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April 27, 2015   Download print version

Fear of aftershocks has Nepal on edge

Exposure to polluted air might affect your brain

Urgent action needed for Indiana HIV outbreak, CDC says

Diet pill death from DNP: Could it happen here?

Potential uses of electronically readable cards for beneficiaries and providers

Disaster planning: Creating a system that works

Ebola outbreak may have led to almost 11,000 additional Malaria deaths


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May 2015

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Fear of aftershocks has Nepal on edge

KATHMANDU, Nepal — Nepal’s capital became a city of whispers and rumors Sunday as residents hunkered down outdoors in tents and cars, and recurring aftershocks from Saturday’s earthquake kept everyone on edge, fearing another big quake.

Food and water supplies ran low. Price gouging began. Electricity was intermittent. Rescuers battled to make it to residents of remote villages — as well as climbers on Mount Everest — to save those still stranded more than 24 hours after the catastrophe. They continued clawing victims out of the rubble, sometimes with their bare hands.

The death toll kept climbing throughout the day and by early Monday it stood at more than 3,600 in Nepal and dozens more in neighboring countries.

Sunday afternoon’s big aftershock in Nepal measured 6.7 on the Richter scale, according to the U.S. Geological Survey, panicking already frightened citizens. As with the quake the day before, the aftershocks were felt as far away as New Delhi.

Two aircraft headed to Kathmandu’s Tribhuvan International Airport from India carrying some rescue personnel and aid workers had to head back to New Delhi because it was not safe to land, forcing a delay in relief efforts. Flights eventually resumed, only to be further delayed again by weather.

On Mount Everest, more snow and ice came crashing down, on the heels of Saturday’s devastating avalanche that left at least 19 reported dead at the mountain’s base camp and hampered rescues. Emergency personnel airlifted around 50 injured climbers by helicopter from the base camp Sunday morning but put help for others on hold after the aftershock. Col. Rohan Anand, a spokesman for the Indian army, said dozens of climbers remained missing at the world’s highest peak.

Outside Kathmandu, many rescue crews had yet to reach the more isolated villages, where authorities fear the devastation would be much worse. The Nepali military circulated aerial photos that showed entire villages flattened.

The United Nations issued a situation report that said that the most affected areas were Gorkha and Lamjung, areas northwest of Kathmandu and close to the quake’s epicenter, with damage to the Kathmandu Valley limited to historic, densely built-up areas. Hospitals were running out of room for storing corpses as well as emergency supplies, the report said.

A United Nations team arrived in Kathmandu on Sunday to assess the damage and identify the most urgent needs.

The biggest challenge is that rescuers still don’t have reliable information about what’s going on in areas outside Kathmandu, including how many people are still trapped, according to O.P. Singh, the director general of India’s National Disaster Response Force.

Relief agencies geared up for a humanitarian response to meet the massive shelter, food, clean-water and sanitation needs.

An urban search-and-rescue team from the Fairfax County Fire and Rescue Department in Virginia will be deployed, the U.S. Office of Foreign Disaster Assistance said on Twitter, with one from Los Angeles on standby.

The United States authorized an initial $1 million for emergency humanitarian needs, the State Department said.

By Sunday, international aid had begun to arrive. India deployed four military planes carrying tons of water and supplies, as well as ten National Disaster Response Force teams trained in search and rescue, and accompanied by sniffer dogs.

China, which gave $3 million in humanitarian aid, sent a ­62-member search-and-rescue team that arrived in Nepal on Sunday. More help is expected from Israel, Malaysia, Pakistan and Sri Lanka.

At Bir Hospital — one of the oldest hospitals in Kathmandu — doctors had treated patients outside in the hours following the earthquake. They had treated more than 300 people and performed 38 back-to-back surgeries on their one functioning operating table, according to Kapil Gautam, a doctor there. Most of the patients had been hurt in roof and wall collapses. More than 100 bodies lay outside in the courtyard, including 10 that were uncovered and had yet to be identified.

Prime Minister Sushil Koirala returned to Nepal on Sunday and immediately met with the cabinet of ministers. The government has directed all medical stores and large supermarkets to remain open. The cabinet also decided to conduct mass public funerals unless relatives claim victims’ bodies.

Saturday’s quake, which measured 7.8 on the Richter scale, had caused widespread damage throughout the Tibet region, India and Bangladesh. At least 62 people died in the Indian states of Uttar Pradesh, Bihar and West Bengal.

In the Tibet region of China, the death toll climbed to 20, with more than 200,000 affected. Houses and a historic temple collapsed. More than 1,500 officers from the People’s Liberation Army have been sent to the region to help in rescue operations, the government said. Visit the Washington Post for the story.



Exposure to polluted air might affect your brain

A new study carried out at Beth Israel Deaconess Medical Center and Boston University School of Medicine reveals that the polluted air we inhale can affect our brain and lead to cognitive loss. Experts say that our brain could decrease in size and people who are most exposed are more likely to suffer from strokes or dementia.

Study lead author Elissa H. Wilker, Sc.D., who is a researcher at the Cardiovascular Epidemiology Research Unit at Beth Israel Deaconess Medical Center and the Harvard T.H. Chan School of Public Health in Boston mentioned that the most affected people are the middle-aged to older ones.

The research targeted a number of 943 people who were at least 60 years old. Their health was first reviewed and they were regarded as healthy – that is, none of them suffered from dementia or had a stroke in the past. They lived in New York, Boston and New England, areas, where pollution is not significant. An MRI (magnetic resonance imaging) was used to analyze the brain functions and structures of all the participants to the study. The images were examined in relation to the pollution levels from the area where the people were living. The aim was to determine what effect pollution has on the brain. The findings were quite surprising.

According to the researchers, the brain volume was smaller by 0.32% in relation to an increase of less than 2.5 micrograms of fine-particle pollution per cubic meter. This pollution usually comes from a wide variety of sources. Car exhaust, which is so common in large cities, is one of them.

A representative of the Boston University School of Medicine, Dr. Sudha Seshadri, Professor of Neurology, stated that people who live in highly polluted areas are likely to have a brain volume smaller than other people who are the same age, thus pointing to the devastating effects air contamination has.

The scans also revealed that pollution could result in a 46% more chances of a person having a silent stroke if exposed to air pollution. When someone has a silent stroke, he/she is generally unaware of it, as they are asymptomatic, but they can lead to more severe ones in the future. Silent strokes are real even if they are small and people might not feel any discomfort. However, the MRI is able to detect them.

Therefore, fine-particle pollution may be more damaging for the brain than other types of contamination, leading to brain atrophy associated with aging. The results of the study were published in Stroke, the American Heart Association journal and are consistent with other studies in the field. Visit Wall Street OTC for the study.



Urgent action needed for Indiana HIV outbreak, CDC says

An outbreak of the AIDS virus among injecting drug users in rural Indiana has spread to at least 135 people, and federal officials are warning communities around the country to look out for similar outbreaks.

The Centers for Disease Control and Prevention said Friday that "urgent action" was needed to control the outbreak in Indiana's Scott County and said it's possible other cities or towns are vulnerable.

A combination of easily available prescription painkillers, a poor economy and a lack of education are fueling the Indiana outbreak. And because there's an epidemic of painkiller abuse across the country, people could be spreading both HIV and hepatitis anywhere, CDC said.

"HIV can gain ground at any time unless you remain vigilant," Dr. Jonathan Mermin, who directs CDC's HIV/AIDS center, told reporters.  "The situation in Indiana should serve as a warning. We cannot let down our guard against these deadly infections," Mermin said.

HIV and hepatitis C both spread via shared needles. In the U.S. 3,900 people become infected each year with HIV because of shared needles. That's down by 95 percent from the 1980s and CDC is not eager to see the numbers come back up again.

But there's a potentially deadly combination as drug users get access to pain pills that they grind up and inject. Users in big cities know not to share needles, they have access to testing, education and fresh needles. But drug users in rural areas where there hasn't been an all-out push to educate people about the risks might not know how dangerous it is, Mermin said.

CDC says an epidemic of opioid abuse is already driving an epidemic of hepatitis. Mermin said there was a 150 percent increase in reports of hepatitis C between 2010 and 2013. "The majority of these are believed to be attributable to injecting drug use," Mermin said.

Deaths from opioid overdoses nearly quadrupled from 1999 through 2011. Add to this the fact that opioid pills are not meant to be ground up and injected, said Indiana State Health Commissioner Dr. Jerome Adams.

"We found that when people are using oral medications and crushing them up, they are not as dissolvable as, say, heroin," Adams said. They must use a fatter needle, and that means more blood and more virus is getting into the needle. If it's shared, everyone gets a higher dose of HIV.

"The overprescribing of these powerful drugs has created a national epidemic of abuse and overdose," Adams said. "We are asking states to take a close look at their most recent data on HIV and hepatitis C diagnoses," Mermin said. "This may help identify communities at unrecognized risk of unseen clusters."

Both the human immunodeficiency virus that causes AIDS and the hepatitis C virus are spread in bodily fluids, including blood. Both can kill people if they are not diagnosed and treated.

Officials painted a picture of families where grandparents sit down to do drugs with their grandchildren, with everyone freely sharing the same needles.

"There are children and parents and grandparents who live in the same house who are injecting drugs together as a sort of community activity," said Dr. Joan Duwve, chief medical consultant for the Indiana department of health.

The CDC and Indiana said they found those affected were crushing and cooking extended-release oxymorphone pills. "Syringes and drug preparation equipment are frequently shared (e.g., the drug is dissolved in nonsterile water and drawn up into an insulin syringe that is usually shared with others)," they wrote.

People are shooting up four to 15 times a day, sharing needles with as many as six other people at a time.

It's clear why they have the time to do so. "Like many other rural counties in the United States, the county has substantial unemployment (8.9 percent), a high proportion of adults who have not completed high school (21.3 percent), a substantial proportion of the population living in poverty (19 percent), and limited access to healthcare," the CDC and Indiana officials wrote.

"This county consistently ranks among the lowest in the state for health indicators and life expectancy."

CDC and health officials are tracking down the sexual partners and needle-sharing friends of all 135 cases. It's a high percentage in a community of only 4,200 people.

For now, CDC is helping Indiana officials track down infections. Needle exchanges are illegal in Indiana, but Gov. Mike Pence, a Republican, has issued an executive order allowing temporary needle exchanges. Doctors from Indiana University have also started helping staff clinics to help drug abusers. Visit NBC News for the story.



Diet pill death from DNP: Could it happen here?

The story of a young woman in the U.K. who died after taking toxic diet pills she bought online will hopefully serve as a cautionary tale for consumers to stay far away from any quick-fix weight-loss product available on the Internet. But the tragic case of this 21-year-old college student is also a stark reminder of how little control health officials in the U.S. and abroad have when it comes to regulating pharmacopeia on the Internet.

Police say she died just hours after taking the tablets that are believed to have contained a "highly toxic and very dangerous" substance called dinitrophenol, or DNP. Researchers say DNP, which has been linked to at least 62 deaths over several decades, makes metabolism skyrocket to the point where patients suffer hyperthermia, rapid breathing and heartbeat, cardiovascular collapse and death.

Dr. David Gortler, a former U.S. Food and Drug Administration medical officer, told CBS News it is possible that a similar incident could occur in the U.S., because the FDA does not have the authority to regulate dietary supplements from other countries that come through the mail. Typically, only when something goes wrong can the FDA take action.

Gortler, who worked at the agency's division of metabolism and endocrinology that reviews drugs for weight loss, and is currently a drug safety expert with, said DNP is an organic chemical that has been used as an antiseptic and in photo development. He added that the chemical compound most likely is available in the U.S. market, but as a cleaning product -- not an approved drug.

Records from the FDA's Office of Criminal Investigation indicate that similar incidents have occurred involving online sales of DNP in the U.S. In 2002, the agency opened an investigation involving the sales of DNP after the father of the deceased young woman wrote a letter to the U.S. Postal Service saying she'd bought the product through the mail.

Through investigating this case, health officials linked two independent ongoing investigations regarding suspicious mailings of DNP. Two men were arrested and convicted for running a business that sold these dangerous fake diet aids.

Another investigation conducted by the FDA's Detroit district office and the postal service led to the arrest of a man in Strongville, OH. In that case, a woman was hospitalized when she began to experience tachycardia [rapid heartbeat], flushing and profuse sweating after taking the pills.

"DNP is a dangerous chemical and has a long history of significant safety issues, which is why it is not an approved drug," Gortler said. "The FDA recommends not taking this drug in any amount. I'm sure the company sending this supplement was only too happy to take her money without warning her of the significant safety issues with this supplement. Basically everyone selling dietary supplements for the purpose of weight loss is a liar and charlatan, preying upon individuals who don't understand the pharmacology of obesity."

In the U.S., even weight loss and dietary supplements that do end up on the shelves at retails stores are not regulated by the FDA. Under the Dietary Supplement Health and Education Act of 1994 (DSHEA), supplements with established ingredients, those that were sold in the U.S. before 1994, may be marketed without any evidence proving they are effective or safe. For new supplement ingredients, DSHEA requires manufacturers to give the FDA evidence that the new ingredient is safe.

The FDA is only required to step in when consumers report that one of these products is unsafe. Because of this, many say the FDA's regulations are too lax. Health officials have recently begun investigating a number of unregulated over-the-counter products, including homeopathic remedies and an amphetamine-type diet supplement called BMPEA. Visit CBS News for the article.



Potential uses of electronically readable cards for beneficiaries and providers

Proposals have been put forward to replace the current paper Medicare cards, which display beneficiaries' Social Security numbers, with electronically readable cards, and to issue electronically readable cards to providers as well. Electronically readable cards include cards with magnetic stripes and bar codes and “smart” cards that can process data.

Proponents of such cards suggest that their use would bring a number of benefits to the program and Medicare providers, including reducing fraud through the authentication of beneficiary and provider identity at the point of care, furthering electronic health information exchange, and improving provider record keeping and reimbursement processes.

The Centers for Medicare & Medicaid Services (CMS) could use electronically readable cards in Medicare for a number of different purposes. Three key uses include authenticating beneficiary and provider presence at the point of care, electronically exchanging beneficiary medical information, and electronically conveying beneficiary identity and insurance information to providers. The type of electronically readable card that would be most appropriate depends on how the cards would be used.

Smart cards could provide substantially more rigorous authentication than cards with magnetic stripes or bar codes, and provide greater security and storage capacity for exchanging medical information. All electronically readable cards could be used to convey beneficiary identity and insurance information since they all have adequate storage capacity to contain such information.

Using electronically readable cards to authenticate beneficiary and provider presence at the point of care could curtail certain types of Medicare fraud, but would have limited effect since CMS officials stated that Medicare would continue to pay claims regardless of whether a card was used due to legitimate reasons why a card may not be present. CMS officials and stakeholders told us that claims should still be paid even when cards are not used because they would not want to limit beneficiaries' access to care.

Using electronically readable cards to exchange medical information is not part of current federal efforts to facilitate health information exchange and, if used to supplement current efforts, it would likely involve challenges with interoperability and ensuring consistency with provider records. Using electronically readable cards to convey identity and insurance information to auto-populate and retrieve information from provider information technology (IT) systems could reduce reimbursement errors and improve medical record keeping.

To use electronically readable cards to authenticate beneficiaries and providers, CMS would need to update its claims processing systems to verify that the cards were swiped at the point of care. CMS would also need to update its current card management processes, including issuing provider cards and developing standards and procedures for card use. Conversely, using the cards to convey beneficiary identity and insurance information might not require updates to CMS's IT systems or card management practices. For all potential uses, Medicare providers could incur costs and face challenges updating their IT systems to use the cards.

The experiences of France and Germany demonstrate that an electronically readable card system can be implemented on a national scale, though implementation took years in both countries. It is unclear if the cost savings reported by both countries would be achievable for Medicare since the savings resulted from using the cards to implement electronic billing, which Medicare already uses. Both countries have processes in place to manage competing stakeholder needs and oversee the technical infrastructure needed for the cards. Visit GAO for the report.



Disaster planning: Creating a system that works

At the 2015 World Congress on Disaster and Emergency Medicine last week, global leaders in humanitarian response debated the utility of a credentialing system for health workers responding to emergencies.

The group introduced the Global Humanitarian Health Association (GHHA), a nascent professional organization for humanitarian workers. The GHHA hopes to serve as an advocacy group while developing a registry of credentialed providers and ensuring that members meet a set of yet-to-be-determined core competencies.

Hilarie Cranmer, MD, MPH, Director of Disaster Response at the Massachusetts General Hospital Center for Global Health and one of the chief architects of the new organization, stressed the need for a unified cadre of professional, consistently trained humanitarian health practitioners.

The days of the "disaster cowboy" hopping on the next plane may be numbered, if GHHA can convince aid agencies and responders that a credentialing system is possible. Proper credentialing would ensure that responders understand the principles of practice in resource-poor settings and have the skills needed to function in a confusing and sometimes dangerous atmosphere. That specialized body of knowledge might not be evident by checking an applicant's medical license or board certification.

The idea of creating a vetting system and scope of practice for providers who respond to global health emergencies has gathered momentum over the past several years. Those efforts have been accelerated by the feeling among some in the disaster response community that "Haiti 2010" represented a dangerous and often embarrassing hodge-podge of inconsistency.

Reaction to the proposal by NGO representatives at the workshop was guarded, although some acknowledged the need for a reliable personnel pipeline.

"We are in a human resources crisis," said Dr. Daniel Martinez Garcia, a pediatric adviser at MSF-Spain's medical department. "We have a lot of trouble finding people and a lot of trouble checking their qualifications." One benefit of a GHHA-type system, he said, would be the ability to certify workers whose training comes from outside of the formal Western system: "Our workforce is increasingly from lower and middle income countries," Martinez explained, "and those are the people who are difficult to validate. There are very few schools of pediatrics in Africa, for example."

Brenna Adelman, RN, MSN, MSPH, a nurse from Knoxville looking to break into the field, said that she would use the system if it combined credential verification with some sort of database. Cost could be a concern, NGO workers like Adelman might be more likely to cough up an annual registration fee if the data were available to a wide range of NGOs and agencies.

But the question of who ultimately has the authority to form a governing body for humanitarian response remains unsettled, especially since the proponents of the structure proposed here represent an elite slice of North American academia. Any system would need to take into account the worldwide diversity of health workers, not to mention the global nature of the population they serve.

One unintended outcome could be the creation of a two-tiered system, one of credentialed humanitarian health responders, and a second informal system of providers operating outside of the formal structure.

What does this mean for the physician who volunteers once a year with a medical mission, or the disaster "junkie" accustomed to finding their own way and helping as much as possible?

Probably nothing, until organizations like the World Health Organization and Doctors Without Borders subscribe to the idea, and smaller agencies follow suit. Host governments would have to adopt the system as well, screening responders for suitability as they cross international borders. Visit MedPage Today for the article.



Ebola outbreak may have led to almost 11,000 additional Malaria deaths

Nearly 11,000 extra deaths due to malaria may have occurred in 2014 because of disruptions in healthcare services caused by the Ebola outbreak in West Africa, a new study suggests.

Another 3,900 extra malaria deaths may have been caused by the interruption of delivery of insecticide-treated sleeping nets, the British researchers said.

"The ongoing Ebola epidemic in parts of West Africa largely overwhelmed already fragile healthcare systems in 2014, making adequate care for malaria impossible and threatening to jeopardize progress made in malaria control and elimination over the past decade," study author Patrick Walker, of the MRC Centre for Outbreak Analysis and Modelling at Imperial College London, said in a journal news release.

The findings suggest that the number of malaria deaths caused by the Ebola outbreak in West Africa was similar to the number of deaths caused by Ebola itself. Close to 10,900 people have died from Ebola in West Africa as of April 19, 2015, according to the World Health Organization (WHO).

The researchers added that large-scale distribution of drugs and treated nets for the upcoming malaria season in May and June could significantly reduce the number of malaria cases and deaths associated with the disruptions from the Ebola outbreak.

The study estimates that if the healthcare system returns to pre-Ebola levels, more than 15,000 malaria deaths will be prevented in 2015.

As the health systems in Ebola-affected countries of Sierra Leone, Liberia and Guinea recover, Walker said that measures need to be taken to prevent malaria infection, such as the emergency mass drug distribution measures recommended by WHO.

The authors of an accompanying editorial from the U.S. Centers for Disease Control and Prevention discussed the toll of Ebola, saying that if an effective disease surveillance workforce is implemented, "health care systems will be strengthened so that the next global health threat will be detected, reported, and contained quickly.

The study appears online April 23 in The Lancet Infectious Diseases. (HealthDay) Visit NIH for the report.