@LancetGH looks at data collection on deaths from the war in #Syria

Thursday, December 14, 2017

The January 2018 issue of Lancet Global Health features an article (and associated commentary) on an analysis of civilian and combatant deaths using data from the Violations Documentation Center (VDC, which until now I didn't even know existed).
This study makes use of the systematic recording of violent deaths from the Syrian civil war by the Violation Documentation Center over 6 years of conflict to provide a systematic analysis of civilian and opposition combatant violent deaths, their demographic characteristics, the causative method or weapon, and spatial and temporal patterns of direct deaths during the conflict. We relate patterns and causes of death to possible violations of international humanitarian law.
The authors don't mince words - they are explicit in their conclusion that the results of the analysis indicate possible war crimes. Of course, pretty much everyone who still cares about Syria already knows that, but additional evidence never hurts - even if it will never make the UN move. What is particularly horrifying is the effect that the increasing use of aerial bombardment in general, and barrel bombs in particular, on civilian deaths - over a quarter of which were children.

Unfortunately, the VDC data only contains deaths that occurred in areas outside of government control (as “information on victims in government-controlled areas can be difficult to obtain”), so the analysis is geographically incomplete and does not include any deaths among Syrian government forces. But the data that is available is incredibly detailed and valuable:
Documentation of the health impact of war and conflict is one of the most difficult yet important public health challenges....Yet, the health and population impact of conflicts is dramatic and their effects long lasting. Any attempt to understand these events requires careful data collection and contemporaneous analysis to capture data that would otherwise be lost. Only through collection efforts such as those mounted by the VDC and analyses like the one presented by Guha-Sapir and colleagues can propel researchers and policymakers into recognising the true costs of current wars and the need to mitigate such consequences in the future.

Last week in @CDCMMWR: #GuineaWorm eradication

Tuesday, December 12, 2017

Dracunculiasis (commonly known as Guinea worm) is by far the most likely candidate for the second disease mankind will succeed in eradicating from the earth. (The first, and only, one so far is smallpox.) Last week's edition of MMWR featured a progress report on eradicating Guinea worm, describing progress in the last 18 months after some setbacks in 2016:
The number of human dracunculiasis cases reported worldwide during 2016 increased to 25 cases in three countries in 2016 from 22 cases in four countries in 2015. However, during January–June 2017, the number of cases reported decreased from 10 cases in three countries during the same period in 2016, to eight, all in Chad. The number of infected domestic dogs doubled from 503 in 2015 to 1,011 in 2016, but declined to 537 during January–June 2017 compared with 653 during the same period of 2016.
Aside from infected dogs, the most significant barriers to eradication are "civil unrest and insecurity in Mali and South Sudan." Somebody please get them to quit fighting over there so I am no longer subjected to images of a Guinea worm coming out of some poor bastard's lower leg in my e-mails from MMWR.

#HIV Round-up: webinars, @AMJPublicHealth articles, and a special issue of @HHRJournal

Monday, December 11, 2017

World AIDS Day is December 1 - which means, first and foremost and most importantly, that we are still fighting HIV and that the work is not done. The silver lining (for epi nerds like me) is that December produces a steady stream of great research and learning material on the full cascade (har) of HIV-related issues in all parts of the world. Below is a sampling of some of the content that caught my eye last week.

Webinars
  • Biomedical Advances in HIV Prevention: PrEP, PEP, Microbicides and U=U,” collaboratively hosted by Regional Resource Network Program (RRNP), the U.S. Department of Health and Human Services, and the Office of the Assistant Secretary for Health, Region II. The provided description was minimal and basically rehashed the title, so I won't include it here, but I will note that "U=U" stands for "undetectable=untransmittable," shorthand for the finding that PLHIV who maintain viral suppression have effectively zero risk of transmitting the virus to their sexual partners. Run time: 1 hour, 33 minutes.
  • "What is the Future of HIV Funding?" by the Kaiser Family Foundation and Funders Concerned About AIDS. True to form (because they are fabulous), KFF has made the slides available in PDF format as well. Run time: 1 hour, 4 minutes.
    As we recognized World AIDS Day this year, the outlook for funding to address the global and domestic HIV/AIDS epidemics remained uncertain. What is the status of U.S. government funding for domestic and global HIV efforts? What about other donor governments and multilateral efforts? What role does private philanthropy play in fighting the epidemic? What is at stake looking ahead? On Friday, December 8, the Kaiser Family Foundation (KFF) and Funders Concerned About AIDS (FCAA) hosted a web briefing to look at the latest data on funding for HIV, trends over time, and what we might expect going forward. The briefing included time for audience Q&A.
  • "Increasing Virologic Suppression: Promising Practices from HIV Health Improvement Affinity Group States" by the National Academy for State Health Policy. (Bonus: NASHP has its own YouTube channel!) Run time: 1 hour, 22 minutes.
    Increasing rates of virologic suppression among people living with HIV is critically important to improving their quality of life and decreasing the risk of further HIV transmission. For the last 12 months, the HIV Health Improvement Affinity Group has worked with state health departments and Medicaid agencies from 19 states to develop and implement performance improvement projects aimed at improving rates of sustained virologic suppression among Medicaid beneficiaries living with HIV. This webinar will feature leaders from the Office of HIV/AIDS and Infectious Disease Policy in the US Department of Health & Human Services, the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and the Centers for Disease Control and Prevention. It will also feature Affinity Group states, Alaska and North Carolina, that will share lessons learned and best practices from their performance improvement projects.

Articles from the American Journal of Public Health:
While AJPH did not run a special December issue on HIV, it has put out a call for papers on "Monitoring Disparities in Prevention and Treatment of HIV, Viral Hepatitis, STDs, and TB" (submissions due January 31, 2018). The January 2018 issue featured several pieces that either directly addressed HIV or are relevant to HIV:

Special edition of Health and Human Rights Journal:
Harvard's HHR Journal does two editions per year, one in June and one in December. Fittingly, the December 2017 edition contained a special section on HIV and Human Rights, done in collaboration with UNAIDS. It features pieces by heavyweights such as Michel Sidibé (current UNAIDS executive director) and Peter Piot (first and former UNAIDS executive director)...and me, in my first publication as sole author! I got a kick out of seeing my paper criticizing South Korea's misrepresentation of itself as having no HIV-related travel restrictions alongside pieces by UNAIDS officials, who recognize South Korea as a restriction-free country despite mountains of evidence to the contrary. I suppose it is a moot point, as UNAIDS has mostly scrubbed its website clean of its initiative to eliminate HIV-related travel restrictions. The link to the issue on its human rights page goes nowhere. Ah, well.

@KHNews calls out @JohnsHopkins and @UMMC for ignoring asthma in Baltimore

Thursday, December 7, 2017

Kaiser Health News published a hard-hitting piece on asthma in low-income housing in Baltimore yesterday, essentially calling out Johns Hopkins and the University of Maryland Medical Center for profiting from the poor in the city's worst asthma hot spot. The article asserts that the two medical centers receive tax benefits and research dollars for "serving the community" while also reaping profits from Medicaid clients who are repeatedly hospitalized with severe asthma attacks, because they do next to no community-based work with the clients themselves - in effect, by not serving the community.
The supreme irony of the localized epidemic is that Keyonta’s neighborhood in southwest Baltimore is in the shadow of prestigious medical centers [Johns Hopkins and UMMC]...Both receive massive tax breaks in return for providing “community benefit,” a poorly defined federal requirement that they serve their neighborhoods.
...
But like hospitals across the country, the institutions have done little to address the root causes of asthma. The perverse incentives of the health care payment system have long made it far more lucrative to treat severe, dangerous asthma attacks than to prevent them.
The authors conducted interviews with asthma patients and their family members in zip code 21223 and visited homes to report on environmental conditions. They also analyzed three years of de-identified hospital admissions data for the state of Maryland. (The methodology is detailed in a box at the bottom of the article.) The analysis is eye-popping, but sadly familiar to those of us who have worked with Medicaid or similar data:
For each emergency room visit to treat Baltimore residents for asthma, according to the data, hospitals were paid $871, on average. For each inpatient case, the average revenue was $8,698. In one recent three-year period, hospitals collected $6.1 million for treating just 50 inpatients, the ones most frequently ill with asthma, each of whom visited the hospital at least 10 times.
They then go on to depict officials from Hopkins passing the buck:
Hopkins’ own research shows that shifting dollars from hospitals to Lemmon Street and other asthma hot spots could more than pay for itself. Half the cost of one admission — a few thousand dollars — could buy air purifiers, pest control, visits by community health workers and other measures proven to slash asthma attacks and hospital visits by frequent users.

“We love” these ideas, and “we think it’s the right thing to do,” said Patricia Brown, a senior vice president at Hopkins in charge of managed care and population health. “We know who these people are...This is doable, and somebody should do it.”
The subtext, of course, is that "somebody other than us should do it," a subtext made all the more obvious with the article's direct contrast to the Children's National Health System in DC, which sends asthma patients to a clinic that provides education to families on how to manage their medications and remove environmental asthma triggers in the home.

The piece highlights the health consequences of low-income housing in a powerful way. I imagine the average middle-class American has no idea that there are people in this country who live in houses with dirt-floor basements or neighborhoods with no trash pickup to speak of, or that there are moms who resort to "[wielding] a BB gun to keep rats from her asthmatic child." I also like the way it draws attention to the divide between the ivory tower and the real world, so to speak - well-paid researchers who receive millions in grants to run studies on asthma public health interventions and publish papers in high-profile journals, but then who have no connection to, or interest in, community programs that could actually scale up those interventions for the benefit of people living in their own backyards.

At the same time, I can see how it could be frustrating for administrators at these hospitals to be villainized in a piece like this when they are also held to account for the other 982 public health crises in a community like Baltimore, which all have their roots in a fragmented, overpriced health care system. The authors mention off-hand that "[e]xecutives...acknowledge that they should do more about asthma in the community but note that there are many competing problems: diabetes, drug overdoses, infant mortality and mental illness among the homeless." Arguably, those executives are absolutely right, and I would argue that it does make more sense for them to prioritize things like drug overdose and infant (and maternal) mortality, particularly when the asthma triggers in low-income housing should be addressed by agencies like HUD. The article interviews Ben Carson and paints him in a positive, almost sage-like light, when it could justifiably throw an equal share of the blame at his feet. It is HUD and similar agencies, not hospitals, that should be providing assistance like holding landlords accountable for shitty housing conditions and interfacing with municipal governments to clean up crack houses and ensure a trash pick-up schedule that respects human dignity.

Overall, though, this is an important piece that draws attention to an issue that does not get enough of it.

@CDCMMWR Vital Signs report: The impacts of undiagnosed and delayed diagnosis of #HIV

Friday, December 1, 2017

An MMWR "Vital Signs" early release on undiagnosed HIV infection and its impact on the epidemiology of the epidemic has been making the rounds this week. The report uses data from the National HIV Surveillance System through 2015 to calculate an estimate for the annual number of HIV infections, both diagnosed and undiagnosed:
The first CD4 test after HIV diagnosis and a CD4 depletion model indicating disease progression were used to estimate year of infection and the distribution of time from HIV infection to diagnosis among persons with diagnosed infection. The distribution of diagnosis delay was used to estimate the annual number of HIV infections, which includes persons with diagnosed infection and persons with undiagnosed infection.
...
The number of persons with undiagnosed HIV infection was estimated by subtracting the number of reported cumulative diagnoses from the number of estimated cumulative infections. The percentage of undiagnosed infections was determined by dividing the number of undiagnosed infections by the total HIV prevalence.
I found the bit about the "CD4 depletion model" to be particularly interesting. This refers to calculating the length of an individual's infection based on their CD4 level at diagnosis by using biomedical data on how quickly HIV kills off CD4 cells. (Most HIV surveillance data comes from lab reports, so surveillance programs receive CD4 and viral load information automatically when the lab report is received.) They can then "backtrack" and compare those estimates with the number of cases that were actually reported for a given year, which allows them to estimate the overall prevalence of HIV and the percentage of those cases that are undiagnosed. The math is relatively simple, but it underscores the importance of supporting disease surveillance systems, as the data they collect can clarify so much of the picture of the overall epidemic.

The article also looks at data on groups at high risk for HIV infection from the National HIV Behavioral Surveillance System, a survey program which collects data from MSM, PWID, and heterosexuals at high risk. Those numbers show that testing has increased among all three groups, but that there were missed opportunities that could be addressed through more widespread routine screening in healthcare settings:
Among persons interviewed through NHBS, the percentage reporting an HIV test in the 12 months preceding the interview increased over time among MSM (from 63% in 2008 to 71% in 2014), persons who inject drugs (from 50% in 2009 to 58% in 2015), and heterosexual persons at increased risk for infection (from 34% in 2010 to 41% in 2016).
...
In each risk group, at least two thirds of persons who did not have an HIV test had seen a health care provider in the past year (Table 2). Among those who had not tested in the past year and had visited a health care provider, approximately three quarters reported not having been offered an HIV test at any of their health care visits.
Unfortunately, it's tough for me to get excited about progress like this because this kind of national data is always two years delayed. The Obama administration made it a priority to reduce the number of HIV infections, so the importance of HIV prevention programs was taken as a given. It remains to be seen whether this progress will be sustained under the current political climate, particularly in the light of the raging opioid epidemic. Unfortunately, we won't know for another two years.