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Global Health, Health Policy, Infectious Disease, Research, Stanford News

Building the case for a national hepatitis B treatment program in China

Building the case for a national hepatitis B treatment program in China

An estimated 100 million people in China are living with chronic hepatitis B infection, making it the most prevalent life threatening disease in the country. If left untreated, hepatitis B can lead to serious liver damage and is the leading cause of liver-related cancer and deaths in China. Despite the availability of effective therapies, there is no national policy in place to cover hepatitis B treatment and many patients, particularly those with rural health plans, can’t afford it.

Now, in the first comprehensive, independent study of its kind, researchers at Stanford and the University of Michigan have published a cost-effective analysis of all available treatments – branded and generic – for chronic hepatitis B in China. The analysis, published today in PLOS ONE, quantifies the economic value and potential life-saving benefits of implementing a national treatment strategy in China.

If China can successfully treat hepatitis B, the rest of the world will follow

The paper is also the first to provide cost thresholds, meaning the specific price point at which a particular drug would be cost-effective or offer cost-savings.

“Health insurance programs in China don’t always cover the most effective medications,” said Stanford research associate Mehlika Toy, PhD, lead author of the study. “In comparing the potential cost-effectiveness of all available treatments, we aim to provide policy-makers in China with the evidence to support the development and implementation of a viral hepatitis treatment program, and information to help support drug pricing negotiations.”

In their analysis, the researchers compared eight different treatment strategies using a statistical model to simulate disease progression and long-term health outcomes. The analysis evaluated chronic hepatitis B patients who had not received prior treatment, but would be eligible for treatment under current international and World Health Organization guidelines.

Costs were determined based on estimated medical management and related costs associated with disease complications, such as cirrhosis (scarring of the liver) and liver cancer, as well as generic and brand drug costs.

The findings showed that certain therapies performed better than others and that not treating at all resulted in the highest health care costs and the worst health outcomes, compared to other strategies. For example, it was shown that 65 percent of non-cirrhotic patients with active hepatitis associated with high virus concentrations (HBeAg positive) would die of hepatitis B-related liver disease in their lifetime if not treated. Alternately, approximately 60 percent of those deaths could be averted if treated with one of two highly potent, low-resistance drugs, entecavir and tenofovir.

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Events, Global Health, Health Policy, Public Health, Stanford News

Using innovation to improve health in the developing world

Using innovation to improve health in the developing world

Ramano RaoHow can Silicon Valley-style know-how help improve health and lift up the lives of the poor in the developing world? That question was the focus of a panel discussion among four distinguished speakers last week at a Stanford conference on global development and poverty.

Panelist Ramana Rao, MD, described one technologically-based solution he helped develop with colleagues in Hyderabad, India:  a 911-type emergency care system which now serves some 750 million people across the South Asian country.

Though the system, users can call a single number – 108 – to summon an ambulance and team of skilled providers who can provide treatment en route to the nearest hospital.  The system, a public-private partnership known as GVK EMRI (Emergency Management and Research Institute), uses advanced call center technology, in which trained operators typically respond to calls within the first ring and relay them immediately to paramedics and emergency medical technicians on ambulances in the field, Rao told an audience of more than 200 people at the Stanford Graduate School of Business.

The system uses Google maps to help quickly locate patients. And the designers have introduced a mobile device app, which can be easily downloaded to call the service and which can be used to track the location of a caller during the first hour, the critical “golden hour” for treating trauma patients, he said.

Panel moderator Paul Yock, MD, PhD, noted the system is far more effective than the fragmented, 911 emergency system in the United States. “It’s a marvelous example of technology leap-frogging what we do here in this country,” said Yock, founder and director of Stanford Biodesign.

The Indian system was made possible in part by the soaring popularity of cell phones in India, used by 950 million people, including the poor.

“The mobile phone has been the most transformational technological advance in the developing world in the last 15 years,” noted panelist Rajiv Shah, MD, administrator of the U.S. Agency for International Development.

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Global Health, Health Costs, Health Policy, Research, Stanford News

A new framework for expanding treatment guidelines for parasitic worm diseases

A new framework for expanding treatment guidelines for parasitic worm diseases

Schistosomiasis outbreakA new health economics evaluation unveiled last week shows historical World Health Organization treatment guidelines for the two most common parasitic worm diseases are far too restrictive, and it provides a framework for the necessary expansion of global treatment programs.

The findings were presented by Nathan Lo, a third-year Stanford medical student, at the American Society of Tropical Medicine and Hygiene Annual Meeting in Philadelphia, which convened infectious disease experts from around the world to share the latest scientific advances in tropical medicine and global health.

These diseases – schistosomiasis and soil-transmitted helminthiasis – are caused by tiny worms found in water and soil that can cause severe discomfort and even death after coming into contact with humans. Together, they infect some 1.5 billion people in the developing world.

The medications to treat these diseases are cheap and highly effective, but there’s a large unmet need in treatment. Under the current WHO guidelines, treatment is focused upon school-aged children living in high prevalence areas. These guidelines have been largely unchanged for nearly a decade and leave many infected people untreated.

“The prevalence thresholds that have defined mass drug administration for nearly a decade were developed based upon expert opinion, but they are not based on rigorous scientific evidence,” said Lo. “We are urging the WHO to consider lowering the current thresholds and expanding global treatment programs.”

Stanford’s Jason Andrews, MD, the senior author of the study, Lo and colleagues have proposed a new framework for determining the optimal treatment strategy – who to treat, how often, and with what medicines – based on prevalence thresholds in a specific community using economic modeling. The findings show that expanding mass drug administration in communities with much lower disease prevalence would not only be cost-effective, but would result in improved quality of life, reduce re-infection rates and lower disease intensity. If adopted, this would result in a five-fold increase in the number of people who would receive treatment in sub-Saharan Africa alone.

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Global Health, Pediatrics, Public Health, Rural Health, Stanford News

Helping newborns through song

Helping newborns through song

Instead of drugs or fancy devices, a small village in India is using dhollak and dafali — drums traditional to the region — to spread awareness about post-natal care and to battle infant mortality. As Becky Bach explains in the latest issue of Stanford Medicine magazine, the effort started as part of a public-health research project led by researchers Gary Darmstadt, MD, and Vishwajeet Kumar, MBBS, who partnered with community leaders in an effort to communicate evidence-based health practices:

In a groundbreaking endeavor, [Darmstadt’s] team worked with communities to slash newborn mortality by 54 percent in less than two years in a large, impoverished area in northern India called Shivgarh.

Their strategy was simple, in principle: embrace the local culture, seek to understand its newborn-care practices, and partner with the community to translate evidence-based recommendations into meaningful communications — metaphors, songs — that could change behavior.

“Songs have traditionally played a key role in the community as a medium for transferring cultural knowledge inter-generationally and within groups,”  Vishwajeet Kumar, director of the Community Empowerment Lab in Shivgarh, told me. In the above video, a group of women, some holding infants, sing about the importance of skin-to-skin care:

Pregnant women and mothers-in-law, who play a critical role in perpetuating the community’s childbirth traditions, were shown how to provide skin-to-skin care, a simple practice that involves placing the bare-skinned baby on the caregiver’s skin, providing love, warmth and access to nourishment. The practice produces immediate, tangible benefits: It improves babies’ color and temperature, and reduces crying and startle responses. The villagers interpreted these signs as the absence of evil spirits, reinforcing their willingness to embrace the change.

A talented local songwriter named Santosh Kumar is responsible for many of these songs, which combine global knowledge with local wisdom, said Vishwajeet Kumar. He works in collaboration with the community to organize gatherings where important early care practices, from sanitation to breastfeeding, are conveyed through his songs.

The story of Shivgarh is a reminder that sometimes health is about more than doctors and big facilities. Sometimes the final puzzle piece can take the form of knowledge and a dedicated community.

Lindzi Wessel is a former neuroscience researcher and current student in the UC Santa Cruz Science Communication Program. She is an intern in the medical school’s Office of Communication and Public Affairs.

Previously: Stanford Medicine magazine tells why a healthy childhood matters and Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival

Ebola, Events, Global Health

From bedside to patient: an Ebola survivor’s remarkable journey

From bedside to patient: an Ebola survivor's remarkable journey

Crozier in Sierra LeoneWhen Ian Crozier, MD, volunteered to treat Ebola patients in West Africa last year, he couldn’t possibly have imagined that he would become a case report in the New England Journal of Medicine and a living example of the serious, long-term consequences of Ebola infection.

Crozier described to a Stanford audience last week his extraordinary journey of survival from Ebola infection after suffering a shutdown of his vital organs and several hemorrhagic strokes.

“If I you had told me on day one that I would develop multisystem organ failure and asked me to predict my chances of survival, I would have said my chances were zero,” he told a School of Medicine audience of more than 100 people. “They [the Emory caregivers] really changed the game… I really think they were walking on the moon, but in a different kind of space suit.”

Crozier, who was a World Health Organization volunteer physician in Sierra Leone, was evacuated to Emory University Hospital in Atlanta, where he spent 6 weeks undergoing intensive treatment. As he began to recover from the infection, he had to relearn some basic functions, such as walking and talking.

Two months after he was discharged from the hospital, he was beset by serious eye problems and was found to be harboring billions of viral particles in his left eye. The infection also left him with some hearing loss and ringing in the ears, sleep issues and some neurologic complications, including seizures and short-term memory loss.

But none of this was apparent during his talk, in which he delivered a detailed, rapid-fire discussion of his remarkable medical journey.

“It must be odd to hear me talking about my own case… in what may seem a detached manner,” he told the audience. “This was not theoretical. I’m standing here, and I’m alive, and yet I’ve described some of the worst disease we’ve seen with Ebola.”

Colin Bucks, MD, a Stanford emergency physician who was a volunteer in Liberia during the Ebola crisis, says Crozier’s experience has given him a new perspective on how best to treat infected patients. Previously it was not standard practice to put patients on ventilators or dialysis machines, as Crozier was, as these were considered impractical and ineffective.

“It made me endorse the aggressive treatments that were previously considered futile,” Bucks told me during Crozier’s visit to Stanford. “So I consider his case pivotal in the way we view this disease.”

Crozier’s visit was sponsored by the Stanford Center for Innovation in Global Health, Stanford Immunology and the Stanford Medical Scientist Training Program.

Previously: Ebola: It’s not overBack home from Liberia, Stanford physician continues to help in fight against EbolaStanford physician shares his story of treating Ebola patients in Liberia and Experience from the trenches in the
Photo, of Ian Crozier with children in Sierra Leone, courtesy of WHO

Global Health, Podcasts, Public Health

It all comes down to truth: Stanford med student digs in on public-health campaigns

It all comes down to truth: Stanford med student digs in on public-health campaigns

While interning in the World Health Organization’s media unit in Delhi this summer, Stanford medical student Michael Nedelman found himself contemplating a question many public health officials and advertisers have struggled with for years: What makes an effective public-health campaign?

Much of the global burden of disease is associated with behaviors that are recognized as being detrimental to health, but – as Nedelman points out in an editorial called Fire with Fire – our current approach to public-health messages and health warnings doesn’t seem to be working.

Take smoking for example. In the 1990s, teen smoking was on the rise, despite the egregious statistics and daunting warnings that tobacco kills. But rather than scaring teens away from smoking, the national “truth” campaign took an unconventional approach. “Instead of dialing up the emotion of their ads, the truth campaign appealed to a different set emotional sensibilities, like humor, and let teens arrive at their own conclusions,” writes Nedelman.

In the editorial and three-part podcast episode (the first of which is above), Nedelman dissects the common “fear-based” trap that cause many public-health advertisements to fall flat and takes a deeper look at campaigns like the “truth” anti-smoking crusade that have been successful in changing behavior and compelling the public to care.

Nedelman is currently taking a year off from medical school to serve as the Stanford-ABC News Global Health and Media Fellow. Tune in for future episodes from his podcast series, Acoustic Nerve, here.

Rachel Leslie is the communications officer at Stanford’s Center for Innovation in Global Health.

Previously: A behind the scenes look at the Stanford-ABC News Fellowship in Media and Global HealthUN’s top health official: Anti-tobacco efforts can lead to better health “in every corner of the world”Study shows anti-tobacco programs targeting adults also curb teen smoking and Europe launches campaign to get young smokers to stop

Education, Global Health, Patient Care, Stanford Medicine Unplugged

From medicine to the mat: Learning self defense

From medicine to the mat: Learning self defense

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

cute karate girl“You hit me!” My sparring partner accused me from behind his hands. We were in a self-defense studio practicing what to do in a mugging situation.

At first I was supposed to mug my six-foot tall, athletically built male partner. He had no problem fending me off safely.

The trouble started when it was his turn to mug me. He stepped past my socially acceptable 3-foot bubble. I panicked. My legs crouched and I lunged forward. My palm drove into his nose.

The mugger stumbled back and suddenly he was my partner again, holding his face.

“Sorry, sorry,” I didn’t know what else to say.

He squared his shoulders and offered to try again. As long as I didn’t hit him.

I nodded, trying to get focused. I was here for a reason. Many reasons actually. It had been a goal of mine to gain some level of proficiency in martial arts since I was little. When I grew up to be five feet three inches and too small to donate blood, I gave up on that particular goal.

Then this summer I spent a month volunteering in a hospital in Uganda. I saw more there than I have had time to process. There were real-life miracles, like when a patient survived after arriving with a blown pupil and an epidural hematoma. There were tragedies that I don’t know if I will ever shake off, such as the small child who died during rounds. There were also preventable snafus, like when one of my fellow volunteers was mugged walking home.

I had decided there were some tragedies I could protect myself from. Additionally, I had taken a year off from medical school to write a novel. The protagonist in my novel is highly trained in martial arts and I wanted to do some field research. When I returned from Uganda, I decided to throw my weight into self-defense classes every Monday and Wednesday evening.

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Emergency Medicine, Global Health, Health Policy, Stanford News, Videos

A look at “India’s medical miracle,” the largest ambulance service in the world

A look at "India's medical miracle," the largest ambulance service in the world

A patient in shock arrives via ambulance at Gandhi Hospital in Hyderabad, India with a gaping wound in his right hand, blood spattered on his blue jeans and T-shirt. Emergency medical technicians wheel him into a dark room in the government-run hospital, where clinicians move quickly to irrigate the wound and pump fluids into the man, who appears to be in his 20s.

With luck, the patient might survive. Ten years ago, he would not have had a chance.

Thanks to some passionate philanthropists, businessmen and medical experts, India today has what we have long taken for granted in the United States: a modern, emergency 911-type system and a cadre of trained emergency responders who have helped save an estimated 1.4 million lives. Begun in 2005, it is now the largest ambulance service in the world and serves more than 750 million people in cities and villages across the Indian sub-continent.

I saw the system in action first-hand in August when I traveled to India, together with about 10 other faculty and staff from Stanford’s School of Medicine, including Dean Lloyd Minor, MD, to celebrate its 10th anniversary amid much color and fanfare. I was there to write a story about the new system for Stanford Medicine magazine.

Begun in August 2005 in the south Indian metropolis of Hyderabad, the service, known as GVK EMRI (Emergency Management and Research Institute), is operated as a public-private partnership, providing its services free of charge, mostly to the very poor. It is a remarkable achievement, given the diversity of India, with its 29 states and more than 120 major languages, and the bureaucracy and corruption that can sometimes impede progress in this vast country of 1.2 billion souls.

“It’s hard to fathom what this system has done in 10 years,” S.V. Mahadevan, MD, interim chair of Stanford’s Department of Emergency Medicine, told me while stationed in one of EMRI’s ambulances. “It could be regarded as one of the most important advances in global medicine in the world today.”

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Global Health, Pediatrics, Stanford News

Stanford Medicine magazine tells why a healthy childhood matters

Stanford Medicine magazine tells why a healthy childhood matters

cover 560 450
I’ve forgotten most of my childhood experiences – which is perfectly normal. But apparently my body remembers many of those experiences – and I learned while editing the new Stanford Medicine magazine that’s normal too. The fall issue’s special report, “Childhood: The road ahead,” is full of stories of researchers realizing the impact early experiences can have on adult health. Some of their discoveries are surprising.

“Some people think kids are protected by virtue of being kids. In fact, the opposite is true,” pediatric psychiatrist Victor Carrion, MD, told writer Erin Digitale, PhD, when she interviewed him for her story on the long-term effects of childhood trauma. Other writers found the same goes for other types of early damage: Kids are resilient but they also carry hidden scars.

The report also includes a Q&A with former President Jimmy Carter on discrimination against women and girls, which he considers the most serious human rights problem on Earth. The online version of the magazine includes audio of the Carter conversation.

Other highlights of the magazine’s special report include:

  • Go to bed“: An article on the devastating toll inadequate sleep takes on teens, with an update on efforts, including a Stanford project, to fix the problem.
  • When I grow up“: A report on the growing need for support of chronically ill children making the jump to adult care, and on the progress that’s being made.
  • Beyond behavior“: A story about a high school student’s return to health after an assault, and the new type of therapy that helped her.
  • Rocket men“: A feature about three rocket-combustion experts teaming up with a pediatrician to analyze the breath of critically ill children at warp speed.
  • Warm welcomes“: An article on blending Western medicine into traditional culture to reduce newborn mortality in the developing world.
  • Bad for the bone“: A quick look at a new way to study the toll of childhood disease on bones.

The issue also has an article on a surprising role for viruses in human embryos, as well as a report from India on how vision, investment and medical know-how has brought about an ambulance system — now 10 years old and one of the most important advances in global health today. The online version includes a video showing the ambulance system in action.

Many thanks to Lucile Packard Children’s Hospital Stanford, which helped support this issue.

Previously: This summer’s Stanford Medicine magazine shows some skin, Stanford Medicine magazine reports on time’s intersection with health and Stanford Medicine magazine traverses the immune system
Illustration from the cover of Stanford Medicine magazine’s fall 2015 issue by Christopher Silas Neal

Global Health, Health Costs, Health Policy, Stanford News

Pharmaceutical adventures in India

Pharmaceutical adventures in India

medication in IndiaIn the course of a recent trip to India, I developed some minor health problems and found myself doing what many locals do: consulting with a pharmacist. India’s cities are peppered with these modest little storefronts, some the size of a large closet, which sit along the street, the pharmacists stationed on a stool behind a counter awaiting customers.

The pharmacies are stocked floor-to-ceiling with a plethora of remedies for whatever ails the human body and spirit. My husband and I sought treatment for an affliction common both to travelers and local Indians, caused by contamination in food and water: diarrhea. Despite our best food precautions, we managed to contract a case of the runs after eating at a very elegant restaurant in Jaipur in the northern province of Rajasthan. When a dose of Lomotil did not prove entirely effective, we decided to turn to a pharmacist for advice, as my experience traveling abroad is that local practitioners often know best how to treat common local problems.

The pharmacist asked us several questions in perfect English: Did we have a fever? Any vomiting? Any stomach cramps? No to the first two, yes to the last. He radiated a sense of confidence. He then produced two sets of pills in silver and green packages. We were advised to take these twice a day. He also gave us an electrolyte replacement solution, to be mixed with purified water and consumed twice daily as well. The pills had names I did not recognize, so I largely took them on faith, explicitly following his directions. The total cost for both of us: the equivalent of $2.50.

“You actually behaved in many ways like a many locals would – like a person who doesn’t have easy access to a health-care provider,” Nomita Divi, program manager of the Stanford India Health Policy Initiative, told me recently when I related my experiences.

Divi took a group of Stanford students – one med student, one masters and two undergraduates – to India for 8 weeks this summer to study this very phenomenon: the role of pharmacists in healthcare delivery in India, where a dire shortage of physicians, particularly primary care physicians, severely limits access to care. These pharmacists often serve as first-line providers, she said. Some have formal training, but many do not and operate on the basis of experience, as the students observed this summer, she said.

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