Papua New Guinea Is Rich in Resources but Poor in Health - The New York Times.
[Nov. 13, 2018]
A mother and her baby at a health clinic where polio vaccines were administered to children in Lae, Papua New Guinea, in July. Vaccination rates are down to 30 percent in some parts of the country. Credit Brendan Esposito/Gavi/EPA, via Shutterstock
Jo Chandler writes:
PORT MORESBY, Papua New Guinea — Polio was vanquished by the Pacific nation of Papua New Guinea 18 years ago. Now, as world leaders gather there for the Asia-Pacific Economic Cooperation summit meeting this week, polio has returned — on top of raging drug-resistant epidemics of tuberculosis, malaria and H.I.V., and deadly flash points of preventable diseases like whooping cough and measles.
All over the country, there are symptoms of a profound public health emergency; young and old are getting sick and dying unnecessarily, while facilities lack basic medicines and equipment.
Doctors and experts say the unfolding crisis is the realization of their worst fears after years of deterioration and neglect.
“We were expecting something like this,” Dr. Anup Gurung, a public health specialist with the World Health Organization, said of the polio outbreak at a news conference in the capital, Port Moresby, in September.
He pointed to the erosion of vaccination rates, which are down to 30 percent in some parts of the country. “It’s like someone lit a paper castle where everything is on fire,” he said.
Officials in Papua New Guinea hope that hosting the Asia-Pacific Economic Cooperation, or APEC, meeting in Port Moresby will elevate the country’s international profile, but the health crisis has become an embarrassment for a nation with an abundance of gold, copper, silver, oil and gas.
A child receiving an oral polio vaccine at a health clinic in Lae in July. Papua New Guinea has 21 of the world’s 109 polio cases this year. Credit Brandan Esposito/Gavi/EPA, via Shutterstock
Public frustration with the summit spending has already led to two national strikes. The collapse of health services has been a focus of the protests.
The return of polio is a clear indicator of the failures, with Papua New Guinea accounting for 21 of 109 cases found globally this year.
The Papua New Guinea outbreak is vaccine-derived, which means that weakened live virus excreted by vaccinated children has mutated and escaped into the rapidly increasing unprotected population. Dr. Gurung blamed “the steady breakdown of the health system” for the country’s polio emergency.
Local and international experts point to three interlinked causes of the country’s health crisis: the collapse of the medical supply chain; changing relations with the country’s biggest aid donor, Australia; and rampant corruption.
Getting medicines, equipment and other supplies around Papua New Guinea has always been challenging. The country has few roads, formidable geography and a widely dispersed population, with about 80 percent living in rural and remote locations.
That improved with assistance from Australia, but the Australian government withdrew from the arrangement in protest in 2013 after Papua New Guinea awarded the national medicine supply contract to a local company that Julie Bishop, then the Australian foreign minister, said had no accreditation and “a history of supplying substandard drugs.”
A community health worker at the Catholic sub-health center in Terapo in September. It operates in a condemned building without water or power and with few medicines.Credit Jo Chandler
The company, Borneo Pacific, won the contract — worth 32 million Australian dollars, or $23 million — despite its bid being millions of dollars higher than those of reputable international organizations. At the time, the Medical Society of Papua New Guinea said the deal would “lead to the deaths of many Papua New Guineans.”
Reports from health facilities across the country indicate those fears have been borne out. (Borneo Pacific did not respond to requests for comment.)
Health workers in aid posts, clinics and even major hospitals regularly report running out of basic medicines like antibiotics, analgesics and antimalarials, said Dr. Sam Yockopua, chief of emergency medicine at the National Department of Health and secretary of the National Doctors Association. Many rural facilities have closed for lack of supplies or workers.
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Dr. Yockopua identified “endemic and epidemic” corruption as the root cause of the health care system’s failures, echoing the findings of international investigations.
A national audit last year also documented widespread “unavailability of lifesaving and essential drugs” and urged the removal of the entire medicine procurement division. The government did not respond to questions about the report’s recommendations.
Dr. Peter Sol, center, an obstetrician at Kerema Hospital, monitoring a patient in the maternity ward in September. "We hardly see those supplies that we used to see before," he said.Credit Jo Chandler
Signs of crisis are everywhere.
About five hours’ drive northwest from Port Moresby, navigating a fractured coastal highway, the Catholic sub-health center in the village of Terapo operates in a condemned building without water or power and with few medicines. It serves more than 500 patients each month, many traveling long distances because government aid posts have closed.
At Kerema Hospital, the major facility in Gulf Province, another hour’s drive, Abel Benedict, a pharmacist, said he had not received his monthly order for four months. Dr. Christopher Munguas, a surgeon, said lifesaving catheters and surgical tubes were often unavailable.
“Drugs are another headache altogether,” he said.
Dr. Peter Sol, an obstetrician, said that before 2014, when the former Australian government agency AusAID was delivering supplies, “you could see all the medicine in remote rural aid posts, health centers. They actually delivered.”
Now, Dr. Sol said, “we hardly see those supplies that we used to see before.”
Despite its immense resource wealth, Papua New Guinea has the lowest life expectancy in the Pacific at 62.9 years, according to the World Health Organization. And it may be getting worse.
The number of people infected with malaria parasites, for example, grew almost ninefold to 432,000 in 2017 from 50,309 in 2014, according to the Papua New Guinea Institute of Medical Research. The survey blames the lack of treatment drugs in many parts of the country, together with a decline in international support.
Similarly, a decade ago, Papua New Guinea was being congratulated for its efforts against the spread of H.I.V.; now, infection rates are rising. A survey has also exposed “alarming rates of H.I.V. drug resistance,” said Dr. Angela Kelly-Hanku of the Institute of Medical Research. This is largely because H.I.V. patients are unable to secure reliable supplies of antiretroviral medications, she said.
A nurse at Mount Hagen General Hospital, left, informing a patient in 2004 that she had contracted H.I.V. A decade ago, Papua New Guinea was being congratulated for its efforts against the spread of H.I.V., but now infection rates are rising.CreditTorsten Blackwood/Agence France-Presse — Getty Images
There is also a national shortage of condoms.
“The most basic H.I.V. prevention tool, and we don’t have enough,” Dr. Kelly-Hanku said.
The country also has some of the most alarming rates of tuberculosis in the world — including drug-resistant strains described as “Ebola with wings” — and the head of the national tuberculosis program recently conceded that the health system was too weak to tackle the problem.
Even larger cities have problems. Prof. Glen Mola, one of the nation’s most senior medical specialists, blamed supply chain failures for a resurgence of stillbirths in Port Moresby.
Until a decade ago, latent syphilis infection in pregnancy was one of the most common causes of stillbirths in Papua New Guinea. This risk was virtually eradicated through universal screening in pregnancy, but then the supply of the $1 finger-prick blood tests dried up last November.
“At Port Moresby General Hospital we didn’t have a case of a death of a baby from syphilis for five or six years, and then we started seeing them again this year,” Professor Mola said.
The hospital has also been running out of H.I.V. antiretrovirals and malaria tests. Surgeons are even rationing procedures because of a shortage of sutures.
Venues for this week’s Asia-Pacific Economic Cooperation summit meeting in Port Moresby, the capital. There have been two national strikes over the government’s summit spending. Credit Vanessa 'Ness' Kerton/Agence France-Presse — Getty Images
Professor Mola said a colleague with extensive experience in Africa had observed that while corruption was common there, in Africa “they skim off the cream and still leave some milk for the people. In Papua New Guinea, they take the lot.”
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Corruption has played a big role in the nation’s health crisis but is not the whole story, said Prof. Stephen Howes, an economist at the Australian National University in Canberra who studies Papua New Guinea. The national government slashed its health budget 37 percent from 2014 to 2016 as commodity prices fell.
Conditions in Papua New Guinea have also been directly affected by the country’s changing relationship with Australia, its nearest neighbor and former colonizer. Like other international donors, Australia has shifted focus in recent years to infrastructure and capacity building rather than saving individual lives through direct services.
“That move out of service delivery was a mistake,” Professor Howes said.
Australia also owed Papua New Guinea a political debt after it agreed to process and resettle asylum seekers in detention camps on Manus Island, Professor Howes said, making Australian officials wary of criticizing the country over issues like corruption.
Though the Manus Island facility closed last year, there are hundreds of refugees still being held in Papua New Guinea. Australia also fears that pressuring Papua New Guinea too much could push it into the arms of China, which is courting Pacific nations.
“We are increasingly looking at P.N.G. through a strategic or in fact through a China lens, and that makes us reluctant to say anything that might annoy them,” Professor Howes said.
China and Australia have both invested millions in supporting the APEC meeting, which the Papua New Guinea public has come to view as a drain on government spending.
Charles Kerere, a parish priest in the Gulf Province village of Lese, said children in his community were dying from illnesses like diarrhea because the aid post had no medicines. He said he feared an outbreak of polio in the province, which recorded its first case in August.
“I’ve been to Port Moresby, I’ve seen lots of money has been pumped into the city,” Father Kerere said. “They are so concerned with trying to please the world leaders that Papua New Guinea is O.K. But under the carpet we have huge problems in our country, and people are suffering. They are crying for services, basic services.”
Infoographic: Afghanistan polio snapshot – September 2018 | GPEI.
Update on polio eradication efforts in Afghanistan for September 2018.
- 3 new wild poliovirus (WPV1) cases were reported in September 2018.
- In the September Sub-National Immunization Days, 5.6 million children under the age of five were targeted.
- 484 permanent transit points (PTPs) were operational across Afghanistan during September 2018.
For full update please click on pdf below.
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Immune Priming and Long-term Persistence of Memory B Cells After Inactivated Poliovirus Vaccine in Macaque Models: Support for at least 2 Doses | Clinical Infectious Diseases.
[Open Access] [Published: 30 October 2018]
As a risk-mitigation strategy to minimize paralytic polio following withdrawal of Sabin type 2 from the oral poliovirus vaccine in April 2016, a single full dose or 2 fractional doses of inactivated poliovirus vaccine (IPV) are recommended. However, limited knowledge exists on long-term persistence of immune memory following 1- or 2-dose IPV schedules.
We examined induction and maintenance of immune memory following single- vs 2-dose IPV schedules, either full-dose intramuscular or fractional-dose intradermal, in rhesus macaques. Humoral responses, bone marrow–homing antibody-secreting plasma cells, and blood-circulating/lymph node–homing memory B cells were examined longitudinally.
A single dose of IPV, either full or fractional, induced binding antibodies and memory B cells in all vaccinated macaques, despite failing to induce neutralizing antibodies (NT Abs) in many of them. However, these memory B cells declined rapidly, reaching below detection in the systemic circulation by 5 months; although a low frequency of memory B cells was detectable in draining lymph nodes of some, but not all, animals. By contrast, a 2-dose vaccination schedule, either full or fractional, efficiently induced NT Abs in all animals along with bone marrow–homing plasma cells and memory B cells. These memory B cells persisted in the systemic circulation for up to 16 months, the maximum duration tested after the second dose of vaccination.
Two doses of IPV, regardless of whether fractional or full, are more effective than a single dose for inducing long-lasting memory B cells.
Original Source Article »
USA: Parents accuse CDC of not reporting children's deaths from polio-like AFM | CNN.
[Updated 1958 GMT (0358 HKT)
[See source article for video reports]
November 13, 2018] Elizabeth Cohen writes:
Moseley, Virginia (CNN)Parents of children who had a horrifying polio-like illness are accusing the Centers for Disease Control of hiding the deaths of two children who suffered from the condition.
The parents say by not publicly acknowledging the two deaths, the agency is intentionally downplaying the severity of acute flaccid myelitis (AFM), a disease that paralyzes healthy children in a matter of hours.
"I feel like they're just sugar-coating this," said Katie Bustamante, whose son Alex, age 6, died in May. "It eliminates my trust in the CDC."
Their accusations come amid a wave of criticism
from parents of children with AFM and from some of the CDC's own medical advisers. In a recent on-camera interview with CNN, a group of parents gave the agency an "F" for its handling of the outbreak.
A CDC official said while she couldn't comment directly on the boys' cases, there may be a "lag" in AFM reporting from physicians to health departments to the CDC.
"I think we want to catch up with the backlog," said Dr. Anne Schuchat, principal deputy director of the CDC, a 30-year veteran of the CDC and a retired rear admiral in the US Public Health Service. "Even the past week we've expanded the number of disease detectives on the program."
Schuchat, who twice served as acting director of the agency and helped lead the fight against pandemic flu, SARS and anthrax, said she was sorry to hear that the parents think the CDC is hiding something.
"I certainly want to make sure the information that we have is shared as quickly as possible," Schuchat said. "We wish we understood all that we need to about this disease and how to best diagnose it, how to treat it and how to give families enough information about what to expect. I think it's very challenging when your child has been through something quite traumatic to not even know what the prognosis is."
She added that there's no simple lab test for AFM, so CDC disease detectives have to carefully review medical records.
Twenty-six states have confirmed cases of AFM, and 11 additional states have possible cases, according to a survey last week by CNN of state health departments. This year there have been 90 confirmed cases of the illness, and 162 cases are currently under investigation, according to the most recent CDC data
On its AFM surveillance
webpage, the CDC doesn't mention any deaths from AFM. At a press briefing
last month, Dr. Nancy Messonnier, director of the CDC's National Center for Immunization and Respiratory Diseases, mentioned that the agency knew of one death in 2017, but did not mention any deaths this year, even when asked about it by a reporter.
Chris and Robin Roberts lost their 5-year old son, Carter, in September after a 2-year battle with AFM. CNN has seen portions of Carter's and Alex's medical records, which show their doctors had diagnosed them with AFM. In Carter's case, doctors at three medical centers -- Virginia Commonwealth University, Johns Hopkins and Boston Children's Hospital -- diagnosed him with the disease.
The CDC has set up a system where physicians report cases of AFM to their state health departments, which in turn report the cases to the CDC.
Two pediatric neurologists who serve as medical advisers to the CDC on AFM say they think the agency could be faster in reviewing and reporting cases and deaths.
"It shouldn't be taking this long to confirm these cases," said Dr. Keith Van Haren, assistant professor of neurology at the Stanford University School of Medicine and one of the CDC advisers. That kind of a turn around time for mortality reviews is a symptom of a disconnect at the CDC."
Carter's parents agree.
"They're doing a s*** job of measuring this, excuse my French," said his mother, Robin, a healthcare IT specialist.
'Mommy, mommy, help me'.
On July 29, 2016, Carter vomited after dinner. The next day he had a fever of 99 degrees but was feeling well enough to eat and drink.
It's just a virus, thought his parents, who have two older children. It was nothing alarming.
The next morning, Robin went into her son's room and found him on the floor.
"Mommy, mommy, help me," his mother remembers him saying.
Robin remembers trying to help Carter stand up. His head flopped back. He couldn't use his right arm. She scooped up her son and took him to the emergency room.
Within a few days, Carter couldn't move anything below his neck. He was put on a ventilator and never came off.
For the next two years, his family and nurses did everything for him. They fed him. They scratched his nose when he had an itch. All day and all night they turned him every 90 minutes so he wouldn't get bedsores.
Carter was undeterred by his illness. He could read books by the time he was four. He instructed his father on how to construct characters out of Legos and medieval swords out of aluminum foil.
Carter went to pre-school, and in August of this year started kindergarten. He came home from his first day beaming about circle time and a pretty little girl in his class who wore a rainbow dress.
A few weeks later, on September 22, he was having trouble breathing. Robin was home alone with him and called an ambulance. His last words to her were: "Mommy, I'm fine."
Today, Carter's ashes sit in an urn in his family's living room.
A doctor wants answers.
Both Carter's parents and Alex's parents say they're not sure if the CDC ever accepted their sons as official AFM cases back when they got sick in 2016.
Alex's mother says his doctor told her he reported his death to the California Department of Public Health, but she doesn't know what happened after that.
In Carter's case, his neurologist Dr. Sanjai Rao, told CNN he filled out paperwork on the CDC's website and following the CDC's instructions, sent the paperwork, lab specimens and MRI findings to the Virginia Department of Health.
An epidemiologist there confirmed Carter's information was sent along to the CDC, according to Rao, assistant professor of pediatric neurology at Children's Hospital of Richmond at Virginia Commonwealth University.
Doctors and parents say part of their frustration is that when they've asked the CDC about cases and deaths, they haven't received responses.
Rao says he reached out to a scientist on the CDC's AFM team, but never heard back.
"I would like answers," said Rao, an assistant professor of pediatric neurology at Children's Hospital of Richmond at Virginia Commonwealth University.
His voice chokes with emotion as he talks about Carter, whom he cared for for more than two years. "I want to know that the process benefits future cases of children with AFM," he said.
Other experts agree with Rao. "We want accurate numbers," said Dr. Kenneth Tyler, professor and chair of the department of neurology at the University of Colorado School of Medicine, and an adviser to the CDC on AFM.
An accurate count could help answer questions, he said. Where are the cases? How old are the patients? Are they male or female? "That helps us understand causation," he said.
"The CDC is in the place of trying to understand the long-term [consequences], and a death is really important," added Van Haren, the pediatric neurologist at Stanford and adviser to the CDC.
Schuchat said the CDC is working hard on AFM. "We are working 24-7 on this and really take this seriously," she said.
She said the agency has established a case definition for AFM, done laboratory testing on samples sent to them by state health departments, and worked with outside experts to publish information in medical journals.
A CDC spokeswoman said in the past two weeks, the agency has added 14 officers from the Epidemiologic Intelligence Services -- known as "disease detectives" -- to help review AFM reports filed by state health departments.
In 2016, when Alex Bustamante was five years old, he had a headache, and then the next day developed paralysis. He became a paraplegic and a ventilator breathed for him. He died in May of this year.
An enterprising parent.
On June 10, 2017, about ten months after Carter got sick, Robin reached out to the CDC.
She was angry.
"I know it may seem menial, a request from a clinically educated mother, but you are doing these children and family a disservice to not further educate physicians or demand surveillance similar to that of Zika," she wrote to an email address she found on the CDC's website.
"Please do what is right by public health standards and gather more data," she continued. "Or, god forbid if you know more than what you say in a limited fashion online please share it with the public and these patients. My son was immunized on schedule we observed very good hygiene precautions and still became a vent dependent quadriplegic overnight."
She received a response two days later.
"We are sorry to hear about your son," it said. "Your comments have been forwarded to the appropriate CDC program for their information. They will contact you directly if they have any questions."
She never heard from the CDC again.
CNN relayed Robin's story to the CDC.
"I'm so sorry to hear that. That's very concerning," Schuchat told CNN. "We are trying to better connect with families, and it's so important that we listen to them."
Several other parents told CNN their emails to the CDC have also gone unanswered. Some of those emails offered help to the CDC from the families' Facebook group
, which has gathered medical information on hundreds of AFM patients.
Messonnier, the CDC doctor, told CNN last month that she'd never heard of the Facebook group.
Last week another enterprising parent got a response from the federal agency. Four-year-old Joey Wilcox of Herndon, Virginia, was diagnosed with AFM in September. His father, Jeremy, works with government agencies as part of his job at a high-tech consulting firm. Wilcox knows how to seek out -- and find -- officials.
He aimed high. Online he found Schuchat's email address, and asked her to meet with him and other parents. He says she responded within 15 minutes.
He thinks one of the reasons for the quick response is the "F" that parents gave the CDC.
That was a pivotal moment," he said of the CNN story.
More than a dozen families are scheduled to meet with Schuchat Tuesday in Washington.
Carter Roberts' and Alex Bustamante's parents will be among them.
CNN's John Bonifield and Michael Nedelman contributed to this story.
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