Archive for the ‘WHO’ Category

Daifailluh al-Bugami was just a year old when his parents noticed that his lips turned blue as he slept at night. It was his weight, doctors said, putting pressure on his delicate airways.

Now Daifailluh is 3, and at 61 pounds he is nearly double the typical weight of a child his age. So the Bugamis are planning the once unthinkable: To have their toddler undergo bariatric surgery to permanently remove part of his stomach in hopes of reducing his appetite and staving off a lifetime of health problems.

That such a young child would be considered for weight-loss surgery—something U.S. surgeons generally won’t do—underscores the growing health crisis here and elsewhere in the Middle East. Widespread access to unhealthy foods, coupled with sedentary behavior brought on by wealth and the absence of a dieting and exercise culture, have caused obesity levels in Saudi Arabia and many other Gulf states to approach or even exceed those in Western countries.

While solid national data are hard to come by, some experts say that obesity has turned into a serious health problem for Saudi children, with an estimated 9.3% of school-age youths meeting the World Health Organization’s body-mass-index criteria for obesity, according to research published in 2013 in the Saudi Journal of Obesity. About 18% of school-age children in the U.S. were considered obese in 2010, according to the Centers for Disease Control and Prevention.

Daifailluh’s doctor, Aayed Alqahtani, is a leading advocate of a radical approach to the problem. Patients travel to him from across the country and the Gulf region. Over the past seven years, he has performed bariatric surgery on nearly 100 children under the age of 14, which experts on the procedure believe is the largest number performed by one doctor on young children.

Dr. Alqahtani’s work is being watched amid a global debate about the appropriate age for bariatric surgery. In the U.S., the minimum is generally considered 14. The World Health Organization, in a 2012 report on pediatric bariatric surgery, concluded that there is a dearth of data available on the long-term outcomes of the procedure in children and that a “conservative approach” is necessary until long-term studies are conducted.

Bariatric surgery has been embraced as an effective and relatively safe procedure for morbidly obese adults. The concern with children revolves mostly around nonsurgical risks, such as how the abrupt change in nutrition could affect long-term brain development and sexual maturation.

Dr. Alqahtani says the decision to operate on Daifailluh is a difficult one because of his age. But after nearly two years of consultation with the clinic, Daifailluh’s obesity-related medical problems haven’t gotten any better. “We should not deprive our patients from bariatric surgery based on their age alone,” the surgeon says. “If they have [medical] conditions that threaten their lives, then we should not deny the bariatric surgery.”

The worsening obesity problem here also is manifesting itself in other ways. Some 20% of the Saudi adult population has Type 2 diabetes, a condition linked to obesity, according to the International Diabetes Federation, compared with 8.3% in the U.S., according to the CDC. The cost of diabetes treatment in Saudi Arabia is expected to rise to $2.4 billion in 2015, more than triple that spent in 2010, according to a recent study in the Journal of Family and Community Medicine.

Obesity, particularly among women, has become rampant across much of the Middle East, particularly in oil-rich Gulf nations. In Kuwait, almost half of adult women are considered obese, while 44% of Saudi women and 45% of Qatari women meet the criteria, according to the International Association of the Study of Obesity. Experts says Saudis, in particular, are more likely to carry certain genes linked to obesity.

Saudi lifestyle and parenting practices may exacerbate the problem, according to doctors at weight-loss clinics. Nannies or cooks are often employed, so parents may not know what their children are eating. Saudis often are coaxed to eat large quantities of food when visiting relatives and friends.

In Riyadh, physical activity is limited, particularly for girls, and high temperatures and few green spaces make walking difficult. School gym classes generally take place just once a week. Western-style fast food is abundant, particularly at the air-conditioned malls frequented by children and families.

Bariatric surgery has become an accepted treatment among obese Saudi adults and is paid for by the government. An estimated 11,000 bariatric surgeries were performed on Saudis in 2012, according to Dr. Alqahtani.

The surgery, of which there are several types, generally reduces the size of the stomach and, with some techniques, rearranges the digestive path to bypass much of the intestines. Some types are reversible but generally considered less effective. After the surgery, patients must eat very small meals—ideally for the rest of their lives. Many studies have shown that adults, on average, lose over 50% of their body weight after surgery.

Increasingly, youngsters are heading to the operating room here, where parents see no other options. These days, Dr. Alqahtani performs surgery on three to four youths a week.

“I have seen in my clinic patients who cannot sleep lying down—they sleep sitting—because of sleep apnea, and their age is 10 years, sometimes 5 years,” says Dr. Alqahtani, a professor in the college of medicine and an obesity specialist at King Saud University.

Pediatric surgeons in the U.S. say they also are facing demands from families to operate on younger patients. Thomas Inge, surgical director of the Surgical Weight Loss Program for Teens at Cincinnati Children’s Hospital, says he will be operating on a 12-year-old later this month. He says that as younger and younger children are referred for consideration of surgery, care teams will need to carefully weigh the pros and cons.

Evan Nadler, a pediatric surgeon at Children’s National Medical Center in Washington, D.C., is considering doing the operation on two young children. He and the family of a 7-year-old D.C. boy have agreed that surgery likely is the best option, he says. The family of an 8-year-old from the Middle East has decided to wait until their daughter is older and can better understand the surgery, he says.

Many doctors say they aren’t ready to follow Dr. Alqahtani yet. Kirk Reichard, chairman of the pediatric-surgery committee for the American Society for Metabolic and Bariatric Surgery, notes that there are no data to show that surgery doesn’t affect young children’s long-term sexual maturation or cognitive functioning. The brain, particularly in growing children, is sensitive to nutrition and needs enough energy to mature properly. Nutrition also has the potential to affect hormones linked to sexual maturation.

Dr. Alqahtani says he has seen evidence of normal growth following the procedure in his under-14 patients, many of whom are now four years postsurgery.

“We will certainly use his experience to inform us in some ways, but [Dr. Alqahtani’s work] won’t take the place of trials,” says Dr. Reichard.

One of the main criticisms from some weight-loss experts about performing the surgery on those under 14 is that changes in diet and exercise can prevent further weight gain. In addition, says Dr. Reichard, “there are a lot of other therapies short of surgery that can be helpful in managing” related medical conditions.

Saudi Arabia’s Dr. Alqahtani says he requires his child patients to enroll in a weight-loss program for at least six months because patients able to lose even a bit tend to have better outcomes after surgery. But he says that by the time families come to him, their children have such substantial health problems it is generally too late for diet and exercise alone.

Dr. Alqahtani was trained as a surgeon at McGill University in Montreal and at a minimally invasive surgery center in Denver. When he returned home to Riyadh in 2002, he says, he was inundated with pediatric patients so obese they were suffering from advanced stages fatty liver disease, diabetes and sleep apnea, a disorder in which patients repeatedly stop breathing for short periods during sleep—all diseases typically not seen until middle age.

Om Abdullah Asiri says she tried to help her 11-year-old son lose weight by restricting his eating at home. But he would eat fast food while out with his friends and plays videogames for hours on end, she says. “I can’t control him outside the home,” she says.

He grew to 250 pounds. His body-mass index—a calculation that uses weight and height to estimate percentage of body fat—was 61. A BMI of 40 or above is the most severe obesity category, according to the World Health Organization.

Ms. Asiri traveled with her son, Abdullah, from their home in Abha, more than 600 miles south of Riyadh, to see Dr. Alqahtani for the operation. Lying on a hospital bed the day before his surgery, Abdullah said he is “happy and ready” for the surgery.

His mother says surgery is the best solution for Abdullah, who has high blood pressure, fatty liver, hip pain and severe sleep apnea. Afterward, he won’t have a choice but to eat better, she says. “The surgery will make him change.” She says he dreams of playing soccer with his friends.

The procedure Dr. Alqahtani performs is called the gastric sleeve, which slices off a portion of the stomach but leaves the rest of the digestive tract intact. It is gaining in popularity because of its good weight-loss results and minimal side effects. The operation, conducted through tiny incisions in the abdomen, takes him just 30 minutes.

One recent morning, he operated on a 20-year-old, two 17-year-olds, a 12-year-old, then Abdullah, who was then 10.

Complications can include bleeding in about 10% of cases, and leaking and blood clots in 1% to 2%. Dr. Alqahtani says he has had only two leaks in 1,700 cases, neither in children.

Dr. Alqahtani says each of his pediatric patients has lost at least some weight, and nearly three-quarters have lost more than 50% of their initial body weight. Abdullah has lost close to 50 pounds since his surgery about two months ago, according to his 29-year-old brother, Ahmad.

Dr. Alqahtani says about 90% of his patients have seen medical conditions such as diabetes and hypertension clear up, according to a paper scheduled for publication in the journal Surgery for Obesity and Related Diseases. He published outcomes on 108 children in the peer-reviewed Annals of Surgery journal in 2012.

Recovery involves a six-week transition diet starting with clear liquids and puréed food. Patients eventually can resume solid foods at much-reduced quantities. At first, patients feel full after just 1 to 2 spoonfuls of food, though they gradually can eat more as their stomachs stretch.

Some bariatric-surgery experts have raised questions about whether children are capable of maintaining the restrictive lifetime diet after surgery or whether they will sabotage the procedure when they become teenagers and have a greater autonomy to eat what they want. Some experts question whether parents should make such a drastic and permanent decision for a child.

The decision has been excruciating for the family of Daifailluh, the toddler from Ta’if. Daifailluh was referred to Dr. Alqahtani’s clinic about two years ago after difficulty breathing sent him to the intensive-care unit at a hospital in his hometown. Doctors there determined the toddler was seriously overweight. His mother, Hessa Salem al-Bugami, says she tried to improve his diet but didn’t have good guidance until she came to Dr. Alqahtani’s clinic, a trip of nearly 500 miles from Ta’if. “I feel like I failed,” she says.

At first, the family wanted Daifailluh to lose weight without the operation. Ms. Bugami says her son has always had an “open appetite” and never refuses food. She says she feeds him brown bread and boiled chicken and rice, and limits his portions, hiding the rest of the food. But his obesity hasn’t improved, she says.

Daifailluh will cry and sometimes throw temper tantrums when he wants food, she says. She has tried distracting him with toys, locking the two of them in a room to play for so long she ended up missing her own meal.

“When he starts crying, it’s hard not to give him any of the food, to make the crying stop,” she says. “I feel like I work really hard, but it’s just too much on me.”

Daifailluh, who was hospitalized again for pulmonary problems, is waiting for a surgery date, which will come if he gets final medical clearance from Dr. Alqahtani.

The entire family is worried about the surgery, particularly the effects of anesthesia and whether the surgery will reduce his appetite too much. Ms. Bugami also worries that her son will regain the weight when he leaves the house eventually and is no longer under her watch.

But that is a concern for another day. “Right now is the most scary situation,” she says.

Write to Shirley S. Wang at shirley.wang@wsj.com

http://online.wsj.com/news/articles/SB10001424052702304851104579360992538215578?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304851104579360992538215578.html

Thanks to Pete Cuomo for bringing this to the attention of the It’s Interesting community.

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ftn of youth

Jackie Snow
for National Geographic
Published July 23, 2013

Five hundred years ago in June, the Spanish conquistador Juan Ponce de Leon started his journey back to Puerto Rico from Florida after becoming the first European to land on mainland America. After exploring the east coast of Florida, he circled the peninsula and explored the west coast, including modern-day Charlotte Harbor, most likely the location he chose for his second voyage.

According to legend, the explorer set out in search of the fountain of youth, a fabled stream that would extend the life of anyone lucky enough to drink from it.

Thanks to the myth of Ponce de Leon’s trip, Florida—known for its large population of retirees—is now awash in “fountains of youth.” Dozens of bodies of water claim the title of the one legendary fountain, from mineral springs to deep-water wells, not to mention water from a variety of sources that is piped into various built structures.

Only one, however, is known to be radioactive. And, oddly, it might be actually extending life.

In Punta Gorda, a town on Charlotte Harbor, a blocky, green-tiled fountain abuts an empty lot near the harbor. A spigot juts out near the top to release water from the artesian well below. Each of the four sides features a picture of a ship, a tribute to Ponce de Leon.

On the side facing away from the street, a public health notice warns that the water “exceeds the maximum contaminant level for radioactivity.”

The water from the well is also heavy in sulfates, which give it a distinctive smell of rotten eggs. This hasn’t stopped the locals from drinking from it regularly.

“I drank out of that well every day,” said Gussie Baker, a resident of Punta Gorda for all of her 78 years.

Baker used to live down the road from the Hotel Punta Gorda, whose guests would frolic in a pool filled with water from the same aquifer. Baker learned to swim in the pool and passed the fountain on her way to school.

“I love artesian water,” she said. Baker doesn’t live as close to the fountain anymore, but says she would drink it if she were nearby.

Punta Gordians proudly declared the existence of a rejuvenative fountain as far back as 1894. In 1926, they mounted a collection drive to pay for the stout little structure that stands to this day. At the height of its popularity, in the mid-20th century, the handle on the tap had to be replaced every six months.

The environmental movement threatened to put a stop to the locals’ enthusiasm for the fountain. In 1974, Congress passed the Clean Water Act, requiring the Environmental Protection Agency to determine safe levels of a variety of contaminants, including radium. All public water sources were to be tested.

Punta Gorda’s water clocked in at 9.2 picoCuries of radium-226 isotope per liter when it was tested in 1983. This exceeded the recommended radium limit, set at 5 picoCuries per liter.

As a result, in 1986, the city council mulled plugging the well, moving the fountain, and hooking it up to city water. But locals fought back.

“They’ve tried several times over the years to close it down, to seal it up, to move it or hook it to the city water, and the public has always defeated that,” said Wilson Harper, a 71-year-old former water utilities supervisor better known as “Water Bill.”

“The last 15 years it’s been as quiet as a church mouse,” he said.

Lindsay Harrington has worked across the street from the fountain in a real estate office and watched the comings and goings since 1997.

Visitors “usually come with lots of plastic bottles, or big plastic jugs that hold maybe five or ten gallons,” he said.

“We did have an occasion where a gentleman would wash his car there, and I always thought maybe he was hoping it would lengthen the use he would get out of it,” he said. “It was his own automobile fountain of youth.”

Radium shows up in 3 to 4 percent of water around the country, according to a recent study by the United States Geological Survey. Many areas have no radium in their local water. Radium mostly turned up in places that had certain rock formations with particular water chemistry that created the perfect radium sink. Florida made up the third most likely area in which to find radium-laced water.

Zoltan Szabo, a co-author of the study who has worked at the United States Geological Survey for 28 years, explained that Florida’s water is frequently encased in limestone, which doesn’t absorb or store radium. “It’s like a bad paper towel,” Szabo said of the common Floridian rocks.

Artesian water supplies are especially low in oxygen, which also helps draw radium out of the water. Szabo hasn’t looked at the Punta Gorda water supply in particular but says the levels of radium at which the fountain tested are not especially dangerous.

The EPA’s recommended levels are very conservative, Szabo said, and are based on drinking a liter a day for 70 years. Even if that was the amount and length of time someone drank the water, the chance of getting cancer is still low, Szabo said, in the range of 1 in 20,000.

“You’re taking a quantifiable risk,” he said. “If you’re smoking a cigarette, you’re taking a quantifiable risk. Probably more than drinking that water.”

But radium isn’t the only thing that turns up in the water. In fact, a much more humdrum ingredient might hold the secret of its appeal. The water from the aquifer is high in magnesium, the second most common mineral in the body after calcium.

More than 80 percent of Americans are deficient in magnesium, which helps the body regulate heart muscles and control high blood pressure. The World Health Organization recommends that drinking water contain at least 25 milligrams of magnesium per liter, and a U.S. Academy of Science study from 1977 found that 150,000 deaths a year in the United States could be prevented with additional magnesium in water.

According to Carolyn Dean, author of The Magnesium Miracle, the fountain’s 46 ppm of magnesium puts it on par with other mineral waters like San Pellegrino.

The compound magnesium sulfate also makes an appearance in the water. It’s better known as Epsom salt, which has been used in baths to ease aches and pains for years.

Magnesium is regularly removed from many bottled waters by a process known as reverse osmosis. And the fluoride added to many public water supplies counteracts magnesium, too.

Magnesium is especially good for older people: Magnesium deficiency increases with age as the body stops being as efficient in absorption, and many drugs senior citizens take interfere with the body’s ability to digest magnesium.

“Water Bill” Harper has noticed that the fountain is especially popular among Punta Gorda’s older folk.

“One of the problems with city water is we have to maintain a chloride disinfection. It makes everything taste funny,” he said. “The people have learned they can go down and take that water, which is not chlorinated, and let it sit in the refrigerator.

“It’s tasty; it has no reaction with any of their medication. Also, [magnesium sulfate] keeps you regular.”

To Harper’s knowledge, the fountain’s water has not been tested for at least 25 years—although the EPA recommends biannual testing.

When this reporter sent the water off recently to be tested, it got a reading of 14.4 picoCuries per liter, plus or minus 6.4. This is, according to Szabo, within the range of what showed up in the previous test. According to the EPA website, zero is the goal for radium levels.

Between this warning and the ubiquity of bottled water, the fountain is much less popular today. Harrington says days will go by without him seeing anyone at the fountain. But there are still some dedicated drinkers.

Margaret Baumherdt has been drinking from the fountain since 1967, years before any warning went up. Baumherdt, who is now 88, moved to the area when she was in her early 40s and remembers having to wait in line to drink the water.

She gets her daughter to drive her to the fountain from her home in nearby Port Charlotte, the town across the harbor, and fills up as many as 40 gallon jugs at a time. She drinks the water exclusively and even uses it to cook meals like spaghetti. Tap water’s chlorine content doesn’t sit well with her. The fountain water, however, is just right.

“I love the taste,” she said.

http://news.nationalgeographic.com/news/2013/07/130719-florida-fountain-of-youth-radioactive-magnesium-health/

MERS-CoV

Saudi Arabia reported today that five more people have been infected with the Middle East respiratory syndrome coronavirus (MERS-CoV), as if to underline yesterday’s warning from the head of the World Health Organization (WHO) that the novel virus is a global threat.

In a brief statement, the Saudi Ministry of Health (MOH) said, “Within the framework of the epidemiological surveillance of the novel Coronavirus (MERS-CoV), the Ministry of Health (MOH) has announced that five novel Coronavirus cases have been recorded among citizens in the Eastern Region, ranging in age from 73 to 85 years, but they have all chronic diseases.”

Also, two more deaths from MERS have been reported in the past few days. Yesterday Agence France Presse (AFP) reported the death of France’s first MERS-CoV patient, a 65-year-old man whose illness was first reported on May 8. And on May 26 the Saudi MOH announced the death of an 81-year-old woman.

With today’s Saudi announcement, the unofficial global case count has reached 49; the death toll stands at 24, according to the US Centers for Disease Control and Prevention (CDC). Unofficially, Saudi Arabia has had 37 cases, with 18 deaths.

WHO concern
Deep concern about MERS-CoV was expressed yesterday by WHO Director-General Margaret Chan, MD, MPH, as she closed the annual World Health Assembly (WHA), the WHO’s policy-making body.

“Looking at the overall global situation, my greatest concern right now is the novel coronavirus,” she said as quoted in a WHO press release. “We understand too little about this virus when viewed against the magnitude of its potential threat. Any new disease that is emerging faster than our understanding is never under control.

“These are alarm bells and we must respond. The novel coronavirus is not a problem that any single affected country can keep to itself or manage all by itself. The novel coronavirus is a threat to the entire world.”

The WHO plans to send a second team to Saudi Arabia in coming weeks to help investigate the mysterious virus, according to a May 25 Arab News story that quoted Chan. The source of the pathogen remains unknown, but several case clusters have shown that it can spread between people in close contact.

“Without that proper risk assessment, we cannot have clarity on the incubation period, on the signs and symptoms of the disease, on the proper clinical management and then, last but not least, on travel advice,” Chan told Arab News.

The WHO, which sent a group of experts to Saudi Arabia earlier this month, will provide a fresh risk assessment ahead of this year’s Haj pilgrimage, which will take place in October, the story said.

Details on deaths
Concerning the five new cases, the Saudi MOH left many questions unanswered, including whether the patients are part of a hospital-centered outbreak of MERS-CoV that began in April in the Al-Ahsa region of Eastern province. The cluster has been reported to include 22 cases with 10 deaths. The statement gave no information on the patients’ conditions, gender, where they live, or how long they have been sick.

The French patient who died became ill on Apr 23, six days after he returned home from a vacation in Dubai, United Arab Emirates. Another person contracted the virus after sharing a hospital room with him from Apr 27 to 29.

The 81-year-old Saudi woman who died was among the previously announced cases in Al-Ahsa governorate, the Saudi MOH said in a May 26 statement. It said she was suffering from chronic kidney failure and other chronic diseases.

Her case appears to be the one announced by the WHO on May 18. That announcement said the 81-year-old’s illness was the 22nd case in the hospital-centered cluster in Al-Ahsa.

The May 26 MOH statement also said that nine other case-patients have recovered and been discharged from hospitals since the first MERS-CoV in Saudi Arabia, which occurred in June 2012.

MERS-CoV designation

In other developments, the WHO announced today that it is accepting the name MERS-CoV for the novel virus, despite a general aversion to geographic references in the names of newly discovered viruses.

“Given the experience in previous international public health events, WHO generally prefers that virus names do not refer to the region or place of the initial detection of the virus,” the agency said in a statement. “This approach aims at minimizing unnecessary geographical discrimination that could be based on coincidental detection rather than on the true area of emergence of a virus.”

The name was proposed by the Coronavirus Study Group of the International Committee on Taxonomy of Viruses, the WHO noted. The statement said the term emerged from consultations with a large group of scientists and represents an acceptable consensus

Patent issues
Also today, a story in BMJ offered more details on intellectual property issues related to MERS-CoV. Albert Osterhaus, DVM, PhD, head of viriology at Erasmus Medical Center in the Netherlands, told the journal that Erasmus has applied for patents on MERS-CoV genetic sequences and on possible related products such as diagnostics and vaccines.

Erasmus scientists were the first to analyze the virus and identify it as novel last year, after an Egyptian physician working in Saudi Arabia sent them a sample. Last week Chan and Saudi officials complained that restrictions imposed by Erasmus on use of MERS-CoV samples that it has supplied to other labs were impeding the investigation of the outbreak.

Erasmus officials have rejected the criticism and said they have supplied samples to all labs that want to use it for public health research and are equipped to handle if safely. But Osterhaus told BMJ, “We have patent applications submitted and that is on the sequences and the possibilities to eventually make diagnostics, vaccines, antivirals, and the like. It’s quite a normal thing if you find something new to patent it.”

He added that Erasmus has not made a deal with any company yet, because it’s too early. “At the end of the day, if you want something to happen for the benefit of public health—including making a vaccine, antivirals, whatever—you need to have at least some intellectual property. Otherwise the companies will not be interested,” he said.

http://www.cidrap.umn.edu/cidrap/content/other/sars/news/may2813corona.html

130412032821-3-bird-flu-0412-horizontal-gallery

A new variation of bird flu that the WHO says has caused at least 11 deaths in China has genetic characteristics that make it well-adapted to infect people. In a report published late Thursday in the New England Journal of Medicine, samples from three patients — all of whom died — had mutations that have previously been shown to increase transmissibility, and to help the virus grow in a mammal’s respiratory tract. The analysis comes amid a modest but steady stream of human cases since the end of March. Saturday, China reported a 7-year-old Beijing girl is the latest person to become infected with the H7N9 flu strain, bringing the total to 44.

The strain is normally found in birds, and until last month was never known to infect people. “The H7N9 situation is evolving very quickly,” said Nancy Cox, director of the Influenza Division at the U.S. Centers for Disease Control and Prevention. “One thing of concern is the pace at which we are seeing the identification of cases.”

On a more reassuring note, investigators have found no evidence that the virus has passed directly from person to person. More than a thousand “close contacts” of the patients are being monitored by Chinese health officials, according to the World Health Organization. One concerning mutation, known as “Substitution Q226L,” was found in two of the first three victims. Past experiments have shown it to make viruses — including the H5N1 bird flu virus — more likely to infect ferrets, which are commonly used in flu research. The same mutation was also found in the viruses that caused the 1957 and 1968 flu pandemics. A second mutation, known as “PB2 E627K,” was found in all three virus samples. According to Dr. Ron Fouchier, a Dutch virologist, this mutation allows the virus to reproduce at much lower temperatures than a standard avian influenza virus. The change lets it grow in a human respiratory tract, which is cooler than the virus’ natural home: a bird’s gastrointestinal tract. In mice, Fouchier said, the mutation makes the infection as much as 1,000 times more virulent. A number of other mutations were found as well, including changes that are characteristic of viruses found in mammals.

“Known normal bird viruses have to adapt substantially to infect people, but not these,” said Fouchier, who said the changes are enough that he would no longer call the H7N9 strain “bird flu.” The first three patients to be identified are an 87-year-old man and a 27-year-old man from Shanghai, and a 35-year-old housewife from Anhui. The woman had visited a chicken market about a week before falling ill. The younger man was a butcher who worked in a market where live birds were sold, although he did not butcher any birds. The 87-year-old had no known exposure to live birds. All three died after suffering severe respiratory symptoms, including acute respiratory distress syndrome and eventually septic shock and multiple organ failure.

In a commentary that ran with the article, Cox and Dr. Tim Uyeki, a physician with the CDC, noted that patients were not given antiviral medication until their illness became severe. Oseltamivir (Tamiflu) or zanamivir (Relenza) should be administered as soon as possible to patients with a suspected or confirmed H7N9 infection, the two wrote. Cox said it remains unclear whether the severe illnesses are typical of H7N9 infection or simply the tip of a large iceberg in which a large number of mild cases are going unnoticed.

“As surveillance has expanded, we’re also seeing individuals with milder cases,” said Cox. “We’re still seeing very severe disease in some cases, but overall I think it’s somewhat reassuring.” The CDC is in the final steps of refining a diagnostic test to identify H7N9 in patients, and Cox said it should be available for distribution in a matter of days. A widely available diagnostic test would allow faster identification of patients who actually have the infection, and would also help disease detectives zero in on how people are being exposed.

Work has begun on a vaccine, although Cox and others said that even if it is eventually needed, a vaccine likely won’t be available for several months. While the overall picture is concerning, flu experts urged calm. “I wouldn’t say a pandemic is more likely than it was a year ago,” Fouchier said. “The only thing we can do as virologists right now is to point out the interesting characteristics of the virus, try to get to the bottom of this story and try to stop further infections.”

http://www.cnn.com/2013/04/12/health/bird-flu/index.html?hpt=hp_t2

Fat-Guy-300x260

A tiny Samoa airline is giving passengers a big reason to lose weight: Tickets sold not by the seat, but by the kilogram. Samoa Air is pricing its first international flights based on the weight of its passengers and their bags. Depending on the flight, each kilogram (2.2 pounds) costs 93 cents to $1.06. That means the average American man weighing 195 pounds with a 35-pound bag would pay $97 to go one-way between Apia, Samoa, and Pago Pago, American Samoa. Competitors typically charge $130 to $140 roundtrip for similar routes.

The weight-based pricing is not new to the airline, which launched in June. It has been using the pricing model since November, but in January the U.S. Department of Transportation approved its international route between American Samoa and Samoa. The airline’s chief executive, Chris Langton, said that “planes are run by weight and not by seat, and travelers should be educated on this important issue. The plane can only carry a certain amount of weight and that weight needs to be paid. There is no other way.”

Langton, a pilot himself, said when he flew for other airlines, he brought up the idea to his bosses to charge by weight, but they considered weight as too sensitive an issue to address. “It’s always been the fairest way, but the industry has been trying to pack square pegs into round holes for many years,” he said.

Travelers in the region already are weighed before they fly because the planes used between the islands are small, said David Vaeafe, executive director of the American Samoa Visitors Bureau. Samoa Air’s fleet includes two nine-passenger planes for commercial routes and a three-passenger plane for an air taxi service. Langton said passengers who need more room will be given one row on the plane to ensure comfort.

The new pricing system would make Samoa Air the first to charge strictly by weight, a change that Vaeafe said is, “in many ways… a fair concept for passengers. For example, a 12- or 13-year-old passenger, who is small in size and weight, won’t have to pay an adult fare, based on airline fares that anyone 12 years and older does pay the adult fare,” he said.

Vaeafe said the pricing system has worked in Samoa but it’s not clear whether it will be embraced by travelers in the U.S. territory. Langton said the airline has received mixed responses since it began promoting the pricing on its website and Facebook. Langton said some passengers have been surprised, but no one has refused to be weighed yet. He said he’s given away a few free flights to some regular customers who lost weight, and that health officials in American Samoa were among the first to contact the airline when the pricing structure was announced.

“They want to ride on the awareness this is raising and use it as a medium to address obesity issues,” he said.

Islands in the Pacific have the highest rates of obesity in the world. According to a 2011 report by the World Health Organization, 86 percent of Samoans are overweight, the fourth worst among all nations. Only Samoa’s Pacific neighbors Nauru, the Cook Islands and Tonga rank worse. In comparison, the same study found that 69 percent of Americans are overweight, 61 percent of Australians, and 22 percent of Japanese. Samoa ranked just as poorly in statistics measuring those who are obese, or severely overweight.

Samoa’s Director General of Health, Palanitina Toelupe, said the airline’s plans could be a good way to promote weight loss and healthy eating. “It’s a very brave idea on their part,” she said. She added that flying on the airline may become too expensive for some large people and that the charging system could only ever be a small part of a larger strategy on weight issues. She said she’d be interested in meeting with the airline to discuss working together.

Ana Faapouli, an American Samoa resident who frequently travels to Samoa, said the pricing scheme will likely be profitable for Samoa Air. “Samoa Air is smart enough to find ways to benefit from this service as they will be competing against two other airlines,” Faapouli said.

http://www.cbsnews.com/8301-505145_162-57577683/samoa-airline-introduces-pay-by-weight-pricing/

dn23276-1_300
A drug-free life beckons for some people with HIV

Two weeks after the revelation that a baby has been “cured” of HIV, reports suggest that a similar treatment can cure some adults too. Early treatment seems crucial, but does not guarantee success.

Asier Sáez-Cirión of the Pasteur Institute’s unit for regulation of retroviral infections in Paris analysed 70 people with HIV who had been treated with antiretroviral drugs (ARVs) between 35 days and 10 weeks after infection – much sooner than people are normally treated.

All of the participants’ drug regimes had been interrupted for one reason or another. For example, some people had made a personal choice to stop taking the drugs, others had been part of a trial of different drug protocols.

Most of the 70 people relapsed when their treatment was interrupted, with the virus rebounding rapidly to pre-treatment levels. But 14 of them – four women and 10 men – were able to stay off of ARVs without relapsing, having taken the drugs for an average of three years.

The 14 adults still have traces of HIV in their blood, but at such low levels that their body can naturally keep it in check without drugs.

On average, the 14 adults have been off medication for seven years. One has gone 10-and-a-half years without drugs. “It’s not eradication, but they can clearly live without pills for a very long period of time,” says Sáez-Cirión.

Last week, a baby was reported to have been “functionally cured” of HIV after receiving a three-drug regime of ARVs almost immediately after birth. Sáez-Cirión warns that rapid treatment doesn’t work for everyone, but the new study reinforces the conclusion that early intervention is important.

“There are three benefits to early treatment,” says Sáez-Cirión. “It limits the reservoir of HIV that can persist, limits the diversity of the virus and preserves the immune response to the virus that keeps it in check.”

Further analysis confirmed that the 14 adults were not “super-controllers” – the 1 per cent of the population that are naturally resistant to HIV – since they lack the necessary protective genes. Also, natural controllers rapidly suppress their infections, whereas these 14 mostly had severe symptoms which led to their early treatment. “Paradoxically, doing badly helped them do better later,” says Sáez-Cirión.

The researchers are trying to identify additional factors that could explain why early intervention only works on some people, hopefully extending the scope for more functional cures.

“This whole area is fascinating, and we’ve been looking very closely at issues of early initiation of treatment, and the potential for functional cures,” says Andrew Ball, senior adviser on HIV/AIDS strategy at the World Health Organization in Geneva.

“The big challenge is identifying people very early in their infection,” says Ball, adding that many people resist testing because of the stigma and potential discrimination. “There’s a good rationale for being tested early, and the latest results may give some encouragement to do that,” he says.

Journal reference: PLoS Pathogens, DOI: 10.1371/journal.ppat.1003211

http://www.newscientist.com/article/dn23276-more-hiv-cured-first-a-baby-now-14-adults.html

 

SHANGHAI, CHINA—Mrs. Y’s death would have stumped many experts. A young mother and loyal wife, the rural Chinese woman showed none of the standard risk factors for suicide. She was not apparently depressed or mentally ill. Villagers said she exuded happiness and voiced few complaints. But when a neighbor publicly accused Mrs. Y of stealing eggs from her henhouse, the shame was unbearable. Mrs. Y rushed home and downed a bottle of pesticide. “A person cannot live without face,” she cried before she died. “I will die to prove that I did not steal her eggs.”

Decades of research in Western countries have positioned mental illness as an overwhelming predictor of suicide, figuring in more than 90% of such deaths. Another big risk factor is gender: Men commit suicide at much higher rates than women, by a ratio of nearly 4 to 1 in the United States, according to the U.S. Centers for Disease Control and Prevention. Other common correlates include city life and divorce. But in China, says Jie Zhang, a sociologist at the State University of New York, Buffalo State, the case of Mrs. Y is “a very typical scenario.”

Zhang oversaw interviews with Mrs. Y’s family and acquaintances while researching the prevalence of mental illness among suicide victims aged 15 to 34 in rural China. Through psychological autopsies—detailed assessments after death—Zhang and coauthors found that only 48% of 392 victims had a mental illness, they reported in the July 2010 issue of the American Journal of Psychiatry. An earlier study of Chinese suicide victims put the prevalence of mental disorders at 63%—still nowhere near as high as accepted models of suicide prevention would predict. Meanwhile, other standard risk factors simply don’t hold true, or are even reversed, in China. Chinese women commit suicide at unusually high rates; rural residents kill themselves more frequently than city dwellers do; and marriage may make a person more, rather than less, volatile.

Such differences matter because China accounts for an estimated 22% of global suicides, or roughly 200,000 deaths every year. In India, meanwhile, some 187,000 people took their own lives in 2010—twice as many as died from HIV/AIDS. By comparison, the World Health Organization (WHO) estimates that suicides in high-income countries total only 140,000 a year. Suicide rates in Japan and South Korea, however, are similar to China’s (see p. 1026), suggesting that this is a regional public health issue. And yet suicide in Asia is poorly understood. “Suicide has not gotten the attention it deserves vis-à-vis its disease burden,” says Prabhat Jha, director of the Centre for Global Health Research in Toronto, Canada.

Emerging research from developing countries like China and India is now filling that gap—and overturning prevailing notions. “The focus of the study of suicide in the West is psychiatry,” Zhang says. While mental illness remains an important correlate in Asia, he says, researchers may learn more from a victim’s family, religion, education, and personality. New findings, Zhang says, suggest that some researchers may have misread correlation as causation: In both the East and the West, “mental illness might not be the real cause of suicide.”

Distressing data

Reliable data on suicide across Asia were once maddeningly scarce. In Thailand until 2003, there was no requirement that the reported cause of death be medically validated—a flaw that rendered the country’s suicide data inaccurate. In India, suicide is a crime, which means it often goes unreported. But the Thai government now has a more accurate reporting system for mortality figures, while Indian researchers are benefiting from the Million Death Study, an effort to catalog causes of death for 1 million Indians in a 16-year survey relying on interviews with family members (Science, 15 June, p. 1372). The study has already produced a disturbing revelation about reported suicide rates. “When we compare our data with police reports, you find undercounts of at least 25% in men and 36% in women,” says Jha, the study’s lead investigator.

New insights from China are particularly instructive. Because suicide carries a stigma, the Chinese government withheld data on the topic until the late 1980s. When information finally came out, it quickly became clear that the country had a serious problem. In 1990, for example, the World Bank’s Global Burden of Disease Study estimated there were 343,000 suicides in China—or 30 per 100,000 people. The U.S. rate for the same year was 12 per 100,000.

But other reports gave different figures, prompting a debate on sources. WHO’s extrapolated total was based on data that China had reported from stations covering only 10% of the population, skewed toward urban residents. As researchers focused on the problem, they arrived at more reliable figures—but also unearthed more mysteries. In an analysis in The Lancet in 2002, a group led by Michael Phillips of Shanghai Mental Health Center and Emory University School of Medicine in Atlanta estimated that from 1995 to 1999, Chinese women killed themselves more frequently than men—by a ratio of 5 to 4. “There was originally disbelief about the very different gender ratio in China,” Phillips says, although later it was accepted.

Today, the suicide sex ratio in China is roughly 1 to 1, still a significant departure from the overall U.S. male-to-female ratio of 4 to 1. In India, the male-to-female suicide ratio is 1.5 to 1, although in the 15 to 29 age group it is close to equal. And yet, WHO estimates the global sex ratio at three men to one woman. (With colleague Cheng Hui, Phillips recently used Chinese and Indian figures to lower that estimate to 1.67 to 1.) Among young adults in India, suicide is second only to maternal mortality as a cause of death for women, according to the Million Death Survey.

In both China and India, cases like Mrs. Y’s involving no apparent mental illness are common. In India, suicide is most prevalent among teenagers and young adults—the cohort that is entering the workforce, marrying, and facing new life stresses. This contrasts with the Western pattern of high suicide rates among the middle-aged, suggesting that although “there might well be some underlying psychiatric conditions, the main drivers of [suicide in India] are probably chiefly social conditions,” Jha says. While cautioning that detailed psychological autopsies are still needed in India, he says, “it’s a reasonable assumption that many of these young folks are not mentally ill.”

Convincing researchers outside Asia may prove an uphill battle. Matthew Miller, a suicide researcher at the Harvard Injury Control Research Center in Boston, says that mental illness may be underdiagnosed in Asia for reasons that aren’t fully understood. That could throw off correlation studies. Phillips, who has worked in China for over 20 years, agrees that underdiagnosis is a problem, and that “many Western researchers still believe that we are just missing cases.” But he rejects that explanation. Even accounting for underdiagnosis, he says, the finding of a lower rate of mental illness among suicide victims has held up in multiple studies. Many Chinese suicide victims, he adds, are “most certainly severely distressed, but they don’t meet the criteria of a formal mental illness.”

Lethal weapons

Assuming that suicide risk is shaped by different factors in Asia, researchers are striving to uncover the roots. One clue may lie in the high proportion of unplanned Chinese suicides. In a 2002 survey of 306 Chinese patients who had been hospitalized for at least 6 hours following a suicide attempt, Phillips and colleagues found that 35% had contemplated suicide for less than 10 minutes—and 54% for less than 2 hours. Impulsiveness among suicide victims in Asia “tends to be higher than in the West,” says Paul Yip, director of the Hong Kong Jockey Club Centre for Suicide Research and Prevention at the University of Hong Kong and one of the authors of a recent WHO report on suicide in Asia. Although impulsive personality traits are sometimes linked to illnesses like bipolar disorder, studies in China have not uncovered full-fledged personality disorders in impulsive suicide victims.

In a tragic twist, impulsive victims in Asia tend to favor highly fatal methods. After interviewing family members and friends of 505 Chinese suicide victims, Kenneth Conner, a psychiatric researcher at the University of Rochester Medical Center in New York, and colleagues reported in 2005 that those who had ingested pesticides were more likely to have acted rashly than were those who used other methods such as hanging or drowning. Pesticides are a leading cause of suicide death in China and India, and the cause of roughly half of suicides worldwide. Pesticides may also explain Asia’s unusual suicide sex ratio, Jha says. In the West, women attempt suicide just as frequently as men do, but they tend to down sleeping pills—and often survive.

The trends in Asia point to a need for innovative prevention strategies. Zhang believes efforts should focus less on mental illness and more on “educating people to have realistic goals in life and teaching them to cope with crisis.” Front and center should be universities and rural women’s organizations, both of which already have active suicide prevention programs in China, he says. Such community-based approaches appear to have been effective in Hong Kong, Yip says. Over the past decade, the territory has rolled out programs for schoolchildren on dealing with stress and outreach groups for older adults. Its suicide rate has fallen 27% since 2003.

But resources in many Asian countries are limited. The vast majority of cities in China and India still do not have 24-hour suicide prevention hotlines. That may make what scholars call means restriction—reducing access to tools commonly used in suicide—a better goal. In Sri Lanka, pesticides once accounted for two-thirds of suicide deaths. Then in 1995, the government took steps to ban the most toxic pesticides. The suicide rate plummeted by 50% in the following decade.

The varying degrees to which mental illness and suicide correlate in East and West may ultimately be beside the point, argues Zhang, who believes a third factor may be the trigger in both regions. Strain theory, which posits that societal pressures, rather than inborn traits, contribute to crime, can help explain suicide, he believes. “Psychological strains usually precede a suicidal behavior, and they also happen before an individual becomes mentally ill.”

When a person is pulled by two or more conflicting pressures, Zhang says, as with “a girl who receives Confucian values at home and then goes to school and learns about modern values and gender equality,” she may be more prone to suicide. Other situational stresses may include a sudden crisis faced by a rural woman lacking coping mechanisms—such as the case of Mrs. Y—or an incident that forces a young man to confront a gap between his aspirations and reality. Zhang found that strain theory held up for his study subjects in rural China. He plans to probe whether it also applies to older Chinese.

Ultimately, Zhang hopes to test strain theory on Americans. The U.S. National Institutes of Health “spends millions and millions of dollars every year on treating mental illness to prevent suicide,” he says. “But no matter how much money we spend, how many psychiatrists we train, or how much work we do in psychiatric clinics, the U.S. suicide rate doesn’t decrease.” It has hovered around 10 to 12 suicides per 100,000 people since 1960.

Such research may be the tip of the iceberg when it comes to debunking long-held ideas about behavior disorders. Alcoholism is another area ripe for exploration, Cheng says: The profile of alcoholics in China contrasts sharply with that in the West. Because of social pressure to drink, Chinese alcoholics are far more likely to be working and married than American counterparts, who are often unemployed and divorced, she says. Suicide, Cheng muses, “is just another example of how environment can change behavior.”

http://www.sciencemag.org/content/338/6110/1025.full