Cruise ship runs - the tourist industry spoiler

Cruise ship outbreaks of nausea, vomiting and diarrhea have been a hallmark of the industry almost since the birth of the industry.  Not a hidden secret, but not something that is included in the tourist brochures – seven days of sun, surf, seafood with great views of the inside of a bedroom and bathroom. 

The vessel sanitation program of CDC provides details on current and past outbreaks going back twenty years.  Also on the website are some historical documents on the history of cruise ships outbreaks http://www.cdc.gov/nceh/vsp/ and the development of a formalized program.  Based on reducing numbers of outbreaks through the last decade, some success appears to be happening.  The office maintains responsibility for cruises that land at any point in a US port.  Returning Alaskan cruises with destinations in Vancouver may not be included in surveillance where no outbreak was identified prior to the last US port.  

Canada however lacks such rigorous surveillance.   Places like the port of Vancouver have protocols for ships entering the port with GI outbreaks, but fall between various jurisdictions relative to their oversight.

Both countries have other dirty hidden secrets from tourists.  Visitors to national parks on both sides of the border may be greeted not only by beautiful scenario and wildlife – but outbreaks of Norovirus during peak summer season are common and rarely reported yet identified. Tracking national park outbreaks is best done through popular and social media, such as the 2013 Yellowstone and Grand Teton parks.

Canada’s favourite national parks are not immune, with outbreaks investigated on both sides of the BC-Alberta border in documents that are in very grey literature and inaccessible.  

Norovirus has a routine annual visit like influenza, the current cruise ship attention merely highlights again. Norovirus running to a bathroom near year    

Fire and tragedy in long term care settings, a future public health threat?

Devastation has struck another nursing home.  Five residents confirmed dead and up to 30 unaccounted for in the quaint village of L'Isle-Verte a couple of hours along the south shore of the St. Lawrence near Riviḕre –du-Loup CTV coverage  .  Tragically it could occur anywhere and has. G and m list of fatal Canadian fires  Global news list of previous fires

A detailed 5-year review in the US looked at some 3000 nursing home fires amongst over 6000 fires in health care facilities – speaking to how common such events actually are, fortunately rarely as tragic with an average of only 6 deaths annually and twenty times as many injuries.  NFPA special report    

Ageing infrastructure, older buildings not compliant with newer safety codes particularly related to sprinklers, faulty electrical and heating, and most commonly kitchen related. Smoking always a possible contributor where facilities have not limited smoking within the building.  The minus 20 temperatures suggesting heating, particularly individual residents efforts to further heat rooms, might be a factor. 

There were over 200,000 long term care beds in Canada in 2010.  In 2012, the annual residential care facilities survey and report were cancelled by the federal government, raising questions on the future ability to track growth and care in residential care settings.  The final report available at Stats Can 2012 report.  Why would such a report be cancelled?  Perhaps in part that one of the main focuses was on cost controls and limitations that would have limited private sector proliferation in residential care settings, merely speculation but consistent with other federal decisions.

With the proliferation of residential care beds in Canada, and the development of a variety of options, residential care may fall under numerous pieces of legislation, inconsistent inspection and investigation, limited accountability for public expenditures and increasing private options.  While publically funded residential care options are generally seen as beneficial in reducing inappropriate acute care facility utilization, systematization and standardization of care can be sporadic depending on the regulatory framework applied to a specific care setting.

The result of the recent proliferation and expansion of options of residential settings becomes a vulnerability for n increasing number of future tragic scenarios. Government policies that support warehousing of seniors unable to live independently in the community have opened the door to even greater exploitation. To this add the loss of family support structures and the growth in aged populations.

Only 8% of those over 65 currently reside in any form of collective living arrangement.  Even for those over 90, living in a private residence is the most common living arrangement.  The proportional growth in care settings can be found at Stats Can Living arrangements for seniors.  While government and health care organizations focus their attention on residential care, this is being done at the expense of supporting the majority who successfully choose to retain their independence. 

The inevitable outcome will be a convergence of factors that will lead to more l'Isle-Verte devastations. 

Minimum wage, Living wage, Assured Basic Income, and the shift to Part-time work

The year has started with a flurry of reports looking at how to best provide support to those that are financially challenged.

It is well acknowledged that an single adult leading a family working full time at minimum wage remains under the poverty line.  However, at that point there are differences of opinion about what poverty advocates should speak up for.

Two pieces worth reviewing, first arguments in Healthy debates January 14, following within days by critiques of the living wage by The Fraser Institute.  Needless to say with opposite conclusions on the value of approaches to increasing economic wellbeing for families and individuals. 

Minimum wage being a legislated lowest denominator for hourly rates.  The Living wage being a construct that speaks to the minimum salary for a full time employee to eke out a living when leading a family.  Neither has consistent methodology.  Both assume full time employment. The living wage was based on conversion of annual costs to an hourly rate.

Concurrently, Statistics Canada released December employment survey showing that full time jobs decreased while overall parttime employment led to a net increase in jobs.  Hidden in the report, participation rate decreased  to just under 2/3rds, those unable to find employment who do not qualify for employment insurance for having never worked, worked insufficient number of weeks, expired EI benefits without finding employment are excluded from unemployment statistics that suggest unemployment rates of just 7.2%

Herein lies the major issue.   Poverty advocates are targeting minimum hours levels of income.  The labour market continues a slide away from full time employment with benefits, to part time or  temporary positions with limited benefits. Simple math, annual income is a function of both hourly rate and number of hours worked.   Put together leads to a resurgence in the concept of the assured (guaranteed) basic income, or what is actually needed annually to survive. 

Few individuals wish to be dependent on social programs.   Rather than blame a minority, its time to blame the system that purposefully holds individuals in economic slavery.  Forcing many to multiple part time jobs and working in excess of accepted working hour standards for employment.  Fueled in the debate by ultra-right wing thoughtless tanks like the Fraser institute.

Before believing that there is a simple solution, pay equity between genders in Canada and most developing countries remains unachieved despite government commitments.  

So what would it take? At least the following fundamental structural changes:

1.       A societal commitment to social wellbeing

2.       A social commitment to reducing inequities

3.       Employment efforts that reinstate full time positions with employee flexibility

4.       Wage and benefit standards

Perhaps more than ever, labour organizations need to speak out – however with stronger unions for professions typified by regular hours, fulltime employee and good benefits, the core values of the labour movement has now been undermined from within and those needing a voice are no longer represented. 

In the meantime, much rhetoric is lost into the air by advocates using differing terms, focusing on activities with marginal benefit, and counterattacked by those who believe the solution to poverty is through increasing profits amongst the richest 1%. 

Greenhouse gas emissions - an innovative illustration of national production and update on Canada's contributions

Climate change and public health are integrally related, and while some folks have been trying very hard to push public health front line staff to take more aggressive stances on climate change policies, without warm embracement.   Embracing environmental health issues that have outcomes measurable over decades is challenging without current political time frames. Incorporating specific targets on issues like greenhouse gases is more tangible and concrete, hence have been more readily accepted without question of the rationale or purpose in achieving such guidelines. 

The more global issues of climate change are worth a discussion.  Today’s trigger came as a retweet originated from Dónall Geoghegan @DonallGeoghegan as a photo of the proportional allocation of greenhouse gases by country.  The innovative design was worth replicating, and the origins other than the Tweet are not ascribed.  

While the graphic looks at arbitrary political boundaries that we are familiar with, adjusted by population the list of top producers changes per capita emissions by country and is dominated by oil and gas producing countries, with Canada sliding into 12 place, two spots ahead of the US. China ranks 121^st, India at 162^nd both of whom appear implicated by the absolute volume production.

Diving deeper Canadian greenhouse gas (GHG) production is documented at National greenhouse gas inventory   An amazingly succinct and clear document to read and follow.   Whether filtered by political manipulation, the purpose of the document is for reporting to the international convention and seems to address current needs in a moderately objective manner.

Of note, that Canada’s major GHG production is broken out in the graphs on both pages 4 and 5.  Energy and transportation dominate the sources.  Alberta producing just over 35% of the GHG.  On a per capita basis, the Maritime provinces,  Quebec and Manitoba are the lowest consumers. Again, the simple adage of oil and gas producing provinces having the highest per capita production of GHGs. 

Oil sands production contributes to about 8% of Canadian GH emissions.   While recognizing the source, it is often useful to review industry developed interpretations and this can be found at Oil sands today GHG and Canadian Association of Petroleum Producers, both of whom emphasize the relative contribution to coal production and the proportionate contribution by the consumer compared with their role in production.   Fair points to consider.

The good news is found in the national inventory document.  Irrespective of the measure,   Canadian GHG have leveled off and are slightly declining.  Will it be sufficient to meet the 2020 Copenhagen Convention target of a 17% reduction?   It wasn’t sufficient to meet the Kyoto targets that Canada quietly abandoned.  

Bird flu - what the cluck?

It finally happened, and those with perhaps less to do on their hands made a media field day out of it and got lots of face time in the media.  Bird flu crossed the Pacific, landed in Vancouver, went to somewhere in Alberta and one human died.  Every death is a tragedy and not to be taken lightly.  

Perhaps the good thing was it was distracting enough to take the attention off western provinces inundated with H1N1 and a body count that is at least 30 and just beginning to chip at the iceberg. 

The H5N1 avain influenza strain arose in southeast Asia back in 2003 and has insipidious spread across Asia and into Eastern Europe and Northern Africa.  Through the end of 2013, 650 cases of human illness had been identified with a mortality rate of nearly 60%. WHO cumulative tabulation    Almost all cases had direct contact with birds.  The slow steady spread of the virus has received considerable scrutiny and remains under the careful eye of the WHO.   

The virus has been subjected to considerable research including the infamous studies on what it would take to mutate the virus into a form that could readily transmit between humans.  Candidate vaccines are already in the works, and formed the basis for the adjuvanted pH1N1 vaccine formulation used in Canada and other countries during the 2009 pandemic event.

The main question that was answered in the recent event was only – when would it appear in North America?   We may still be interested in whether avian flyways will result in infected birds becoming established in North America as the H5N1 naturally continues to work its way easterward towards the Atlantic, a direction that is not normal for influenza strains in their annually west to east migration. 

Now that the hype is over.   Can we return to focusing attention on the immediate concerns caused by the resurgent wave of pH1N1 and its unique 2014 manifestations?  

Out in the cold - the understudied public health effects of frigid temperature

For those who have any interest in the relationship between health and weather, this site has some interesting postings. Weather that kills; Communicating the risks of weather; air pollution and AQHI

As a polar vortex captures much of North America, and temperatures in Saskatchewan are at in inhumane -50 C wind chills, there is lots of talk about the safety concerns since we all know the discomfort associated with getting too cold.

Little is said of the deaths associated with cold. For some reason, we have been able to parse out the impact of heat, but have little on the impact of cold.  Multiple studies have demonstrated that the risks associated with subzero temperatures continue to rise as temperature drops, in fact the risk begins to increase as temperature dips below about 20C, so once we are into subzero temperatures, the relative risk is about 10% higher, and by -30 that risks is over 20% and likely closer to 30% - however the data are scarce since major cities don’t experience such extreme temperatures for long enough periods to parse out the impact (for examples see AJE eastern US cities)

Frustratingly, even in studies looking at ambient temperature, the focus is on the increased temperature such as science direct Asian capitals while the graphic relationship shows the steeper curve in mortality as temperature drops

So why is cold, being left out in the cold?  The relationship between the increase in deaths seems to be more complex, as issues like wintertime crowding, circulation of influenza and other viruses complicate the analysis of the long term baseline information.  This should be adjustable for, and in doing so some estimates of the real risks of cold weather undertaken. 

As this site has noted, it may be estimated that colder climates contribute up to 5000 deaths annually in Canada.

So as we bundle ourselves inside, perhaps someone with time series regression knowledge might produce a paper on what we in Canada know only too well, that the cold can be uncomfortable and tragically it sometimes kills.

For the sociologists, some understanding of who is affected by hypothermia and who dies during cold spells would help fill an icy void in our understanding of the Canadian chill. 

Why is this an understudies area?  Look at the news, the concern is about infrastructure, about being stranded in heated airports, about the inconvenience in having events and schools closed.  It affects us all in our daily activities, and perhaps in doing so we are sliding over those that suffer through such disastrous temperatures.

Influenza 2014 - pandemicH1N1 the sequel

It sounds like an awful movie title, but the pandemic H1N1 strain is entering for a second show. 

The best way these days to figure out what is happening with influenza is not to use the usual updates from  PHAC fluwatch   CDC Fluview  or WHO influenza .   The best way is to watch the news stations and search engines like Google flutrends.

This year is appearing a bit different.  By the numbers so far, this is a solid “average influenza year” with many surveillance measures on the 10 year median.   There is something different however that is attracting attention.

The dominant strain is the same pandemic H1N1 that goes by the name of A/pdmH1N1/California/07/2009 which wreaked havoc and caused devastation in 2009.  While the impact of that year was that of a really bad influenza year, and many detractors claiming that public health cried “wolf”, the reality is the wake of devastation was substantive with about half million deaths worldwide.  Lancet 2012 publication

What is being seen this year is sporadic severe illness in person under 65 with co-morbidities including morbid obesity.   Surveillance systems are not refined enough to piece out demographics on severe illness which comparatively may be different from prior years. 

Alberta seems to be earliest out of the Canadian starting block this year, perhaps we can expect other provinces to begin reporting similar experiences as school begins to return. 

A ProMed posting from people in BC provides a strong indication of relative susceptibility amongst the under 65 population, and potentially among the naïve under 5 age group.

Lets hope that the early indications fizzle quickly, but while hoping for the best, be prepared for what others are already experiencing.  

Out with the Old – and In with the New

Welcome to 2014!!!!!!   

A great time to celebrate our children. Starting with infant mortality where the Washington Post reports the graph of the year as the remarkable gains in infant mortality in the past two decades since the gruesome genocide.  

There is a great Unicef report on child mortality that is worth looking at for good news at the global level http://www.unicef.org/media/files/2013_IGME_child_mortality_Report.pdf   

Closer to home,  it would be great to report that the state of children in this country is thriving, but it is not.  Canada’s progress on infant mortality is not impressive with essentially stagnant rates over the past decade and a pitiful 16^th out of 17 compared to peer countries (only the US being worst). That report from the Conference Board of Canada.  Careful review of IMR in the graph below over the past decade may show the impact of the 2008 recession and the slow recovery from the economic turmoil. (data from Index Mundi).  

Hidden in this is the large variation in the country which can be found at Stats Canada where New Brunswick and BC typically demonstrate infant mortality rates that are half those of Manitoba, Saskatchewan and Newfoundland combined.  Nunavut rates are consistently three to five times higher than the national average with the other territories tending to be higher than the national average.

A 2008 report speaks to child security in the country as declining over the previous decade and while it provides explanations as to why the observed increase, its not a report that received attention Child abuse and neglect 2008.   It will behoove the current government to continue the 5 yearly update through 2013 – and one can wonder if that is likely to occur.

In 2009 one of the Chief Public Health Officer (CPHO) reports that rarely get any attention devoted itself to children’s health issues growing up Well.  Reviewing the next steps section and commitment of the CPHO one must wonder if the report had any impact as healthy child development policies have been mired in a dessert, surveillance has become scarcer with many reports now merely archived, and no further specific attention to children from subsequent CPHO reports.  2014 will see the departure of our first CPHO

Of course one would hope that  Statistics Canada would be the definitive source for child circumstances in Canada, supplemented by CIHI for health specific information.   On the later site, its hard to find mention of children at all. (although a good report on severe dental caries  was published in 2013). As to Statistics Canada, look carefully at the dearth of recent and relevant discussions of the state of children in Canada hidden amongst what appears to be plethora of material.

Perhaps the motto for our current government is “In with the Old, Out with the New”.  

Myopia appears to have higher prevalence in those elected to office, it is a correctable condition. 

May 2014 bring all peace, happiness, health and prosperity. May it also bring attention to the plight of Canadian children, quickly becoming a neglected generation.