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Demographic effects of the U.S. opioid crisis    The U.S. National Center for Health Statistics recently released findings from its analysis of health data and concluded two things: 1) life expectancy for White females and males declined during 2014-15 and 2) the age adjusted death rate for the same demographic groups and Black males increased during 2014-15.[1] A second U.S. government report, The Surgeon General’s Report on Alcohol, Drugs, and Health[2], found an increase in mortality for middle-aged While males and females was driven by substance abuse (both alcohol and drugs) and suicide during 1999-2014. The report further stated that substance abuse accounted for a four month decline in life expectancy for White Americans. There is a third research report[3] indicating middle-aged White males and females without college degrees are dying disproportionately from drug and alcohol poisonings and suicide. Taken together, these three reports indicate some groups of White males and females are dying from preventable causes. Although the precise reasons for these observations are unclear, there are documented associations between using pain relief treatments containing opioids and opiate drug abuse.[4] Additionally, other U.S. government data indicates persons who have not completed a college degree experience more unemployment,[5] which can be a significant source of stress. One of the current health challenges for the United States is providing healthcare to economically distressed communities; this includes substance abuse treatment. In a clinical study on the efficacy of using non-medical community health workers to counsel patients on strategies to reduce the ill effects of alcohol abuse in India, the researchers found the community health workers had a positive effect in reducing the consequences of alcohol abuse for the patients they counselled.[6] One characteristic shared by many communities in India and the United States is limited access to effective substance abuse treatment. The social and economic costs of early death and diminished health are significant, both in local communities and to the national economy. If community health workers can improve outcomes for those with limited health resource access and do so at a relatively low cost, perhaps it should be considered a potential solution to the serious alcohol abuse problem. The clinical study in India reported the training requirements for the community health workers were quite modest, high school completion and two weeks of classroom training followed by a six month internship. There is the added advantage that the community health workers are knowledgeable about local conditions. Recent health data documents a serious problem along some specific demographic groups in the United States. The clinical study indicates a solution that could improve the lives of those struggling with alcohol abuse. Notably, when asked to comment on the Indian study, Yale University Professor of psychology stated, “effective treatment does not require professional degrees,” and the studies “should be used to change mental healthcare in the world.”[7]
   [1] Xu JQ, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2015. NCHS data brief, no 267. Hyattsville, MD: National Center for Health Statistics. 2016   [2] U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: 2016.   [3] Case A and Deaton A, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” Proceedings of the National Academy of Sciences, December 8, 2015, volume 112, number 4, pp. 115078–15083   [4] Case A and Deaton A, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” Proceedings of the National Academy of Sciences, December 8, 2015, volume 112, number 4, pp. 115078–15083   [5] U.S. Department of Labor, Bureau of Labor Statistics, Employment Projections, March 15, 2016, available at https://www.bls.gov/emp/ep_chart_001.htm on December 16,2016.    [6] ‘Counselling for Alcohol Problems (CAP), a lay counsellor-delivered brief psychological treatment for harmful drinking in men, in primary care in India: a randomised controlled trial ' Nadkarni, Abhijit et al. The Lancet , Volume 0 , Issue 0 , DOI: http://dx.doi.org/10.1016/S0140-6736(16)31590-2    [7] National Public Radio, Goats and Soda – Stories of life in a changing world, “Neighbors Treating Neighbors For Depression And Alcoholism,” December 15, 20164:22 PM ET, Heard on Morning Edition, by Joanne Silberner    


Ebola Outbreak in Congo (Kinshasa)  In the May 29 Ebola situation update, the World Health Organization (WHO) reported no new confirmed or suspected cases have been detected in the Democratic Republic of Congo (DRC).[i] The outbreak was reported to WHO on May 11 and as of May 28, 101 contacts of the two confirmed cases, three probable cases, and fourteen suspected cases currently under surveillance remain symptom-free. An additional 289 contacts have completed the 21 day surveillance period. A total of 583 contacts were registered.  WHO epidemic models indicate a low risk of additional cases based on available epidemiological data but the remote location of the outbreak and the proximity of displaced persons from the conflict in neighboring Central African Republic are complicating factors for this specific outbreak response. Regional media reports[ii] on May 30 indicate 20,000 people have fled to DRC’s Bas Uele and Ubangi provinces where Ebola cases have been reported. Contingency planning to deploy an investigational vaccine if more cases are detected is ongoing. The vaccine, which was developed by Merck, completed phase III clinical trials and was shown to be effective in study participants in Guinea.[iii]   [i] World Health Organization, “Ebola Virus Disease - Democratic Republic of the Congo, External Situation Report 16,” May 29, 2017. Available at http://apps.who.int/iris/bitstream/10665/255600/1/EbolaDRC-30052017.pdf?ua=1 on May 30, 2017. [ii] Africa Times, “C.A.R refugees fleeing violence into neighboring DR Congo,” May 30, 2017. Available at http://africatimes.com/2017/05/30/c-a-r-refugees-fleeing-violence-into-neighboring-dr-congo/ on May 30, 2017. [iii] World Health Organization press release, “Final trial results confirm Ebola vaccine provides high protection against disease,” December 23, 2016. Available at http://www.who.int/mediacentre/news/releases/2016/ebola-vaccine-results/en/ on May 30, 2017.   


 Why dental care is as important as medical care and how it affects health The Washington Post recently published an article[i] about a two day dental clinic on Maryland’s eastern shore and it highlights the continuing problem of health disparities. The article was an anecdotal report about the consequences of dental neglect and it also presented a stark picture of the choices many low income people face when the healthcare they need is not covered by most medical insurance programs. While the Affordable Care Act does provide access to dental insurance, it is often a separate insurance program with separate insurance premiums and the only required dental coverage is for children. Poor dental health is a co-factor for many chronic diseases, such as diabetes and heart disease, and directly contributes to ill health. Dental care is often not considered as urgent as other health problems because the symptoms may be subtle and the impact on overall health is not widely recognized. Oral healthcare, however, is as essential as medical care.  Oral healthcare disparities are closely correlated with income and education. Data from the U.S. Department of Health and Human Services Healthy People 2020[ii] initiative shows a consistent pattern of differences in the rate of dental care during 2007-2014. Persons living in families with income at less than 100 percent of the poverty line had half the rate of yearly dental care as those in families with incomes over 400 percent of the poverty line during 2007-20014. Similarly, persons with less than a high school diploma had yearly dental care at about one third the rate of persons who had completed some college during 2010-2014. Other factors, such as the availability of dental services in non-urban areas and low rates of dental insurance coverage, contribute to poor oral health.  Researchers at the University of Buffalo (New York) investigated an association among type 2 diabetes in young people aged 10-19, the presence of inflammatory biochemical markers, and oral health.[iii] Type 2 diabetes is an unusual diagnosis for young people but the incidence rates are rising, largely driven by the obesity crisis. The research results showed that obese participants who already had a type 2 diabetes diagnosis tended to have higher rates of poor oral health. Poor oral health, as shown by the presence of gingivitis (an inflammatory gum disease), and higher levels of inflammatory biochemical markers were observed in the group with diabetes than were observed in normal weight study participants and obese study participants who did not have a diabetes diagnosis. The public health significance is an increased risk of compromised health from other chronic disease  Preventive healthcare is the most efficient and effective means to control healthcare costs and generally leads to better health outcomes. Dental care is an essential component of preventive healthcare because oral health is directly linked to overall health. The inflammatory conditions that accompany dental disease play a role in the development and progression of chronic systemic diseases.     [i] “Some Americans spend billions to get teeth whiter. Some wait in line to get them pulled.” The Washington Post, May 13, 2017. Available at www.washingtonpost.com   [ii] See U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, healthypeople.gov  [iii] See Janem, W.F. and others (2017), “Salivary inflammatory markers and microbiome in normoglycemic lean and obese children compared to obese children with type 2 diabetes,” PLoS One 12(3):e0172647. https:doi.org/10.1371/journalpone.0172647    


AMR resistant bacteria in drug manufacturing effluent – a potential health threat  The correspondence section of The Lancet Infectious Diseases journal[i] recently posted a letter describing the discovery of drug resistant bacteria at pharmaceutical manufacturing sites in three Indian cities. The authors stated of the thirty-six sites tested, sixteen were found to have drug resistant bacteria. This included four sites harboring bacteria resistant to carbapenems, which are often described as the antibiotics of last resort. Additionally, the authors noted the insufficient regulation of the release of pharmaceutical waste that contains active antibiotic drugs into the local environment. A public health concern is the potential exposure to resistant bacteria in contaminated soil or ingestion of the resistant bacteria by local animals and humans when contaminated river water is consumed. The introduction of resistant bacterial species to distant areas via the ballast tanks of ocean-going merchant ships is another potential risk.  Measures to eliminate the presence of antibiotics in waste effluent, either by alterations in manufacturing processes or wastewater treatment before the effluent is released into the environment, would mitigate the risk of increased antimicrobial resistance.   [i] See Akram Ahmad, and others, “Pharmaceutical waster and antimicrobial resistance,” www.thelancet.com/infection, Volume 17 June 2017.AMR; DOI: http://dx.doi.org/10.1016/S1473-3099(17)30268-2  New research may lead to improved seasonal influenza vaccine effectiveness  Seasonal influenza infections are one of the most significant disease challenges facing the United States. During the 2013-14 flu season, the U.S. Centers for Disease Control and Prevention estimated there were over 45,000 excess deaths attributable to the disease.[i] An elegant retrospective analysis of clinical samples from flu patients with compromised immunity recently suggested a novel approach to improve the effectiveness of the seasonal flu vaccines and potentially reduce the number of illnesses and deaths associated with the disease. Research published in the eLIFE journal Genomics and Evolutionary Biology, Microbiology, and Infectious Disease, reports similarities were observed between the genetic mutations of (A/Brisbane/10/2007 (H3N2)) subtype influenza viruses found in chronically infected patients and the genetic mutations of (A/Brisbane/10/2007 (H3N2)) subtype influenza virus found among the population at large.[ii] The significance of these findings is that surveillance and monitoring of viral mutations in a small number of patients during the course of the flu season may provide critical data for the formulation of a more effective vaccine for the next flu season than current methods. Additional research is needed to confirm the reported results and ascertain if they hold true for multiple influenza A virus strains.  Seasonal flu vaccines must be reformulated every year because the influenza A virus mutates rapidly and rapid mutation of the pathogen degrades vaccine effectiveness. The major challenge facing health officials is to ascertain the structure of the mutated virus so vaccine effectiveness can be maximized. The research study obtained influenza virus samples collected between 2005 and 2010 from immunocompromised patients and sequenced the virus genome to determine how the virus mutated over time. Because the viral samples were collected in the past, it was possible to compare the study virus samples with the viruses that eventually emerged. The importance of using clinical samples from patients with chronic flu infections was that it allowed the researchers to monitor how the virus changed over time. Once the samples from the patients were sequenced, the researchers obtained and sequenced virus samples from the population at large during the same time period (2005-2010) and compared the sequencing results to determine if they corresponded genetically. The fact that the sequences for the two groups were similar suggested the possibility that influenza A viruses respond to evolutionary pressures and mutate in similar ways. This could provide important insights into virus characteristics that may be expected to emerge the following year.  The dynamics of influenza virus mutations are complex and follow-on research questions include whether the results hold true for other influenza A subtypes and how to use the research data to optimize vaccine efficacy for an entire population. The published research results, however, are important and may ultimately lead to improved seasonal influenza vaccines.  [i] Rolfes MA, Foppa IM, Garg S, Flannery B, Brammer L, Singleton JA, et al. Estimated Influenza Illnesses, Medical Visits, Hospitalizations, and Deaths Averted by Vaccination in the United States. 2016 Dec 9 [Date Cited]; https://www.cdc.gov/flu/about/disease/2015-16.ht  [ii] K.Xue et al, “Parallel evolution of influenza across multiple spatiotemporal scale,” eLife 2017;6:e26875 doi: 10.7554/eLife.26875, available at https://elifesciences.org/articles/26875, accessed on June 29, 2017.    


Climate change and vector-borne disease   One of the consequences of climate change and global warming is an extended breeding season for mosquitoes and an increased risk of the spread of mosquito borne diseases. While using insecticides is a traditional approach to mosquito control, the development of resistance has reduced the effectiveness of the chemicals in killing the insects. Additionally, concerns about the adverse effects from insecticide exposure for humans and beneficial insects has limited the efficacy of applying increasing quantities of these toxic chemicals. Ongoing research to identify new approaches for insect control is ongoing but in the short-term, we will rely on prevention and treatment of insect borne diseases to reduce their impact on humans.    Combustion of wood, and later coal, powered the industrialization that began in the nineteenth century. Steam, created by the burning of wood, coal, and petroleum products, drove the engines that milled grain, moved trains and boats, and enabled machine manufacturing. While powered machines animated the transition to large scale production and achieved labor efficiency that facilitated the birth of the modern economy, it also began the processes that increased atmospheric carbon dioxide and created climate change. A build-up of carbon dioxide in the earth’s atmosphere from the burning of fuel acts as a heat trap and leads to the gradual rise of terrestrial temperatures. The change in temperature causes changes in local environmental and meteorological conditions.    One of the most significant results of increasing temperatures is the change in habitats for insects, especially mosquitoes that transmit infectious diseases. During the twentieth century the United States was able to eliminate diseases such as dengue and malaria by controlling the mosquitoes responsible for disease transmission. Because disease transmission was disrupted, the pathogens disappeared from the people living in the area. In recent years, however, the risk of previously eliminated mosquito transmitted infections in the United States has increased due to a re-introduction of the mosquitoes who transmit the disease from areas where the diseases are still present (primarily through international shipping), and the shortening of extended cold periods that killed mosquitoes during winter.    Insecticides have been the most commonly used tool for mosquito control but its effectiveness has declined due to the development of resistance.[i] Increasing quantities of insecticide no longer reliably kill mosquitoes. Additionally, the use of toxic chemicals raises health concerns for humans and beneficial insects, such as honeybees, that are exposed when insecticides are used. Research to identify chemicals that kill mosquitoes without harming humans and beneficial insects is ongoing, but the development of commercial products does not seem imminent. In the near-term, it is likely the observed trends of longer mosquito breeding seasons and the incidental importation of mosquito-borne pathogens will continue. Effective disease control will rely on direct prevention and treatment of humans. A reduction in the effects of climate change will be part of the long-term solution to reduce the numbers of mosquitoes transmitting disease.   [i] See U.S. Centers for Disease Control and Prevention, “Insecticide Resistance,” available at https://www.cdc.gov/zika/vector/insecticide-resistance.html, on June 13, 2017.   

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