Multidrug resistant leprosy, Tuberculosis costs; Clinical trial problems; Milk formula mispercetions, Rheumatoid arthritis drug unavailable

Doctors in Shandong have reported China's first cases of multidrug resistant leprosy. Testing 85 samples of the causative bacteria Mycobacterium leprae, doctors found that some were resistant to  standard antibiotic treatments including dapsone, rifampin and ofloxacin.

In theory, tuberculosis treatment is free in China, but in reality patients  still face enormous out-of-pocket costs for treatment, a study from Jiangsu show. In a survey of treatment costs for people in the province, researchers from Nanjing Medical University found that the average cost per patient was as high as 19,000 yuan (US$3000). Even for patients who could claim back medical costs on their health insurance, out of pocket costs were still around 14,000 yuan ($2260) a year for clinic visits, hospital stays, tests and drug therapy.

Clinical trials are difficult to set up and run in China due to a lack of qualified and experienced clinical research staff and poor research infrastructure, an experts says. Dr Wu Yangfeng Wu of the Peking University Clinical Research Institute (PUCRI) said clinical trials required a pool of many hundreds of clinicians who were educated and well versed in basic research techniques - something which China lacked. He told Forbes that China's medical institutions also lacked  basic infrastructure and research management systems to conduct trials. There were also few allowances or rewards for doctors who took part in research, he added.

As many as one in five village doctors have latent tuberculosis, according to a study carried out in the Chinese province of Inner Mongolia. Dr He Guangxue and colleagues at the Chinese Center for Disease Control and Prevention, Beijing, surveyed 880 village doctors and found that 19.5% had positive tuberculin skin reactions. Latent tuberculosis risk was highest in doctors who had been in practice for a long time and for doctors who had more exposure to patients, they showed in PLOS One.

About 90% of Chinese mothers opt for milk formula within a month of giving birth, often driven by misguided beliefs and fears, a study from Sichuan has found. In a survey of 695 new mothers, 88% had initiated formula within 4 weeks of giving birth, often believing that babies slept better after fed with formula, and many believing they had insufficient breastmilk.

One of the best drug treatments for rheumatoid arthritis is out of reach for many Chinese patients because of cost, rheumatologists say. Chinese clinical experience with tocilizumab (Actemra) showed that it was highly effective and safe.  However, the high cost of the drug limits its prescribing in China, according to Dr Wang Geng of the Department of Rheumatology and Immunology, Changzheng Hospital, The Second Military Medical University, Shanghai.

Hypertension treatment outdated; Infants hit by Group B Streptococcal infections; Liver disease brings ruinously medical bills; Caesarean sections the norm; Li Keqiang unhappy with pace of health reforms

by MICHAEL WOODHEAD
Treatment of high blood pressure in China is quite backward because it is exactly that - treatment of just the raised blood pressure, with no attention to other cardiovascular risk factors. Cardiologists now emphasise that it is essential to treat a person's overall cardiovascular risk, not just focus on single risk factors such as blood pressure. But a study carried out in 274 hypertensive patients in Zhejiang found that  found that 28% were still smoking, 39% drank regularly and only 21% exercised frequently. The average salt intake per day was above the national recommended level of 6g. The study also found that most patients were taking only one drug for high blood pressure, which was inadequate to control their blood pressure. Many were taking 'herbal' medicines that actually contained out of date and dangerous western antihypertensives such as reserpine. As the authors conclude: "The study revealed outdated and inadequate treatment and health education for hypertensive patients, especially for those who have high risk scores for CVD. There is a need to review the community-based guidelines for hypertension management."

In Shenzhen, researchers at the Children's Hospital have shown that invasive group B streptococcal infection is an important pathogen in infants under 90 days old, resulting in in high mortality and neurological sequelae. The streptococcal infection strains showed strong resistance to clindamycin and erythromycin.

Liver disease is an expensive condition that often sees families facing ruinous medical bills in China. A study carried out at a Kunming hospital found that the average yearly cost of medical treatment for hepatitis B was 19,496 RMB, while patients with cirrhosis faced bills of up to 46,061 RMB. While public medical insurance helped pay for some of the costs, catastrophic health expenditure occurred for families affected by all these illnesses.

China's high rate of caesarean sections will be difficult to bring down to more healthy levels, according to researchers. In a  survey of a112,138 women they found the cesarean delivery rate was 55% and as high as 66% in some regions. Two thirds of the cesarean deliveries were scheduled and performed before labour  and about 40%%  were performed without any recognised medical indications. About 57% of the caesareans were done on request of the mother.

Meanwhile, the progress of health reform is obviously too slow for the Premier Li Keqiang. This month he has called for more medical reform measures to overcome 'difficulties' in the healthcare system. In written instructions he identified problems areas that needed attention, such as hospitals should be prevented from being "financed by drug sales" He also said that more effort should be given to reform of county-level hospitals and more serious diseases needed to be covered by medical insurance. His orders came after reform measures were introduced across all county-level hospitals and are now being piloted in 100 city-level hospitals.

Gong Xi Fa Cai! Medical news in the Year of the Sheep

Chinese New Year is upon us, with businesses closing up for a long holiday and most Chinese families looking forward to a reunion. But of course people still get sick at Spring Festival and the Chinese media has been full of stories praising the heroic and dedicated doctors and nurses who forego the holiday and put duty ahead of family to stay at work.  There are stories of doctors working solo for 24 hours to keep up with all the demand during the Spring Festival. From Hubei there is the story of the man bitten by his rabid pet dog who went to the hospital and was hugely relieved to find that the infectious diseases doctor was on duty to give him a rabies injection. At Fuzhou Hospital on New Years Eve the medical and nursing staff gather together to have the "big family banquet" that they would normally have with their families at home.  And there is even a story of the doctor at a Zhejiang leper colony who was urged by his ailing patients to go home and see his family rather than spend New Year on duty at the sanatorium.

Not all doctors have been heaped with praise at Chinese New Year, however. In Guangzhou there has been an uproar among the medical community after the city authorities sent anti-corruption teams in to raid hospitals just before Spring Festival. The city disciplinary affairs committee said the inspection teams were looking for evidence of bribes and 'hongbao' (red envelopes) given by patients to doctors. The raids have so far turned up little evidence of bribery, and doctors have been indignant at being suspected of corruption. They objected to having their everyday items such as snacks being documented - and also being questioned in detail about the origin of their possessions - and even for receipts for goods. Doctors said the actions of the inspectors went beyond their powers and the actions should have been a matter for the police. One doctor said a public hospital was not a place where bribes could be openly given or solicited among colleagues - and he was also indignant that many doctors had prepared hongbao or gifts for their families which were assumed by inspectors to be bribes from patients.

Chinese New Year is also a peak risk time for influenza in China. In Guangdong it has been reported there have been 53 cases and 13 deaths from  H7N9 avian influenza. In neighbouring Hong Kong there has also been a very severe flu season caused by the regular influenza H3N2 strain which has been causing as many as 18 deaths per day in the city. There have been reports of shortages of antivirals such as Tamiflu in Hong Kong, and the flu vaccine this year has been ineffective because the H3N2 strain of flu is a new mutation that is not covered by the vaccine. Of course influenza does not stop at the border, so we can only assume that the flu toll has been equally high in mainland China.

Another major infectious disease under the microscope this week is the recent outbreak of measles  affecting more than 1200 people in Beijing. Infectious disease specialists in the capital found that most of the cases originated in wholesale clothing markets popular with  locals and international visitors - so an MMR vaccination might be a pre-requisite if you are going to the Silk Market. The analysis found that many of the cases occurred in migrant workers who (unlike Beijing residents and tourists) had low levels of measles vaccination. The researchers recommended that outreach services be set up to vaccinate migrant workers in Beijing and "the offer of measles vaccine to workers as they register to live and work in the commodity markets might be a reasonable strategy to prevent future measles outbreaks."

In other news this week - the high demand for blood products in China is driving  a thriving black market in organised gangs of donors, organised by the so-called "blood heads" who are paid thousands of RMB for supplying blood. In the field of diabetes, some Chinese endocrinologists have been blasted in the pages of the Lancet for writing a review article that recommended the use of expensive new drugs as first line treatment for diabetes. Their critics say the endocrinologists failed to mention the more effective and cheaper drugs such as metformin - and the Chinese doctors also failed to mention their financial conflicts of interest with the Big Pharma makers of the expensive new drugs.

And finally, the quality of medical education in China has been questioned in several articles published this week. The Year of the Sheep is a milestone for China's medical educators in that they are now requiring a standard 5+3 medical degree + internship program be implemented nationally. However, some commentators have said that the new system will be no better than the current haphazard postgraduate 'Masters' programs if medical graduates receive insufficient clinical experience and supervision. They also say that the internship scheme should include 'exit examinations' to ensure that trainees have actually acquired the specialist skills they have trained in. Coincidentally this week Shanghai media report that trainee doctors get little experience in anatomy because there is a national shortage of donated cadavers. Chinese culture prohibits citizens from 'donating their bodies to science' as is done in the west. This means that Chinese medical graduates get all their anatomy learning from textbooks and have very little "hands on" experience. This is worrying for students going into specialties such as surgery - as they may never have practiced techniques such as cervical spine surgery before being asked to do the real thing. Not surprising then that a special anatomy cadaver training class at Shanghai's Fudan University was heavily oversubscribed.

新年快乐!

My weekly news blog for 1 Feb

The medical news in China has been dominated this week by the death of a doctor at a Luoyang hospital after a brawl with a drunken patient. Both fell down a lift shaft and were killed. It's just the latest in a long line of violent incidents against medical staff. Each time one occurs there are protest by staff, stern editorials in the media and vows to crack down on such incidents. There have even been gimmicks, including plans to have 'volunteers' or police patrols in hospitals to defend doctors from violence and defuse violent situations And yet still they continue. I can't understand why Chinese hospital don't have 'crash' alarms like they do in western countries, that trigger lockdowns and mutual protection protocols.

On a more positive note, Chinese drug makers have registered the world's first Sabin-inactivated poliovirus vaccine (S-IPV). The vaccine, developed by the Chinese Academy of Medical Sciences is being produced by the Institute of Medical Biology within the Kunming Hi-Tech Zone. It is said to be more effective than the current oral polio vaccine and also inexpensive.

Such a vaccine may have a role in remote parts of China such as Xinjiang, which recently reported an outbreak of polio. After more than a decade being polio free, in 2011 there were 23 polio cases reported, 55% of which were in young adults.  The polio was presumably brought in from the neighbouring Muslim state of Pakistan, where polio has not been eradicated due to the Taliban.

Another first for China this week was the first patient to be treated - and survived - a new H5N6 strain of avian influenza. The patient treated by well-known specialist Dr Zhong Nanshan at Guangzhou hospital after contracting the infection from - guess where - a live poultry market (why don't they just shut them down for good?). Dr Zhong said this was the second patient to contract the dangerous infection - the first one died. he said the second patient had been treated with high doses of antivirals and was in a stable condition. China is also struggling with a winter outbreak of H7N9 avian flu, with 30 cases so far around Guangdong.

In the healthcare reforms, some healthcare managers have said that hospital reforms should focus on the model of funding, and switch to an 'activity based funding' system to reward outcomes. At a meeting of the Beijing Chinese Peoples Consultative Committee they said that the funding system based on "diagnosis-related groups" (DRG)  would "break the link between doctors' incomes and prescriptions, thereby preventing excessive medical treatments and over-prescription of drugs." Hospital managers complained that they were underfunded because fees had been fixed at low prices set in 1999 whereas costs (and incomes) had risen considerably since then.

Well, fees may be too low according to hospital managers, but some patients still can't afford them. A woman has made news in Kunming by dressing up in a wedding gown and offering herself for marriage to any man who will pay her brother's medical fees. Her brother has leukaemia and she says he needs 300,000 yuan for treatment. China is supposed to have a public health fund for people with catastrophic illness, but it obviously hasn't trickled don to this young man.

My January news blog ...

Regrettably, I am cutting back on my blogging about China medical news this year. I've been doing this for more than a year now, out of enthusiasm and my own personal interest in the area, but it's becoming too much of a burden on my time. And of course it is all unpaid. Unless there is a sponsor out there who wishes a regular stream of China medical news? After my day job doing much the same thing about Australian medical news I find it hard to sit down at home and do the writing for this blog. So from now on I shall probably only update the site about once a week. That is not enough to cover the many things happening in healthcare in China, but that's your lot. As they say in Yorkshire, you don't get owt for nowt.

This week I have been reading about how patients in Shanghai with chronic diseases will now be able to pick up their repeat prescriptions from community clinics instead of the big hospitals. It's a move intended to relieve the overcrowding at the tertiary hospitals and sounds like an obvious and sensible idea. Whether it will work or not depends on whether China's hospital-obsessed patients can be persuaded to show up at the low-status community clinics.

There are also moves to try curb China's high levels (approaching 50%) of caesarean section intervention in pregnancy. A feature article by Yang Wanli describes how some obstetricians in China are trying to persuade women to opt for natural birth. However, the barriers are a lack of available analgesia for women in labour and the industrial production-line mentality of China's hospitals.

Rural health is a major issue in China this month, with the State Council approving a plan to boost the rural medical workforce. The Council wants to see rural areas of China have qualified doctors replace the current 'barefoot' practitioners. However, well-meaning intentions will not fix the huge rural medical workforce problem in China. The simple problem is that university qualified doctors do not want to work in rural villages. The pay is pathetic, there is no status and the workload is high. As this article shows, the current rural medical workforce is mostly unqualified and often dangerously lacking in skills.

That's not to say that rural health is completely hopeless in China. There have been great achievements in some areas of public health such as immunisation and basic child health. However, as a major article by Chinese paediatricians the Archives of Diseases in Childhood shows, the next step for China is to try reduce the incidence of more complex diseases in children. China has done well in tackling the easily preventable causes of child disease, now it must turn its attention to the difficult stuff - the consequences of preterm birth, and the many congenital and metabolic diseases.

One problem with monitoring China's progress in child health is knowing whether or not the official  figures are true. Take measles vaccination for example. According to official reports, China has 95% measles vaccine coverage of infants. But when researchers analysed the causes of measles outbreaks in Hunan and Jiangsu that affected hundreds of children they found that the actual rates of measles immunisation more like 80%.

And finally, for those who put their faith in western healthcare companies helping improve the health of China, take a cautionary look at the sorry tale of GSK. A well regarded company in the west, GSK was the subject of high profile bribery allegations and a court case that jailed one of its British executives for  his role in the bribes to doctors and hospitals. Now the company is reported to be cutting the jobs of 1000 employees in China following the downturn in its business there (including a 60% drop in revenue).

Plague debrief: what really happened in the July 2014 Gansu case of pneumonic plague?

by Michael Woodhead
In July 2014 a case of pneumonic plague was widely reported in the media.

The victim was a 38-year old shepherd who caught the infection from a marmot (the usual carriers of the infection) after it was caught by his dog. At the time it was widely reported that the town of Yumen (near Jiayuguan) where he was treated, had been put into lockdown. None of the 30,000 residents were allowed to leave town and more than 150 close contacts were kept under observation in quarantine. It looks like Chinese authorities did the right thing - but only after a fatal delay in the initial diagnosis. A new report published by the local infection control team gives more details of the case.

Dr Ge Pengfei and colleagues say that the man contracted the Yersinia pestis infection from an infected marmot after it was caught by his dog on 11 July. He skinned the marmot for its pelt and fed the meat to his dogs. Two days later the shepherd started to develop respiratory symptoms and went into a nearby village to seek treatment. However, when he first went to the local clinic on 15 July he was mis-diagnosed as having a simple respiratory tract infection and given just a prescription for an antibiotic (clindamycin) and some anti-inflammatories. When his condition worsened later that day he was seen by doctors at the hospital in Yuman, who diagnosed pneumonia on x-ray and they gave him an ineffective antibiotic, cefoperazone, and more anti-inflammatory treatment.

It was only later that night when the man's condition deteriorated further and he started coughing up blood that throat swabs were taken, which showed the presence of the characteristic Yersinia bacilli when tested. Doctors then gave the man the recommended treatment of IV streptomycin, but this was too late and probably did more harm than good in the rapidly advancing conditions of the infection. Streptomycin must be used with great care in advanced plague because it cases the Y. pestis bacteria to burst (lysis) and release large amounts of the endotoxin that causes septic shock. This is what happened in the case of the Gansu shepherd, whose quickly deteriorated in the early hours of 16 July and he died at 5am.

The infection control team said they also detected Yersinia infection in the man's sister in law and in two patients who had been in close contact with him at the hospital. These people were among the 150 close contacts subject to quarantine and to preventive treatment with streptomycin. This containment strategy worked, as none of the close contacts developed full blown pneumonic plague.

The infection control team said them man may have survived if his infection has been detected earlier. However, the village clinic and hospital had only limited medical facilities, and the plague was only picked up when cultures were examined under a microscope.

They said that local clinics in areas such as Gansu where plague is present (on average there is one case per year in the region) should be alert for the early signs of the infection - and be prepared to take a careful history to see if there has been any contact with potential sources such as marmots and infected dogs. Despite the death of the patient, they said the incident had shown that quarantine and antibiotic prophylaxis procedures for contacts were effective.

"Doctors need to improve awareness and ask about contact history for the possibility of plague infection to avoid misdiagnosis," they recommended.

International Journal of Infectious Diseases.

Drug resistant bacteria - just how much of a problem are they in a typical Chinese hospital?

by Michael Woodhead
With broad spectrum antibiotics easily available over the counter in China  - and the Chinese cultural expectation of an antibiotic as the magic bullet for every viral fever - it's not surprising that drug resistance is a major problem in the PRC. 
But just how common is the problem for a typical provincial hospital? The rather worrying answer is quite a big problem. A study carried out in the Liaocheng People's Hospital in Shandong has found that one in three bacteria samples obtained from around the hospital were multi-drug resistant. Researchers at the hospital took almost 10,600 microbial samples from around the hospital and found that  33.4% were multi-drug resistant pathogens such as ESBLs producing E. coli and A. baumannii. The blackspots for resistant bacteria were in surgical departments and the intensive care department. Samples obtained from respiratory and secretions were the greatest source of resistant bacteria. The obvious consequences of these multi-drug resistant bacteria are treatment failure, longer hospital stays, increased mortality, and higher hospitalisation costs. As the authors conclude, their findings show the need for much greater attention to antibiotic resistance, especially from respiratory cases and surgical wounds.

China's best case scenario for an Ebola outbreak: 3000 deaths

by Michael Woodhead

With more than 600,000 annual passenger arrivals from Africa and a poor to non-existent public health infrastructure in most parts of the country, China faces  a very real risk of an Ebola outbreak. That the verdict of infectious disease specialists who have modelled what will happen if a person with Ebola lands in China and is not detected immediately.

Dr Chen Tianmu and colleagues from the Changsha Center for Disease Control and Prevention have used data from previous Ebola outbreaks overseas and also from outbreaks of dengue and HIV viruses in China to model the likely spread of the infection before it can be brought under control. They modelled several different scenarios based on different levels of infectivity of the virus and different levels of detection and containment.

They based their calculation on the fact that there were 524,900 African visitors and 112,966 Chinese returning from Africa each year in China. Based on current distribution of Ebola Virus Disease and the rates of carriage in Africa, they estimated that 0.04%–0.16% of these arriving passengers in China (255–1021 people) may carry Ebola. Even if an optimistic assumption is made that only 1% of them slip through the entry-exit inspection and only 1% of these are not picked up by further reporting and monitoring follow ups, this would still mean 3-10 Ebola virus carriers could be at large in China.

The researchers noted that China lacks a primary care system and most sick patients go direct to hospitals that are overcrowded and where Ebola patients might spread the virus to others. China also has limited public health reporting and surveillance systems for much of the country, and it would therefor be possible that cases of Ebola virus could be misdiagnosed and slip though the net until the patient became symptomatic and infectious.

The researchers then calculated that the likely impact of such 'index cases' spreading the Ebola infection to others would be outbreaks of Ebola in China affecting between 6000-10,000 people. With a likely fatality rate of around 50% this would mean a severe mortality burden for China, they wrote.

Writing in Travel Medicine and Infectious Diseases, they said the lack of Ebola testing facilities in China and poor infection control practices would further encourage the spread of the infection, they predicted. Other factors, such as the lack of quality control on blood transfusions (as seen with outbreaks of HIV and hepatitis) would also increase the risk of spreading Ebola in China, they warned.

"Even if a good surveillance and monitoring system is implemented at immigration, an effective and efficient local medical response system involving primary health care providers and awareness of the general public is necessary to minimise the risk of an Ebola Virus outbreak due to other unknown sources," they suggested.

Prejudice against leprosy patients triggers riots in Hainan over new medical centre

by Michael Woodhead
Deeply felt cultural phobias and prejudices about infectious diseases have triggered mass riots in the southern province of Hainan, where local residents in Haikou violently opposed the construction of a leprosy recovery centre.
According to local reports, thousands of local residents in Hainan clashed with riot police over the construction of a new dermatology clinic in the Sanjiang district for  patients recovering from infections including leprosy and STDs.
Although authorities explained that patients who had recovered from leprosy were no longer infectious, this was not enough to assuage the fears of local residents, who strongly opposed the building of the clinic and rest facilities in their neighbourhood. Authorities said the clinic was a rehab centre for elderly people who had recovered from the disease and who were no longer contagious, but local people violently opposed the building of the clinic.
According to Chinese state media, local people clashed with police and overturned police vehicles. Several police and local residents were injured in the riot.
Local authorities were reported to have ceased construction of the clinic until a consensus could be achieved with local residents.

In China's hospitals, one in three doctors have latent tuberculosis infection

by Michael Woodhead
It's an avoidable occupational hazard that Chinese doctors could well do without: tuberculosis. 

A  study carried out in a general hospital in Henan has found that one in three healthcare staff have latent tuberculosis infection. The figures are even worse for a nearby infectious diseases hospital where almost 60% of doctors had latent tuberculosis infection.

First some clarification: as the CDC points out:

Persons with latent TB infection do not feel sick and do not have any symptoms. They are
infected with M. tuberculosis, but do not have TB disease. The only sign of TB infection is a
positive reaction to the tuberculin skin test or TB blood test. Persons with latent TB infection
are not infectious and cannot spread TB infection to others. Overall, without treatment, about 5 to 10% of infected persons will develop TB disease at some time in their lives.

So, people with latent TB do not pose a serious risk to patients, but they themselves face a high risk of developing active tuberculosis disease.

In the study of 712 healthcare workers at a 1600-bed general hospital and a 600-bed infectious diseases hospital in Zhengzhou, researchers found that the tuberculin skin test-positive prevalence was 34% in the general hospital and 58% in the infectious disease hospital.

Dr Zhou Feng and colleagues who did the study said that health staff faced high risks of tuberculosis if they worked with infected people, such as those with HIV who often have co-infection with tuberculosis. Rates of infection were also highest in staff with longer years of working in the hospitals, presumably due to greater duration of exposure to risk.

Writing in PLOS One they said many staff did not use personal protective equipment such as  face masks and N95 respirators when working with infectious patients, despite this being recommended in guidelines.

Another problem with detecting and treating tuberculosis in healthcare workers was the low rate of tuberculin skin testing for the infection: many healthcare workers refused testing, and the most effective testing kits were too expensive for many Chinese hospitals. The findings also highlighted the limitations of the regular chest X-rays used to screen workers for active tuberculosis disease.

As the authors conclude - more emphasis is needed on observing and adhering to basic infection control and prevention practices in Chinese hospitals:

"Comprehensive guidelines should be developed for different types of medical institutions to reduce tuberculosis transmission and ensure the health of healthcare workers," they suggest.

Nearly 700 dead in Yunnan rabies epidemic - mass culling of dogs needed to stop spread to Lijiang and Dali

by Michael Woodhead
Yunnan is in the midst of a rabies crisis and drastic action is needed to curb the disease in dogs before it spreads to popular tourist towns such as Lijiang and Dali, Chinese researchers say

In the year 2000 there were only three cases of rabies in the whole of Yunnan, but in the following decade there was an epidemic of the disease and 663 people died. The explosion in rabies cases has mostly affected eastern parts of the province adjacent to Guizhou and Sichuan, and the rabies cases are linked to increasing ownership of dogs in rural areas - and better transport links.

In a report published in the journal Emerging Infectious Diseases this week, researchers from the Yunnan Institute of Endemic Diseases Control and Prevention say a mass culling of dogs in the province is urgently needed to curb the ongoing spread of rabies. They say many rural households have dogs that are apparently healthy but harbouring and spreading rabies. Vaccination is not practical for the tens of thousands of poorly supervised dogs in rural towns and villages, and therefore culling is the only realistic option, they say.

In their article they says that rabies had been all but eliminated from Yunnan by the late 1990s after serious outbreaks in the 1980s. In the year 2000 there were just 3 cases in one county, but since then the disease has spread to 77 counties within the province and the epidemic shows no sign of abating. The problems has become so bad that Yunnan is now the focal point for the spread of rabies not just within China but also for neighbouring counties such as Laos and Burma, they claim.

Rural families often own two to three dogs and there is little legislation to enforce vaccination, they note. In addition, better road links and increased ownership of vans and cars means that dogs are now traded over a much wider area and they are also sold to restaurants for dog meat.

They propose a four point plan for the most severely affected regions of Yunnan, which include Wenshan, Zhaotong, Qujing, and Honghe counties.

1 Domestic dogs should be confined in the household at all times.
2. All unsupervised dogs and domestic dogs within the affected villages to be killed.
3. Vaccination of all  dogs in neighboring villages as an emergency and temporary measure.
4. Provide free rabies vaccination to all susceptible people and educate local inhabitants regarding the
risk of rabies.

If these measures are not adopted immediately, rabies can be expected to spread to the tourists towns of Lijiang and Dali, they warn. In the longer term, compulsory vaccination programs for all dogs will be needed to curb rabies. However, they are pessimistic about the prospects for such a campaign.

"The greatest obstacle to removing the threat of rabies is the low level of political commitment because dogs are not regarded as economically useful animals in Yunnan Province," they conclude.

Resisting the Japanese invader: the China success story against Japanese encephalitis

by Michael Woodhead
 As China cranks up its media hate campaign against its former enemy Japan, the country can actually celebrate victory in its war against another 'Japanese' invader from the 1940s: Japanese encephalitis. 

This mosquito borne viral disease used to cause about 200,000 cases of severe neurological illness in China every year at its peak in the 1960s and 70s - with about 30% patients dying and many of the survivors  left with lasting neurological disability as a result of the infection.

The name is misleading - the disease did not originate in Japan, but was first identified there in the 19th century. The infection was first recorded in China in the 1940s and became widespread in the 1960s - partly because of the breakdown in public health preventive activities during the chaos of Mao Zedong's Cultural Revolution.

A vaccine against the virus was developed in Japan in 1965, and China started manufacturing its own vaccine a few years later.  Writing in the journal PLOS Neglected Tropical Diseases, Dr Gao Xiaoyan and colleagues at the Chinese Centre for Disease Control and Prevention, Beijing, describe how Japanese encephalitis was brought under control in China.

The initial Chinese vaccine was only available in limited quantities and required many doses. It was expensive and was only available to privileged cadres and Party members, not to the peasants who were most at risk of the disease. With more than half the cases of Japanese encephalitis in the world, China continued to work on improving the vaccine and eventually developed one in 1988 that was more convenient and could be mass produced at relatively low cost, to make it affordable for public health use.

This vaccine was gradually made available at a cost of 1 yuan to rural residents, and was fully subsidised as a free vaccine after the year 2005. Since it was included in the "Expanded Program of Immunisation" this cheap and effective vaccine had reduced the incidence of Japanese encephalitis in China from 21/100,000 people to just a fraction of 1 per 100,000 - a remarkable achievement.

But the vaccine is not the only reason for the drastic reduction in Japanese encephalitis in China. Other public health measures were implemented by local health authorities to reduce mosquito breeding and transmission:  pig farms were moved away from villages,  sewage disposal was improved to reduce mosquito breeding, and mosquito breeding grounds in areas of static water were eliminated.

The threat from Japanese encephalitis has now been markedly reduced in the more prosperous eastern provinces of China but it remains a problem in the poorer parts of southwest China. Nevertheless, Chinese researchers say other developing countries can copy the Chinese model for eliminating Japanese encephalitis: low cost programs using inexpensive vaccine and anti-mosquito measures.

China has its first non-imported dengue outbreak in a decade

by Michael Woodhead
Last year, Yunnan experienced an explosive outbreak of  dengue fever spread by mosquitoes.

This was a strange and worrying phenomenon because Yunnan has been dengue free for many years. China has had a few outbreaks of dengue in recent years but they tend to have been in south eastern provinces such as Guangdong, and they are usually related to imported dengue fever. The infection is not endemic to Yunnan.

However, in 2013 health workers in Xishuangbanna had to deal with a huge outbreak of this often severe, life-threatening disease. There were 1245 cases of which 136 patients were hospitalised and 70 were classified as severe cases. The symptoms included severe haemorrhage (including massive vaginal and gastrointestinal bleeding), severe plasma leakage (such as pleural effusion, ascites, or hypoproteinaemia), and organ failure. Twenty of the cases  deteriorated to shock.

In an analysis of the outbreak published in the International Journal of Infectious Diseases, Dr Zhang Fuchun of the Guangzhou 8th People's Hospital say the dengue fever was caused by a new virulent strain of the virus known as serotype 3 (DENV-3). But the main reason for the severity of the outbreak was that the infection was spread  more rapidly by a different type of mosquito - Aedes. aegypti. The usual type of mosquito seen in Yunnan is known as Aedes albopictus, and dengue caused by this species tends to be milder and short lived. The researchers say the 'double whammy' of a new strain of dengue and a new strain of mosquito combined to "carries a high risk for a severe epidemic and endemicity" in an area that was until recently dengue free.

China's answer to Ebola: a lethal haemorrhagic fever that kills 20,000 people a year

by Michael Woodhead

Like many other countries, China has gone into a hysterical spin about the threat posed by Ebola virus disease.

Authorities have dusted off the useless thermal scanners last used in the avian flu outbreaks, and have started screening passengers arriving at from Africa at Chinese airports. And despite the World Health Organization saying that China does not need to be overly concerned about the disease, authorities have been issuing stern warnings to health workers about being vigilant for Ebola and also looking with suspicion on the African expats living in cities such as Guangzhou. The irony is that China has seen its own counterpart of Ebola virus disease, a killer disease that has been increasing dramatically in the last two years.

But first some background: Ebola is a haemorrhagic fever, caused by the Ebola virus, which belongs to the  Filoviridae family of RNA viruses. The virus comes from apes and bats and is only transmitted between humans by body fluids such as blood and saliva - in Africa it has been spread by hunters cutting up meat from infected animals, and spread to healthcare workers and close relatives to touch the dead bodies of Ebola victims at traditional African funerals. In the latest outbreak there have been 1323 confirmed and suspected cases of Ebola reported, and 729 deaths. That's a mortality rate of 55% according to my calculator.

What to make then of China's recent little remarked but lethal cases of haemorrhagic fever? In April, Dr Du Hong and colleagues from the Center for Infectious Diseases, Tangdu Hospital, Xian, described the horrific symptoms of some of the 356 patients who had been treated at their hospital for  "hemorrhagic fever with renal syndrome" (HFRS),  a disease caused by Hantavirus that is spread by rats (or more specifically in their droppings, which may become aerosolised and spread to anyone working near where rats have been active).

The symptoms are similar to Ebola: fever, circulatory collapse with hypotension, hemorrhage, but also with acute kidney failure (hence the name renal syndrome). The difference between Ebola and HFRS is that the Hantavirus disease has a death rate of 'only' 40%. For China, which has had about 50,000 cases of HFRS annually, that means about there have been, at a conservative estimate, 20,000 deaths from Hanta virus every year. Makes the 730 Ebola deaths in Africa look fairly insignificant doesn't it? And as with Ebola, there is no treatment or vaccine for Hantavirus, only supportive care.

And that's not all. China has other types of haemorrhagic fever. This month The Lancet carries a report of the emergence of one, known as "severe haemorrhagic fever with thrombocytopenia". This is a viral disease spread by ticks, caused by the SFTS phlebovirus in the Bunyaviridae family. According to Dr Liu Quan and colleagues from the State Key Laboratory of Veterinary Etiological Biology, Lanzhou, SFTS was first reported in 2010 and has since been found in 11 provinces of China, with about 2500 reported cases, and an average case-fatality rate of 7%. That's about 175 deaths. As the study authors say with some understatement: "The disease has become a substantial risk to public health".

China is the epicentre for Hantavirus haemorrhagic fever in the world, but it is not the only country affected. The disease is also seen in Europe and the US - a Denver man died of the infection just this week. But with tens of thousands of Chinese people dying every year from this terrible haemorrhagic disease, perhaps China ought to worry more about curbing Hantavirus - and the rats that carry it - rather than panicking over the threat from an African outbreak of Ebola.

Survey reveals the bad antibiotic habits of Mainland Chinese

by Michael Woodhead
Chinese people have developed bad habits of antibiotic misuse such as self medicating with OTC products, not finishing the course and hoarding leftover antibiotics for later use, a new study shows.
Doctors at the University of Hong Kong made the worrying findings when they surveyed recent Chinese immigrants on their knowledge and attitudes towards antibiotic use.  They conducted focus group interviews with 56 recent migrants from mainland China and also conducted phone surveys with 134 Chinese and 1600 Hong Kong residents.
The survey showed that both Chinese and Hong Kong-born Chinese had many erroneous beliefs about antibiotics, including the belief that they were effective against viruses and the common cold. One in ten Chinese patients had never heard of antibiotic resistance and most believed that antibiotic would weaken the immune system. A significant minority of Chinese believed antibiotics had significant side effects such as drowsiness or loss of appetite, and said they would stop taking antibiotics when the symptoms had cleared up rather than finishing the full course. About one in seven said they would  keep leftover antibiotics and store them in the fridge to 'recycle' them for later use. A similar proportion said they would seek to self medicate with antibiotics bought over the counter  - sometimes for 'prevention' of infections - even though OTC sale is illegal in Hong Kong.
In the focus groups, many mainland Chinese said they were accustomed to the IV antibiotic infusions that are routinely given to feverish patients in China, and they believed that the oral antibiotics prescribed by doctors in Hong Kong were less effective and led to the infection persisting for longer. However, some respondents said they trusted doctors in Hong Kong more than those in China, and tended to accept their advice on antibiotics and would not ask for antibiotics if they were not recommended.
The researchers from the University of Hong Kong said their survey dispelled the myth that mainland Chinese demanded more antibiotics from doctors. It showed that many recent mainland Chinese migrants had acquired some knowledge of appropriate antibiotic usage during their stay in Hong Kong, but the knowledge was not always translated into practice. They suggested that antibiotic education campaigns were needed for both Hong Kong Chinese and their mainland counterparts.

Downton Abbey? No, Beijing: domestic servants have fake health ceritficates, risk passing on infections to kids

by Michael Woodhead
For a newspaper that is supposed to be upholding the spirit of socialism, the Beijing Daily is sounding uncannily like the bourgeois Daily Mail these days. 
In today's issue there is a lengthy feature dedicated to investigating the question of whether domestic staff can be trusted when it comes to health and hygiene. More specifically, the paper has an in-depth report on the bona fides of the health certificates that nannnies, cleaners and other domestic ayi-style servants present to their employers as evidence of their suitability for working in the household. The Beijing Daily reports the case of a female obstetrician, Zhao Li, who spent months and more than 10,000 yuan looking for a suitable nanny for her 2-year old daughter. When she found the right nanny, she was assured by the domestic staffing agency that the woman was of good character and had a health inspection certificate. However, being a meticulous medical mother, Zhao Li was concerned about the possible risks to her daughter's health and decided to double check the nanny's health status by having her undergo a health checkup at her own hospital. She was shocked to discover that the young nanny was hepatitis B positive and also had a fungal skin infection. "My daughter could have been exposed to many infectious diseases. These health certificates they present are worthless," she told the paper.
When reporters from the Beijing Daily inquired further they found that  nannies and other domestic staff are not required by law to have the state-monitored health checks that are required by other employment sectors such as hotel and food preparation staff - and yet they do much the same work. Domestic staff are certified by the employment agencies, which have a vested financial interest in showing that their 'workers' are in excellent condition. The health checks for domestic staff are done by private clinics and there is no supervision of their standards or identity checks - it was reported that some would-be employees sent a healthy 'impersonator' in to have their tests done for them. A spokesman for a reputable public hospital (the PLA 302 Hospital) that has  a clinic for employment health certification said that many domestic servants were migrant workers and often had been exposed to many infectious diseases. As well as hepatitis they frequently detected diseases such as tuberculosis, measles, intestinal and skin diseases. Females they tested sometimes had vaginal thrush and other sexually transmitted diseases (STDs), the spokesman said.
A doctor at the hospital said domestic servants might pass on viral, bacterial and fungal disease to household members via washing facilities, eating utensils and if they were in contact with the bathroom. The Beijing Daily report concludes that it is an anomaly that domestic helpers are not covered by regulations related to employment health checks. They advise that anyone employing a nanny or domestic cleaner/cook should have them checked for a wide range of diseases including respiratory infections (eg tuberculosis), STIs, intestinal diseases (eg amoebic dysentery), hepatitis, skin diseases and also have up to date vaccinations for childhood infections.

Dysentery in China - the good news and the bad news

by Michael Woodhead
Dysentery is one of those disease most westerners associate with 'the olden days' - or the Third World. 
Bacillary dysentery, also known as Shigellosis, is the severe gastro disease of poor hygiene, spread by faecal contamination. Ten years ago dysentery was still relatively common in Guangzhou, but a new report shows the city has brought rates of the disease down with a co-ordinated campaign to detect and manage cases and prevent further outbreaks. In 2006 the city had about 12 cases of dysentery per 100,000 population - so for a city of 8.5 million people that's more than a thousand cases a year. To tackle the infection, the city health department implemented the "Intestinal Infectious Disease Surveillance, Prevention and Control Program" (IIDSPCP). This means that once a patient is suspected as having Bacillary dysentery, public health workers target their household with preventive measures such as quarantine, disinfection, and good personal hygiene practices mandatorily implemented by local government. This program has seen the rate of dysentery cut to around 2 per 100,000. Good news so far. However, public health staff say dysentery still remains a problem in the poorest families - as judged by the high rates among children who do not attend school. They now account for the largest group of patients with dysentery.
This social group - usually migrant workers from the poor inland provinces - is China's new underclass. As the report notes: "They are usually lacking in adequate sanitation, with low health risk awareness, and more likely to have exposure to contaminated food or water. It has been reported that compared to the other group, the school-age children not attending school have higher incidence in many infectious diseases such as hand-food-mouth disease, infectious diarrhea, and hepatitis A."
Interestingly, the other high risk group for dysentery is young people aged the people aged 20-44 years - perhaps because they take part in more social activities, have more chance to contact with Shigella patients or carriers, and have more leisure time, and finance to travel and thus more likely to have exposure to Shigellosis.
As the report authors conclude: "more effort should be made to enhance health education about dysentery and monitoring/targeting at school-age children not attending school ... .as well as establish strategies for prevention of the disease in China."

The two unknown tick diseases that are killing many Chinese

by Michael Woodhead
Two virtually unknown tick born rickettsial diseases have become a serious threat to human health in China, health authorities have warned. In just a few years the diseases caused by tick-borne A. phagocytophilum and E. chaffeensis have become common in rural areas and cause disease including multiple organ failure and death, according to Dr Zhang Lijun and colleagues at the Department of Rickettsiology, National Institute for Communicable Disease Control and Prevention, Beijing.
In a new paper they report that the first cases of human granulocytic anaplasmosis (HGA) occurred in Anhui Province in 2006 and then in Shandong. They said human granulocytic anaplasmosis is a serious disease in which about half of patients are hospitalised, 40% of patients have multiple organ dysfunction syndrome, and the fatality rate can be as high as 8%. However, they suspected that in China infections with the two rickettsial diseases were often not recognised, and were misdiagnosed as hemorrhagic fever with renal syndrome (HFRS).
In their own study they analysed 7,322 serum samples from farmers  and found that 10-15% farmers had been exposed and were at substantially increased risk of the diseases. A second analysis of 819 blood samples from urban residents from showed that 4-12% of urban residents had been exposed and were also at high risk of the tick-borne diseases. Worryingly, the infections were carried by a wide range of ticks, not just one species, and the ticks were found on many domestic animals and livestock including dogs, goats, sheep, cattle, horses, rabbits and rodents.
"In China, the free-range feeding of animals is a major part of livestock production, in contrast to livestock production in modern developed countries. Animals roam hills for feeding during daylight and return at sundown. In such a situation, animals can return with many ticks from wild fields. Moreover, most farm families own two to three dogs for guarding their animals and belongings, and these dogs also roam freely in and out of yards. Therefore, it is not surprise that contacting with domestic animals is regarded as a main exposure risk," they noted in Biomed Research International
The researchers concluded that the wide distribution of the tick-borne infections and their serious nature meant that their transmission and risk factors "urgently needed to be further investigated."
[Editor's Note: The risk of tick borne diseases in China is not insignificant: a US student became paralysed after being bitten by a tick during a school trip to China and was awarded $42 million in damages against her school in a US court last year]

Measles resurgent in China as migrant children miss vaccinations

by Michael Woodhead
China looked like it was on track to eliminate measles until two years ago, but now the infection is making a comeback among unvaccinated young children, the World Health Organisation has warned.
In a report of the progress towards measles elimination in China a WHO surveillance study notes that China has seen dramatic reductions in rates of measles since it implemented and expanded childhood vaccination campaigns in the 1980s  and 1990s. Rates of the infection fell from 572 per 100,000 in the 1960s to below 10 per 100,000 since the 1990s. Since then, further reductions in measles have been seen as children have been given two doses of measles vaccine with uptake rates of more than 90%. There have also been additional 'catch up' measles vaccination campaigns in provinces where continuing outbreaks of measles have occurred. This resulted in the annual number of cases coming down from 140,000 per year in 2008 to under 10,000 in 2012. However, as the WHO Bulletin report notes, there has been a resurgence in 2013, with the number of cases bouncing back to around 24,000 in that year. The report says most of the measles cases occurred in young children who had missed one or all of their scheduled vaccination doses, although a few also occurred in adults. It says the resurgence is disappointing, especially as it follows intensive 'catch up' campaigns. In their report, the WHO researchers say it is likely that many of the unvaccinated children spreading measles will belong to migrant worker families who have left their hometown and thus drop out of the measles vaccination and reporting programs based in schools and local health centres.
"The resurgence of measles seen among young unvaccinated Chinese children in 2013 indicates a weakness in routine immunisation that allows some children to miss one or both of their scheduled doses of measles vaccine. Such weakness must be eliminated if a further resurgence in the next few years is to be avoided and measles is ever to be eliminated in China," they conclude.
"Improvements in the identification and location of children who are new to an area may permit marked improvements in vaccine coverage" they note.

The top 8 medical news stories from China for Thursday 1 May

1. A person's blood group may influence their survival from cancer according to oncologists in Guangzhou. In a study of patients with oesophageal cancer they found five year survival rates were 50 % for patients with blood type A, 45% for type B, 51% for type O, and 61% for type AB.

2. The incidence rate of type 1 diabetes is increasing at a rate of 14.2 % per year in Shanghai and if present trends continue, the number of new type 1 diabetes cases will double from 2016 to 2020, researchers say.

3. Chinese neurologists say people with atrial fibrillation may be able to avoid the need to take lifelong anticoagulant drugs to prevent stroke by using a minimally invasive surgery procedure called left atrial appendage closure (using a system created by Boston Scientific Corp - could be an advertorial).

4. The introduction of the New Cooperative Medical Scheme (NCMS) has increased access to healthcare for elderly people, but not had any effect on their overall health, a study from Nanjing University shows. The study found that the health cover did not affect overall health status and did not reduce the out-of-pocket spending of elderly people.

5. An outbreak of hand, foot, and mouth disease that hospitalised 1844 children in Central China from 2011 to 2012 was caused by a mixture of co-circulating coxsackievirus A16 (CVA16). and enterovirus I71 (EV71). This may have contributed to the genomic recombination between the pathogens say researchers from Wuhan University.

6. The whistleblower 'Corridor Doctor' doctor of Mianyang who worked in a corridor after being suspended from her job for two years, has now been sacked. Authorities said Dr Lan Yuefeng had been absent for almost two years and had been disruptive and uncooperative. Her colleagues rejected charges of overservicing at the hospital and went on strike claiming she had made false allegations and damaged their reputation.

7. Health authorities in Beijing are urging adults to have measles vaccination after a surge in cases in thecity. They say there has been a spike in cases in the past two months, and more than half of the infected are in adults, probably because protection from childhood vaccination has waned.

8. Radiologists in Sichuan claim that resting-state functional MRI could be useful in providing early and accurate diagnosis of ADHD. In a study published in Radiology, Dr Qiyong Gong of the West China Hospital of Sichuan University, showed that the boys with ADHD had altered structure and function in certain areas of the brain, such as the orbitofrontal cortex and the globus pallidus. that play in executive inhibitory control - the ability to control inappropriate behaviors or responses.