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The Use of COVID-19 Prediction Models in Guiding Policy Decisions

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By Amanda Perofsky, PhD

Image by Arek Socha from Pixabay 

Models are essential tools for estimating biological aspects of pathogens, how diseases will spread, and the impacts of policies and interventions. Indeed, there is a two-decade history of utilizing mathematical and computational approaches for public health, particularly for preventing and controlling outbreaks of emerging pathogens and informing intervention strategies (Viboud et al. 2018). Recent examples include the 2009 H1N1 influenza pandemic and the MERS (2014-2016), Ebola (Western Africa: 2014-2016; Democratic Republic of Congo: 2018-present), and Zika (2015-2016) epidemics. Since the 2009 H1N1 pandemic, government agencies have organized infectious disease challenges to formally engage the disease modeling community and improve forecasting performance for both endemic and emerging pathogens, such as seasonal influenzadenguechikungunya, and Ebola. Soon after the novel coronavirus SARS-CoV-2 emerged in Wuhan, China in late 2019, researchers participating in the US Centers for Disease Control and Prevention’s annual challenge to predict seasonal flu activity mobilized to produce short-term forecasts of COVID-19 deaths for the United States. 

Mathematical and computational approaches are especially critical during the coronavirus disease 2019 (COVID-19) pandemic, due to uncertainties regarding biological and immunological aspects of SARS-CoV-2 infection, the logistical hurdles in accurately estimating COVID-19 infectionsprevalence, and mortality in communities, and the immense health, economic, and societal impacts of the pandemic. As a consequence, the COVID-19 pandemic has sparked efforts by numerous research groups to forecast cases, hospitalizations, and deaths and predict how public health interventions will alter epidemic trajectories. These models have significant policy implications as decision makers in government, public health, and health care seek to swiftly minimize cases and deaths, allocate limited medical resources, avoid hospital surges, and mitigate the socioeconomic upheaval caused by the pandemic. 

Models are inherently simplified versions of complex biological, epidemiological, and social processes and can vary widely in terms of methodologies, assumptions, uncertainties, conclusions, and policy recommendations. Various COVID-19 prediction models aim to capture epidemic dynamics from a global scale down to the resolution of countries, states, counties, or cities and are used to inform decision making on a range of time horizons, from days to weeks to months. 

The three main modeling and computational approaches for predicting COVID-19 epidemic dynamics include: 

1. SIR/SEIR compartmental models sort individuals into susceptible (S), exposed (E), infected (I), and recovered (R) compartments and use differential equations to dictate how individuals move through these compartments. Given the epidemiologic and virologic evidence for SARS-CoV-2 transmission from asymptomatic and pre-symptomatic people (Furukawa et al. 2020), many COVID-19 SIR/SEIR models subdivide the infected compartment into asymptomatic and symptomatic individuals. Hospitalized, ICU, and death compartments are also typically incorporated, as these are the main indicators that inform COVID-19 public health decisions. For example, researchers at Columbia University have built a metapopulation SEIR model to simulate COVID-19 transmission within and among US counties and to make daily and short-term projections of incidence, hospitalizations, and deaths. 

Modelers make assumptions concerning the number of individuals that initially fall into each compartment and the rate of flow between compartments. These flows are governed by different parameters, such as the period of time it takes one infected person to infect another person (“the serial interval”), contact rates between individuals, the average number of infections caused by one infected person (“the basic reproduction number” or “R0”), the rates at which different demographic groups recover and die, and whether protective immunity after recovery is long-lasting or waning. The values for several of these parameters were unknown at the beginning of the COVID-19 pandemic and remain difficult to quantify until we have more comprehensive surveillance data and knowledge concerning the SARS-CoV-2 transmission process. For example, the relative incidence of asymptomatic to symptomatic infections and whether asymptomatic infection confers protective immunity continue to be key uncertainties and affect the number of tests required for testing-based interventions. To minimize the impact of incomplete data and erroneous assumptions, modelers typically perform sensitivity analyses, in which they tweak initial conditions and parameter values across several model runs.

2. Agent-based models  (ABMs) use real-world data to create synthetic populations of individual “agents” (i.e., people) with realistic spatial and sociodemographic characteristics and then simulate disease spread in these populations over discrete time steps. Agent-based models examine the role of individual-level processes in generating population-level dynamics and are useful for modeling counterfactual outcomes in the face of complexity (Marshal and Galea 2015). However, like SIR/SEIR models, they are reliant on assumptions concerning the infection process and the timing and effectiveness of different interventions and policies, such as social distancing and stay-at-home measures. The Institute for Disease Modeling’s Covasim (COVID-19 Agent-based Simulator) incorporates age structure and population size, transmission networks in households, schools, workplaces, and communities, age-specific disease outcomes, and within-host viral dynamics to project cases and peak hospital demand. Northeastern University’s Global Epidemic and Mobility Model (GLEAM) is a hybrid SIR-ABM model that simulates 3200 subpopulations worldwide, and mobility between these subpopulations, to describe and project the spread of COVID-19 in the United States.

3. Curve-fitting/extrapolation models such as the Institute for Health Metrics and Evaluation (IHME) model, are statistical models that do not model the person-to-person disease transmission process itself. For example, the IHME model uses reported deaths for countries outside of the US where the COVID-19 pandemic has already hit. It then examines where the US falls on that mortality curve and applies statistical approximations to forecast future death counts, assuming that systematic variation across locations is due to the timing of social distancing measures and that other differences are explained by random effects. Unlike SIR/SEIR models and ABMs, statistical models are not reliant on difficult-to-estimate epidemiological parameters, such as R0. However, because they can only estimate the initial wave of cases, statistical approaches are not suitable for projecting longer-term epidemiological dynamics. Despite criticism from the scientific community concerning the validity of the curve-fitting/extrapolation approach for long-term projections and IHME’s forecaststhe White House has relied on the IHME model as a national guide for projecting peaks in deaths and hospital demands

Given the sparsity of data on SARS-CoV-2 transmission, the effectiveness of different public health interventions, and population behavior once interventions are relaxed, there are broad uncertainty bands in model projections, and even models with similar objectives and methodologies can produce disparate estimates. Some forecasting models assume existing interventions and population behavior will continue through the projected period whereas others make assumptions concerning how interventions and social distancing will change in the future. Thus, it is important for decision makers to not rely on a single model for projections and to understand the key assumptions underlying each model. Nicholas Reich, a biostatistician at University of Massachusetts Amherst, and colleagues have recently combined sixteen mortality forecasts from different disease modeling groups to produce national “ensemble” forecasts for one to four-week horizonswhich are released weekly by the CDC. Reich plans to start evaluating the accuracy of individual models so that more accurate models are weighted more heavily in ensemble projections. Though estimates for national models are now converging due to increasing data availability and an overall decrease in daily COVID-19 cases across locations, forecasts will likely diverge again in the coming weeks as social distancing measures are relaxed in many US states

Katriona Shea, a theoretical ecologist at Penn State University, and colleagues advocate a systematic approach beyond ensemble forecasts, in which contributions from multiple groups are leveraged to support decision making (Shea et al. 2020). Shea and colleagues’ proposed process entails applying formal expert elicitation methods to generate and synthesize ideas across multiple models and to share important insights among research groups. A decision theoretic framework is applied to account for uncertainties within and between models and to achieve well-defined policy objectives. Their research team was recently awarded a Grant for Rapid Response Research (RAPID) from the National Science Foundation to immediately implement this process to inform COVID-19 policy. By utilizing the many research groups already producing forecasts, this strategy should be straightforward to implement and produce more robust results from the existing process of CDC’s COVID-19 forecasting collaboration. 

The dynamic circumstances surrounding the COVID-19 pandemic and “patchwork” of highly-localized outbreaks and government responses make it difficult for modelers to produce forecasts beyond a few weeks. Thus, there is a less coordinated effort to predict longer-term epidemiological dynamics. While the COVID-19 pandemic has increased interactions between modelers and decision makers, these interactions can be tense and difficult because social distancing measures are economically costly and policy decisions are not based solely on public health outcomes. Despite these challenges, models are essential for addressing questions related to disease spread and resource management. As the pandemic progresses, models should also play fundamental roles in supporting decisions related to triggering and relaxing social distancing and lockdown measures, the delivery of widespread testing, clinical trial designs, and vaccination strategies (Currie et al. 2020). 

Written by sciencepolicyforall

May 22, 2020 at 12:38 pm

Promoting well-being with Integrative Health Care

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By Prasanna Parvathaneni, PhD

Source: Osher Collaborative

In the current crisis of the Covid-19 pandemic, the significance of both scientific research, and science policies, towards human health are far more apparent than ever. Leading a healthy lifestyle of exercise and diet, boosting immunity, coping with stressful situations during the difficult times and combating the ailments to the best of our ability, all necessitate developing a holistic well-being. Integrative healthcare incorporates these aspects of whole person well-being through integrative medicine. Health policies play a key role in raising public awareness as well as promoting the quality of research in this area to make it a possibility for the society.  

What is Integrative Medicine

Integrative medicine (IM) is a healing-oriented medicine that takes account of the whole person, often including mental, emotional, functional, spiritual, social, and community aspects. IM combines complementary and alternative medicine (CAM) practices with conventional medicine. For example, using acupuncture to help with side effects of cancer treatment or using guided meditation as an adjunct to enhance postoperative recovery after cardiac surgery. In recent years, IM has gained prominence with support from respected research institutes, such as the U.S. National Institute of Health’s National Center for Complementary and Integrative Health (NCCIH) whose vision is that “scientific evidence informs decision making by the public, health care professionals, and health policymakers regarding the use and integration of complementary and integrative health approaches”. Similarly, Osher Collaborative for Integrative medicine, comprising of seven academic centers that possess unique and shared strength in the areas of research, education and clinical care, aims to “study, teach, and practice integrative medicine”.

To identify how IM can address chronic medical conditions, there are a number of privately and publicly funded research studies across the world that focus on specific aspects of complementary or alternative medicine in certain medical conditions like spinal injury, pain, depression, suicidal ideation, post-traumatic stress disorders, and epilepsy. In addition, there are some intervention studies that focus on the health benefits of meditation, like “Behavioral: Training for Awareness, Resilience, and Action (TARA)” conducted by Dr. Tymofiyeva’s group at University of California, San Francisco and “Brain Imaging Technology to Examine the Effects of Meditation” piloted by Dr. Lazar’s group at Massachusetts General Hospital using brain imaging.

What are the gaps

In spite of the above-mentioned efforts, IM is still not a well-known or widely adapted concept in public health. A survey from Pew research center from 2017, indicated that, “about one-third (32%) of U.S. adults say they have heard a lot about alternative medicine, and 54% say they have heard a little, while 13% say they have heard nothing at all about alternative medicine.” The report also indicated that “roughly three-in-ten adults have tried alternative medicine in conjunction with conventional medical treatment”.  

The World Health Organization (WHO global report on traditional and complementary medicine 2019. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO) reported global progress in traditional and complementary medicine (T&CM) over the past two decades. The review included contributions from 179 WHO Member States. It provided valuable information for policymakers, health professionals, and the public on the potential contribution of T&CM to health and well-being. The report consisted of five parts including national framework for T&CM, product regulation, practices and practitioners, challenges faced by countries and country profiles. For example, regarding challenges, the top five issues faced by 113 member states include lack of research data, lack of financial support for research on T&CM, lack of mechanisms to monitor safety of T&CM practice, lack of education and training for T&CM providers, lack of expertise within national health authorities and agencies. Member states in WHO regions of Americas are indicated to have made significant progress (in the period of 2005 and 2018) in the development of national policies, laws and regulatory systems for T&CM.

Role of public policy

Below are some initiatives that can integrate IM into patient care and promote public participation in leading healthy lifestyles:

  • Health insurance policies that incorporate integrative health care-related therapies
  • Public education programs on self-care in schools and workplaces.
  • Research studies on multimodal approaches using IM to inform policymaking
  • Collaborations between conventional and complementary approaches
  • Funding to encourage healthy lifestyle initiatives and to research that aims to foster whole person health along with disease control.

The best way to help people make healthy lifestyle changes is at the large-scale, population level through public health efforts and policy changes. The U.S. based Integrated Healthcare Policy Consortium (IHPC) is a broad coalition of healthcare professionals, patients, and organizations that advocates for an integrative healthcare system with equal access to a full range of health-oriented, person-centered, regulated healthcare professionals. 

What is the current state?

Osher Collaborative indicated that their “members are actively engaged in treating patients, publishing perspectives and developing research studies relevant to the COVID-19 outbreak”. John Weeks, an editor-in-chief of JACM, a writer, speaker and a change agent,  mentioned that it is good to see that NCCIH has developed an initiative to use IM to cope with stress during Covid-19 and is reportedly considering others, from an interview with Dr. Helene Langevin on NCCIH’s response to Covid19. He also highlighted divergent views of different governments on Complementary and Integrative Health and Medicine in a Call to Action on COVID-19 Support Registry. This registry was launched to document evidence on traditional medicine systems for stakeholders, including the World Health Organization, and to highlight the potential for these systems as integrative approaches for the COVID 19 crisis. 

In the Journal of Alternative and Complementary Medicine (JACM) commentaryDr. Patwardhan from the AYUSH Center of Excellence, Center for Complementary and Integrative Health at the Savitribai Phule Pune University, India recommended public health approach of Ayurveda and Yoga for covid-19 prophylaxis . A number of research papers were published related to the use of Chinese Traditional Medicine in combating Covid-19. IM can carefully evaluate these recommendations or approaches and look into ways on how they can be integrated with conventional medicine to improve quality of care through empirical studies. 

What’s in store for the future?

In the current crisis of Covid-19, it is important to develop a framework to incorporate IM into evidence-based, reproducible research using quantifiable health metrics. Over the next year, NCCIH is seeking input from its stakeholders to develop a fifth Strategic Plan, which will guide the Center’s research efforts and priorities over the next 5 years (Fiscal Years 2021–2026).  Such initiatives that include IM should be highly campaigned to bring awareness to the public and to encourage participation from diverse stakeholders. 

While advancements in scientific research play a significant role in improving quality of life, equally important is the role played by science policies, which transmit scientific knowledge and its uses for the common good. Drafting policies for the short- and long-term welfare of our population require tremendous care and commitment. Strong communication within and between scientific areas is key to develop integrative healthcare approaches and policies. In addition to encouraging research studies for disease management and control, policymakers, scientists, healthcare professionals should stress the importance of IM to promote a healthy lifestyle. 

I would like to thank my friends and colleagues in the field for sharing their insightful thoughts on integrative medicine:

I think it is in general very empowering to think about “the whole person” medicine approach, which is how I understand “Integrative Medicine”. This approach, I find, treats a person with more respect by considering all aspects of that person’s life, their emotions, values, behavior, relationships, social circles, etc. Instead of focusing on a very confined problem with a specific body organ, one looks at the person as a whole. Motivation to lead a healthy lifestyle is a natural consequence of this way of thinking.”  – Clinical Researcher and Meditator

Integrative Medicine harnesses the patient and requires his commitment to promote a healthier lifestyle as part of following medical advice in general. The patient becomes responsible and a key player in the treatment plan which in turns reflects on the patient’s self-esteem and sense of capability. This is a positive way to improve patients’ adherence to medical orders and utilize the effect of positive thinking as well as healthy lifestyle habits.” – Clinician

Written by sciencepolicyforall

May 15, 2020 at 1:45 pm

School-Based Health Education Works – But Fails to Meet Education Guidelines

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By Kristyn Kamke, PhD

Image by Gerd Altmann from Pixabay

A considerable burden of disease in the United States is attributed to 17 risk factors, including tobacco use, poor diet, alcohol and drug use, limited physical activity, and risky sexual activity. These risk factors represent modifiable health behaviors, highlighting an opportunity to prevent leading causes of disability and death, including cancer, heart disease, and diabetes. Studies show that primary prevention, which refers to intervention prior to the onset of a health problem, not only provides the optimal chance of reducing disease incidence but is also more cost-effective than secondary or tertiary prevention (i.e., intervention at early stages of a health problem or management of an existing health problem to slow or stop progression, respectively). Health risk behaviors typically begin in adolescence, establishing childhood and early adolescence as prime developmental stages to implement primary prevention strategies. Given children and adolescents spend an average 7 hours per day in school on 181 days of the year, school-based health education serves as one of the most common, effective, and opportune methods of primary prevention. Unfortunately, many state- and school-level health education policies and/or implementations fail to meet established guidelines, limiting the overall health impact of school-based health education.

Health education is a theory- and research-based academic subject, which imparts health knowledge onto students, encourages them to develop skills in behavior maintenance and change, and models healthy behavioral norms. The National Health Education Standards advise students in grades 3-12 receive 80 hours of health education per year, amounting to about 27 minutes per day each school year. In 45 states and DC, health education is required every year from elementary school through high school, and health education is either recommended or required for some grade levels in the remaining 5 states. This requirement is based on research showing that establishing and maintaining health behaviors requires time and sustained education and practice to be effective. However, a Centers for Disease Control and Prevention (CDC) report on school health reveals that a median 49% of schools in each state required more than one health education course for grades 6-12 in 2018, suggesting students are receiving inadequate time for learning and practicing health behaviors. 

In addition to insufficient time spent on school-based health education, health education policies and implementation are not adequately comprehensive. According to researchers at Child Trends, only 30 states and DC have comprehensive health education laws (i.e., those that address at least 75% of recommended health education topics). Physical activity topics are most comprehensively covered (69.3%), whereas pregnancy, HIV, and STD prevention are covered at the lowest rate (17.6% for grades 6-8; 42.8% for grades 9-12). Some of the most neglected coverage areas for each health topic are those focused on skill development. Thirty-two states and DC require that health education includes health skills training, such as analyzing the influences of health behavior; accessing valid health information, products, services; goal-setting; decision-making; interpersonal communication; self-management; and advocacy. While educators report teaching these skills in health education, it is unclear to what degree students are able to practice them, a necessary component for establishing healthy behaviors. For example, teachers in only 60% of schools per state reported that students had the opportunity to practice sexual health skills (e.g., communicating with a partner about sex), the only topic area in which skill practice was assessed. 

Perhaps most alarming is the lack of requirements for an evidence basis for school-based health education. While a median 86% of schools provide information on goals, objectives, and expected outcomes of health education for teachers, only about 76% provide written health education curriculum, 65% provide guidance on the sequence of health education, and 67% provide plans to assess student performance. This lack of guidance is exacerbated by the fact that only 3 states require and 8 states recommend health education teachers have a certification in health education, and 15 states advise health educators pursue professional development training, although both certifications in health education and professional development training are associated with better student outcomes. Thus, it is unclear what education students are getting and if that education results in increased implementation of healthy behaviors. 

Implementation of health education without a supporting evidence-based foundation risks more than just failure to improve health outcomes — it can also make health worse. A notable example of this is the substance abuse prevention program D.A.R.E., widely implemented across the United States with little research backing. Subsequent evaluations of D.A.R.E. suggested that D.A.R.E., at best, had no effect on drug use behavior and, at worst, actually increased drug use, disproving the proverb that something is better than nothing. Unfortunately, the ability to implement evidence-based health education is limited by the dearth of evidence-based, comprehensive health education programs. Most extensively evaluated and efficacious health education programs target a specific health topic (e.g., tobacco use), with only 3 commercially available programs that cover multiple topics. Even if schools were financially able to acquire multiple health education curricula targeting individual health topics, difficult for schools who lack funds for health education, evidence would still be needed to support the sequence in which health education topics should be covered and whether multiple curricula can be effectively combined. Furthermore, comprehensive health education interventions are more efficient than those covering individual topics, given many health-related skills can be translated across health domains. This highlights an area in which researchers must intervene, to both aid in development and evaluation of comprehensive health education interventions. 

Schools are optimally positioned to engage in primary prevention of key health risk behaviors in the US through provision of health education to students. While states have embraced the necessity of health education, often recommending or requiring it, implementation of health education in schools has failed to meet many established guidelines, of which just a few are presented here. Discrepancies between state policy and school-based health education policy and implementation may be attributable to several factors, such as perceived lack of time for health education in already busy schools attempting to meet federal academic standards, lack of oversight from states to evaluate implementation of health education, unclear guidelines for educators responsible for delivering health education, or lack of funds to acquire evidence-based health education programs. Regardless of reason, traditional academic subjects, such as science or math, are prioritized above health education, which threatens the health of children and adolescents. However, academic achievement-focused goals should not preclude efforts to establish rigorous health education guidelines. In fact, academic achievement is bolstered by student health. The time has come to support health education as a vital element of education, providing students with the opportunity to live longer, more productive and healthier lives.

Written by sciencepolicyforall

March 6, 2020 at 3:54 pm

The Challenge of Global Health Diplomacy

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By: Somayeh Hooshmand, PhD

Image by Jukka Niittymaa from Pixabay

Improving population health is the central concern for all human societies. In the past, it was enough for a nation to take action on their own to improve the health of their citizens. In today’s globalized world, there aren’t any borders or walls for a wide range of health issues. Migration and mobility of people within and between countries around the world, the high volume of trade, the flow of information and the flow of capital across geographic boundaries can spread diseases (such as polio, anthrax, HIV/AIDS, SARS, pandemic flu) and threats of bioterrorism quickly, thereby affecting many countries simultaneously. Consequently, many health issues cross national borders and cannot be resolved by any one country acting alone and other nations cannot pull away from action. It requires a wide array of activities between nations as well as collaboration between many sectors (both governmental and nongovernmental) and better communication among nations to strengthen economic growth, national security, human dignity and human rights, human security, social development as well as environment. 

Global health is focused on achieving improvements in the health and well-being of all people worldwide, and involves many disciplines both within and beyond the health sciences. In today’s world, heath is tied up with foreign policy and policy makers often need familiarity with the different policies and ongoing international political diplomacy and negotiations to address crises. To this end, the Oslo Ministerial Declaration was drafted in 2007, by seven foreign ministers including Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand, to promote and discuss the importance of integrating health issues into foreign policy. In the declaration, it is clearly stated that “We believe that health is one of the most important, yet still broadly neglected, long-term foreign policy issues of our time…We believe that health as a foreign policy issue needs a stronger strategic focus on the international agenda. We have therefore agreed to make ‘impact on health’ a point of departure and a defining lens that each of our countries will use to examine key elements of foreign policy and development strategies, and to engage in a dialogue on how to deal with policy options from this perspective.”

In the 21st Century, health has become increasingly relevant to foreign policysecurity policy, development strategies. As each nation has its own constitutional, political and financial differences according to their own standards and circumstances, it has become clear that new skills are needed to conduct global health diplomacy and negotiations in the face of other interests. 

The direct or indirect effect of economic, socio-cultural, and political factors on health requires more diplomats to enter the health arena to interact with the non-governmental organizations and non-state actors, scientists, and activist groups. On the other hand, public health experts need to be trained and have the practice and experience of diplomacy. Both public health experts and diplomats need to interact more productively to create effective outcomes throughout global health negotiations to solve global problems. Global health diplomacy (GHD) aims to promote international cooperation in solving health problems. It can be defined in a number of ways, though overall it is defined as “multi–level, multi–actor negotiation processes that shape and manage the global policy environment for health”.  Global health diplomacy is of considerable importance not only in the discipline of foreign policy but also within other disciplines such as international law, politics, economics and management. However, the challenges in diplomatic negotiations and foreign policy which support global health goals are vast and diverse and are greatly in need of effective leadership and collective action.

One of the challenges in global health diplomacy is the lack of a shared goal and differing political priorities between nations in deciding which health issues should be included explicitly in national foreign policy. Countries attempt to link health issues to foreign policy and national security threats in order to receive significant political support and funding. International resources are generally limited and new funding and development assistance for health is difficult to obtain. Policy makers need to be educated in identifying a particular health issue as a national or international priority and determining its importance relative to other public health issues in order to avoid drawing resources away from health issues of global importance.

However, some health issues – particularly infectious diseases like poliomyelitis – are widely considered as global concerns and inserted into foreign policy issues for countries, but they are not a national security threat. Although addressing these issues is not rooted in a concern for their economic or security impact, they require sustained support and resources to achieve a global good.

Another challenge facing health diplomacy is while the health sector wants to focus its attention more on improving the conditions that allow people to be healthier, foreign policy places importance on national security and economic growth as its top priorities. The health sector must balance the fact that while health is their central goal, it is often not the central goal of foreign policy and can have a negative impact on foreign policy. Therefore, they can sustain engagement and trust among each other by finding mutual benefit in the context of global health goals. 

Although, several governments have placed health issues more prominently in foreign policy decision-making over the past decade, some non-democratic nations have placed little significance in incorporating health issues into their foreign-policy agendas. 

Global health diplomacy plays an important role in advancing human security and ensuring human rights and dignity by linking health and international relations. Human security is concerned with human freedoms and human fulfillment. However, some human security issues have remained a major source of human security violations in undemocratic regimes, like mass atrocities, human trafficking, torture and genocide, war, bioterrorism, environmental degradation, and public health crises. One of today’s global health diplomacy challenges on human security arises from the fundamental values differences in the political character of democratic and nondemocratic countries in negotiations. Some of the key values of democratic governments – like transparency and freedom, pursuit of happiness, justice, and equality – would naturally lead to an increase in human security. These core values differ extremely from the values of authoritarian governments which are based on compliance, coercion and propaganda. Therefore, these two regime types have very little in common and health diplomacy cannot lead to lasting agreement and peace in addressing human security problems. In global health, promoting democracy could improve population health and can contributed to a significant power shift within global health diplomacy.

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Science Policy Around the Web November 29th, 2019

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By Maria Disotuar, PhD

Source: Pixneo

To Drive Down Insulin Prices, W.H.O. Will Certify Generic Versions

Without insulin, a person with type 1 diabetes cannot survive, and the cost and accessibility to insulin continues to be a problem for individuals suffering from this incurable autoimmune disease. Diabetes mellitus is a chronic metabolic disease characterized by high blood glucose levels. There are two types of diabetes, Type 1 diabetes results from the loss of pancreatic β-cell function, resulting in an inability to produce insulin, a peptide-based hormone. On the other hand, Type 2 diabetes patients are resistant to insulin. Those suffering from Type 1 diabetes require daily insulin therapy to stay alive, and patients with type 2 diabetes require insulin therapy to maintain a healthy lifestyle. Currently, more than 400 million people worldwide have diabetes and this number is expected to increase in the coming years. The main problem being that there are no generic forms of insulin and the price for current insulin analogs has gone from approximately $20 per vial to $250 per vial depending on the type of insulin. This price increase over the past 20 years has made insulin unaffordable for many individuals particularly for younger generations of Americans struggling to pay student loans. For these individuals, seeing the price of insulin jump from $4.34 to $12. 92 per milliliter has meant rationing the lifesaving drug to the bare minimum – a deadly decision for some.

As a response to the growing demand for insulin and skyrocketing prices, the World Health Organization (WHO) has proposed a two year prequalification pilot project, which will allow pharmaceutical companies to produce generic insulin to be evaluated by WHO for efficacy and affordability. These types of pilot projects have been previously deployed to improve the accessibility of life saving drugs for malaria, HIV, and tuberculosis. These efforts have led to an increase in production and market competition leading to reduced costs for individuals.

Currently, the major producers of insulin, Eli Lilly, Novo Nordisk, and Sanofi have welcomed the prequalification program, vowing to be a part of the solution not the problem. According to WHO, companies in several countries, including China and India, have already expressed interest in the pilot project. This shift in insulin production would allow companies producing insulin domestically to enter the global market. As WHO-certified suppliers, these new competitors could dramatically drive down the price of insulin and improve accessibility on a global scale. Despite this positive global outlook, there are still some hurdles to cross for Americans to obtain these generic insulin products. The main one being that the pharmaceutical market is regulated by the FDA and the review process can be expensive for smaller companies. Nonetheless, Americans are fighting back to reduce the cost of insulin and other life savingdrugs, prompting lawmakers, presidential candidates, and the President to prioritize reduced drug prices for Americans. These mounting pressures will hopefully lead to a faster solution for this life or death situation.

(Donald G. McNeil Jr., The New York Times)

Will Microneedle Patches Be the Future of Birth Control?

In 2018, the The Lancet reported that between 2010 and 2014 44% of all pregnancies in the world were unplanned. Despite medical advances in sexual and reproductive health, new contraceptive methods are needed to expand accessibility and improve reliability for women. In the United States, the establishment of the Affordable Care Act (ACA) and health policies such as the Federal Contraceptive Coverage Guarantee, which requires private health plans to include coverage for contraceptives and sexual health services, has improved family planning for women of reproductive age. Despite the social and economic benefits of improved family planning and enhanced accessibility, conservatives continue to challenge these beneficial health policies. Unfavorable changes to these policies could result in major barriers for women to access some of the most effective, yet pricier forms of contraceptives such as intrauterine devices (IUDs) and implants. Studies show these long-acting forms of birth control are up to 20 times more effective in preventing unintended pregnancies than shorter-acting methods such as the pill or ring. Thus, new long-term contraceptives with reduced cost barriers would be essential in reducing unintended pregnancies and enhancing economic benefits on a global scale.

To address this issue, researchers at the Georgia Institute of Technology and University of Michigan in partnership with Family Health International (FHI) – a non profit human development organization, have developed a long-acting contraceptive administered by a patch containing biodegradable microneedles. The patch is placed on the surface of the skin and the microneedles painlessly come into contact withinterstitial fluid resulting in the formation of carbon dioxide bubbles, which allow the microneedles to detach from the patch within 1 minute of application. The needles themselves do not introduce a new contraceptive hormone, rather they provide levonorgestrel (LNG), which is regularly used in IUDs and has been deemed as safe and efficacious. After dissociation from the patch the needles slowly release LNG into the bloodstream. 

Thus far, the pharmacokinetics of the patches has been tested on rats and a placebo version has been tested in humans to test the separation process between the patch and the needles. The in vivo animal studies indicate the patch is able to maintain LNG concentrations at acceptable levels for more than one month and the placebo patch was well tolerated among study participants with only 10% reporting transient pain or redness at the site of patch application. Lastly, the researchers analyzed conceptions and acceptability of this new contraceptive method among American, Indian, and Nigerian women compared to oral contraceptives and monthly contraceptive injections administered by a physician. The results indicate women overwhelmingly preferred the microneedle patch method over the daily pill (90%) or monthly injections (100%). The researchers expect the patch to be simple to mass produce and a low-cost contraceptive option, which will reduce cost barriers and improve accessibility for women. Although the results of the study are promising, additional studies will have to be completed to address some of its limitations. Future studies will have to increase the number of animals used in the study and the number of human participants. Additionally, the release profile for LNG will likely need to be extended beyond 1-month to truly address the need for new long-acting forms of contraceptives. Finally, clinical trials will have to be completed to test the efficacy and general reliability of this method at reducing unintended pregnancies. If the microneedle patch is approved, it would be the first self-administered long-term birth control to enter the market, which could ultimately lead to enhanced accessibility for women with limited access to health care.

(Claire Bugos, Smisothian) 

Science Policy Around the Web – April 14, 2017

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By: Leopold Kong, PhD

Fatty foods: By Lucasmartin2 (Own work) [CC BY-SA 4.0], via Wikimedia Commons

Health Policy

Banning Trans Fats in New York Prevented Thousands of Heart Attacks

In an effort to lower the incidence of heart disease, the leading cause of death in the United States, the FDA will prohibit food manufacturers from using trans fats next summer. FDA’s decision was based on decades of research linking trans fat consumption with increased risk of heart disease. A study published this Wednesday in JAMA Cardiology provided further support for the ban. Using data from the New York State Department of Public Health, collected from 11 counties where trans fats restriction was recently implemented, the researchers showed a statistically significant decline in heart attack (7.8%) and stroke (3.6%) events since then. “The most important message from these data is that they confirm what we predicted — benefit in the reduction of heart attacks and strokes,” said the lead author, Dr. Eric J. Brandt, a fellow in cardiovascular medicine at Yale. “This is a well-planned and well-executed public policy.” With the rising cost of health care in the United States, the FDA’s long awaited trans fat ban is urgently needed to lighten the public health burden. (Leah Samuel, STATNews)

Vaccine Research

The Human Vaccines Project, Vanderbilt and Illumina Join Forces to Decode the Human Immunome

Rapidly evolving viruses such as HIV and Hepatitis C have been difficult targets for traditional vaccine development, in which inactivated viruses or viral proteins are used as vaccine components. Despite the success of small molecule therapeutics against HIV and Hepatitis C, an effective vaccine remains the most cost effective solution to curb the global pandemics caused by these viruses. Scientists now seek to optimize vaccine candidates based on a deeper understanding of host-pathogen interactions using multidisciplinary approaches, ranging from protein engineering and evolutionary biology to immunology and genetics. To facilitate these sophisticated efforts, the Human Vaccines Project, an international public-private collaboration, was established. A major initiative of the project, the Human Immunome Program, is led by Vanderbilt University Medical Center. Now, Illumina has joined the collaboration to help decipher the genetic features of the immune system, or the “immunome,” using cutting edge sequencing technology. DNA sequences from immune cells during infection may capture how the immune system adapts to viruses, providing guidelines for vaccine design. “Successfully defining the human immunome will provide the foundational knowledge to usher in a new era of vaccine, diagnostic, and therapeutic development,” says Gary Schroth, vice president for product development at Illumina. Greater understanding of the immunome may also lead to more effective cancer vaccines. (Human Vaccines Project)

 

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Science Policy Around the Web – February 21, 2017

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By: Rachel Smallwood, PhD

Obesity

Should We Treat Obesity Like a Contagious Disease?

Researchers are modeling obesity from a public health perspective as a contagious disease. There are many factors associated with obesity, including genetics, low levels of physical activity, and high caloric intake. An earlier study examined the effects of different social factors on an individual’s risk of being obese; it found that people with obese friends and family were at an increased risk for obesity, and this trend was influenced by how close the relationships were.

In this model of the prevalence of obesity, the researchers included a factor to represent obesity as a “social contagion”, reflecting those previous findings and indicating a potential increased risk and increased prevalence due to transmission from one person to another. This mechanism is assumed to be related to people adopting the behaviors of those close to them; notably, activity levels and type and quantity of food consumed. The model predicts obesity rates in populations with terms associated with the genetic contribution to obesity, the mother’s non-genetic contribution to her offspring, and the prevalence of obesity. Essentially, the more obese individuals there are in a society, the more likely it is for someone to know and interact with an obese person.

The models indicate that obesity prevalence plateaus around 35-40% without an intervention. The model is still fairly primitive, but the researchers hope that in future it could provide insight into the effects of potential interventions. For example, is it better to target an intervention to individuals who are already obese, or should the reach of the intervention be more broad and target the population as a whole? When the models reach a level of complexity comparable to the existing factors for obesity, they can be a powerful tool in preventing and addressing the epidemic. (Kelly Servick, Science Magazine)

Autism

Brain Scans Spot Early Signs of Autism in High-Risk Babies

A study recently published in Nature showed that alterations in brain development in children who go on to be diagnosed with autism precede behavioral symptoms. High-risk infants’ brains were scanned with MRI at 6, 12, and 24 months. It was determined that the infants who were subsequently diagnosed with autism had a faster rate of brain volume growth between 12 and 24 months. Additionally, between 6 and 12 months, these infants had a faster rate of growth in the surface area of folds on the brain, called the cortical surface.

Taking these findings, the research team used a machine learning approach called a deep-learning neural network to make a model to predict whether an infant would be diagnosed with autism based on their MRIs from 6 and 12 months. This model was tested in a larger set of infants, and the model correctly predicted 30 out of 37 infants who went on to be diagnosed (true positives), and it incorrectly predicted that 4 infants would be diagnosed with autism out of the 142 who were not later diagnosed (false positives). These results are much more robust than behavior-based predictions from this same age range.

More work needs to be done to replicate the results in a larger sample. Additionally, all of the participants were high-risk infants, meaning they had a sibling who was diagnosed with autism, so the results are not necessarily generalizable to the rest of the population. Further studies need to be done in the general population to determine if these same patterns are observable, but that would require an even larger sample due to the lower risk. However, the early detection of symptoms and prediction of diagnosis are potentially valuable tools, especially considering another recent publication showed that early intervention in children with autism affects the severity of symptoms years down the road. (Ewen Callaway, Nature News)

Science Funding

Ebola Funding Surge Hides Falling Investment in Other Neglected Diseases

Funding totals from 2015 reveal a trending decrease in funding for neglected diseases, excluding Ebola and other viral hemorrhagic fevers. Neglected diseases are diseases that primarily affect developing companies, thus providing little incentive for private research and development by commercial entities; the other diseases include malaria, tuberculosis, and HIV/AIDS. Given the recent surge of funding for Ebola research, the analysis firm, Policy Cures Research, decided to separate it from the other neglected diseases in its analysis to observe funding patterns independent from the epidemic that dominated the news and international concerns. Funding was tracked from private, public, and philanthropic sources.

The funding for Ebola research has primarily gone to development of a vaccine, and over a third of the funds were provided by industry. For the other diseases, the decline in overall funding is mostly represented by a decline in funding from public entities, primarily comprised of the governments of large, developed countries. Those countries accounted for 97% of the research funding for neglected diseases in 2015, so any significant change in that funding category would affect the overall funding amounts. However, there was also a slight decline in philanthropic funding. When including Ebola with the others, funding of neglected diseases was actually at its highest in the past ten years. It is not known whether money was funneled from the other diseases to Ebola research, or if this decline is indicative of less research spending in general. (Erin Ross, Nature News)

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February 21, 2017 at 10:03 am

Science Policy Around the Web – November 22, 2016

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By: Rachel Smallwood, PhD

Photo source: pixabay

Federal Research Funding

US R&D Spending at All-Time High, Federal Share Reaches Record Low

Recently released data from the National Science Foundation (NSF) showed trending increases in scientific research funding in the US across the past several years. Estimates of the total funding for 2015 put the value at an all-time high for research and development (R&D) funding for any country in a single year. In 2009, President Obama stated a goal to devote 3% of the USA’s gross domestic product (GDP) to research, and we have been making slow progress to that point; in 2015, 2.78% of the GDP went to research. Businesses accounted for the largest portion of overall scientific funding, contributing 69% of the funds. The second largest contributor was the federal government; however, it had the lowest percentage share of the total since the NSF started tracking funding in 1953, and the actual dollar amount contributed has been declining since 2011. Therefore, although the overall percentage of GDP going to research is increasing, that increase is driven by businesses, whereas the GDP percentage contributed by the federal government has dropped to almost 0.6%.

When taking a closer look at types of research, the federal government is the largest funding source for basic science research, covering 45% of the total. However, businesses make up the majority of the funding for applied research (52% in 2014) and experimental development (82% in 2014). This disproportionality in funding types combined with the decreases in federal research spending are concerning for the basic science field. There is more competition for less money, and this concern is compounded by uncertainty and questions about President-Elect Trump’s position on and plans for scientific funding. Aside from a couple of issues, primarily concerning climate change and the environment, he has said very little about science and research. Many scientists, institutions, and concerned citizens will be watching closely to see how science policy develops under Trump’s administration and its effects on federal spending and beyond. (Mike Henry, American Institute of Physics)

Biomedical Research

‘Minibrains’ Could Help Drug Discovery for Zika and for Alzheimer’s

A group of researchers at Johns Hopkins University (JHU) is working on a promising tool for evaluating disease and drug effects in humans without actually using humans for the tests. ‘Minibrains’ are clusters of human cells that originated as skin cells, reprogrammed to an earlier stage of development, and then forced to differentiate into human neural cells. They mimic the human brain as far as cell types and connections, but will never be anywhere near as large as a human brain and can never learn or become conscious.

A presentation earlier this year at the American Association for the Advancement of Science conference showcased the potential utility for minibrains. A large majority of drugs that are tested in animals fail when introduced in humans. Minibrains provide a way to test these drugs in human tissue at a much earlier stage – saving time, money, and animal testing – without risking harm to humans. Minibrains to test for biocompatibility can be made from skin cells of healthy humans, but skin cells from people with diseases or genetic traits can also be used to study disease effects.

A presentation at the Society for Neuroscience conference this month demonstrated one such disease – Zika. The minibrains’ growth is similar to fetal brain growth during early pregnancy. Using the minibrains, Dr. Hongjun Song’s team at JHU was able to see how the Zika virus affected the cells; the affected minibrains were much smaller than normal, a result that appears analogous to the microcephaly observed in infants whose mothers were infected with Zika during the first trimester.

Other presentations at the meeting showcased work from several research groups that are already using minibrains to study diseases and disorders including brain cancer, Down syndrome, and Rett syndrome, and plans are underway to utilize it in autism, schizophrenia, and Alzheimer’s disease. Though there might be a bit of an acceptance curve with the general public, minibrains potentially offer an avenue of testing that is a better representation of actual human cell behavior and response, is safer and more affordable, and reduces the need for animal testing. (Jon Hamilton, NPR)

Health Policy

A Twist on ‘Involuntary Commitment’: Some Heroin Users Request It

The opioid addiction epidemic has become a significant healthcare crisis in the United States. Just last week the US Surgeon General announced plans to target addiction and substance abuse. He also stated the desire for a change in perception of addiction – it is a medical condition rather than a moral or character flaw. Earlier this year, the Centers for Disease Control published guidelines that address opioid prescribing practices for chronic pain, strongly urging physicians to exhaust non-pharmacologic options before utilizing opioids. In response to the rising concern over prescription opioid abuse, steps have been taken to reduce prescriptions and access. This has resulted in many turning to heroin – which is usually a cheaper alternative anyway – to get their opioid fix.

One of the first steps in treatment and recovery for addiction and dependence is detoxing. However, opioids are highly addictive and many people struggle with the temptation to relapse. Additionally, many of the programs designed to help with the initial detox have long wait lists, are expensive, and may not be covered by insurance, further deterring those with addiction and dependence from getting the help they need. These factors have caused many to start turning to their states, asking to be voluntarily committed to a program on the basis that they are a danger to themselves or others because of their substance abuse. This is currently an option in 38 states. These programs can be held in either privately-run institutions or in state prisons. However, this practice is controversial because if the person’s insurance does not cover their stay, it falls to tax payers to foot the bill. While this is unpopular with some, advocates say the civil commitment laws are important options while there may be no other immediate ways for an individual to get help. (Karen Brown, NPR)

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November 22, 2016 at 9:00 am

Science Policy Around the Web – November 4, 2016

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By: Courtney Kurtyka, PhD

Source: Flickr, by Wellington College, under Creative Commons

Science Education

Unexpected results regarding U.S. students’ science education released

The National Assessment of Educational Progress (NAEP) is a nation-wide exam and survey used in the United States to ascertain student knowledge and education in key areas. Recently, the 2015 science education results from fourth, eighth, and twelfth graders in the United States were released, and showed some surprising outcomes. Out of seven different hands-on activities that students were asked if they completed as part of their curriculum, only one (simple machines) showed a positive correlation between activity participation and scores on the exam. Some activities (such as using a microscope or working with chemicals) showed no correlation with scores on the exam, while students who engaged in activities such as handling rocks and minerals actually performed worse than students who did not. Furthermore, not as many students engage in scientific activities as part of their curriculum as one might expect. For example, 58% said that they never used simple machines in class, while 62% say they never or rarely work with “living things”.

An anonymous expert on the assessment suggested that one potential explanation for these unexpected results is that the assessment asks whether students completed any of these activities “this year”. Therefore, for the results from twelfth graders, students who use rocks and minerals in class tend to be in lower-level science courses, and are more likely to not perform as well on the exam as students in higher-level courses that would not include that activity. However, this does not account for the low level of reporting of scientific activities overall.

Another concerning aspect of the exam is related to the reporting of the results. The National Center for Education Statistics (NCES), which manages the NAEP, operates a website that is both difficult to use and incomplete. In fact, when using the drop-down menu of results from the survey, only the results of activities that have positive correlations with test scores are listed. NCES has said that they show results based on what they think are of greatest interest to the public.

While some cite the positive results as a reflection of the success of active learning techniques, others note that 40% of twelfth graders who took the NAEP did not have a “basic” knowledge of science. Additionally, these results are interesting for many because the twelfth graders reflect the first students to have spent their entire education under No Child Left Behind, which mandated annual assessment of reading and math for third through eighth graders. Since many have argued that this law leaves less room for teaching topics that are not tested (such as science), examining students’ scientific performance under these guidelines is important. (Jeffrey Mervis, Science Magazine)

Health Disparities

Sexual and gender minorities are officially recognized as a minority health population

The National Institute on Minority Health and Health Disparities (NIMHD), one of the institutes and centers within the National Institutes of Health, recently officially recognized sexual and gender minorities (SGM) as a distinct minority health population. The SGM population is very diverse, including lesbian, gay, bisexual, and transgender communities, as well as those from additional sexual and gender classifications that differ from various norms (such as traditional, cultural, etc.).

Multiple health disparities (meaning that the likelihood of disease and death from particular diseases and disorders in that group differ from the average population) have been identified in the SGM population. Some of these issues include a lower likelihood of women who have sex with women getting Pap smears and mammograms, and higher rates of depression, panic attacks, and psychological distress in gay and bisexual men.

Previously, the NIH requested a report on SGM health that was published in 2011, and later created the Sexual and Gender Minority Research Office (SGMRO) following the results of the report. Now, this official designation will allow researchers focused on SGM health to be able to apply for health disparity funding from the NIH, and Karen Parker (the director of the SGMRO at the NIH) said that she hopes that it will lead to increased interest in applications to support health research related to this population. (Nicole Wetsman, STAT)

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November 4, 2016 at 9:00 am

Science Policy Around the Web – October 21, 2016

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By: Leopold Kong, PhD

Source: Flickr, under Creative Commons

2016 Elections

The polling crisis: How to tell what people really think

The conflicting polling results for the US presidential elections have been a source of no small confusion for American voters. Skepticism over polling is further justified by recent failures, as in the 2013 provincial elections in British Columbia when the Liberal Party won against expectations, or the Brexit referendum. Two major challenges make polling less accurate, and changes are underway to address these issues.

The first major challenge is obtaining public opinion. In the past, pollsters can simply call people at home, but this is increasingly difficult with the rise of cell phone use. Currently, only 50% of US households have landlines compared to 80% in 2008. Federal regulations require mobile phones be called manually, and people often don’t answer cell phones from an unfamiliar number. People who do answer these numbers might represent a biased population. Despite these limitations, calling cell phones are more accurate than online polls, which are less regulated and could easily be manipulated. Using texting instead of direct calls could also increase response rates.

The second major challenge is predicting who will vote, which is particularly difficult in the US with low voter turnouts of about 45-50%. To predict this, each pollster organization uses a proprietary mix of factors such as voting history and political engagement. “Likely voter modeling is notoriously the secret-sauce aspect of polling,” says Courtney Kennedy, Director of survey research at the Pew Research Center in DC. Furthermore, these models may generate unconscious bias for pollsters to “herd” polling to better reflect predicted expectations. Improvements are underway, including using a probability model versus a discrete yes/no model, and greater transparency in methodology.

With the changing face of demographics and technologies, polling science is evolving to keep pace. (Ramin Skibba, Nature)

Health Policy

Two HPV shots instead of three

Human papilloma virus (HPV) is responsible for about 5% of all cancers in the world, including 70% of throat, neck and oral cancers, and 90% of all anal cancers. Originally, an effective vaccine was approved in 2006 for a three-dose regimen to confer protection. Since then, clinical data reviewed has shown protective efficacy with only two doses in Costa Rica. The Advisory Committee on Immunizations Practices at the Centers for Disease Control and Prevention (CDC) has now recommended two doses of the vaccines for pre-teen boys and girls.

“The pediatricians and other people I talked to said the new recommendation is a game changer with that schedule,” said Kevin Ault, MD, professor of OBGYN at the University of Kansas Hospital. “It’ll make it easier for the doctors, easier for the parents and easier for the kids.”

This recommendation is very timely, and may boost vaccination rates, which have risen very slowly so far. Teen girls getting the vaccine only increased from 60% in 2014 to 62.8% in 2015. Doctors have been timid about promoting the shots with parents, who may not want to have discussions about their children having sex. A lighter vaccination schedule may help. Furthermore, it reduces cost significantly for implementing the vaccine in low and middle-income countries, and thus may greatly aid in curbing the global cancer burden. (Associated Press, STAT)

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October 21, 2016 at 9:00 am

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