23 Mar 2018

How to help people with tuberculosis avoid the medical poverty trap

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Shantytown near Lima, Peru. Inspired By Maps/Shutterstock.com
Tom Wingfield, University of Liverpool 
Rosario hacks into a handkerchief, coughing up the bloodstained phlegm that plagues her chest in the mornings. On hearing the noise, two heads pop up from under a blanket – Rosario’s twins, Gonzalo and Bruno. A wail starts up from the crib in the corner of the one-room shack. As she puts baby Angelita to her breast, Rosario ponders her situation.

It’s been half a year since her husband Samuel passed away, two months since this horrible cough started, and six days since the doctor told her she had tuberculosis and she started the medicines. Nearly every day since then, Rosario has had to make the hour-long, bumpy minibus journey to the tuberculosis clinic – Angelita in hand – so the nurse can witness her taking the drugs.
But Rosario just can’t get to the clinic today. Her neighbour can’t look after the twins, and Rosario has no money to pay for the minibus ride. More pressingly, there is no food left to cook nor kerosene to cook with.

Rosario quickly calculates that, after deducting two packets to feed the twins, she has enough biscuits left to sell for a small profit at the minibus stop. For today, at least, that will stop the family going hungry. But it will also mean not arriving at the clinic until after it shuts – too late to take her medicines.

A social disease

Rosario’s situation in a Peruvian shantytown is not fictional, not isolated, and not new. Nearly a century and a half ago, Rudolf Virchow, the father of social medicine, recognised that tuberculosis (TB) and poverty were inseparably linked in a vicious cycle. He called TB “a social disease”. Indeed, the improvements in poverty levels, living conditions and nutrition that occurred during the Industrial Revolution in Europe were associated with a fall in TB rates, many years before the discovery of the TB bacteria or TB medicines. Today, the poorest households continue to suffer the highest levels of infectious diseases and, in trying to access healthcare, can be pushed deeper into poverty and ill health – the so-called “medical poverty trap”. There is no disease that better typifies this trap than TB.

Rudolf Virchow, the father of social medicine. Wikimedia Commons

Despite this, recent global TB control strategy has been disproportionately focused on medicines and tests rather than addressing the social causes of the TB epidemic. And so, today, Rosario’s terrible dilemma continues to be faced by many of the roughly 10m people worldwide who will develop tuberculosis this year (1.3m of whom will die).

This is one of the reasons why the global response to TB is not working. A more holistic approach to TB control is needed that addresses not just the disease but also the person who has the disease and the circumstances in which they live.

In its 2015 End TB Strategy, the World Health Organisation (WHO), for the first time in the modern era of TB control, called for social support and poverty alleviation strategies for people with TB to reduce the hidden costs of treatment, reduce stigma, empower patients, and increase TB prevention, the number cured and their overall well-being. But evidence that this type of strategy works was limited.

Testing the theory in Peru

The multi-disciplinary Innovation For Health and Development research team, which I joined in 2010, has been working for the past two decades in shantytowns near Lima, Peru, to generate new evidence to fill this knowledge gap and support TB-affected households.
One of our first tasks was to measure households’ hidden costs of TB treatment. Hidden costs (like those Rosario faces) included travel to clinics, food and lost income.

We found that when these hidden costs exceeded a fifth of a household’s annual income, the patient in the household was more likely to abandon treatment, fail treatment or die. In essence, the threshold of costs that we had measured had been catastrophic, not only to household finances but also to the TB patients’ health. This threshold, among others, was subsequently endorsed by WHO in their TB patient costs survey, which is being deployed around the world.

Our findings had identified a crucial factor explaining why medicines alone were not controlling TB. In response, we provided social and financial support for TB-affected households. Financial support consisted of bank transfers (up to US$40 per month) to reduce the hidden costs of TB and enable access to TB care. Social support included household visits by our research nurses and mentoring from mutual support groups led by former TB patients to empower households to access care and reduce stigma.

The intervention was a success. Supported TB patients were significantly more likely to complete their treatment or be cured, and their children were more likely to take medicine to prevent TB.
Rosario (not her real name) was one of the patients who received this support. Using the money she received throughout her treatment, she was able to keep going to the clinic and ensure that Gonzalo, Bruno and Angelita were fed regularly, and took medicine to prevent TB. She is now cured of TB and able to work.

The ConversationHelping households affected by TB to avoid the medical poverty trap, and providing them with moral support and hope, can enhance TB care and prevention. Without it, we won’t achieve the End TB Strategy goal of eliminating the disease by 2050, and millions more vulnerable households, like Rosario’s, could continue to suffer an entirely avoidable downward spiral of poverty and ill health.
Tom Wingfield, NIHR Academic Clinical Lecturer in Infection and LIV-TB Collaboration Lead, University of Liverpool

This article was originally published on The Conversation. Read the original article.

14 Mar 2018

Five diseases you can catch from pets

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Love them or hate them, it is hard to get away from pets. And even if you don’t own one yourself, you are likely to come across them (or things they have left behind) regularly.

Most interactions between humans and pets are likely to be overwhelmingly positive. But pets can carry some diseases that affect us. Such diseases, termed zoonoses, are usually very mild, but the rarer ones can be more severe.

Here are some of the infections people can catch from their pets:

1. Rabies

Rabies is perhaps the archetypal zoonosis. A virus whose name alone has the potential to cause fear. The virus is largely found in unvaccinated dogs and other canine populations.

In areas that still have rabies, people – often children – usually become infected when they are bitten by an affected dog. The virus attacks the brain, and once symptoms develop, there is sadly no cure, and those affected die. The good news is, it can be prevented by vaccinating dogs and other wild carnivores. Many parts of the world are now free of the virus, including the UK and large parts of the rest of Europe, and in many others, national campaigns are under way to achieve this.

2. Ringworm

Some zoonotic skin infections are not uncommon in pets but usually mild in humans. These can be shared with owners because of our love for warm houses, and close contact with our pets. Ringworm is one such infection.

Ringworm is actually a misnomer. It is not a worm at all but a microscopic fungus, closely related to the cause of athlete’s foot in people. Affected cats, dogs and other animals may show very few signs. However, in its classical form, pets with ringworm usually have circular areas of hair loss. The affected area of skin becomes scaly, flaky and itchy. It is very treatable, but can occasionally cause scarring.

3. Salmonella

A variety of potentially zoonotic bugs live in the intestines of pets. These rarely affect humans. However, when they do, they can be severe. We have all probably heard of salmonella, largely because of risks, now thankfully much diminished, from eggs. Dogs and cats can also carry salmonella, sometimes causing diarrhoea. Salmonella is also quite commonly present in pet reptiles and amphibians, as well as in so-called “feeder mice” that are fed by some to pet reptiles.
It’s always a good idea to wash your hands after handling both pets and raw pet food. It is also a good idea to have separate areas for preparing raw animal food and human food.

Pet reptiles can carry salmonella. SGr/Shutterstock.com

4. Toxoplasma

Toxoplasma is a common parasite in cats that they can also shed in their faeces. For most humans, it is entirely benign. However, if a woman first becomes infected during pregnancy, it can, albeit rarely, have severe complications for the developing foetus.

Pregnant women should take simple additional precautions around hand hygiene, avoiding cat litter trays, especially those not cleaned regularly, and avoiding eating uncooked garden produce where cats may have had access to the soil.

5. Bites and scratches

Some argue for bites and scratches to be included as a zoonosis. If we do include them, they are likely to be among the most common zoonoses. Never nice, always painful, and in disturbing, rare cases – usually involving children – they can be fatal.

Cat bites and scratches can transmit a bacterium called Bartonella henselae, the cause of “cat-scratch disease”. Both bites and scratch wounds can become badly infected causing further pain. Scars, both mental and physical, can be lifelong in those that have been attacked. Children and those exposed occupationally, such as postmen, are perhaps most at risk.

As with most infections, zoonotic infections have a greater potential to do harm in people whose immune systems are compromised, such as the elderly and those suffering from immunosuppressive diseases (such as HIV/AIDS), or undergoing immunosuppressive therapies (such as chemotherapy). However, even if your immune system is compromised, you can still benefit from owning a pet. And with care and a little knowledge of the risks, you can avoid infections.

The ConversationThankfully, zoonotic infections are not common. Most infections we get are likely to come from other humans. However, the risks of zoonosis can be minimised by being aware of them and by taking simple hygiene precautions at home. And, if in doubt about the risks, you can always consult your GP or a veterinary surgeon.

Alan Radford, Professor of Veterinary Health Informatics, University of Liverpool
This article was originally published on The Conversation. Read the original article.

17 Nov 2017

World Antibiotic Awareness Week

Cajsa Isgren was a resident in equine surgery at the PLEH, and is currently undertaking research for her PhD at University of Liverpool. Here she shares some of the issues around antibiotic resistance in horses and how it relates to her research for World Antibiotic Awareness Week (13-19th November 2017).

Antibiotic resistance is a global problem, which not only affects people, but also our much loved pets and horses. You may wonder how antibiotic resistance applies to you and your horse, especially if your four-legged friend is ‘fit as a fiddle’ and you have been fortunate enough not to call the vet out for anything apart from routine visits. Should your horse get ill in the future it is important to understand why your vet may, or may not prescribe antibiotics.

Antibiotics inhibit the growth or kill bacteria and since the revolutionary discovery of penicillin by Alexander Fleming in 1928, infections that were previously likely to be fatal, could be treated which revolutionised human and animal medicine! since then many other antibiotics have become available and we take it for granted that if we were to suffer from a serious infection, these would always be available to treat the infection. However, bacteria are very adaptable, like animals they are able to evolve and adapt to their environment, except they can do this very quickly, as a bacteria can multiply every 20 minutes, so from one bacteria you can get up to 16 million in 24 hours. When they are challenged with antibiotics some bacteria may develop changes in their DNA, so that the antibiotic can no longer attack their bacterial target, or they may acquire new DNA or ‘resistance genes’ which also stops the antibiotic acting on its target. These ‘resistance genes’ can jump from one type of bacteria to a different types thus making the problem worse. These ’resistant’ bacteria may then further multiply making the infection harder to treat or spread to other individuals and they can also survive in the environment waiting for the next opportunity to cause infection.

You may also presume that drug companies will develop new antibiotics to deal with these resistant bacteria, however no major new types of antibiotic have been found in the last 30 years. The problem is that looking for new antibiotics and getting them to the stage where they can be used in a person or animal is very expensive and it’s a big financial risk for the pharmaceutical companies. Any new novel drug would be kept as a ‘last resort’ and would certainly not be for widespread use and would be kept for human use only. As equine vets, when we are faced with a horse with a bacterial infection the ’gold standard’ is to treat that animal with an appropriate antibiotic based on growing the bacteria in the lab and testing which antibiotics are able to kill it. Sound easy doesn’t it? The problem is time, as culture and antibiotic sensitivity takes at least 48 hours and in the mean time we have to make an appropriate choice of antibiotic based on the type of bacteria likely to be causing the infection.  There is less resistance to some of the more recently developed antibiotics and it may seem like a tempting option to reach for such drugs when in fact these should be preserved for those infections which have failed to improve to ‘first line’ antibiotics and/or where culture and sensitivity results reveal the infection is resistant to all other antibiotics and hence justifies such use.

I am an equine vet and I am currently doing a PhD at University of Liverpool and am in my second year of study. My research project is on ‘The emerging problem of antimicrobial resistance in hospitalised horses’ and my study involves looking at this issue in UK equine hospitals.  Previous research has identified that just like in people; horses may carry certain types of resistant E. coli bacteria in their faeces when they are in the hospital.  Whilst they are in the gut of the horse, they are unlikely to cause any harm and the horse is likely to stop shedding these bacteria a few weeks after they have left the hospital or stopped receiving antibiotics, which may also make them carry such bacteria for longer. You may wonder why this is of any interest if it does not cause any harm.The resistant E. coli may act as a potential source of infection should the horse have a wound or an incision, or become more susceptible from another type of infection if they are poorly. There is also a risk of these resistance genes in these E. coli jumping to other types of bacteria hence we are interested in ways to reduce this. This study is looking at identifying different factors that make the horse more likely to carry these resistant bacteria, such as antibiotic use and how they are managed in hospitals. This work will enable us to identify those horses which are more likely to carry these bacteria and then we can look at what changes we can implement to stop them carrying such resistant bacteria and preserve antibiotics for future use in horses. 

3 Nov 2017

International One Health Day

Professor Matthew Baylis is a ‘One Health’ researcher, and is leading on a new project ‘The One Health Regional Network for the Horn of Africa (HORN)’ to improve the health and wealth of people in the Horn of Africa. Here he explains the concept of One Health, and why it is important.

November 3rd is International One Health Day. One Health is the idea that the health of people, animals, plants and the environment are interlinked, and that health will be optimised by different disciplines (such as medicine, veterinary science, social science, environmental science) working together rather than independently. It goes to the heart of multidisciplinarity in science, with large gains to be made by bringing together experts who may approach the similar problems with different skill sets and approaches.

Blood sampling of a pig during the People Animals and their Zoonoses (PAZ) Project in Western Kenya (year 2010) Image: Dr Kelvin Momanyi, ZED Group (www.zoonotic-diseases.org)

There are innumerable examples of advances in human medicine that have led to improvements in animal health – as just one example, some of the biggest equipment used in the University of Liverpool’s animal clinics (such as MRI scanners) were originally developed for use in human hospitals.  But there are also many examples of veterinary medicine leading to improvements in human health or medicine.  In the UK, we are now safe to eat raw or undercooked eggs owing to a major programme to eliminate salmonellosis from the layer industry. The incidence of human rabies in much of East Africa has declined, owing to vaccination not of people, but of dogs.  My favourite example relates to transmissible spongiform encephalopathies. In the early 1960s members of the Foré tribe in Papua New Guinea were dying from a novel disease called Kuru (related to variant CJD). An American medic attempted transmission experiments with chimps that were not successful, leading to the conclusion that the disease was of genetic origin. The medic spoke on this in the UK and, in the audience, was a veterinarian.  The vet recognised that the characteristics of Kuru seemed identical to that of a sheep disease called scrapie, which had been shown to be transmissible. He alerted the medic, who repeated the experiments, this time successfully, and went on to get the Nobel Prize for Physiology (the medic, not the vet, of course).

Find out more about International One Health Day here.

The University of Liverpool is a big player in the area of One Health. We have a long history of multidisciplinary research in the area of zoonotic disease. Most recently, we have been awarded a large RCUK-funded Global Challenges Research Fund (GCRF) Growing Research Capability (GROW) award called One Health Regional Network for the Horn of Africa (HORN), which aims to strengthen institutions and train researchers and support staff in areas relevant to One Health in 4 countries of the Horn of Africa: Kenya, Ethiopia, Eritrea and Somalia. It is early days, but you can follow progress here.

6 Mar 2017

An Unexpected Evening of Popular Science

Kyle Spence is author of the crime novels Murder Incorporated and Murder Syndicated, a lover of all things science, and grew up enraptured with the works of Roald Dahl. Here he writes about his recent visit to watch IGH's Professor Tom Solomon's Marvellous Medicine show at the Northern Ireland Science Festival

When he first took to the stage in the trendy Black Box Theatre, Belfast, what struck me most about Professor Tom Solomon was that he had the quintessential look of a scientist -  tall, lean, bespectacled.

I was soon to learn that Tom is a charming and charismatic man who took some ‘squiffy’ technical issues in his stride to engage and regale the audience, during his event, "An Unexpected Evening with Roald Dahl’s Doctor" part of the Northern Ireland Science Festival. Tom talked with obvious affection about the night on call, 25 years ago, as he was hunched over his computer and the patient who kept slowly walking by for a nosy at the research he was writing up. It was his first encounter in which Tom was to learn that Roald Dahl was much more than the author of books that generations have grown up loving.

Sipping from a glass of wine Tom captured the packed audience with the remarkable early years of Dahl’s life, you may recognise some of the tales from ‘Boy’ and ‘Going Solo’ for as we were to discover the events of his life greatly influenced his writing, and in a way this helped the author to deal with them. The hard times of his life were also the inspiration behind Tom’s new popular science book, Roald Dahl’s Marvellous Medicine; from the accident in New York that made him the driving force behind a neurosurgeon and a toymaker to develop a new valve for the treatment of hydrocephalus for his son, Theo; to the tragic passing of his daughter Olivia at only 7 years old from measles encephalitis that spurred him to become a major advocate for measles immunisation at home and abroad, contributing to thousands of lives saved.

And when Dahl’s first wife Patricia Neal suffered a stroke the author and his family, friends and neighbours worked tirelessly in an effort to rehabilitate her, that started a medical revolution in stroke therapy and became a keystone in the Stroke Association. The codes of speech Dahl had recorded from Patricia to better understand what she was trying to say formed the basis of the idiosyncratic speech of that much beloved character, the BFG.

Tom spoke of these things with a mixture of wit, compassion, and at times I dare say reverence, though there was also a bit more risqué humour from Dahl’s short stories served with a cute little cocktail called the William and Mary, I won’t spoil the surprise.

Before I finish I must mention the  book written by Tom ‘RoaldDahl’s Marvellous Medicine’ gives greater insight than could be covered in our intimate evening’s chat. Most importantly as with Dahl’s oft noted altruism, all royalties of Tom’s book will go to charities that work in areas of interest to Dahl.

So how do I close about a fantastic, entertaining, educational, poignant, sometimes tragic but deeply wonderful evening of anecdotes about an author whose legacy lives on like a whiffsy time-twiddler?
When asked by a member of the audience how he felt about Roald Dahl, Tom Solomon replied simply, “I loved him.”

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