The top three medical stories from China this week

Medical exam fraud: A medical examination cheating ring has been uncovered in Hebei after a 29 year old woman was found to be taking a postgraduate exam in place of someone else. The woman was arrested after it was found the ID card did not match the details of the doctor who was supposed to be taking the test, who was from Chengdu. The woman said she was paid 60,000 yuan (about US$9000) to take the test on behalf of another person. The woman, who was originally a doctor, said she had given up her job in 2013 after she discovered she could make more money through exam fraud.

Influenza deaths: There have been three severe cases including one death from severe H5N6 influenza in Guangdong and a further death of an overseas visitor from H1N1 influenza, according to media reports. Chinese media said that a a 25-year-old man from Shenzhen, was in a serious condition in hospital. A 26 year old woman died of the same infection in Shenzhen last week, while a third person in Zhaoqing, Guangdong was in a serious condition. Meanwhile a Guyanese man has died of H1N1 influenza in a Miami hospital after returning from China. The infections are presumed to have come from exposure to live poultry and it is not thought there is a high risk of human-to-human transmission.

Air pollution harms fetus: Pregnant women who are exposed to the high level of air pollution in China are likely to have low birth weight babies, a study shows. Exposure to high levels of PM2.5 particles, as found in China's smogs, was linked to a decrease in birth weight and an increased risk of low birth weight, according to a study by specialists at the Guangdong Women and Children Hospital, Guangzhou. The doctors said the effect of air pollution on fetal growth was similar to that seen with cigarette smoke, and was due to immature fetuses being more susceptible to air pollution because they are in critical periods of organogenesis.

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.

Baby for sale to pay medical bills | Ambulances misused by non-urgent callers | Avian flu returns more virulent

 

Rural migrant sells baby to pay medical bills

A rural migrant women from Sichuan has been trying to sell her baby on the street of Fuzhou to raise money to pay medical bills for the baby's father. Police were called when the women displayed a sign saying "Boss fled after industrial accident and we don't have the money for treatment; I'm willing to sell my child to save her father." The woman said she had already paid Y7000 in medical bills for treatment of her husband who had injured himself after falling from a construction site. Some sympathetic passers-by gave the women some money before she was persuaded to end her 'sale.'

Beijing ambulances used for non-urgent cases

Ambulance services in Beijing are overstretched because 80% of cases they transport are non-urgent and do not need to attend the emergency department, a survey has found. Only 20% of the people brought in to hospital by ambulances had life-threatening conditions, according to a report from the Beijing's Health Planning Commission, which found that most of the ambulance patients could be treated in the outpatients department. The commission has suggested that patients are triaged before being taken to hospital as many critically ill patients are left without transport while ambulances are dealing with non-urgent calls.

Avian flu returns more lethal

The severity of H7N9 avian flu in China increased with the "second wave" last winter and the virus may return in an even more virulent and lethal form this winter, researchers have warned. The lethality of the H7N9 virus increased by 48% from the first wave in 2013 to the second wave in 2014, according to Dr Li Feng and colleagues at the Key Laboratory of Surveillance and Early-warning on Infectious Disease at the China CDC, Beijing. In the latter part of the first wave the death rate among hospitalised patients was 17% for young people under 60 and 42% for people over 60. In the second epidemic the death rate was 36% in people under 60 years, and 59% in people aged 60 years or above.
"If another epidemic of human infections with influenza A(H7N9) virus occurs in the winter of 2014/15, proactive control measures on the poultry-human interface may be preferable to reactive measures," the researchers suggested.

Most Chinese unwilling to pay for vaccines

by Michael Woodhead
Most Chinese people are unwilling to pay for vaccines to prevent common infections such as influenza and pneumonia, a study has found.
In a survey of more than 2600 people in three provinces, researchers from the China Center for Health Development Studies, Peking University asked whether people would be willing to pay the market price for influenza vaccine that costs 80 yuan ($12) and for a course of pneumococcal conjugate vaccine that costs 860 yuan ($138). Only 8% of people surveyed said they would pay for pneumococcal vaccine while 45% said they were willing to pay for influenza vaccine. The average price people were willing to pay was 60 yuan for influenza vaccine and 200 yuan for pneumococcal vaccine, according to the study in Vaccine.
Put another way, the number of people willing to have pneumococcal vaccine would increase from 8% to 25% if the price reduced from 860 to 400 yuan. The demand for influenza vaccine would increase from 45% to 70% if the price reduced from 80 to 40 yuan.
The researchers said the widespread unwillingness to pay for vaccines reflected their high price in China and the lack of any government subsidy. They said profit mark-ups on vaccines mark ups were high in China (as much as 43%) and they generally cost much more than in other countries.
"Our results suggest that both innovative vaccine pricing mechanism and expansion of financing sources are needed to alleviate economic barriers to self-paid vaccines," they concluded.

Beijingers still unprepared for influenza pandemics

by Michael Woodhead
Despite the many deaths from H7N9 influenza over the last year, most Beijingers lack basic knowledge about influenza prevention and do not use basic hygiene practices to avoid spread of the infection, a study has found.
In a survey of more than 13,000 Beijing residents found that only 7% had the minimum standard of knowledge and behaviour in relation to influenza prevention.
When asked to complete a survey on influenza, only 24% had adequate influenza-related knowledge, 12% showed influenza prevention behaviour although 43% possessed influenza prevention skills,
The survey tested Beijingers on their knowledge about the disease and its symptoms; and also assessed practices towards influenza and people with influenza-like-illness such as cough etiquette, use of masks, hand washing, and the need to seek medical care for influenza.
The survey also measured skills necessary to avoid and manage influenza such as use of a thermometer, attitudes towards flu vaccine and understanding of information materials related to influenza such as medication instructions.
The low levels of "health literacy" showed that more work was needed to encourage Chinese
"Improvements are needed in terms of certain aspects [of health literacy], particularly for the elderly and the population of rural districts," said Dr Zhang Li and colleagues from the Beijing Centre for Disease Prevention and Control. 
Update: A study from Guangzhou has also shown widespread misunderstanding about the threat of H7N9 infection. In a survey of more than 1000 city residents, more than 80% did not believe they would be at risk of H7N9 infection from live poultry markets. Resident wrongly believed that poor hygiene practices in markets were responsible for the disease risk, and the vast majority opposed permanent closure of live poultry markets, instead favouring 'rest days' when trading is suspended for cleaning and disinfection.

Six of the top medical news stories from China

1. China has a huge shortage of midwives, and would need a further 800,000 to meet the WHO standard of one for every thousand women of child-bearing age, according to a new report. Health officials say the problem will worsen as China adopts a two child policy.

2. Efforts to control pneumococcal disease and Haemophilus influenzae type b (Hib) in children by vaccination are failing due to low immunisation rates and delayed immunisation, a study from Shanghai shows. A review of vaccination records for 28,000 children up to the age of seven found that 51% had one dose of Hib vaccine and 11.4% had one dose of pneumococcal vaccine. Only 8.2% of children had Hib vaccine at the right time and only 0.5% had timely pneumococcal vaccine. Rates were particularly poor for migrant children, the study found.

3. Rates of hypertension have increased in China and yet treatment and control of the condition remain poor, according to researchers from Shandong. In a study of more than 4000 people they found that the incidence of hypertension increased from 2.9 per 100,000 people in 1991–1997 to 5.3 in 2004–2009 Antihypertensive treatment and control rates for hypertension were 5.7% and 1.7% in 1991–1997 and 19.9% and 7.6% in 2004–2009, respectively.

4. The rate of disabilities from road crashes in China has skyrocketed as the number of cars on the road has increased over the last two decades. The incidence rate for road traffic disabilities increased over time from 1.50 per 100,000 people in 1980 to 11.2 per 100 000 persons in 2005, according to Professor Zheng Xiaoying of the Institute of Population Research, Peking University.

5. Malaria is still a major problem in central China especially during floods and rainy periods of the summer. A study from Mengcheng County, Anhui found that there were 3683 malaria were notified during the study period of May to October 2007 Most of the cases occurred a week to a month after flooding and waterlogging. Public health action should be taken to control the potential risk of malaria epidemics after wet weather, the researchers from Shandong University said.

6. The recent outbreaks of H7N9 avian influenza also resulted in many mild and asymptomatic infections as well as severe life threatening cases, researchers from Guangdong have reported. Their surveillance program noted 21 cases of infection in Guangzhou, China in 2013 and 2014, of which several were mild or asymptomatic infection. Family clusters occurred, suggesting limited person-to-person transmission of the H7N9 virus, they said.

Smoking deprivation | Suicidal ideation in school students | Obesity surgery | Oestrogen in the environment

About 7% of Chinese people smoke so much their spending on cigarettes deprives the household of essential items like food, a study from Beijing has found. Low-income smokers were more likely to have smoking-induced deprivation.

Suicidal ideation occurs in one in three Chinese high school girls and 20% of boys, a study of 5249 students in Anhui Province of China has found.

Laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy are safe and effective for the treatment of morbid obesity, resulting in 63% and 76% loss of excess weight, a study from Nankai Hospital of Tianjin Medical University has shown.

The waist circumference cut off for high risk of central obesity and metabolic syndrome is 85 cm for women and 90 cm for men, researchers from Shandong have shown.

In Shanghai, almost one-in-five boys are obese and 8% of girls are obese. The prevalence of combined overweight and obesity is 49% for boys and 31% for girls aged 8-15-years, according to a study that found rates of obesity started to increase from age 10 years.

Oestrogen hormones are widely used in animal rearing in China and this leads to high levels of the hormones in excreted manure which is then used on crops, perpetuating the environmental contamination and human exposure, researchers from the State Key Laboratory of Water Environment Simulation, Beijing have shown.

The highly pathogenic strain of H7N9 avian influenza is quite different from other H7N9 strains seen in China and appears to have come about by re-assortment with the H9N2 strain, according to researchers from the Guangdong Provincial Center for Disease Control and Prevention.

Infliximab is safe and effective in Chinese patients with ulcerative colitis, resulting in 85% response rates and 62% remission rates after 30 weeks of treatment. However, relapse rates are high, say researchers from the Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou.

Illegal ambulances in Beijing ... dogs spread H7N9 ... new vaccines for EV71: eight medical news stories from China

by Michael Woodhead

1. Illegal ambulances in Beijing
One of the most bizarre stories of the week is that of the 'fake' ambulances plying their trade around Beijing hospitals. After hearing about fake drugs and fake doctors being widespread in China it should not come as any surprise to hear that shanzhai (山寨) unofficial ambulances are also operating. According to the Beijing Times the illegal ambulances park near major hospitals in the city and offer their transport services to patients. It is said that the poorly-equipped unofficial ambulances work in collusion with the hospital staff (who receive commissions) to charge patients exorbitant prices for transporting patients to and from hospitals and as transfers between hospitals. "Security guards at many hospitals have tried to stop these illegal ambulances from operating in and around their facilities, but they are afraid of being sued by patients and family members for delaying medical treatment," the article says.The unofficial ambulances have found a gap in the market because there is an insufficient number of genuine ambulances, the article says.

2. Dogs spread H7N9
Feral dogs that live around poultry farms and live poultry markets may be a key to spreading of the disease, say researchers from South China Agricultural University, Guangzhou. In a study of 2357 dogs, they found that 4% showed evidence of influenza A infection (though not specifically H7N9). Writing in Clinical Infectious Diseases, they said that feral animals "may increase the risk of the emergence and transmission of novel influenza A viruses and serve as a threat to both veterinary health and human public health ... As man lives in very close contact with dogs in many areas of the world,we posit that surveillance for novel viruses among feral dogs living in close proximity to
live poultry markets or poultry farms could serve as an early warning system of viral threats to man."

3. Zhejiang markets ground zero for avian flu
In the same vein, researchers in Zhejiang have found that poultry kept in local markets carry a veritable cocktail of influenza viruses including H7, H9 and H5 and two NA subtypes (N9 and N2), as well as H7N9-related reassortment intermediates H9N9. "The co-circulation not only reveals that Huzhou is one of the geographic origins of the novel H7N9 virus, but also poses a potential threat to humans in the future," they conclude.

4. Hand foot and mouth vaccine in the pipeline
More optimistic news in relation to another virus, namely EV71 enterovirus, the causative agent fro hand foot and mouth disease. A review article from the Third Military Medical University and National Engineering Research Center for Immunological Products, Chongqing notes that China has developed three promising vaccines against the disease that have passed Phase III trials, and are expected to be available in the near future.

5. Antivirals in more kindergartens
The scandal over the drugging of kindergarten children with antivirals is widening, with claims that a kindergarten in Jilin has also been giving the drugs without parental consent. The initial reports from Shaanxi that children were being given antiviral prophylaxis supposedly to prevent coughs and cold have justifiably caused outrage among parents. The odd thing is why such an obscure antiviral as the biguanide moroxydine was chosen to give children.

6. Ulcers from fat injections
A 38-year old Beijing woman is taking legal action against a Chaoyang health and beauty spa for half a million yuan in compensation after the "fat dissolving injections" she was given resulted in severe ulcers. In a court case the woman said the 'medical' staff at the clinic were unqualified and the "no side effect" lipolysis injections turned out to be albumen that triggered allergies and skin ulceration requiring skin grafts.

7. Gay 'cure' clinics do thriving business
The Economist has a feature on the 'homosexuality cure clinics' in China, where people can pay around $1700 or a three month program of psychological treatments that supposedly deter them from having gay tendencies by giving them unpleasant injections and treatments in while watching sexual imagery. The clinics are said to be encouraged by the Confucian social pressure to be a good child and conform with traditional Chinese values.

8. Fake medical ads still widespread
And while we are on the subject of dodgy treatment Xinhua reports that advertisements for fake and worthless remedies and clinics are as widespread as ever, despite laws intended to crack down on the. In a long article, Xinhua reporters describe how newspapers are still full of ads for fake treatments or treatments for which exaggerated claims are made. Industry insiders said the marketing of fake medical products and services was a high profit, low risk business as there was little enforcement. Government departments said fake products were widespread and it took a lot of time and resources to track them down and prosecute offenders.

Poultry industry demands 'avian' be dropped from H7N9 influenza virus description, threatens legal action

More than a thousand poultry breeding and trading companies have signed a petition letter calling on government departments to stop using the term 'avian' in respect to the H7N9 influenza virus, saying the link has caused catastrophic losses to their industry.
The letter organised by the China Animal Husbandry Association says that 'avian flu' is not an official term used by WHO and should not be used by ministries such as the National Health and Family Planning Commission.
The companies said the warnings about live poultry had caused panic among consumers who shunned the products, leading to a billion yuan in economic losses fr the industry. The poultry industry leaders said ther use of the term 'avian' was irresponsible and unscientific and should not be used. They said if ministries did not stop using the term they would take legal action to force them "to safeguard the rights and interests of the industry members".
The industry association also called on the government to take immediate measures to save the poultry  industry.

Human-to-human transmission of H7N9 reported in Shandong family cluster

by Michael Woodhead
A probable case of human-to-human transmission of H7N9 avian influenza has been reported by researchers in Shandong province investigating a family cluster of the infection.
A 36-year-old man who developed the infection in April last year in Zaozhuang seems to have transmitted the H7N9 virus to his four year old son, according to Dr Liu Ti and colleagues from the Shandong Provincial Center for Disease Control and Prevention. Writing in the journal BMC Infectious Diseases, they describe the case histories of the family cluster, and conclude that the son had no exposure to poultry as a source of infection but had prolonged contact with his sick father.
The father became infected with H7N9 avian influenza in mid April, possibly from being in proximity to poultry markets, they found. He had no close contact with poultry but there were poultry farms and markets in the area where he lived, the found. The "index case" developed a severe fever and sought medical help. His son became infected seven days later, but he had no exposure to poultry as he remained at home with his sick father before the father was hospitalised with pneumonia. The son had prolonged, close contact with his father, including eating together, and he also became infected with H7N9 and was hospitalised. Both father and son eventually recovered from H7N9 infection and were later discharged from hospital.
“The infection of the index case probably resulted from contact with environmentally contaminated material. For the son, the probable infection source was from the index case during unprotected exposure, but the possibility from the environment or other sources could not be completely ruled out,” the researchers said.
“Though it is difficult to ascertain the infectious source for the two cases, the emergence of H7N9 clusters requires urgent attention because of the possibility that a change in the epidemiological character could spread more easily among people,” they concluded.

My top10 medical stories from China for Saturday 22 February

1. Smoking with a water pipe confers a 'profound' risk of chronic obstructive pulmonary disease (COPD) among people in south west China and also carries a high risk from passive smoking, researchers have shown.

2. Patients with pneumonia of unexplained origin should be promptly investigated for H7N9 risk factors such as exposure to poultry and they should also be given pre-emptive antiviral treatment such as Tamiflu, the Beijing health department has ordered.

3. About 85% of Chinese doctors experience burnout, with those who are younger, unmarried and working in emergcncy medicine having the highest risk of serious burnout, a study shows.

4. Fertility clinics in China need to become more patient-friendly as they are perceived as too impersonal and lacking in transparency and respect for patient informed consent, researchers say.

5. The stigma of mental illness in Chinese culture means that patients with schizophrenia often do not understand their medication and are unwilling to take any anti-psychotic medication, according to a study from the Guangzhou Psychiatric Hospital.

6. H. Pylori infection rates are over 90% among people in their thirties in Jiangsu, which may explain high rates of gastric cancer in the region, say researchers from Nanjing.

7. Babies in Shenyang have increased rates of neurodevelopmental deficits because their mothers were exposed to high levels of organophosphorous pesticides during pregnancy, according to a study in PLOS One.

8. Adenovirus has emerged as a significant cause of serious pneumonia in China, with a study showing that 5% of cases are attributable to the virus.

9.  People with tuberculosis are also at high risk of HIV, with rates of around 3% in groups tested in TB patients from Guangxi, Henan and Sichuan, say Chinese researchers.

10. A mediation service for patients involved in medical disputes with hospitals is to be launched in Shanghai and it will be open to patients where compensation claims exceed 30,000 yuan ($2900) regardless of whether the hospital refers them.

"Fake" GPs in Shanghai | 5-in-1 vaccine shortage | Appointments by WeChat: China medical news for Friday 14 February

Shanghai appears to lead China in the introduction of family doctors, but many of the so-called general practitioners (GPs) are fake, says Zhu Shanzhu, the chairman of the Society of General Practice, Chinese Medical Association. In an article in Global Times, Dr Zhu says that Shanghai is on target to have a GP for every resident by 2020, when people will be able to register with a family doctor working out of their local community health centre. However, Dr Zhu says many of the family doctors assigned to the health centres are not true GPs because they are specialists such as surgeons. Shanghai must therefore commit to training doctors in family medicine, she said.

A second death has been reported from the novel influenza strain H10N8 in Jiangxi. According to Shanghai Daily, a 75-year-old man died in Nanchang. Health authorities have urged the public to stay away from live poultry.

Shortages of the popular paediatric 5-in-1 combination vaccine have been reported due to transport congestion and delays ove the Chinese New Year. The imported vaccine, made by Sanofi, immunises against diphtheria, tetanus, pertussis, polio and Haemophilus influenza Type B and costs around 600 yuan for each of the four doses. Parents prefer it over free domestic vaccines because it reduces the number of needles their child has from 12 to four.

Hospitals in Beijing are offering appointments and medical results via WeChat, ECNS reports. The social media service is being offered by 21 municipal hospitals to patients who sign up and obtain a password.

A Shaanxi woman claims one of her kidneys was secretly removed during an operation she had more than 20 years ago. The woman made the shock discovery that she was missing a kidney when she had a hospital scan for back pain. The only possible explanation was that it must have been removed when she had an operation on her ovaries 26 years previously, she told TV reporters. The woman returned to the hospital where she had the operation but they rejected her claims and denied all responsibility for the incident.

A hospital in Hainan is pioneering a new model of "treat first, pay later" care. The hospital in Haikou has dropped the usual registration system in which patients pay a deposit ahead of treatment. the hospital managers say the new system is more convenient, but relies of the trust of patients to pay for their treatment afterwards. Non-payers will be put on a black list and refused further treatment, they said.

A Beijing academic has called on the government to stop the tobacco industry's deceptive marketing of "low tar, less harmful" cigarettes. Professor Yang Gonghuan of the Department of Epidemiology and Statistics, Institute of Basic Medical Science, Chinese Academy of Medical Science, says the claim that low tar cigarettes are less harmful is incorrect. However the slogan is used by industry to encourage smokers to stay with the habit. Writing in Tobacco Control, he urges the government to "stop the execution of this deceptive strategy for tobacco marketing".

And a kidney specialist in Guangzhou has been praised in the Chinese media for continuing to work despite being confined to a wheelchair. Reports say Dr Ke continued seeing 20 patients a day at the PLA 458 Hospital over the Chinese New Year despite having broken her patella and being unable to walk. Patients praised the doctor but she said any of her colleagues would have done the same thing.

Illegal Beijing bird markets the source of exported H5N1 influenza virus

A backstreet illegal poultry market stall in Beijing was the likely source of the highly pathogenic avian influenza A(H5N1) virus infection that killed a Canadian visitor, infectious disease specialists have suggested.
In January a 28-year old woman developed H5N1 infection on her return to Alberta after visiting Beijing. She died after developing neurological complications. It was assumed that she had picked up the infection in Beijing but it was reported that she had not had close contact with poultry while in the city.
However, the woman probably picked up the virus from one of many illegal poultry market stalls that exist in Beijing, according to Dr Yang Peng of the Beijing Center for Disease Prevention and Control. In a letter to the Journal of Infection this week, Dr Yang says the Canadian case was only the second such case of H5N1 to be linked to the city. He describes a similar case in which a 19-year old woman developed H5N1 infection and died in 2009. Analysis showed that the H5N1 virus was avian in origin and belonged to clade 2.3.4. The woman had bought a live healthy duck from a street market and she had prepared it for cooking. Dr Yang said poultry breeding and live markets were prohibited in Beijing, but illegal markets had sprung up in the suburbs, and these sold poultry reared in nearby Hubei and Tianjin districts.The stall area where the women bought the duck tested positive for H5N1, according to Dr Yang. He therefore suggested that the recent Canadian case of H5N1 may have occurred after the visitor passed through a street market or stall.
The findings "indicate that illegal and uninspected selling and transportation of live poultry from regions outside of Beijing may have posed a high risk on human infection with avian influenza in the general population of Beijing currently. The enhanced inspection of illegal selling of live poultry, the strict regulation of transporting live poultry from regions outside of Beijing, as well as health education on changing dietetic culture is greatly warranted in Beijing, in order to reduce the risk of infection with avian influenza viruses in the general population of Beijing including visiting foreigners," the letter concluded.
And in another development this week, the full genomic analysis of the Beijing-derived H5N1 case has been published in the Emerging Infectious Diseases. The analysis "provides valuable insight into the presence of mutations that may reflect adaptive changes, altered virulence, and/or transmission phenotype," the researchers said.

Antibody vaccine for H7N9 is more effective than Tamiflu, say Shanghai researchers

translated by Michael Woodhead
Shanghai researchers say traditional inactivated vaccines cannot be developed against H7N9 but they have developed a gene vaccine which is more efficacious than Tamiflu against the virus.
According to an article in the Workers Daily, an antibody therapeutic vaccine that is effective against the current strain of H7N9 has been developed by Shanghai researchers and is now about to start  clinical trials. Researchers at the Shanghai Public Health Clinical Centre Infectious Disease Research Institute said they had developed antibodies that were effective against H7N9 in vitro and they are now starting tests in humans.
Professor Xu Jianqing of the Infectious Disease Research Institute said that work on the vaccine began in April last year after the first major H7N9 influenza virus outbreaks.  He said the team had made a breakthrough with a gene vaccine in December when they injected the vaccine into 30 mice infected with H7N9. After 30 days none of the mice had died and none had signs of H7N9 infection, which represented the first real proof of efficacy.
Professor Xu said many other research groups in China were doing H7N9 vaccine research but using  traditional inactivated vaccines. However, he said experiments had shown time and again that compared to other influenza viruses, the H7 influenza virus was not amenable to being incorporated into an inactivated vaccine, as it was deformed by the chemicals used, rendering the immune response inadequate. Similar efforts by Dutch researchers to develop a vaccine against the H7N3 virus strain in 2003 were also a failure for a the same reason. This showed that inactivated vaccine technology was not going to catch on for the H7 virus, he said.
The Shanghai researchers had therefore taken the bold step of taking the most important genetic material from the H7N9 virus and implanting it into a mature vaccine carrier. This was the equivalent of putting it into a safe and inserting this into a cell, said Professor Xu. And because the virus structure was not destroyed by putting it into an egg albumen, it elicited a good immune response, he added.
Professor Xu said the new vaccine would be suitable for people at high risk of H7N9 such as those working in live poultry markets and household members.
Within Shanghai's R&D community the new H7N9 vaccine was seen as a breakthrough after an audacious attack. Xu Jianqing said the immune system of H7N9-infected people produced antibodies, and the sooner the body produced antibodies the better the prognosis. He added that Tamiflu was effective if given within the first few days of viral infection, as this was the 'empty' window before the body had started producing its own antibody.  But after more prolonged infection Tamiflu quickly became ineffective,  and drug resistance appeared quickly. Researchers were inspired to try using exogenous antibodies during this initial 'empty window' period when there was no natural H7N9 antibody being produced. The observed effects of the gene vaccine were clearly better than Tamiflu during this period, said Xu Jianqing. In fact, in 2003 during the SARS outbreak, there had also been small scale treatment models of experimental antibody treatment that were successful in curing a patient.
It is reported that at present the H7N9 antibody treatment has already successfully completed two phases of in-vitro testing and it is estimated that Phase 3 testing will be complete within one month. From among the 100+ types of antibody currently in testing the best will be selected for clinical use.

Vaccine for H7N9 | No smoking in medical centres | Cosmetic surgery boom among young Chinese

Vaccine developed for H7N9
Shanghai researchers say they have developed a "gene vaccine" for the H7N9 avian flu virus for humans that has succeeded in primary animal tests, according to Shanghai Daily. The claim was made by officials at an infection disease research body under the Shanghai Public Health Clinical Center

Now influenza H6 is a threat to humans
Yet another kind of avian influenza virus has been found to pose a threat to human health in China - this time it is H6. Researchers from Lanzhou tested samples from live poultry markets in southern China from 2008–2011 and found that among the 257 H6 strains tested, 87 viruses couldbind to human receptors. They found that there were 30 different H6 genotypes, showing that these viruses are actively circulating and reassorting in nature. "Our study demonstrates that the H6 avian influenza viruses pose a clear threat to human health and emphasizes the need for the continued surveillance and evaluation of the H6 influenza viruses circulating in nature," they concluded in the Journal of Virology.

Subway station radiation not a health threat
Operators of subway stations in cities such as Beijing and Chengdu say the radiation from security scanners poses no threat to human health. The doses from a typical security scan are equal to around 0.007 mSv per year if a person is scanned daily. This is lower than the safety standard of 1 mSv per person a year. Most X-rays are contained within the machines by protective curtains that block X-rays from escaping," and environmental expert told the Beijing Daily.

No smoking rule for medical centres
Doctors have been advised to deliver stronger anti-smoking messages to their patients ,according to ECNS. According to the report, doctors have been told by the National Health and Family Planning Commission to inquire and record the smoking history of patients during their initial diagnosis to help smokers quit. The NHFPC also says that there should be no smoking in medical establishment and medical workers are also asked not to put ashtrays in their offices. The NHFPC also recommends that smoking clinics be set up.


Cosmetic surgery rates highest in young people
Cosmetic surgery and other cosmetic procedures such as ear piercing have become very popular with young people during the holiday period, according to Xinhua. Many stalls in a Shenyang market offered ear, lip, tongue, nose and belly button piercing over the New Year holiday. The operators claimed to be trained nurses but failed to produce any medical license.  A cosmetic surgeon said that there had been a rise in young people undergoing minor surgeries too, with children as young as eight or nine getting double-eyelid surgery to give them the appearance of larger or "Western" eyes.

Pollution decreases Chinese men's sperm | H5N1 virus carried by wild birds | Adenovirus threat to PLA | Tuberculosis control failing

Pollution reduces Chinese men's fertility
The high levels of pollution found in Chinese cities are reducing the quality of men's semen, a study form Chongqing has shown. Researchers from the the Institute of Toxicology, College of Preventive Medicine, Third Military Medical University, Chongqing measured air pollution levels in Chongqing and in surrounding rural areas. They found an inverse correlation between measures of pollution such as PM10, SO2 and NO2 and semen quality. Published in the journal Environmental Pollution, their findings show that the highest sperm concentrations were seen in rural areas, whereas the lowest were seen in downtown areas of Chongqing. Conversely, the highlest levels of pollution were seen in urban areas, peaking in winter months.
"Exposure to higher concentrations of PM10, SO2, and NO2 in urban ambient air may account for worse semen quality in urban males," the researchers concluded.

Migratory birds carry pathogenic influenza virus
Wild birds migrating through Yunnan have been found to carry the highly pathogenic influenza H5N1 virus. A sampling of birds trapped by researchers found that the average carriage rate of H5N1 was 5%, but in some species such as cuckoos the rates were as high as 22%. The researchers said the birds could be possible vectors of influenza, especially if they shared ponds and drinking water with domestic birds. The findings are published in the Virology Journal.

Tuberculosis control failing because of migrant workers and the elderly
Doctors in rural Jiangsu say tuberculosis control is a problem because of difficulty in diagnosing and treating the disease in migrant workers and the elderly. These two groups were repeatedly documented as the main obstacles in effective tuberculosis control by doctors in a rural county near Suzhou. When interviewed by researchers, doctors also expressed their frustration with the lack of new drugs for treating tuberculosis patients. They said elderly patients were less health conscious and more prone to side effects, so doctors had to put extra effort into convincing elderly patients to adhere to TB treatment. Migrant workers were another probelm for TB control because they were often poorly educated, had little awareness of TB and had difficulty completing long term treatment because of their transient lifestyle. Difficulties also arose because migrant workers were poor and not covered by local health insurance schemes to pay for medical treatment and drugs for TB.
"Migrant workers coming from rural parts of China present a gloomy prospect for TB control in China," the researcher from the School of Public Health, Nanjing Medical University said in PLOS One.

Respiratory virus threat to PLA
Clinicians in Sichuan have reported that a novel adenovirus is posing a serious threat to the health of China's military. The human adenovirus 55 (HAdV-55) has caused outbreaks of sever acute respiratory disease among adults and seems to be common in military trainee institutions. In an analysis of the virus found in samples from almost 200 young Chinese infected in recent years they found that it often caused severe pneumonia. They charactrised the makeup of the virus and warned that it posed a threat, but more research was needed to understand its diversity, dissemination, and transmission in China.

H7N9 may be confined to Chinese due to susceptibility gene?

by Michael Woodhead
A H7N9 influenza pandemic may be confined to Chinese people because of a susceptibility gene that makes them much more prone to severe H7N9 disease, a new review has noted.
The IFITM3 gene (interferon-induced transmembrane protein-3 gene) increases influenza disease severity, but it is uncommon among Caucasians, a report in the journal Clinical Infectious Diseases notes.
The IFITM3 gene is more common in Chinese people and could account for a widespread population risk of severe H7N9 infection, says Dr David Hui of the Chinese University of Hong Kong.
In a commentary on risk factors for H7N9, Dr Hui notes that recent research has shown that 70% of Chinese patients who had severe influenza infection had the susceptibility gene. The gene is associated with a six-fold higher risk of severe influenza, he notes, and has also been linked to higher influenza mortality. A genetic susceptibility may also explain clusters of the infection in family members.
The study released last year concluded that: "because the risk genotype occurs with such a high frequency [in Chinese people], its effect translates to a large population-attributable risk of 54.3% for severe infection in the Chinese population studied compared with 5.4% in Northern Europeans."
Dr Hui also remarks on another surprising finding from a new review of  influenza patients: smoking appears to be protective against hospitalisation for the disease. This 'counter-intuitive finding' might be due to some anti-inflammatory effect of nicotine, he suggests.
The review found that H7N9 influenza tended to affect older men and those with co-morbidities such as cardiovascular disease. It also had a more protracted course than other forms of influenza, with an average time from onset to death of 18 days.

UPDATE: Another recent study has shown that compared to Caucasians, Chinese people have lower levels of an immune protective mechanism against H7N9 influenza virus known as CD8⁺ T lymphocyte (CTL) immunity. The same study also shows that Alaskan and Australian Indigenous people may be particularly vulnerable to H7N9.

Medical news headlines from China - Friday 24 January

China's foray into pharma research hits setbacks

An article in Caixin looks at Chinese pharmaceutical company efforts to develop therapeutic vaccines that will cure hepatitis B rather than just prevent it. This is a potentially lucrative market given that 10% of Chinese have the infection.  However, the R&D efforts of three companies - including a brewery - to develop a hepatitis B vaccine have proved disappointing, resulting in falls in their stock prices. Research efforts for a therapeutic vaccine have been characterised by delays, poor results and concerns about adverse effects of the new products. Some experts have said the vaccines may do more harm than good while others have said that there may no longer be a need for therapeutic vaccines if hepatitis B is prevented by immunisation.

Private investors in hospital must tackle local government

Another feature in Caixin  takes a look at the recent relaxation of rules that allows private investment in public hospitals. It uses the example of a Chinese pharmaceutical company that tried to buy a stake in two hospitals in Kunming. The article concludes that the local governments which control the hospitals have the power to make or break an investor's plan and stand as the biggest barriers to the kind of public hospital reform advocated by the central government.

Red envelopes still needed for medical care

An editor at the China Daily admits he had to use guanxi and "favours" to get a hospital bed for his father after he suffered  a stroke in Beijing. In his article, Bai Ping says it is extremely difficult to get a hospital bed in Beijing because many people come to the capital from outside in the hope of getting superior treatment in the city's hospitals. Bai Ping says his family now faces huge medical bills and they feel themselves at the mercy of doctors over treatment and costs that they do not know much about.

Unvaccinated China faces grim flu season
China faces a serious flu season because of low levels of immunisation, infectious disease specialists have predicted. The influenza virus is much more active this year and there are three major strains of the flu virus: H1, H3 and Influenza B, according to Feng Zijian, deputy director of the Chinese Center for Disease Control and Prevention (CDC). China's flu vaccination rate remains at 2 to 3% of the population each year, lagging far behind 27% in the US. Low vaccination rates are thought to be due to a general lack of awareness among the Chinese public about the dangers of influenza, as well as concerns about the safety of domestic vaccines, according to the Shanghai Daily.

Trains should have medical facilities
Long-distance trains should provide on-board health facilities, according to China Daily. Many passengers become sick on long distance journeys that can last 2-3 days in China, but they cannot get off the train because their ticket will become invalid. Some long-distance trains have infirmaries but the medical service on trains cannot meet serious emergencies. The railway authorities, therefore, should assign medical professionals to the infirmaries and stock them with as much emergency medicines as possible.

Wenling doctor killer in court

The man accused of attacking and killing a doctor at the First People's Hospital of Wenling in Zhejiang province in October has appeared in court charged with murder. Lian Enqing, 33, is suspected of stabbing to death Wang Yunjie, 46, and severely wounding two other physicians, according to China Daily. It is believed he was unhappy with a surgery done on his nose at the hospital. 

Zhejiang researchers identify the two greatest risk factors for H5N1 avian flu infection

After analysing an outbreak of H5N1 avian influenza in Zhejiang in 2011-12, researchers have the two main risk factors for infection as being in close proxiity to poultry and being somewhere wehere large numbers of birds are bred.
In a study of 3,453 environmental samples, 3% tested positive for H5 avian influenza virus and 4.7% of 1,169 people tested seropositive for anti-H5N1 antibodies. The H5N1 virus detection rate was highest in poultry slaughtering and processing plants (14.6%). and the most common sources of infection were sewage (4.5%), drinking water (3.1%), faeces (2.3%), cage surface (2.0%), and slaughtering chopping boards (7.0%). The two main risk factors for infection were direct or close contact with poultry (five fold higher risk) and breeding numerous poultry (four-fold higher risk). Source:  Journal of Thoracic Diseases