Tag Archives: The Lancet

Will the UK Win Gold in Public Health Preparedness?

In all likelihood, there will be no large-scale public health crises during the London 2012 Olympics. But Dr. Brian McCloskey has to prepare, just in case. That’s his job as the London director of the UK’s Health Protection Agency (HPA), the UK-government-funded yet independent public body charged since 2004 with protecting the health of the country’s population from all threats, including those from infectious disease, chemicals, violence, and anything else that may arise. The HPA also collaborates with the World Health Organization on “emergency preparedness for Mass Gatherings and High Consequence, High Visibility events,” Dr. McCloskey explained at the 22nd European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), sponsored by the European Society of Clinical Microbiology and Infectious Diseases.

Dr. Brian McCloskey/Photo by Miriam E. Tucker

“Mass gatherings” are nothing new for London, which has routinely hosted large music and sporting events against a backdrop of ongoing terrorist threats. However, the Olympics represents one of the largest public health challenges yet, in terms of sheer scale and international media scrutiny, noted Dr. McCloskey, who has been with HPA since its inception and was director of public health with the U.K.’s National Health Service for 14 years prior to that.

The Olympics officially begins July 27 and ends 12 Aug. 12, followed by the Paralympics 29 Aug. 29 to Sept 9. In addition, London will also host the Olympic torch relay, Queen Elizabeth’s Diamond Jubilee beginning in May, Wimbledon in June, possibly the largest-ever gay pride festival in late June-early July, and the Notting Hill Carnival in August. “In other words, there will be one long party in London from May through September,” he commented.

In all, the Olympics will comprise 26 sports in 34 venues, with 10,500 athletes, 17,000 people living in the Olympic Village, 21,000 media and broadcasters, and approximately 180,000 spectators per day in the Olympic Park. The challenge, he said, is to plan to respond to anything that can happen without disrupting life for Londoners.

Dr. McCloskey and his colleagues have been studying experiences at previous Olympics, as well as published literature on mass gatherings such as the yearly Islamic pilgrimage, or “Hajj,” to Mecca. Indeed, “mass gatherings” is an emerging area of medicine that was explored in depth earlier this year in a series of six articles in The Lancet. There is also a WHO advisory group on mass gatherings, and even a specialty curriculum being developed, he said in an interview.

Judging by previous experience, “The most likely thing to happen is nothing at all. Most Olympic Games go off without any problems, with only minor impact on the public health service and on public health. But, we do need to think about all the things that could happen.”

Mass gatherings have been associated with both food/waterborne and airborne/respiratory infectious diseases. Yet, less than 1% of healthcare visits in Sydney during the 2000 Olympics were for infectious diseases. In the 2006 winter Olympics in Torino, Italy, surveillance for acute gastroenteritis, flulike illness, measles, and other health-related events turned up nothing unusual as compared with non-Olympics time periods.

London Underground Billboard/Photo by Miriam E. Tucker

During the 2012 Olympics, the HPA will deliver a “Situation Report” each morning to Olympics organizers, describing the state of public health in England and highlighting any potential issues. Managing rumors will also be important, he noted.

Laboratory surveillance, clinical case reporting, and syndromic surveillance—based on patient complaints—will all be enhanced during the Games, with the help of primary care providers and hospitals around the U.K. Any triggers will be followed up, with a much lower threshold and greater speed than usual. In fact, most of these surveillance systems have been in place for at least a year now. “So we’re feeling very comfortable,” Dr. McCloskey said.

And these measures will last beyond the Games. “We will have at least two new surveillance systems in the U.K. as a legacy afterwards…What you get is improved public health systems but also better recognition of the importance of public health and better working relationships…Every country I’ve talked to who’s hosted the Games says we can expect that legacy. Provided nothing goes wrong. But of course, it’s not going to go wrong, it’s all in place, so come and enjoy it.”

–Miriam E. Tucker (@MiriamETucker on Twitter)

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Filed under Allergy and Immunology, Emergency Medicine, Epidemiology, Family Medicine, Gastroenterology, Health Policy, Hospital and Critical Care Medicine, IMNG, Infectious Diseases, Internal Medicine, Pediatrics, Primary care, Pulmonary Diseases and Sleep Medicine, Sports Medicine, Uncategorized

Worldwide Diabetes Burden Swelling

Like the unstoppable tide of aging Baby Boomers and the worldwide flood of obesity-related problems, the burden of diabetes is expected to hit tsunami proportions. The number of people with diabetes hasn’t crested yet, but there already may be more people “under water” than expected.

Photo by Sherry Boschert

While the World Health Organization suggests that more than 220 million people around the world have diabetes, and one study estimated 285 million people had diabetes in 2010, a more recent analysis calculated that 347 million people worldwide have diabetes, investigators reported in The Lancet. That’s more than double the 153 million cases worldwide 3 decades ago.

Type 2 diabetes typically begins in middle age, so aging populations play a role, as do rising rates of obesity, a major risk factor for the disease. Using the World Health Organization’s more conservative numbers, an estimated 3.4 million people died in 2004 from problems related to diabetes, 80% of them in low-income and middle-income countries.

It’s no wonder that I heard languages from all over the world being spoken at the American Diabetes Association (ADA) annual scientific meeting. The 17,600 attendees were invited to place push-pins on a world map to show where they’d come from. Some did, providing a snapshot of the international participation in the meeting.

Photo by Sherry Boschert

Affluent countries whose physicians can more easily afford international travel to the meeting are more heavily represented, but the map still gives the impression of one world fighting a common disease. The keys to preventing or slowing diabetes are known and well shared — don’t smoke, eat a healthy diet, be physically active regularly (like 30 minutes of brisk walking 5 days per week), and maintain a normal body weight. If there’s one solution to this one-world problem, it may lie in finding a way for people of all nations to follow that advice.

Easier said than done. But as a major study presented at the meeting calculated, treating people at high risk for diabetes in the United States by either enrolling them in a lifestyle intervention program (to change eating and exercise habits) or by prescribing the drug metformin was extremely cost-effective compared with doing nothing.

Teaching people to “swim,” as it were, or throwing them a pharmaceutical life jacket, may be cheaper and better than expecting them to surf a tsunami.

–Sherry Boschert (@sherryboschert on Twitter)

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Filed under Endocrinology, Diabetes, and Metabolism, Family Medicine, IMNG, Internal Medicine

MMR, Autism and Wakefield: Unringing the Bell

Dr. Paul A. Offit/photo by Mitchel Zoler

On February 14, The Philadelphia Inquirer ran an essay by Dr. Paul A. Offit, pediatric infectious diseases specialist and childhood vaccine champion, with his take on recent developments in the Dr. Andrew Wakefield/autism/measles, mumps, and rubella vaccine fiasco. Dr. Offit, chief of infectious diseases at The Children’s Hospital of Philadelphia, has had a special interest in the spurious links between childhood vaccinations and autism, and he wrote a 2008 book on the subject.

On February 2, the editors of The Lancet retracted Dr. Wakefield’s controversial and ultimately fraudulent 1998 report that purported to document a causal link between administration of the MMR vaccine to children and their quick development of autism. Dr. Offit’s essay cited other scandalous events linked to the infamous paper, such as reporting by a British journalist that showed Dr. Wakefield received more than $750,000 from a personal-injury lawyer who planned to file lawsuits based on the autism links Dr. Wakefield reported in The Lancet.

Dr. Offit also cited some of the unfortunate consequences of Dr. Wakefield’s 1998 paper: “Wakefield’s belief that MMR caused autism has morphed into other strongly held beliefs: thimerosal…was responsible; or other vaccine ingredients, or too many vaccines given too soon.”

These cumulative vaccine slanders “had their effect,” Dr. Offit continued. “During the last few years, outbreaks of whooping cough in the United States have increased, in some instances mimicking epidemics seen in the pre-vaccine era. And, in 2009, three children in Philadelphia died from meningitis caused by” the Hemophilus influenzae type b bacterium, “which could have been safely and easily prevented” by following U.S. vaccine guidelines.

Even though The Lancet officially eradicated Dr. Wakefield’s 1998 report from the medical literature, it will be hard “to unring the bell,” Dr. Offit said in his essay yesterday. It is hard “to reassure people once you’ve scared them;” The Lancet’s retraction “will do nothing to restore the lives of children lost in this sad, tragic episode.”

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Drug And Device Safety, Family Medicine, IMNG, Infectious Diseases, Pediatrics, Practice Trends, Primary care

Addressing Postpartum Hemorrhage

courtesy of flickr user hanneoria

Even with the marvels of modern ob.gyn. care, women still die of postpartum hemorrhage, especially in developing countries and anywhere that resources are limited. Two studies published this week in The Lancet support the off-label use of oral misoprostol as an alternative to intravenous oxytocin. Oxytocin is the first-choice medication for postpartum hemorrhage, according to the World Health Organization.  The problem is, oxytocin requires refrigeration, plus someone who has IV equipment and knows how to use it. Misoprostol tablets can be stored easily and given orally.

Each of the two randomized trials included more than 800 women. In one study, oxytocin was significantly more effective than misoprostol at controlling postpartum bleeding with no prophylactic treatment. But bleeding was controlled within 20 minutes for 90% of the women in the misoprostol group (vs. 96%) of the women in the oxytocin group, which lead the researchers to conclude that misoprostol might be a viable option in certain circumstances, despite the lack of statistical significance.

In the second study, oxytocin was not significantly more effective than misoprostol at controlling bleeding after 20 minutes when women in both treatment groups received oxytocin prophylactically.

These studies are promising, but one gap in the research is whether giving misoprostol prophylactically, as well as postpartum, can reduce bleeding even more. If oxytocin isn’t feasible postpartum, it may not be available for prophylactic use, either.

For my World Wide Med column in Internal Medicine News, I interview doctors about their experiences practicing medicine in parts of the world where resources are limited. I have so far focused on internists, not ob.gyns., but some of these physicians, and many other U.S. physicians who have practiced overseas, may well have been involved in delivering babies in resource-limited circumstances simply because they were the only ones there. I wonder how these doctors handled postpartum hemorrhage in those situations?

—Heidi Splete (on twitter @hsplete)
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Filed under Family Medicine, IMNG, Internal Medicine, Obstetrics and Gynecology