marmot argues that empowerment is the key for reducing health inequalities and improving health across nations. But empowerment cannot be achieved by any magic bullet. One of the most revealing stories in the book is where Marmot, approached by a journalist — hard on the release of the World Health Organization Commission on Social Determinants of Health report, Closing the gap in a generation — is asked: “What’s the one thing you would recommend to the US President?” Marmot replies: “One thing? Read my report.” His point, made throughout the book, is that empowering a population requires broad societal change.

Empowerment is not simply equality of opportunity. Having the skills and capacity to grasp opportunity is essential. The child, who is read to less, talked to less and loved and valued less, is also much less able to exploit opportunity. Similarly, the parent educated in a poorly funded school and working a disempowering job for low pay is less able to provide a child-nurturing environment. The good news, from Marmot’s text, is that poverty and its consequences are not destiny. However, to break the link, societies do need to invest in some clear interventions: high-quality extended education, and taxes and social transfers to reduce child poverty. This book provides ample evidence that this works to improve not just the health and wellbeing of individuals but also builds wealth and prosperity in nations.

[Editorial] Morocco’s long road to comprehensive palliative care

In May, 2014, the World Health Assembly unanimously adopted the resolution on strengthening of palliative care as a component of comprehensive care throughout the life course and called on member states to ensure that it is integrated into all levels of the health-care system. Many countries—not only low-income and middle-income ones—struggle with the provision of comprehensive palliative care. Morocco is no exception, but an assessment of its progress and failures highlights important areas for others to consider.

WHO declares Zika virus a threat of ‘alarming proportions’

Health authorities are on high alert to prevent a mosquito-borne virus linked to thousands of birth defects in South America getting a toehold in Australia.

Though there is no evidence the Zika virus, which health experts suspect has infected millions in Brazil and surrounding countries in recent months, has been transmitted in Australia, authorities are concerned about the possibility someone infected with the disease overseas may travel to central and northern Queensland, where mosquitos capable of carrying the disease are found.

“There is very low risk of transmission of Zika virus in Australia, due to the absence of mosquito vectors in most parts of the country,” the Health Department said, but added that “there is continuing risk of Zika virus being imported into Australia…with the risk of local transmission in areas of central and north Queensland where the mosquito vector is present”.

Australia’s preparations come amid mounting international alarm over the rapid spread of the virus and fears it is linked to an increased incidence of serious birth defects including abnormally small heads and paralysis.

World Health Organisation Director-General Dr Margaret Chan said the virus was “spreading explosively” in South and Central America since being first detected in the region last year, and the WHO’s Emergency Committee has been convened to consider declaring the outbreak a Public Health Emergency of International Concern.

The virus, which is closely related to the dengue virus, was first detected in 1947, and there have only ever been 20 confirmed cases in Australia – six of them in 2015 alone, and all of them involving infection overseas.

Only about 20 per cent of those infected with the Zika virus show symptoms, and the disease itself is considered to be relatively mild and only lasts a few days.

But there is no vaccine or treatment, apart from rest, plenty of fluids and analgesics, and Dr Chan said the speed of the virus’s spread and its possible link to serious birth defects meant the threat it posed had been elevated form mild “to one of alarming proportions”.

A causal relationship between Zika virus infection and birth malformations and neurological syndromes has not yet been established, but is strongly suspected.”

But there are concerns, yet to be scientifically verified, that the virus may cause microcephaly (small or under-developed brain) in unborn infants.

In Brazil, a four-fold increase in the number of cases of microcephaly last year coincided with widespread outbreaks of the Zika virus, increasing suspicions of a link.

An investigation by the Brazil Ministry of Health found that of 35 cases of microcephaly recorded in a registry established to investigate the outbreak, 74 per cent of mothers reported a rash illness during their pregnancy. More than 70 per cent of the babies were found to have severe microcephaly, and all 27 that underwent neuroimaging were found to be abnormal.

“The possible links, only recently suspected, have rapidly changed the risk profile of Zika, from a mild threat to one of alarming proportions,” Dr Chan said. “The increased incidence of microcephaly is particularly alarming, as it places a heart-breaking burden on families and communities.”

The Department of Foreign Affairs and Trade has issued a travel advisory recommending that pregnant women considering travelling to countries where the Zika virus is present to defer their plans.

“Given possible transmission of the disease to unborn babies, and taking a very cautious approach, pregnant women should consider postponing travel to Brazil or talk to their doctor about implications,” the Department said.

The Brazil outbreak has drawn particular attention given that hundreds of thousands of athletes, government officials and tourists are expected to travel to the country later this year for the Olympic Games.

DFAT has issued similar travel advice for all 23 countries where the virus has been identified – almost all of them in Southern or Central America, except for the Pacific island nation of Samoa and Cape Verde, off the north-west African coast.

The Health Department has issued advice for clinicians to consider the possibility of Zika virus infection in patients returning from affected areas, and said authorities were ready to act if it appeared in areas where mosquitos capable of transmitting it were present.

“In the event of an imported case in areas of Queensland where the mosquito vector is present, health authorities will respond urgently to prevent transmission, as they do for dengue,” the Department said.

Adrian Rollins

News briefs

Harvey named to Friends of Science in Medicine board

Associate Professor Ken Harvey, from Monash University’s School of Public Health and Preventive Medicine, has been appointed to the executive of Friends of Science in Medicine (FSM). He has been an influential member of the Commonwealth Pharmaceutical Health and Rational Use of Medicines Committee and most recently served on the Federal Government’s Natural Therapies Review Committee, which found no evidence for the effectiveness of any of the 18 common taxpayer-supported alternative treatments reviewed. Dr Harvey was a member of the expert group that drafted the World Health Organization’s Ethical Criteria for Medicinal Drug Promotion. FSM was established in 2011 and is supported by almost 1200 leading Australian scientists and clinicians. “No one has done more to protect consumers from the unethical marketing of prescription and ‘alternative’ medicines in our country,” said FSM president, Professor John Dwyer, AO.

Anatomy bestseller from 1613 published online

Columbia University in New York has digitised the 1661 translation of an anatomy “flapbook”, first published in 1613, and which remained a bestseller for 150 years. Catoptrum Microcosmicum, originally in Latin, “explains the human body, using movable flaps to take people down through successive layers”, reports Gizmodo. “The first layer was the person delicately draped in a way that preserved their modesty. The layer of drapery came off first. The book features a female figure and a male figure, both shown from the front and the back. Each figure is drawn with one foot standing on a skull.” Also featured is a pregnant female torso, which Gizmodo described as “the creepiest experience imaginable” and includes a “crotch-demon”. Available online at https://archive.org/details/ldpd_11497246_000.

Chromium in the spotlight

Gizmodo reports that University of New South Wales and University of Sydney researchers have found that popular chromium supplements are partially converted into a carcinogenic form when they enter cells. The National Health and Medical Research Council recommends 25–35 micrograms of chromium daily as the adequate adult intake. A maximum of 200 micrograms per day is considered safe by the US National Academy of Sciences. Over-the-counter supplement tablets, available in Australia and most commonly used for weight management, body building and type 2 diabetes, have been found to contain up to 500 micrograms each. The research, originally published in the chemistry journal Angewandte Chemie, was conducted on animal fat cells, which were x-rayed to allow scientists to observe the behaviour of chromium in the cell. The researchers say more study is needed to conclusively say whether the supplements significantly alter cancer risk.

Zika joins list of mosquito-borne nasties

A rare mosquito-borne virus called Zika is spreading from its African home through Asia and the Americas, with the United States Centers for Disease Control issuing its first travel advisory for the disease, for travellers through Puerto Rico, Wired reports. “In Brazil, the number of infants born with shrunken, malformed brains has gone up by a factor of 10 since Zika entered the country, and scientists there are trying to establish a causal link to the virus.” Closely related to dengue fever and yellow fever, Zika is hard to detect because “the classic test for Zika — checking a person’s blood for antibodies that bind to the Zika virus — spikes a false positive when it sees antibodies for those other two diseases”. Complicating the issue is that Zika also appears to be spread through sexual contact.

[Editorial] Breastfeeding: achieving the new normal

Breastmilk makes the world healthier, smarter, and more equal: these are the conclusions of a new Lancet Series on breastfeeding. The deaths of 823 000 children and 20 000 mothers each year could be averted through universal breastfeeding, along with economic savings of US$300 billion. The Series confirms the benefits of breastfeeding in fewer infections, increased intelligence, probable protection against overweight and diabetes, and cancer prevention for mothers. The Series represents the most in-depth analysis done so far into the health and economic benefits that breastfeeding can produce.

Ebola re-appears just as outbreak is declared over

More than 100 people in Sierra Leone have been placed into quarantine following confirmation of the death of a woman from Ebola.

Just hours after the World Health Organisation declared “all known chains of transmission [of Ebola] have been stopped in West Africa”, laboratory tests confirmed that a 22-year-old woman who died near the Sierra Leone capital Freetown on 12 January had contracted the deadly disease.

The discovery is a blow to hopes that the world’s deadliest outbreak of the disease, in which more than 11,300 people died, was finally over.

Sierra Leone health authorities are still trying to identify the source of the transmission, though the news agency Reuters reported that late last month she had travelled to an area near the border with Guinea which had been one of the last remaining hot spots in the country before it was declared Ebola-free on 7 November.

Reuters reported a joint statement of the Sierra Leone Ministry of Health and the Office of National Security said in which they announced 109 people had been quarantined, including 28 considered to be at high risk.

Authorities are considered that relatives of the dead women washed her body before burial, a cultural practice that had been blamed for helping the rapid transmission of the deadly disease during the outbreak.

In its announcement just before the latest case was confirmed, the WHO had declared an end to the outbreak in Liberia, but warned that the battle to eradicate the disease was not yet complete.

“The job is not over. More flare ups and expected and…strong surveillance and response systems will be critical in the months to come,” the Organisation said.

Liberia was first declared free of Ebola transmission in May last year, but there have been two flare-ups since – the most recent in November.

The WHO made its declaration on 14 January, 42 days after the last Liberian patient confirmed to have Ebola twice tested negative for the disease. The period allowed for two incubation cycles of the virus.

It said the date marked the first time since the epidemic began two years ago that all three of the hardest-hit countries – Guinea, Liberia and Sierra Leone – had not had a single case in 42 days.

But the WHO urged the need for continued vigilance and swift action when cases were identified.

It said the three West African countries remained at “high risk” of small outbreaks, most likely caused by the virus persisting in survivors even after recovery.

“WE are now at a critical period in the Ebola epidemic as we move from managing cases and patients to managing the residual risk of new infections,” the WHO’s Special Representative for the Ebola Response, Dr Bruce Aylward, said.

Dr Aylward said the risk was diminishing as the virus gradually disappeared from the population of survivors, “but we still anticipate more flare-ups, and must be prepared for them”.

Health authorities are concerned that the latest case in Sierra Leone did not present as a typical Ebola infection, causing delays in its diagnosis, and that there may have involved a breakdown in procedures around the safe handling of a patient infected with the disease.

Adrian Rollins

Improving health literacy in refugee populations

We must ensure that people of refugee background have the confidence, support and resources to manage their health

Health literacy is defined as the degree to which an individual can obtain, communicate, process and understand basic health information and health services to make appropriate decisions about their health.1 Low health literacy is inextricably linked to poor health outcomes. Individuals with limited health literacy have higher rates of illness and more hospitalisations.2 Acquiring good health is a process that requires access to health care and health knowledge to inform positive health behaviour coupled with ongoing access to necessary resources.

The refugee experience is often characterised by displacement with limited access to services and basic necessities. For resettled refugees, low health literacy can be expected as they navigate a new country, language and culture. The stressors of cultural and language differences, and securing housing and employment may exacerbate trauma, leading people to feel isolated and helpless, with attendant symptoms of sleeplessness, poor concentration and emotional issues. The psychological effects of trauma may be long term and experienced intergenerationally.3 Many may have had disrupted education owing to protracted time in precarious living situations, so it cannot be assumed that they have reading ability in their own language. Further, due to displacement and changes in family composition, traditional ways of sharing health information may be fragmented.

Such experiences have a profound impact on the way people engage with health information, health care services and preventive health activities.4 Being clear about the role of health services and health care providers, and explaining the purpose of appointments, benefits of preventive activities and recommended treatment regimens may assist. The situation is complex — a standard knowledge base cannot be assumed, precaution is necessary and the provision of information needs to be modified.5 Clinicians could mindfully adapt their skills to care for this population; however, we recognise that the provision of information is not necessarily straightforward. Our research found little consistency in the approach that maternity care providers take to providing health information.6 Afghan families reported that they mostly received brief verbal information, a few received written information in their own language, and some had seen pictorial information. Many sought information and advice from family members overseas, and several obtained information from the internet.

Providing the best possible standards of professional interpreting requires systems to facilitate access, training and practice.7 Enabling people to communicate freely in their own language supports the development of trust, respect, rapport, cultural safety and relationship-centred care.8 The role of interpreters is to provide a language service with strict parameters with no ongoing relationship. Bicultural workers, however, may assist people to navigate health services, get to appointments and negotiate expectations. They also act as an aid for clinicians to understand differing health beliefs and social circumstances that may affect decision making. Bicultural workers provide a bridge to reduce the social distance that often exists between health professionals and clients.

The health care setting offers a dynamic learning environment in which clinicians are in a key position to improve health literacy.9 A tool that encourages two-way participation is teach-back. Teach-back is an evidence-based communication strategy that requires health professionals to ask the individual to repeat back what they have explained but in their own words. It is not a test of the individual’s memory.10

Some health literacy advocates suggest that assessing health literacy is an important step in addressing health disparities.2 However, this has the potential to create shame and stigma. Many measurement tools do not inquire about the full scope of health literacy and are narrowly focused on reading, writing and numeracy deficits. If applied, assessments need to be completed in the context of relationship-centred care.8

The health system needs to support clinicians to adopt novel ways of responding to low health literacy.11 A health-literate organisation is defined as one that makes it easier for people to navigate, understand and use information and services to take care of their health.12 A health-literate organisation would recognise that refugees may have concerns that are perceived as more immediate than their personal health status.13 People of refugee background are often worried about finances, learning English and family members who remain in dangerous situations. To support clinicians working with diverse communities, health services need to develop stronger local service partnerships that broaden access to existing community and local resources.

We believe that improving health literacy in this population involves much more than access to information — it is about people having the confidence, support and resources to manage their health. Health literacy in refugee populations could be tackled by multifaceted, multidisciplinary interventions and policies that are responsive to these unique circumstances.14

Health gets a guernsey in Paris

The right to health has been explicitly recognised in the agreement negotiated at the United Nations Paris climate change talks, boosting hopes of an increasing focus on the health effects of global warming.

In its preamble, the Paris Agreement directed that, when taking action on climate change, signatories should “respect, promote and consider their respective obligations on…the right to health”.

Director of the World Health Organisation’s Department of Public Health, Environmental and Social Determinants of Health, Dr Maria Neira, hailed the declaration as a “breakthrough” in recognising the health effects of climate change.

“This agreement is a critical step forward for the health of people everywhere,” Dr Neira said. “The fact that health is explicitly recognised in the text reflects the growing recognition of the inextricable linkage between health and climate.”

Dr Neira said that health considerations were essential to effective plans to adapt to climate change and mitigate its effects, and “better health will be an outcome of effective policies”.

Under the Paris deal, countries have expressed an “ambition” to limit global warming to less than 2 degrees Celsius, the point at which science suggests climate change becomes untenably dangerous.

While avoiding setting an explicit target, the signatory countries, including Australia, committed to “pursuing efforts to limit the temperature increase to 1.5 degrees Celsius”.

Attempts to orchestrate concerted global climate change action have in the past been frustrated by arguments over who should bear the greatest responsibility for causing climate change and, as a consequence, who carries the greatest obligation to ameliorate its effects.

Developing countries have argued that industrialised nations have become rich on fossil fuel-based economic activity and should bear the greater share of the burden in adopting to its consequences.

But developed countries have countered that any progress they make in curbing greenhouse gas emissions should not be simply offset by an increase in emissions from emerging economies.

The Paris agreement has sought to break the impasse by detailing a framework of “differentiated responsibilities” for climate action. Developed countries are expected to take the lead in reducing greenhouse gas emissions, but developing nations are also expected to contribute.

To help drive the global response, it is expected that by 2020, countries will contribute $US100 billion a year to a global fund to help finance emission reduction and climate change adaptation measures.

Though the agreement does not include any enforcement mechanism, countries are required to provide an update on their climate change action each five years, and each successive update has to be at least as strong as the current one, leading to what the framers of the document will be a “ratcheting up” of measures over time.

The promising outcome to the Paris meeting followed a call by the AMA and other peak medical groups worldwide for more concerted action to prepare for and mitigate the health effects of climate change.

In an updated Position Statement on Climate Change and Human Health released last year, the AMA highlighted multiple health threats including increasingly frequent and severe storms, droughts, floods and bushfires, pressure on food and water supplies, rising vector-borne diseases and climate-related illnesses and the mass displacement of people.

AMA President Professor Brian Owler said significant health and social effects of climate change were already evident, and would only become more severe over time.

“Nations must start now to plan and prepare,” Professor Owler said. “If we do not get policies in place now, we will be doing the next generation a great disservice. It would be intergenerational theft of the worst kind – we would be robbing our kids of their future.”

The AMA’s Position Statement on Climate Change and Human Health can be viewed at: position-statement/ama-position-statement-climate-change-and-human-health-2004-revised-2015

Adrian Rollins

[Comment] A worldwide shift in polio vaccines for routine immunisation

The world is now closer to global polio eradication than ever before. In 1988, when the World Health Assembly set its sights on complete eradication of polio, an estimated 350 000 paralytic cases occurred and 125 countries were considered endemic. In 2015, only 39 cases have been detected in two countries (as of Sept 8, 2015).1 At present, only wild poliovirus type 1 is known to be circulating. The last outbreak of naturally occurring type 2 wild poliovirus occurred in 1999, and type 3 wild poliovirus has not been detected since 2012.