Archive for the ‘Infectious Diseases’ Category
But one thing remains true: “People have a very weird perception of large numbers,” [Dr. Brockmann] said. “If you have 2,000 cases of flu in a country of 300 million, most people think they’re going to be one of the 2,000, not one of the 299,998,000.”
I think people have a wierd perception of risk, and that is often influenced by media attention. Which reminds me of a memorable article from the New York Times Op-Ed page in 2003 – remember West Nile Virus? “Never Bitten, Twice Shy – The Real Dangers of Summer” by Ropeik and Holmes.
Yes, the graphic is not perfect (see this critique at Edward Tufte’s blog), but does get across the idea that risk perception is not always influenced by the facts. And is expanded in this article in Health Affairs “Dealing with the Dangers of Fear: The Role of Risk Communication” by Gray and Ropeik.
Ok, but what about the facts? The fast moving breaking news often plays fast and loose with the truth, and can spread alarming information. Early reports of the swine flu in Mexico seemed to have extremely high mortality reports, especially among young adults. Now, with new evidence of confirmed cases, the virus is looking alot milder. When I first read that influenza virus could survive for 10 days on money, I thought it was another casualty of the truth, as the avian-human-swine flu reported in a press briefing by the CDC. However, in this case, the facts seem to check out (Survival of Influenza Virus on Banknotes, Thomas et al), unlike the potluck origins of the swine flu which ProMED reported to be, upon closer examination – just swine flu.
More on risk perception:
Here’s a conversation with David Ropeik in the New York Times, and he wrote a book with George Gray – Risk: A Practical Guide for Deciding What’s Really Safe and What’s Really Dangerous in the World Around You
Reckoning with Risk: Learning to Live with Uncertainty – Gerd Gigerenzer
Thermal scanners purchased after the SARS outbreak have been mobilized for border screening. Super-cool, but do they work to stop the spread of an epidemic?
The New York Times led with this image, but now the story link has been updated. Here’s the original text by Donald G. McNeil, Jr. on border controls:
Given extensive human-to-human transmission, the World Health Organization raised its global pandemic flu alert level on Monday, but it recommended that borders not be closed nor travel bans imposed, noting that that the virus had already spread and that infected travelers might now show any symptoms.
However, many countries are tightening border and immigration controls, and on Tuesday Britain advised against any nonessential travel to Mexico. Japan announced that it would no longer allow Mexican travelers to obtain visas upon arrival. The United States, France and Germany have also warned against nonessential travel to Mexico.
Here’s my understanding of how it works: the thermal scanner camera detects infrared radiation (IR). Basically any object emits IR which intensifies as it gets hotter. The camera has a sensor which detects IR and converts it into a temperature reading. In this system it does it visually.
However, when you first get flu, you don’t have a temperature, and the thermal scanner only measures skin temperature on your face, so an early fever (which raises your core temperature) is also not detectable.
So – does it work? Work done by Bitar et al as a followup to SARS control was published in February 2009: International travels and fever screening during epidemics: a literature review on the effectiveness and potential use of non-contact infrared thermometers In the early stages of a pandemic when less than 1% of people will be feverish, fever screening at the border is of limited use – from the paper “When we fixed fever prevalence at 1% in all studies to allow comparisons, the derived positive predictive value varied from 3.5% to 65.4% ” So thermal scanners aren’t very useful when very few people have fever.
However, check out this view from William Saletan in Slate: Heat Check – Swine Flu, Body Heat and Airport Scanner
On another note, I’m wondering why journalists don’t seem to have quick access to infectious disease specialists. In the New York Times, an environmental health epidemiologist is quoted in the debate, and here in the Cape Times, a sociologist who now specializes in the public understanding of biology. Where are the infectious disease experts? Maybe the CDC needs to draw up a list of media contacts among their top virologists and infectious disease specialists. Maybe part of science education should be a course in writing on science for the public, as well as how to write (and read!) papers.
Swine flu is in. In the rush to cover this latest possible pandemic, newswires are alive with activity, blogs and social networking sites are buzzing, and the CDC and WHO are back in the limelight. This despite the fact that the number of cases are limited (only 40 confirmed infections have occurred in the US).
The rush of news has been accompanied by a rush to track that news. The WSJ, amongst others, has a tracking website, including a map of infections in North America. Best of all, Google has a map showing how the infection is traveling.
This rush was started by Google Flu Trends, a website that tracks flu-related search queries to estimate influenza levels in different US states. Further studies suggested the same approach might work for other diseases as well.
Analyzing Google Trends
So how has Google Trends, the broader application of the Flu Trends concept, performed in the current scenario? A quick analysis shows that Google search results did in fact increase over the past few days (see chart – source: Google Trends).
A quick analysis shows three items worth mentioning:
- First, while Google Trends does show an increase in search activity on “swine flu,” the first uptick in activity only occurred on April 23. By contrast, the first news stories appeared on April 21 when two cases were confirmed in California.
- Second, Google Trends reports that the majority of search queries were from New Zealand, USA, UK, Canada, and Australia. Only a very small minority were from Mexico. Yet, Mexico is the country supposedly at the heart of the pandemic.
Explaining the Discrepencies
I had used a Google Trends like methodology two years ago to track the evolution of climate change as an issue in news coverage. Having worked on that, I can propose a few general reasons that explain why Google Trends is limited in this case.
First, it appears that Google Trends follows with some time lag, actual infections. This should not be surprising, as people are not likely to search for a disease before having had some exposure to it. This does not mean that it is not a useful tool for tracking diseases over the long term. At the very least, the response time of a system based on GT might be lower.
Second, the current scenario shows that Google Trends is highly susceptible to “noise.” Prior to this outbreak, swine flu was probably not a commonly known disease, and queries on it were extremely rare (if not non-existent). Thus, even the slightest uptick in search activity would show up as a major change. That uptick was provided by the highly charged media coverage of the subject. Given this, one wonders if the search results are more “noise” and less people with a genuine interest in the subject. So, Google Trends is likely to be more accurate where general knowledge of a subject (the baseline) is high, and media coverage (noise) is low.
Finally, and most interestingly, why is it that most of the search results came from the US, while Mexico is more exposed to it? Not surprisingly, this methodology only works where both a large number of the population and media are on the internet.
What Next for Google Trends?
When discussing why most search queries occurred in the US, it is worth noting another fact about the swine flu outbreak – that it has traveled extremely fast. Originating in Mexico, it has been carried to the USA, Spain, and New Zealand. This brings into question the validity of using the geographic source of search queries as a reliable indicator of where the disease actually is.
Still, it may also offer a way to enhance Google Trends. What if Google Trends data was combined with travel data on the number of people traveling from a “hotspot” of an infectious disease. It would be logical to assume that popular destinations, or ones which receive travel groups, would be the most likely next locations for further infections. Thus, a map could potentially be created of not only where the disease is generating interest, but where it might be headed.
Of course, Google does not have access to such data – though at some point it may decide to acquire a travel operator. But the general lesson is simply that to make Google Trends more useful, search query data needs to be looked at together with real-world data (such as travel data or hospital records).
It is still early days for the swine flu outbreak, but some commentators are already suggesting the “social web” has actually created hysteria rather than help track the disease. That may be true, but it is hardly a problem of the “social web.” As a reader on the FP pointed out, “Twitter is only a natural extension of a typical neighborhood.”
So, in this “typical neighborhood,” what the swine flu outbreak has done is illustrate where Google Trends does well – in tracking general interest amongst heavy Internet users. But it also exposes limitations – the methodology is (not surprisingly) susceptibility to “noise” from media coverage and is biased towards countries and issues that are online. This does not mean that the idea itself is flawed. Just that it must be taken with a pinch of salt, and that it needs work – especially interfacing it with real-world data streams – to make it really useful.
First, a bit of housekeeping – we are tinkering with the look of the blog and considering moving it to another platform, if you have any feedback about what you like and don’t like, let us know.
Published today in the CMAJ, Early detection of disease outbreaks using the Internet, is worth skimming:
“The Internet…is revolutionizing how epidemic intelligence is gathered, and it offers solutions to some of these challenges. Freely available Web-based sources of information may allow us to detect disease outbreaks earlier with reduced cost and increased reporting transparency. Because Web-based data sources exist outside traditional reporting channels, they are invaluable to public health agencies that depend on timely information flow across national and subnational borders. These information sources, which can be identified through Internet-based tools, are often capable of detecting the first evidence of an outbreak, especially in areas with a limited capacity for public health surveillance.”
The limitations section includes the below list, but I wish they went into much more detail about what the internet is not good for (probably detecting trends among the elderly for example) and more examples of misinterpreting the data. On a related note to using ICTs for surveillance, Jaspal wrote a fairly detail post on Google Flu Trends that you should also check out.
It’s been more than two years since we reported on Seattle as the new Geneva, that is, as the new epicenter of global health activity. An article in this morning Journal-Sentinel (Water-engineering firms see potential, challenge in developing countries) – which includes an exclusive interview with the Acumen Fund’s chief executive Jacqueline Novogratz – suggests that Milwaukee is angling to do the same for water technology:
It’s an issue that almost certainly will preoccupy business leaders in metro Milwaukee in their strategy to brand the region as an international hub of water technology. The metro area is home to scores of water-engineering companies. Gov. Jim Doyle and the University of Wisconsin-Milwaukee this month announced plans to invest millions of dollars for UWM to become a center of freshwater research.
An 2008 article from the same newspaper (Area’s tide could turn on water technology) provides more evidence:
[F]our of the world’s 11 largest water-technology companies have a significant presence in southeastern Wisconsin, according to an analysis of data from a new Goldman Sachs report.
Wall Street has tracked automakers, railroads and retailers almost since there were stocks and bonds. But water remains a novelty. Goldman Sachs Group Inc. didn’t begin to research water treatment as a stand-alone industrial sector until late 2005.
While several large MNCs have shown an active interest in clean water in developing countries (e.g., Procter and Gamble, Vestergaard Frandsen, Dow) open questions remain as to what role large MNCs will play in providing access to safe water for the one billion people who don’t have it.
(Thanks to Dr. Jessica Granderson for sending the link)
Last Thursday, I had the opportunity to view a PhotoVoice exhibition at the University of California, Berkeley organized by Haath Mein Sehat (HMS), a group working to improve access to clean water and sanitation in six slums of Hubballi and Mumbai, including Dharavi.
It was exciting to see a group effectively blend the advocacy elements of PhotoVoice with the design elements of cultural probes. The difference between the two approaches is less in the methods and more in the use of the outputs. In this case, they organized the exhibition to raise awareness and break down stereotypes of slum life, and they are using the photographic corpus to guide the design of both programs and technologies related to their core mission.
What I was most interested in from a design perspective were the instructions given to community photographers and how this tied back to the mission of HMS. The results below followed from the simple prompt: “Represent your daily experience with water”.
I was just sent this information (thanks to Becky!) about a new round of funding for microbicides, which comes on the heels of promising results from a trial of the PRO2000 microbicide candidate. We covered this a couple of years ago and at the time I said – the potential of this drug is revolutionary. With microbicides there was great excitement and hope, then there was failure and now there is some maturity. Okay, maybe I am overstating the case, the take home point is that we still don’t have a product and this is not cheap, easy, or quick. Developing a drug is complicated, involves huge risk, can take decades and is highly uncertain. Let’s review the drug development time line again for those of you not familiar – the graph below gives the most simplistic picture:
The early microbicide discussions took place almost 15 years ago (International Working Group on Vaginal Microbicides, source). Over half that amount of time, from 2000-2007, $1.1 Billion has already been invested in microbicide R&D! It takes anywhere from $200M to $1 Billion to bring a single novel drug to market. Let’s hope one of these compounds works and makes it through phase III. But how much will we have spent? $2 Billion, $3 billion? If it works, it will have been worth the money, however, we must ask if we took the most efficient financial route to get to the end point and if there were better financial models – that is a valid question.
Purely as entertainment I enjoyed Slum Dog Millionaire and because of the Oscar victory people have become more curious about global slums. How do I know this? The hits on this blog have increased in the past two days with people specifically drawn to a previous post we did: Dharavi: Mumbai’s Shadow City. Take the following with a grain of salt, but note the increase in interest:
“Movies have a powerful ability to evoke a sense of the exotica about the locations in which they are filmed. They are widely acknowledged to inspire travel to those destinations….According to Expedia sources, post ‘Slumdog Millionaire’, Mumbai now tops the chart of global tourist destination.” Source Yahoo News
Additionally, OneWorld Health has decided to explicitly use the movie as a avenue to educate people more about global health needs:
The Institute for OneWorld Health, the non-profit pharmaceutical company that develops drugs for people with neglected infectious diseases, announced it is launching a new awareness campaign inspired by the highly acclaimed Oscar-winning film, Slumdog Millionaire…OneWorld Health is running a full-page ad in the New York Times on Monday, Feb. 23. Slumdog Millionaire, an underdog story about poverty, love and hope, won eight Oscars at last night’s Academy Awards ceremony, including Best Picture. For the full story see OWH here.
A by product of Slum Dog is that tens of millions of people who previous had very little knowledge about global poverty got a little glimpse into that world. Picking up on this curiosity, another place to learn more is a fantastic multimedia project by Magnum Photos that is well worth your time (hat tip to TinkuB) :
The above two headlines on global health funding flows and allocation caught my attention. The original study was published in PLoS Medicine. The article has some great figures (some of which I have reproduced below). A few things immediately stick out – the amount concentrated on HIV/AIDS, TB and malaria is astounding. Second the US is providing 70% of the funding and on the surface one could argue that other countries really could be pitching in more. On that note, the Gates Foundation by itself is out funding the European Commission almost 4 to 1 – if that isn’t embarrassing I don’t know what is. Finally, the US Department of Defense is high on the list (surpassing USAID). Interesting stuff:
“HIV/AIDS, tuberculosis and malaria initiatives accounted for about 80% of the $2.5 billion that was spent on research and drug development for developing countries in 2007… However, pneumonia and diarrheal illness, which are two major causes of mortality in developing countries, received less than 6% of funding.”
Want to know what 50 cents can buy? Watch the video in full, read the press release below (announcement to be made today at Davos) and check out http://www.just50cents.org/:
I will link to the full press release when it’s up, in the meantime here is the intro:
Global Network for Neglected Tropical Diseases Receives $34 Million Gates Foundation Investment to Scale up Prevention and Treatment Efforts
New “End the Neglect 2020” Campaign Aims to Greatly Reduce the Burden of NTDs Davos, Switzerland, January 30, 2009 –
“The Global Network for Neglected Tropical Diseases today announced that it has received $34 million through a grant from the Bill & Melinda Gates Foundation to the Sabin Vaccine Institute to step up the global effort to prevent and treat neglected tropical diseases (NTDs). These debilitating and sometimes deadly diseases affect 1.4 billion people worldwide who live on less than $1.25 a day. With the new grant, the Global Network is launching a campaign to catalyze additional funding and will establish a global alliance to scale up NTD treatment and prevention efforts. “
Controlling NTDs is considered a “best buy” in public health because of the availability of extremely low-cost interventions and the resulting high return on investment. For approximately 50 cents per person per year, the seven most common NTDs – which together represent 90% of the global NTD burden – can be effectively treated. ”
We are generally focused on solutions and here, but I couldn’t help but post this news story on pharmaceutical “waste” being dumped into the water supply in India and what the subsequent impact might be (drug resistance, unknown clinical damage to those who consume the water, environmental destruction):
PATANCHERU, India –When researchers analyzed vials of treated wastewater taken from a plant where about 90 Indian drug factories dump their residues, they were shocked. Enough of a single, powerful antibiotic was being spewed into one stream each day to treat every person in a city of 90,000.
And it wasn’t just ciprofloxacin being detected. The supposedly cleaned water was a floating medicine cabinet — a soup of 21 different active pharmaceutical ingredients, used in generics for treatment of hypertension, heart disease, chronic liver ailments, depression, gonorrhea, ulcers and other ailments.
Those Indian factories produce drugs for much of the world, including many Americans. The result: Some of India’s poor are unwittingly consuming an array of chemicals that may be harmful, and could lead to the proliferation of drug-resistant bacteria.
In India, villagers near this treatment plant have a long history of fighting pollution from various industries and allege their air, water and crops have been poisoned for decades by factories making everything from tires to paints and textiles. Some lakes brim with filmy, acrid water that burns the nostrils when inhaled and causes the eyes to tear… “I’m frustrated. We have told them so many times about this problem, but nobody does anything,” said Syed Bashir Ahmed, 80, casting a makeshift fishing pole while crouched in tall grass along the river bank near the bulk drug factories. “The poor are helpless. What can we do?”
I was recently contacted by a non-profit organization based in Washington D.C called International Action (IA) to help them raise awareness about the problems they are tackling in Haiti. IA installs water treatment systems in Port-au-Prince, Haiti using chlorinators. Chlorniators, according to IA, are very cheap, simple, easy to install and maintain. It would be interesting to see how this method stacks up against other water sanitation efforts in terms of costs & financing, logistics, sustainability, adoption/use and impact.
Haiti Innovation recently profiled IA: “At the end of five years, IA aims to have installed 500 chlorinators covering most of the Port-au-Prince metropolitan area, giving clean water for the first time to 2.5 million people.” You can view some of the locations IA is working in with their nifty Google maps mashup:
Below is a guest post from Amelie over at IA:
Guest Post by International Action
Among 147 countries Haiti scores last on the water poverty index scale according to the World Water Council (WWC). This means that Haiti is the country with the worst access to clean water in the world.
In fact, most water sources in Haiti are contaminated with human waste and disease. The result is a tragedy. Haiti has the highest infant mortality rate in the Western Hemisphere and this is due to preventable waterborne diseases such as chronic diarrhea, typhoid and hepatitis.
International Action, a Washington D.C based non-profit installs water treatment systems called chlorinators on top of local public water tanks. They now protect more than 450,000 Haitians with clean, safe drinking water in 23 of the poorest neighborhoods in Port-au-Prince.
International Action’s special tablet chlorinators are easy to install, use and maintain, they do not require electricity and therefore they are ideal for the developing world. The system is simple: 10% of the water runs through the device, dilutes the chlorine tablets and mixes it with the rest of the water in the tank. The chlorine levels are safe, pre-set and regularly tested. A chlorinator can provide clean water for up to 10,000 people for the smaller model LF1500 and 50,000 for the larger one LF2000.
The biggest installation in Jalousie supplies a community of 50,000. The local hospital has instantly noticed a reduction in the cases of waterborne diseases which they must treat. Analyses of the water have shown that germs of typhoid, cholera and hepatitis are no longer present in Jalousie’s water; waterborne diseases have virtually disappeared in the communities which have the chlorinators installed.
During the month of December, International Action has installed 6 new chlorinators in the neighborhood of Delmas 30. The population is thrilled because although they receive water from CAMEP — Independent Metropolitan Water Company — four days a week, they do not drink it because it is contaminated. In early December, CAMEP called International Action for help. 50,000 more Haitians are now protected with clean, safe drinking water provided by International Action.
For more information visit our website at www.haitiwater.org
A few days back Aman wrote a post about Google Flu Trends. Thought I’d add a few thoughts here after reading the draft manuscript that the Google-CDC team posted in advance of its publication in Nature.
By the way, here’s what Nature says: Because of the immediate public-health implications of this paper, Nature supports the Google and the CDC decision to release this information to the public in advance of a formal publication date for the research. The paper has been subjected to the usual rigor of peer review and is accepted in principle. Nature feels the public-health consideration here makes it appropriate to relax our embargo rule
Ginsberg J, Mohebbi MH, Patel RS, Brammer L, Smolinski MS, Brilliant L. Detecting influenza epidemics using search engine query data. Draft manuscript for Nature. Retrieved 14 Nov 2008.
Assuming that few folks will read the manuscript or the article, here’s some highlights. I should say I appreciated that the article was clearly written. If you need more context, check out Google Flu Trends How does this work?…
- Targets health-seeking behavior of Internet users, particularly Google users [not sure those are different anymore], in the United States for ILI (influenza-like illness)
- Compared to previous work attempting to link online activity to disease prevalence, benefits from volume: hundreds of billions of searches over 5 years
- Key result – reduced reporting lag to one day compared to CDC’s surveillance system of 1-2 weeks
- Spatial resolution based on IP address goes to nearest big city [for example my current IP maps to Oakland, California right now], but the system is right now only looking to the level of states – this is more detailed CDC’s reporting, which is based on 9 U.S. regions
- CDC data was used for model-building (linear logistic regression) as well as comparison [for stats nerds - the comparison was made with held-out data]
- Not all states publish ILI data, but they were still able to achieve a correlation of 0.85 in Utah without training the model on that state’s data
- There have attempted to look at disease outbreaks of enterics and arboviruses, but without success.
- For those familiar with GPHIN and Healthmap, two other online , the major difference is in the data being examined – Flu Trends looks at search terms while the other systems rely on news sources, website, official alerts, and the such
- There is a possibility that this will not model a flu pandemic well since the search behavior used for modeling is based on non-pandemic variety of flu
- The modeling effort was immense – “450 million different models to test each of the candidate queries”
So what does this mean for developing world applications?
Here’s what the authors say: “Though it may be possible for this approach to be applied to any country with a large population of web search users, we cannot currently provide accurate estimates for large parts of the developing world. Even within the developed world, small countries and less common languages may be challenging to accurately survey.”
The key is whether there are detectable changes in search in response to disease outbreaks. This is dependent on Internet volume, health-seeking search behavior, and language. And if there is no baseline data, like with CDC surveillance data, then what is the best strategy for model-building? How valid will models be from one country to another? That probably depends on the countries. Is it perhaps possible to have a less refined output, something like a multi-level warning system for decision makers to followup with on-the-ground resources? Or should we be focusing on news+ like GPHIN and Healthmap?
Another thought is that we could mine SMS traffic for detecting disease outbreaks. The problem becomes more complicated, since we’re now looking at data that is much more complex than search queries. And there is often segmentation due to the presence of multiple phone providers in one area. Even if the data were anonymized, this raises huge privacy concerns. Still it could be a way to tap in to areas with low Internet penetration and to provide detection based on very real-time data.
In case you missed this in the NY Times today – fascinating experiment with a new Google tool on the frontiers of diseases surveillance and global health trends. Remains to be seen how useful this will be and lots of validation needs to be done, but this is yet another example of people outside of traditional health/public health communities who are on the leading edge of public health innovation:
“What if Google knew before anyone else that a fast-spreading flu outbreak was putting you at heightened risk of getting sick? And what if it could alert you, your doctor and your local public health officials before the muscle aches and chills kicked in? That, in essence, is the promise of Google Flu Trends.
“Google Flu Trends (www.google.org/flutrends) is the latest indication that the words typed into search engines like Google can be used to track the collective interests and concerns of millions of people, and even to forecast the future.”
We have discussed before how data indexed on the web can used for all sorts of fascinating things. We had a previous posts on global health job trends and also on publications that use the terms global health and private sector. The graphs below show a large increase in both areas, however there are dozens of caveats with this kind of trend analysis and the below graphs have to be taken with a grain of salt:
1. Global Health Job Trends (see for full post)
2. Trends: Development/Global Health in the Business Press (see for full post)
Here’s an interesting idea from McKinsey – analysing decision maker networks to speed vaccine adoption.
Nearly 11 million children die every year due to a lack of vaccinations. McKinsey research suggests that network analysis, which companies use to improve business outcomes by analyzing information flows and personal relationships, could speed their adoption. Specifically, these techniques can shed light on the complicated processes and interactions that underpin (and often slow down) the introduction of vaccines.
The process of introducing vaccines varies from country to country and involves the influence of many stakeholders—ministries of health and finance, international agencies such as the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), nongovernmental organizations (NGOs), community leaders, experts on disease, and funders, to name just some of the players. Defining roles, decision rights, and data requirements for this constellation of participants is difficult. The resulting confusion slows decision making and compounds chronic problems, such as poor infrastructure and limited public-health budgets. Delays, sometimes as long as 15 to 20 years, between the introduction of a vaccine in developed countries and its adoption in developing ones are the result.
Surveys were done on vaccine introductions in Egypt, Mauritania, Mexico, and Zambia. Only Mexico consulted international disease experts, which helped speed adoption of the vaccine. We found as well that in all four countries surveyed, finance representatives either had no role in the process of deciding whether and when to introduce vaccines or were peripheral to it—and usually brought in near its end.
With slight modifications I lifted the below from the CIMIT Blog (note Video on their blog), certainly a needed innovation for global health:
Via CIMIT: Microfluidic CD4 Cell Counting for Resource-Limited Settings
“The HIV pandemic has created an unprecedented global health emergency. In response, the price of effective, life-saving HIV drug treatment has been reduced by 99%. More than $10 billion is now invested each year to treat people suffering from HIV and AIDS…BUT Treatment is only half the battle. “
“Of the 33 million people living with HIV worldwide, fewer than 10% have access to CD4 counts, the critical blood test used by clinicians to decide when to start treatment. Fewer than 1% have access to viral load assays, which are used for infant diagnosis and for patient monitoring. Both tests are considered essential to effective treatment. The Use Case for appropriate CD4 and viral load tests appropriate for resource-limited settings is clear”:
- Tests need to be performed by a minimally skilled health worker,
- A the true point of care,
- Reliably and inexpensively, and
- Wth reasonable accuracy and precision. The HIV pandemic thus represents an unprecedented opportunity to drive technology development in point-of-care diagnostics.
“Based on this Use Case, William Rodriguez’s lab has developed a series of technologies for an integrated CD4 cell count device, with microfluidics as the key platform…Integrating these microfluidic technologies has led to a prototype handheld device that can accurately capture CD4 cells from a 10 microliter fingerstick sample of whole blood, and accurately measure CD4 counts in under 8 minutes.”
More than 12 years (let that time horizon sink in) after the first indications of success, there will be a large scale trial for a new malaria vaccine. The potential global health implications of this are obvious, read the full news article, it has some good tidbits in it:
“With the exception of Mosquirix, there’s no possibility of one coming on the market within five or six years…It took eight more years of development and testing before scientists were ready to conduct a large-scale trial of the vaccine. London-based Glaxo and its partners will begin a $100 million study of Mosquirix later this year, vaccinating 16,000 children in seven African countries. If the results are positive, the drug could be on the market as soon as 2011, making it the first vaccine against the deadly disease. “
When most people think of global health they think of infectious diseases and all of the associated images this conjures up (and it is harder to capture provocative images of chronic diseases). However, as we have empahsized before, developing countries are facing a dual burden of both chronic and infectious diseases.
This past Tuesday I was privileged enough to attend the launch of the new Health Affairs issue on global health in China and India. I was joined by an esteemed panel of guests who gave great presentations about various issues facing these two nations. Unfortunately I don’t have time to summarize all of their talks but encourage you to read them in the latest issue. I want to focus on Dr. Somnath Chatterji’s paper because the projections of the aging of China and India are quite stunning and the associated social and economic implications will be profound.
Somnath Chatterji runs the WHO’s Study on Global Ageing and Adult Health (SAGE). Here are some highlights from his paper and quotes I picked up (these are based on my hand written notes, so please forgive any factual mistakes):
The pace of change is stunning – what took 100 years in France (the graying of the population) is going to take place in 30 years in China/India (I can’t remember which one he specified). “Aging has been on the backburner…but China and India are facing dramatic demographic shifts in very short periods of time”.
By 2030, 65.6 percent of the Chinese and 45.4 percent of the Indian health burden are projected to be borne by older adults.
By 2019 in China and 2042 in India, the proportion of people age sixty and older will exceed that of people ages 0–14.
Within the next 20 years there will be 42 million diabetics in China and 80 Million in India.
“In four decades 40% of the worlds elderly population will be in China and India…these countries are getting older before they get richer”.
“Traditionally, people think of chronic diseases as diseases of the of the rich, this is probably not going to be true for China and India…we really need longitudinal data to track this”.
There are dozens of issues that come to mind when hearing these projections, some of which include – access, who will get access to care? how will the delivery system be set up for this? where will the focus be (primary care?)? how will this be financed at both health system level and a household level – how much payment will be borne by the patient? can we use capacity developed for tackling infectious diseases for chronic diseases (a very different ballgame in some ways)? what will be the role of the private sector? if the private sector gets involved heavily to sell their drugs and devices in this new “market” – will that lead to better infrastructure for delivery and distribution of medical supplies? how will this impact the economic growth of these countries? There are many more pressing questions, but I will stop here.
Another one of the articles in this global health issue is on obesity in China. This paper is authored by one of world’s leading experts in nutrition (Barry Popkin). We covered some of this before in a recent issue of Scientific American and here is the link for the new paper. Kudos to Health Affairs for the issue and to Burness Communications for a well run launch.
(Summary of ProMedMail Report of 24 January 2008)
Responding to concerns raised by Indonesia and other developing countries, the WHO has instituted an electronic tracking system to track H5N1 isolates submitted, and what is done with them. Vietnam and Indonesia have provided the most isolates, but are concerned that private companies that are developing vaccines from these isolates will market vaccines that are too expensive for developing countries to purchase in the event of an outbreak. In 2007, as a result of these concerns, Indonesia withheld samples for 5 months.
A country-by-country list of submissions has been created, and the tracking system permits anyone to search for particular isolates by date of submission, source country, host species, and several other variables. The system provides a page of detailed information for each isolate, including a list of all the laboratories to which the virus has been distributed, including pharmaceutical companies.
The Uganda Ministry of Health has its work cut out this month. From the front page of the December 5th Daily Monitor:
AS the country grapples with the deadly Ebola outbreak in western Uganda, medics are struggling to contain a rising spate of meningitis and bubonic plague in West Nile [district], cholera in Hoima and Buliisa [districts], and yellow fever in the northern district of Kitgum.
Depending on the source, 19 to 21 deaths, including two doctors, have been attributed to the latest Ebola outbreak. No news yet on results from the two suspected cases in Mbarara and not much new found on HealthMap. Otherwise, life continues as normal here. At the University chapel across the road from our place, there’s a wedding on the lawn. Great weather for a wedding today. The academic term ends this week. Mbarara University students are in exams.
Last Friday the Ugandan dailies the New Vision and Monitor both reported 16 deaths and 51 cases of Ebola in the western Uganda district of Bundibugyo bordering Congo. The mountainous area is also experiencing an influx of Congolese refugees from recent fighting in the eastern states of Congo. As of Monday morning there are 18 confirmed deaths and 58 cases.
Over the weekend, the Sunday Vision updated the story suggesting that the outbreak may have originated from social contacts during a goat roast in August. The Sunday Vision published a Reuters story reporting that CDC tests concluded the outbreak is due to a previously unknown strain which appears to have a lower case fatality rate.
This is only the second confirmed outbreak of Ebola in Uganda. The first killed more than 200 between August 2000 and January 2001 in the north of the country. According to doctors at the hospital in the town where we live, there were several local cases then when an infected soldier returned home to Mbarara town. The hospital here has an isolation unit from that time, I’m told.
It’s an interesting opportunity to see when web-based early reporting sites first noticed the outbreak. HealthMap picked up stories from November 29th forward. HealthMap sources include Google News and other less visible sites such as ProMED Mail at the International Society for Infectious Diseases. A Technorati search turned up blogposts reporting after the reports hit the news wire. No site that I’ve found has anything prior to November 14th (The Monitor, Uganda) which if offline reports of early cases in September are true, would indicate a great deal of needed improvement in early online detection. In comparison, the three Marburg cases from Kamwenge district in early August were quickly reported and quarantined.
Tomorrow is World AIDS Day and instead of “barraging you with [another set of] statistics, gruesome photos, or heart-wrenching stories” (quote credit to Mr. Casnocaha), I want to alert you to something we prefer here – solutions, problem solving, technology, and creative thinking. Piya Sorcar, a doctoral student in Stanford’s Learning, Sciences & Technology Design program has used her considerable skills to figure out how to reach the minds of children in devleoping countries when it comes to HIV/AIDS education.
Incorporating a variety of techniques from several disciplines Piya has generated an animation based educational technique and curriculum, the first of its kind in this area. The first results from this groundbreaking technique are in and they have been outstanding. The indefatigable Sorcar has plans to disseminate the educational curriculum free to schools and other organizations. She also has plans to launch the animation on social networking sites such as Orkut (very popular in some developing countries) and Facebook.
This educational technique and curriculum has taken over 2 years to develop and as far as we know no one else is using this animation based method. This work is truly inspirational, overcomes various methodological barriers and just as importantly political barriers (especailly in countries where sex education is banned). The early results indicate tremendous success. I highly encourage you to read the full story below and visit the website where the animation can be viewed: http://www.interactiveteachingaids.org/
We previously covered Piya Sorcar’s work in a post last year and it has been the most read post on this blog with over 1700 visits. You can view that here for further background information.
Lasly, there is much more to say about Piya’s work which we will save for another post. I have placed some links about World AIDS Day below this entry and as a side note – even rock group Queen is getting into the action with their first new recording in a decade to mark the event.
Doctoral student creates groundbreaking animation to teach HIV/AIDS prevention in developing countries
To combat the stigma associated with discussing HIV/AIDS and sexual practices in India and other developing countries, doctoral student Piya Sorcar has developed a groundbreaking animation-based curriculum to teach HIV/AIDS awareness and prevention in a culturally sensitive manner to young adults around the world.
Sorcar’s project, Interactive Teaching AIDS, is already being used in several countries…The animation emphasizes the biology of HIV/AIDS, presenting a storyline with a dialogue between a curious student and a friendly yet authoritative cartoon “doctor” on the biological facts about HIV,its spread, and its prevention.
“What’s groundbreaking is that she’s shown that we can inform people about AIDS while respecting the culture,” said Communications Prof. Clifford Nass, an advisor to Sorcar’s Ph.D. project. “That’s an enormous accomplishment.”
“The result was Interactive Teaching AIDS, an animation-based tutorial featuring a friendly cartoon doctor and patient who guide participants through the biological aspects of AIDS transmission. The tutorial is available online and on a CD.”
A recent study of the application in India by Sorcar with 423 students in private schools and colleges in North India, showed significant gains in learning and retention levels after interacting with the 20-minute animated tutorial. Prior to testing, only 65% knew that HIV was not spread through coughing; after the tutorial, this percentage increased to 94%. Students stated that they were comfortable learning from the tool, and more than 90% said they learned more about HIV/AIDS through the animated tutorial than any other communication method such as television or school. One month after initial exposure to the tutorial, students were rapidly seeking and educating others about HIV/AIDS prevention through their networks, with nearly 90% sharing information they learned from the tutorial with someone else.
BBC reports that “a study published in the Public Library of Science journal by researchers from the Harvard School of Public Health suggests the policy has saved Brazil around $1bn between 2001 and 2005.” The article itself is available freely online as a part of the open access policy of PLoS.
From the Harvard School of Public Health press release:
The results showed that, although costs for Brazil’s locally produced generic antiretroviral drugs (ARVs) increased from 2001 to 2005, the country still saved approximately $1 billion in that time period through controversial price negotiations with multinational pharmaceutical companies for patented ARVs. Since 2001, Brazil has been able to obtain lower prices for patented ARVs by threatening to produce AIDS drugs locally. Though these negotiations initially prompted major declines in AIDS drug spending, HAART costs in Brazil more than doubled from 2004 to 2005. The steep increase reflects the fact that more people living with HIV/AIDS began treatment and are living longer. The increase also reflects the challenges associated with providing complex, costly second- and third-line treatments as people develop resistance to first-line drugs, live longer and require more complex treatment regimens.
Figure 6 from the article – Impact of Alternative Price and Quantity Scenarios on Total ARV Costs, 2001–2005 – shows how the increase in spending is primarily related to increases in quantities rather than costs (Figure 6.A). This figure also shows how much would have been spent if there were no price changes (6.B) and the theoretical minimum that could have been spent by buying the lowest-priced generics on the market (6.C).
This is a fascinating idea that was sent to me by Cat Laine over at AIDG. I know I am always raving about their blog, but really if you haven’t managed to check it out – go over there right now. Onto the story which may or may not have benefits for modeling real world epidemics: “A fantasy plague that accidentally ran amok in the Internet’s most popular game world, populated by nine million flesh-and-blood players, may help scientists predict the impact of genuine epidemics…”
This story is not only a case of researchers being very innovative but also yet another example of how the business world is getting invovled and make a contribution to solving global health problems. The company that makes World of Warcraft is Vivendi a, giant global media company, that has entered into dicussions to possibly provide scientific data for research.
Online gamers rehearse real-world epidemics
“Virtual playgrounds such as World of Warcraft, launched in 2004, could soon become testing grounds for the all-too-real battle against bird flu, malaria or some as yet unknown killer virus….As technology and biology become more heavily integrated in daily life, this small step towards the interaction of virtual viruses and humans could become highly significant.
The unlikely path to a collaboration between hard science and hard-core gaming began in late 2005, when Blizzard programmers introduced a highly contagious disease — dubbed “Corrupted Blood” — into a newly created zone of the game’s Byzantine environment.
World of Warcraft is a “multiplayer online role-playing game” in which players — numbering in the tens, or hundreds of thousands — use computer-controlled avatars to fight battles, form alliances, and dialogue simultaneously on the Internet. At first the “patch”, as new elements such as the disease are called, worked as expected: experienced players shrugged it off like a bad cold, and weaker ones were left with disabled avatars.
But then things spun out of control. As in reality, some of those carrying the virus slipped back into the virtual world’s densely populated cities, rapidly infecting their defenseless inhabitants. The disease also spread — much like real influenza or the plague — via domesticated animals abandoned by players for fear of infecting their avatars, leaving the sickened pets to roam freely. Programmers tried to set up quarantines, but they were ignored. Finally, they resorted to an option not available in the real world: they shut down the servers and rebooted the system.
This was the first time that a virtual virus has infected a virtual human being in a manner resembling an actual epidemiological event…To date, epidemiologists have relied heavily on mathematical simulations to forecast the spread of contagious diseases across large populations.” But crunching numbers has limitations, says Fefferman. “There is no way to model how people will behave” in a pubic crisis, she said.
“How many will run away from a quarantine? Will they become more or less cooperative if they are scared? We simply don’t know.” Which is where the virtual netherworlds come into the picture. They can help scientists to “feed appropriate parameters into existing epidemiological models,” she said.
Wired magazine has a fascinating piece from last month on the “ultimate medical diagnostic device” which is being developed in collaboration with the private sector. It is by Thomas Goetz who runs his own blog: Epidemix. Excerpts below:
“Our inability to diagnose and track infectious disease quickly and accurately remains a serious problem…The problem with cultures is that they take a long time — three weeks or more — to produce a definitive result. In those three weeks, antibiotics may be fortifying the bacteria’s resistance rather than curing the patient. In those three weeks, a TB patient goes back into the population and spreads disease. In those three weeks, the bacteria have enough time to escape our grasp. What’s needed, then, is a new way to diagnose the disease: one at least as fast as the sputum microscopy test, as accurate as the culture, and refined enough to differentiate between garden-variety bacteria and drug-resistant strains. What’s needed is nothing less than a new gold standard…Those tests might finally be at hand. There is a crop of diagnostic tools on the horizon… Dozens of companies are investing hundreds of millions of dollars to develop these new tools.”
“TruDiagnosis: It combines advances in microfluidics (miniaturized pumps and channels), microarrays (micron-sized sensors affixed to a chip), and engineering into what could be the ultimate medical gadget: a handheld device that, using a small sample of blood or spit, reveals in mere minutes every pathogen inside the body.”