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Clean hands may make the difference between life and death

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Girls at a school in Cambodia wash their hands using water from a school WASH facility. © UNICEF/Bona Khoy

When good hand hygiene and other infection prevention and control (IPC) measures are followed, 70 per cent of infections can be prevented in health care settings, according to a new World Health Organization (WHO) report published on Friday.

The coronavirus pandemic and other disease outbreaks have highlighted the extent to which healthcare settings can contribute to the spread of infections.

“The COVID-19 pandemic has exposed many challenges and gaps in IPC in all regions and countries, including those which had the most advanced IPC programmes,” said Tedros Adhanom Ghebreyesus, WHO Director General.

‘An unprecedented opportunity’

Today, out of every 100 patients in acute care hospitals, seven in high-income countries and 15 in low and middle-income nations will acquire at least one healthcare associated infection (HAI) during their hospital stay – one in 10 of whom will die.

Newborns and patients in intensive care are particularly at risk, the report reveals, and almost half of all sepsis cases with organ dysfunction in adult intensive-care units are linked to healthcare.

WHO’s first-ever Global Report on Infection Prevention and Control brings together evidence from scientific reports, and new data from WHO studies.

“It has also provided an unprecedented opportunity to take stock of the situation and rapidly scale up outbreak readiness and response through IPC practices, as well as strengthening IPC programmes across the health system,” said the WHO chief.

Making a case

The impact of healthcare linked infections and antimicrobial resistance on people’s lives is incalculable, says WHO.

Over 24 per cent of patients affected by health care-associated sepsis and 52.3 per cent of those treated in an intensive care unit die each year.

Moreover, deaths are increased two to threefold when infections are resistant to antimicrobials.

With regional and country focuses, the new WHO report provides a situation analysis of how IPC programmes are being implemented globally.

While addressing the harm that HAIs and antimicrobial resistance pose to patients and healthcare workers, it also highlights the impact and cost-effectiveness of infection prevention and control programmes as well as the strategies and resources available for States to improve them.

Data analysis

In the last five years, WHO conducted global surveys and country joint evaluations to assess the implementation status of national IPC programmes.

Comparing data from the 2017-18 to 2021-22 surveys, the percentage of countries with a national IPC programme did not improve; and in 2021-22, only 3.8 per cent of countries had all IPC minimum requirements in place at the national level.

In healthcare facilities, only 15.2 per cent met all the IPC minimum requirements, according to a 2019 WHO survey.

Heartening developments

However, some encouraging progress has been made, with significantly more countries appointing IPC focal points; dedicated budgets for IPC and curriculum for front line healthcare workers’ training; national IPC guidelines and programmes for HAI surveillance; and hand hygiene compliance established as key national indicators.

Strongly supported by WHO and others, many countries are scaling-up actions to put in place minimum requirements and core components of IPC programmes.

Sustaining and further expanding this progress in the long-term is a critical need that requires urgent attention and investments.

Investments needed

“Our challenge now is to ensure that all countries are able to allocate the human resources, supplies and infrastructures this requires,” said Tedros.

WHO is calling on every nation to boost investments in IPC programmes – not only to protect patients and health workers, but also to improve health outcomes and reduce health-care costs and out-of-pocket expenses.

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More Global Approach Needed to Control Monkeypox

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With increasing numbers of monkeypox virus among 1.3 billion people, African health experts have expressed worriness over lack of appropriate vaccines to contain the outbreak in Africa. That however in mid-August, the acting director of the Africa Centers for Disease Control and Prevention, Ahmed Ogwell, said there two partners “largely multilateral institutions and non-African governments” have shown some interest in helping out with manufacturing of vaccines without offering detailed information.

“Let us get vaccines onto the continent,” Ogwell, said in a weekly media briefing pointing to another instance of 1.3 billion people on the continent without access to a vaccine, as it has been with the Covid-19 pandemic. Africa remains the only part of the world with no doses of the vaccine, according to the Africa Centers for Disease Control and Prevention.

More monkeypox deaths have been reported on the African continent this year than anywhere in the world. Since May, nearly 90 countries have reported more than 31,000 cases. At least 2,947 monkeypox cases have been reported in 11 African countries this year, including 104 deaths, but most of the cases reported are suspect ones because the African continent also lacks enough diagnostic resources for thorough testing, the Africa CDC director Ogwell said.

The lack of vaccine doses and shortage of diagnostics is an echo of the challenges that Africa’s 54 countries faced for months during the Covid-19 pandemic as richer countries elsewhere raced to secure supplies. Given the continuous spread of the monkeypox virus especially in central and west African regions, raises the question of exploring the accesibility of vaccine supply. It relates closely plans to provide educational materials and educating the public about the virus spread, the risk of contracting it (means of transmission) – there has to be a stark acknowledgment of a preventive approach.  

Although the current explosion of cases has occurred in men, experts say there is no biological reason the virus will remain largely within the community of men who have sex with men. “We certainly know it’s going to spread to family members and to other non-male partners that people have,” said Dr. Jay Varma, director of the Cornell Center for Pandemic Prevention and Response. The real question, he said, is whether it spreads as efficiently in those groups as it does among close sexual networks of men who have sex with men.

The World Health Organization classified the escalating outbreak of the once-rare monkeypox disease as an international emergency in July. Outside of Africa, 98% of cases are among men who have sex with men. With a limited global supply of vaccines, authorities are racing to stop monkeypox before it becomes entrenched. WHO has, however, warned against supply discrimination. 

Early August, Wendy Orent, the author of “Plague: The Mysterious Past and Terrifying Future of the World’s Most Dangerous Disease” and “Ticked: The Battle Over Lyme Disease in the South” wrote in Los Angeles Times Op-Ed: Monkeypox is not the next Covid. But it’s spreading from the same failures.

The expert explained that monkeypox a well-studied disease: In the past, it has been concentrated primarily in rural West or Central Africa and transmitted from a bush animal to a person, who then would spread it to limited family members in close contact. During the 2003 outbreak in the U.S., people caught it directly from pet prairie dogs that got infected by small mammals imported from West Africa. None of the U.S. cases that year spread to another person.

In contrast, the recent outbreak is spreading more widely person-to-person. But if governments take the right steps and help block transmission by giving key resources to those most at risk – currently gay and queer men – monkeypox can be contained. The global alarm sounded on this virus should be a warning to intervene now while the disease is manageable and take steps to limit future outbreaks, two goals well within reach.

Monkeypox was first detected among monkeys kept in a Denmark laboratory in 1958. Only in 1970 did doctors record a human case, indicating that monkeypox could also infect people. The disease, which closely resembles smallpox, wasn’t distinguished as a separate infection until smallpox was nearly eliminated. Smallpox vaccination campaigns kept both diseases at bay until 1980, when the World Health Organization declared smallpox eradicated and vaccination campaigns ended.

Smallpox spread only through humans, with no animal population keeping it alive. It evolved over millennia to become a true human specialist, effective at transmission and overcoming immunity. Centuries of an arms race in Africa, Asia and Europe allowed the smallpox virus to fine-tune its attacks on the human immune system. When it burst into the previously unexposed populations of the Western hemisphere via European invaders, the sharpened teeth of smallpox met no resistance. Some scholars estimate that 90% of native Americans died of it.

That monkeypox is spreading rapidly is undeniable. While monkeypox isn’t at this point a truly sexually transmitted disease like gonorrhea or syphilis, sexual contact has driven this outbreak. Monkeypox spreads through intimate physical contact, including direct contact with monkeypox pustules loaded with virus. People may not realize that their malaise is monkeypox in its early phase. Although anyone touching an infected person or their sheets, clothing and towels could theoretically catch monkeypox, the highest risk remains in concentrated networks of friends, companions and lovers.

The scandal of monkeypox is that this worldwide outbreak has happened at all. An epidemic has persisted in Nigeria since 2017. A more deadly strain has caused thousands of suspected cases and likely killed hundreds in the Democratic Republic of Congo (DRC). We have for years had the capacity to vaccinate those most at risk via two doses of Jynneos, the safer, updated version of the old smallpox vaccine. But we haven’t done so, and now the virus has reached the Western world. Now millions of doses have been ordered for the U.S. alone – and none yet for Africa.

Why do we in the West only pay attention when a disease outbreak directly threatens us? That’s the real outrage, the real question. The only answer is a more global approach to health, a recognition that when disease breaks out in one part of the world, it often will – as Covid and now monkeypox have shown us – affect us all.

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`Medicine from the Sky` Drone Delivery Programme Set for Take-off in Pradesh

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Medicine from the Sky, a flagship initiative by the World Economic Forum, is to be launched in Arunachal Pradesh, north-east India, on Independence Day, 15 August.

The aim is to document how health systems in remote parts of the state respond to the integration of drone-based supply chains. After numerous confidence-building pilot schemes across the country, the Arunachal Pradesh initiative focuses on a more elaborate agenda involving deeper operational planning and observations.

The six-month programme will be centred around four pillars:

  • Basic healthcare needs – regular services for vaccines; iron, folic acid, nutrition supplements; prophylactic and mass drug administration; diagnostic sample collection; emergency medications; blood and blood products
  • Ecosystem skill levels, terrain, weather considerations – identification of local stakeholders, including engineering, medical, paramedical, humanities and management colleges; technical and skill development institutes; find continuous source for weather data and real-time prediction
  • Survivability, scalability and sustainability – resource estimation, impact assessment and economics
  • Stress testing of drone platforms – ascertaining ability of available technologies to handle undulating terrain

“In mid-2021, we undertook a field study in Arunachal Pradesh, along with the Public Health Foundation of India, to learn more about the local health distribution system, disease profile and the nature of the terrain. Traversing the Seppa-Bameng belt by road, in particular, made it evident that drones were an absolute necessity,” said Vignesh Santhanam, Lead, Aerospace and Drones, World Economic Forum.

“Through our learnings in Telangana, we are looking to stress-test our systems in Arunachal Pradesh under the liberalized drone regime while factoring in economic principles from the point of initiation. For this purpose, we will work on two bell-weather districts – East Kameng and Lower Subansiri – over an extended time frame and supplement ongoing central initiatives with data and examples while empowering local governments with drone-based solutions. We are also planning awareness campaigns for local youth and students,” he added.

In a first of its kind approach to raise awareness among rural youth, the District Collector of East Kameng has called on all heads of participating villages to nominate “drone ambassadors” in parallel with an essay-writing competition on drones for village school students.

In the context of celebrations for India’s 75 years of independence, the initiative will be formally launched at East Kameng district in the presence of key state officials, care workers, local youth and key partners – the Public Health Foundation of India, Redwing Labs, Tech Eagle, Apollo Hospitals HealthNet Global (clinical partner) and USAID which will contribute to the drone programme. The initiative will be launched by Pema Khandu, Chief Minister of Arunachal Pradesh in the presence of key decision makers including Mama Natung, Minister for Environment & Forest, Sports & Youth Affairs and Water Resources, Arunachal Pradesh; Sharat Chauhan, Health Secretary, Arunachal Pradesh; Pravimal Abhishek Polumatla, East Kameng Deputy Commissioner; Nabam Peter, CEO, State Health Authority; and Vignesh Santhanam, World Economic Forum.

The East Kameng leg of the initiative is supported by SAMRIDH Healthcare Blended Financing Facility and the United States Agency for International Development (USAID).

Medicine from the Sky

In June 2020, the World Economic Forum in partnership with the state of Arunachal Pradesh hosted a session to discuss the use of drones in medical logistics and delivery in remote tribal areas. Floods and landslides have often impacted the last mile delivery of medicine, isolating populations. The session was quickly followed by a field visit in north-eastern India by the World Economic Forum and the Public Health Foundation of India. Discussions with local healthcare workers and visits to remote health establishments clearly established the urgent need for drone corridors across the state.

“East Kameng district has a hilly terrain which makes it difficult to access interior areas, particularly during the monsoon season. I am sure drone-based drug delivery will be a game-changer in strengthening access to healthcare in such remote areas. I hope the project will give us the answers and clarity for large-scale implementation,” said Pravimal Abhishek Polumatla, district magistrate.

“By delivering medical supplies much faster than road-based logistics, the drone network would serve the remote areas by offering access to diagnostics, essential medicines and vaccines. We are hoping this will reduce out-of-pocket expenditure for patients,” he added.

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Why more heatwaves endanger our health and ability to work

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As the Earth warms, heatwaves are expected to occur more often, with sharper intensity and for longer periods. Rising temperatures adversely affect worker productivity and human health, but for policymakers to take substantive action for heat adaptation, and meet what researchers see as a life-saving Paris climate agreement, making an economic case is key.

BY NATALIE GROVER

As the Earth warms, heatwaves are expected to occur more often, with sharper intensity and for longer periods. Rising temperatures adversely affect worker productivity and human health, but for policymakers to take substantive action for heat adaptation, and meet what researchers see as a life-saving Paris climate agreement, making an economic case is key. This article first appeared in Horizon Magazine in August 2020.

It’s actually quite easy for us to point out the problem — we have increasing temperatures, increasing frequency of heatwaves…it affects our physical and cognitive performance,’ said Lars Nybo, a professor of integrative physiology from the University of Copenhagen, Denmark. He worked on a project called HEAT-SHIELD designed to examine the effects of heat exposure on worker productivity in industrial sectors that employ half of Europe’s workforce: manufacturing, construction, transportation, tourism, and agriculture. The project ran from January 2016 until December 2021.

Globally, 2021 was among the seven hottest on record, with Europe experiencing its hottest summer to date. In the Mediterranean region, an intense and prolonged heatwave in July and August lead to new temperature records and devastating wildfires, a poignant reminder that the achievement of the Paris climate agreement to keep global mean temperature increases well below 2°C is as important as ever.

Data from HEAT-SHIELD project suggest that exposure to external heat in combination with physical activity, which elevates the body’s production of heat, can result in physiological changes that can diminish occupational performance, via reduced working endurance, vision, motor coordination and concentration. This can lead to more mistakes as well as injuries.

‘Roughly 70% of all European workers, at some time during the working day, are not optimally hydrated,’ Prof. Nybo said. The solution to the problem, he added, is intuitive: drink water, replace electrolytes and reduce physical activity, but implementing these measures whilst maintaining productivity is where things get tricky. 

‘You could just say to the worker stay at home and drink cold margaritas in the shadow to prevent heat stress,’ he joked. ‘But that will not help productivity.’

Productivity

As coordinator of HEAT-SHIELD, Prof. Nybo and his team were tasked with not just assessing the extent of the problem — modelling the expected rise in temperature in Europe in the coming years and its impact on worker productivity ­— but also devising and implementing solutions that are location and vocation specific to adjust to the inevitable increases in temperature.

A construction worker wears a safety helmet, which impairs the body’s ability to purge heat, but the worker thinks this problem cannot be solved because it is intrinsic to their work, Prof. Nybo noted.

Surmounting challenges like this was one of the key objectives of the project — conceiving ways to weave in heat mitigation strategies alongside the practicalities of the job.

For instance, outdoor workers should be vigilant of weather patterns and plan work earlier in the day during periods of extreme heat, take a short break every hour and secure easy access to water. Similar remedies for workers in enclosed settings could mean a combination of air conditioning, working in shade and improving ventilation — keeping in mind the ecological footprint of such measures.

But on a macro level, for climate change policymakers to take concrete action here and now ­— the numbers are key, Prof. Nybo said.

In Europe, agricultural and construction workers for instance, lose some 15% of effective working time when the temperature goes beyond 30°C, which works out to almost one working day per week, he noted, citing HEAT-SHIELD analyses.

If you are a policymaker, he says, the numbers show that there’s an incentive to act now: if you mitigate the problem the cost will stabilise at a lower level in the long run than if you don’t.

Excessive heat

Diminished worker productivity and the downstream economic damage are prominent impacts of rising temperatures caused by climate change. But to get a full picture of the consequences, it’s necessary to understand what excessive heat does to the human body.

It can damage organs such as the heart and the lungs, exacerbate a range of diseases, and increase the risk of death.

Extreme heat can increase the occurrence of heart attacks and strokes in susceptible patients due to increased blood viscosity, and raise the risk of cardiovascular death in vulnerable patients. Hot, humid days can also trigger asthma symptoms and have been shown to increase airway resistance, while warmer climates tend to extend the pollen season.

Another side effect of rising temperatures is the association with air pollution — the largest environmental killer in Europe, causing roughly 500,000 premature deaths annually.

Observational data and modelling suggest that as it gets warmer, air pollution levels — particularly surface ozone gas (O3) and fine particulate matter (PM2.5) — increase in some populated regions, even when emissions of air pollutants have not risen, as well as create conditions favourable for forest fires.

Both extreme heat and air pollution raise the risk of cardiovascular and respiratory disease, which currently costs the European Union an estimated €600bn a year. If these environmental stressors continue to accumulate unabated, these costs could jump.

Projections

But the synergistic relationship between air pollutants and rising temperatures is not well understood and existing health-risk projections in Europe do not properly account for adaptive measures that can be taken to ameliorate associated health risks, according to Dr Kristin Aunan, a senior researcher at the Norway-based Center for International Climate Research.  

‘There’s quite a lot of literature on short-term impact — in terms of the day-to-day variation on the impact of heat stress on mortality — but when it comes to long-term impact, there is not a lot of information,’ she said.

As part of a project called EXHAUSTION that kicked off in 2019 and is due to run until May 2023, researchers including project coordinator Dr Aunan, are focused on quantifying the risks of cardiopulmonary disease in different temperatures.

The project is also working on identifying interventions to minimise the risks to health sparked by environmental stressors and demystifying the link between air pollution and temperature hikes.

Quantifying the cascading effect of cardiopulmonary diseases on the economy is key to affecting action on climate change, she suggests.

EXHAUSTION researchers, for instance, are devising a macro-economic model that tracks increased hospitalisation and mortality in different age groups to measure the impact on the broader economy in different European countries. ‘We also have a bottom-up model — where you put a price on every premature death or hospital admission and add up to estimate the economic cost.’

One of the main questions the researchers hope to answer is the magnitude of impact limiting temperature spikes to 1.5°C — the aim of the Paris climate agreement — will have on health. 

‘I have no answer to that today — but the reason why we’re doing this project…is that we think there are reasons to believe that being able to comply with a Paris agreement will save very many lives and reduce human suffering,’ Dr Aunan said.

‘When you discuss climate policy and discuss the costs of it — it’s very expensive to reduce emissions of greenhouse gases, etc. But you also need to consider the benefits and that’s what we are doing with this project — hoping that we can contribute to the other side of the coin.’

This article first appeared in Horizon Magazine in August 2020.

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