Re-Opening Precipitately? Look at India

"I think the problem is that what we are seeing is that this idea of herd immunity is messy."

"Whether we're talking about a single mutant or double mutant or triple mutant, we're seeing quite a few different mutations." 

"The real question for us is figuring out, as quickly as possible, with India, what does this variant mean? Is there a correlation between B.1.617 and the crisis that they're in right now [does it have enhanced properties?} For Canadians, that's the information we need to know."

What does it tell us from our own personal standpoint? It tells us we are still dealing with the same virus.We've got to be vigilant with that stuff if we don't want to see this new variant, or any other variant, transmitting widely through our community. Because once it hits a tipping point, we can't stop it in its tracks."

Jason Kindrachuk, virologist, University of Manitoba

"[Following the first wave in India the numbers started nose-diving early in the New Year], and everybody started celebrating, declaring success, that 'we're out of the woods'."

"And we thought a good proportion of Indians would have gotten naturally infected last year and would have antibodies, and then vaccination started."

"And then the Indian government, in its wisdom, opened up in a hurry. No social distancing [as millions attended religious festivals and super-spreader political rallies], masking went down, public health measures were relaxed and testing went down."

"And then we started to see the number climb again. You've seen the graph, right? It looks like a rocket going up. I've never seen anything like it."

Dr. Madhukar Pai, Canada Research Chair in epidemiology and global health, McGill University

Paramedics wearing protective equipment wheel a patient into the emergency department at Toronto's Mount Sinai Hospital. THE CANADIAN PRESS/Chris Young

 

A directive was issued to hospitals in Ontario in April that non-urgent care in the operating room must cease. Surgeons, nurses and anesthetists should be prepared to redeploy to the COVID wards and the ICU. Triage meetings have become regular events to discuss which of the cases presenting must be sent to the operating room and which patient appears on the brink of permanent or irreparable harm, and that person must then wait -- 'declined'. This is called the reality response to a desperate situation.

India's catastrophic COVID-19 wave has brought with it a dire situation with doctors sending out SOS messages pleading for oxygen. It is where opportunistic variants are now beginning to spread widely in Canada, causing great alarm, but in comparison to the situation in India, a mere ripple as opposed to that nation's riptide of illness. On a number of recent consecutive days India has posted unbelievably huge single daily COVID caseloads such as 332,730 cases and 2,263 deaths. Daily. Mind-boggling.

New Delhi, the nation's capital, is riddled through with COVID cases and they continue to rise. "If we open up everything, give up on public health and not vaccinate rapidly the new variants can be devastating", warned Dr. Madhukar Pai of McGill University. It is as yet unknown whether India's growing caseload owes to new infections or how much reinfection is involved. Studies out of Manaus in Brazil suggest that up to half the population in some of India's largest cities had been infected previously in the first wave, resulting in a fairly high immunity in the population.

Only now has Canada officially closed the air corridor for a month for direct-passenger flights from India and Pakistan to enter Canada. Too late, unfortunately, to prevent a new 'double mutant' from arriving. The B.1.617 variant has already been identified in British Columbia, Quebec and Alberta. "Variants of concern" now account for over half of confirmed COVID-19 infections in Canada, Friday's new modelling confirm.

In the Greater Toronto Area patient transfers are increasing, COVID patients being sent to other, less-crowded hospitals in Ontario to relieve some Toronto hospitals briefly, before even more patients arrive, as anticipated. Pregnant women are now being over-represented in Toronto hospitals with COVID, populating ICUs, requiring emergency C-sections. A new phenomenon has arisen where an average of two people a day die at home, becoming critically ill so suddenly there is no opportunity for them to arrive at a hospital.

 

Despite the Covid-19 surge, crowds have been allowed to gather for Kumbh Mela in Haridwar, India. Photograph: Anushree Fadnavis/Reuters

 

Word of a "triple mutant" virus detected now in India has turned the heads of virologists and infectious disease specialists. There is speculation, but no hard data available, about how these variants behave together, or on the background of other mutations. The variants all carry an alphanumeric soup of mutations, some more threatening than others. B.1.617 is imbued with several mutations shared by other variants shown to have a measure of antigenic escape; in other words the capacity of a virus to evade its host's immune system.

The situation is so grave it is imperative that vaccinations be sped up by all necessary means. Complicated by the reality that vaccines are in short supply, thanks to the incompetence of the federal government that chose early on to do business with China, until that fell through and vaccines had to be sourced elsewhere, late in the game, through more infinitely reliable venues. Masking, distancing and all other infection prevention control measures continue to be in mind of everyone in an effort to control as much as possible, the trajectory of the coronavirus surge.

 

A patient with breathing problems is seen inside a car while waiting to enter a COVID-19 hospital for treatment   Reuters

 

Deaths are known to be under-reported in India, with infections likelier to reflect three million per day, than the official tallies. Space to cremate people is no longer so readily accommodated; there are simply too many to deal with. The vaccination programs are not proceeding as speedily as they should. Vaccine production in India has run into difficulties with the emergence of a scarcity of supplies for which they have turned to the U.S. to expedite the materials needed, held there in greater abundance. India is no longer releasing vaccines outside their interior emergency, and the U.S. is reluctant to release materials they may themselves need. A deadly spiral.

Entire families are becoming ill, the young being infected along with all others in India, and similar reports are beginning to come out of Ontario, with entire families arriving at hospitals with COVID. People in their 30s or 20s in intensive care. Natural acquired immunity may not be adequate in protecting from the new variants, Dr. Pai worries. "But we really need to see this as a global problem. If you have fires raging in India, or Brazil, or somewhere else next month, we will never get out of these pandemic cycles."

A mass cremation of victims who died due to the coronavirus disease (COVID-19), is seen at a crematorium ground in New Delhi   Reuters

Vaccination Imperatives, DRC

"Ebola is not the only epidemic the country [Democratic Republic of Congo] is experiencing, nor is it the most deadly."
"If the question is how come, with this effective vaccine [Ebola vaccine], we haven't been able to stop it, I think the answer is that it's not getting to the right people at the right time."
Dr.Seth Berkely, head, global vaccine alliance GAVI

"Due to the lack of sufficient scientific evidence on the efficacy and safety of other vaccines as well as the risk of confusion among the population, it was decided that no clinical vaccine trials will be allowed throughout the country."
DRC Ministry of Health

"There are areas where surveillance is weak, mainly because of insecurity. So sometimes the virus gets into a locality relatively undetected. Right now we are chasing the virus as it moves from place to place. What's important is to take a more structured approach that looks at the things that are stopping the public health response from happening."
"As we step up our engagement with communities, including by listening to their needs beyond Ebola and finding ways to meet them, we are seeing some of the reticence to the response ease."
"This will take time in some areas that have historically been distrustful of outsiders. We are making progress, but need to do more. The virus will find a way to continue to replicate if we don't have all the holes plugged."
United Nations (UN) Ebola response coordinator, David Gressly

A Ugandan health worker administers an Ebola vaccine to a child in Kirembo village, near the border with the Congo in Kasese district, Uganda in June 2019. (James Akena/Reuters)

Recently returned from the Democratic Republic of Congo, Dr. Berkeley muses over the fragile state of circumstances in the country, wracked with the results of never-ending conflict and Islamist terrorist attacks by Boko Haram -- which have placed ongoing stress on the ability of a government newly-awakened to the imperative of vaccinating the nation's children to prevent not only Ebola but but other vaccine-preventable diseases that have taken their deadly toll on vulnerable children.

This year in the DRC there has been a 700 percent increase in measles cases, the cause of 2,000 deaths, a public health crisis that has been overlooked, while the fear of Ebola takes centre-stage. The government of the DRC declared the absence of routine immunization in the country represents a health emergency as it initiated an aggressive program to launch a new program aiming to inoculate a greater number of children against a hitherto-overlooked health threat.

The Ebola epidemic overwhelming the country at the present time was declared recently by the World Health Organization to represent an internationally concerning health emergency. The current DRC Ebola epidemic is considered a case study in vaccine limitations where even the most reliable tools cannot function in the absence of public trust -- notoriously weak in the Democratic Republic of Congo.

Vaccine-preventable diseases rising world-wide, might see health authorities looking to the DRC as a learning opportunity in how such emergencies are to be handled for greatest effectiveness in other countries, with particular emphasis on the vital necessity of high vaccination rates alongside allied fundamentals of public health. Putting the DRC in the spotlight as a literal living laboratory in handling this kind of health emergency.

The vaccine most successfully utilized to date, developed in Winnipeg, Manitoba, which was tested during the last major such epidemic has been the most reliable, yet even so the vaccine alone cannot solve the growing problem of infection. Officials harbour fears that Ebola will spread more rapidly if it becomes established in the east, close to the border with Rwanda; up to 40 percent of new cases are turning up in the community of Goma, indicating further spread remains a real risk.

Ebola has killed 1,700 people thus far, and adding that to the rise of diseases like measles and an impending crisis in the public health system of the DRC looms, resulting from the population's endemic mistrust of health and other officials operating the country's public health system. Heroic efforts have now been recognized in the DRC where 180,000 people have been vaccinated in relatively short order, with another 460,000 doses of vaccine available.

This, in a nation afflicted with ongoing violence, conflict and mistrust. Islamist terrorist groups have inflicted countless attacks on health workers, making their work more dangerous and difficult. Still, according to Dr Berkley, the Ebola vaccine has ensured the outbreak has been prevented from reaching the point of "spinning out of control". Without the vaccine the current outbreak would in all probability become even more serious than the West African Ebola epidemic that killed over 11,000 people in 2014-16.

A second crisis has emerged, however, even as the Ebola epidemic continues to fester, with measles and cholera outbreaks.

More than 110,000 people in the Democratic Republic of the Congo have received an experimental Ebola vaccine, which appears to have helped slow spread of the deadly virus.

World Bank/Vincent Tremeau (CC BY-NC-ND)

Hypothesizing Teen Anguish

"What we found was that yes, incidents of self-harm are increasing, and so are emergency department visits with mental health concerns."
"But I don't think any of the study team members expected such a dramatic rise from 2009 to 2017."
"Engagement with social media could lead to increased rates of self-harm, at least for vulnerable adolescents. This could happen in several ways: by normalizing self-harm, by triggering it, by getting teens to emulate self-harming peers, or by exposing youths to cuber bullying."
"We have hundreds of kids coming to Ontario emergency departments with these problems. The rate is going up every year. The rate is not slowing down."
"But the number of child psychiatrists at CHEO [Children's Hospital of Eastern Ontario, Ottawa] and child psychologists hasn't changed over that period. The number of emergency department personnel hasn't changed. That is really a problem."
"Efforts should be made to increase the supply of and access to evidence-based treatments for adolescents who self-harm or have mental health problems."
"Where possible, it's important to deliver these services to youth before they need to come to an emergency department."
Dr. William Gardner, senior scientist, CHEO Research Institute

CHEO emergency entrance. Wayne Cuddington / Postmedia

The trend toward teenagers turning to self-harm as an expression of their mental health needs being unanswered by health services represents a challenge to any society. Obviously, understanding the motivation or the pathology behind this trend of teens self-harming should be recognized as one of urgent need, both for the medical community and society at large to involve themselves in, since the cost to young peoples' mental health is so grievous and the loss to society of well-adjusted youth is increasing should mark this as a health emergency.

Research, led by Dr. William Gardner and published in the Canadian Journal of Psychiatry, points out that self-harming teen episodes have over-doubled between 2009 and 2017. What, however, is the driver? And until that is understood and measures taken to ameliorate the situation, it is more than obvious that the condition will continue and continue to accelerate. Teens reacting to unidentified stressors have been cutting or poisoning themselves and they are recognized as being at risk for repeated self-harm, and possibly suicide attempts.

There are hints of the increase in self-harm being coincidental in timing with the iPhone's introduction, leading to the ubiquitous use of smartphones in society in general, and among young people in particular. Canada saw iPhones being sold from the summer of 2008 onward and the suspicion among many is that this marked the beginning of increased self-harm among teens. The increased use of iPhones appears to have matched the increase in teens self-harming, according to the research hypothesis.

"Having all these phones in your pocket could be very difficult" for teens who are self-conscious about their social status or appearance to begin with, making them more vulnerable to facing social rejection or being emotionally bullied on-line. The other side of the equation, suggested Dr. Gardner, was that some emotionally unstable youths could benefit through social media, providing them with a venue away from social isolation, encouraging them to look elsewhere for validation, or even realize that they could benefit from health treatment.

The research was based on data retrieved from emergency departments province-wide, between 2003 and 2017, relying on data revealing a trend seen at hospitals and in communities increasingly in recent years.  Rates of youth emergency visits for self-harm happened to decrease by 32 percent between 2003 and 2009, and then swerved dramatically upward by 133 percent between 2009 and 2017. Mental health visits to hospital emergency rooms increased by 78 percent between 2009 and 2017 for all youths, while those linked to self-harm and mental health visits were higher for females, increasing more steadily than for males.

The findings, according to Dr. Gardner, a professor of epidemiology at University of Ottawa, and senior research chair for child and adolescent psychiatry, raise concerns relating to treatment for adolescents who present at emergency departments with mental health issues, where those departments are not equipped to deal with the needs of the teens due to a shortage of appropriate medical personnel. A shortage echoed by child and youth mental health workers province-wide.

As far as the researchers are concerned, emergency departments which represent the first contact in mental health issues for families do not present as an ideal setting for adolescents in crisis, requiring mental health services. Mental health followup through community-sourced medical care where the needs of self-harming teens are the focus remain the most effective source of help. Such followups have been identified with a reduced chance of repeat self-harm by teens, speaking to the success of such community health groups whose critical shortage disadvantages the growing numbers of teens in need.

The Imbecility of Paramedic Abuse by Patients

"I find that the worst cases of abuse don't leave a wound. It is the sexual assaults that are the most frustrating because it is often not brought on by people in an altered mental state, such as dementia, but by people who are disgusting."
"Most often drunks, who don't believe women should be in uniform and don't respect them in the field."
"I don't get too bothered by stuff [exposure to insults, violence while on the job]. And if that person was in an altered state when something happened -- then I honestly don't think twice about it afterwards, because they have absolutely no idea what they are doing."
"I see people on their worst day. Even if it isn't something we'd consider an emergency -- it is that person's emergency -- and if we can make that day even a little better, that's the high of doing this [job as a frontline first-responder as a paramedic]."
Jennie Cubitt, paramedic, rural Ontario

BBC News   Paramedic Jerry Patton had a brick thrown at him while he was treating a patient

Canadian society is hugely dependent in times of urgent medical situations, on the knowledge that they can dial a simple set of three numerals -- 911 -- to alert professionals skilled in the medical sciences and the art of patient care, to their emergency. They do so out of desperation, finding themselves in a situation they cannot themselves either solve or help themselves out of. If it isn't the individual themselves who calls, then it is an onlooker, someone else who recognizes the gravity of the situation.

Once that call is made, another trained professional at the other end of the telephone line asks critical questions and guides the caller, based on the response to those queries, how to act until the brief moments pass when an ambulance will respond to their emergency and the paramedics in charge of that ambulance will efficiently and expertly take over all the necessary reactions in response to the critical health/medical situation; the results of an accident, of the onset of a health crisis, a violent assault; whatever has occurred.

The paramedics come to the situation prepared in every conceivable way. They are experienced, having faced many and varied situations to which they have previously responded. They are exquisitely trained in medical procedures. Their vehicle is equipped with high-tech medical and diagnostic machinery, as well as drugs and medications which most medical emergency situations may call for in the perhaps desperate, interim treatment of a patient, until arrival at a hospital emergency department.

Paramedics have witnessed and been engaged in aiding the most vulnerable people caught in medical emergencies, and this continual exposure cannot help but have a traumatizing effect on their sensibilities. But these highly trained, socially and emotionally motivated professionals take as much as they can in stride and forge on, knowing that their response can be critical to whether or not a child or an adult, victims of accidents or health breakdowns, survive an episode in their lives requiring aid.

So it comes as something of a shock to be informed that these selfless, dedicated professionals are on occasion subjected to verbal and/or physical abuse; contempt for them as human beings, and belittling as health professionals, even while they are in the process of aiding the individual determined to inflict abuse on them. In an interview with a writer for the National Post newspaper, Joe O'Connor, Jennie Cubitt speaks of being kicked, punched and bitten.

She has been physically beaten, resulting in black eyes, split lips, as well as having been humiliated and assaulted sexually, even by those she has been administering life-saving protocols to. She ventilates on occasion by posting some of her miserably adverse experiences on a social media platform, popular with health-care workers such as doctors, nurses and paramedics, worldwide.

The Sun.Co.UK

Heidi, 29, was sexually assaulted by a 75-year-old patient in the back of her ambulance

A 2010 survey of over 1,300 paramedics from Ontario and Nova Scotia  reported that 26.1 percent of respondents had been subjected to physical assaults in the year previous to the survey, with over 40 percent speaking of having been physically intimidated, while close to 70 percent were verbally abused and 2.7 percent were victims of sexual assault. Drexel University in Philadelphia conducted a study in 2015, finding paramedics more than a dozen times likelier to be injured by a patient than a firefighter would be on the job.

Paramedics do have a right to defend themselves, but they will be charged with assault should they fight back. It's difficult to imagine how one might defend oneself without fighting back, actually. Yet, according to Jennie Cubitt, the prevalence of assaults against paramedics is vastly under-reported. Mot considering it, with a mental shrug, as 'part of the job', a situation she feels " . . . needs to be addressed".

In Australia, the situation of attacks against paramedics has become such a problem that the idea of body cameras was considered. The 12-hour shift is hugely stressful, and for obvious reasons, apart from the prospect of being assaulted while on the job. Yet these are the people that society depends hugely upon to respond in a timely and efficient manner, using their skills and their experience to bring people in desperate situations out of their most immediate danger.

"Nobody wants to go to work worried about being attacked," says Leeds paramedic Richard Bentley (Photo: John Gladwin/Sunday Mirror)