tag:theconversation.com,2011:/us/topics/respiratory-disease-4531/articlesRespiratory disease – The Conversation2024-02-26T19:30:04Ztag:theconversation.com,2011:article/2240472024-02-26T19:30:04Z2024-02-26T19:30:04ZA pandemic that won’t go away – as COVID enters its 5th year, NZ needs a realistic strategy<p>February 28 marks four years since COVID-19 was <a href="https://www.linkedin.com/posts/michael-baker-73b18710_rampant-covid-poses-new-challenges-in-the-activity-7166926211187765248-pt32?utm_source=share&utm_medium=member_desktop">first reported</a> in Aotearoa New Zealand. Many of us are probably surprised this virus is still causing a pandemic. </p>
<p>The World Health Organization refers to COVID-19 as a <a href="https://www.scientificamerican.com/article/rampant-covid-poses-new-challenges-in-the-fifth-year-of-the-pandemic/">continuing pandemic</a>. As Scientific American put it recently, it “has been the elephant in every room — sometimes confronted and sometimes ignored but always present”. </p>
<p>It wasn’t meant to be like this. The main wave of the 1918 influenza pandemic <a href="https://wwwnc.cdc.gov/eid/article/29/9/22-1265_article">swept through New Zealand</a> in eight weeks, killing 9,000 people – almost 1% of the population. Then it was largely gone, returning as a new seasonal flu virus. </p>
<p>In doing so, it defined how pandemics were expected to behave. This model was written into pandemic plans and collective thinking across the globe.</p>
<p>But COVID is <a href="https://tewhatuora.shinyapps.io/covid19/">still circulating</a> four years after New Zealand reported its first case, and more than two years after the Omicron variant arrived and infection became widespread. </p>
<p>Constantly present, it is also occurring in waves. Unexpectedly, the current <a href="https://www.phcc.org.nz/briefing/covid-19-finishing-year-high-we-need-vigorous-coordinated-response">fifth wave</a> was larger than the <a href="https://www.phcc.org.nz/briefing/aotearoa-new-zealands-fourth-wave-covid-19-and-why-we-should-care">fourth</a>, suggesting we can’t rely on the comforting assumption that COVID will get less severe over time. </p>
<h2>Unpredictable evolutionary shifts</h2>
<p>These waves are driven by the interaction of the organism (SARS CoV-2 virus), the host (human characteristics such as immunity and behaviour), and environmental factors (such as indoor ventilation). </p>
<p>Continuing viral evolution is a major contributor to the changing dynamic. The virus has demonstrated an ability for large, unpredictable evolutionary shifts that dramatically alter its genome and spike protein. </p>
<p>The result is an enhanced ability to evade prior immunity and infect more people. This jump was seen with the highly mutated <a href="https://www.nature.com/articles/s41467-023-43703-3">BA.2.86 subvariant</a> in mid-2023. </p>
<p>Its offspring, JN.1, has acquired additional changes and is causing such a wave of new infections it could potentially be the <a href="https://theconversation.com/the-emergence-of-jn-1-is-an-evolutionary-step-change-in-the-covid-pandemic-why-is-this-significant-220285">next variant of concern</a>, with its own Greek letter. It is now driving epidemic increases across the globe, <a href="https://esr-cri.shinyapps.io/wastewater/#region=Wellington&log_or_linear=linear&period=twelveMonthsButton">including in New Zealand</a>. This dominance by a single subvariant takes us back to the first year of Omicron in 2022.</p>
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Read more:
<a href="https://theconversation.com/i-have-covid-how-likely-am-i-to-get-long-covid-218808">I have COVID. How likely am I to get long COVID?</a>
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<h2>Under-counting the pandemic impact</h2>
<p>The pandemic continues to have a large, visible health impact. It is a leading cause of serious illness and death, mainly in older populations and those with existing long-term health conditions. </p>
<p>In 2023, it caused more than <a href="https://www.phcc.org.nz/briefing/covid-19-finishing-year-high-we-need-vigorous-coordinated-response">12,000 hospitalisations and 1,000 deaths</a> in New Zealand.</p>
<p>But COVID-19 also has an important and largely unmeasured <a href="https://www.science.org/doi/10.1126/science.adl0867">burden of disease</a> as the cause of long COVID, which may become its biggest health impact. A growing number of studies are describing an estimated incidence of long COVID of 5% to 15% of all infections.</p>
<p>For example, a recent <a href="https://www.nature.com/articles/s41467-023-43661-w">large study</a> of almost 200,000 Scottish adults reported that, after adjustment for factors that might confuse the results, long COVID prevalence following an infection was 6.6% at six months, 6.5% at 12 months, and 10.4% at 18 months. </p>
<p>These findings illustrate an important feature of long COVID: recovery can take <a href="https://theconversation.com/long-covid-symptoms-can-improve-but-their-resolution-is-slow-and-imperfect-212015">two years or more</a>, with <a href="https://gh.bmj.com/content/6/9/e007004">symptoms that fluctuate</a> over time.</p>
<h2>An integrated respiratory disease strategy</h2>
<p>New Zealand now needs a strong, integrated response to COVID-19 and other respiratory infections.</p>
<p>The major pandemic interventions have not changed: vaccination, public health and social measures to prevent infection, and antivirals for more vulnerable groups. The evidence has firmed up that long COVID risk is <a href="https://www.cambridge.org/core/journals/antimicrobial-stewardship-and-healthcare-epidemiology/article/effectiveness-of-covid19-vaccine-in-the-prevention-of-postcovid-conditions-a-systematic-literature-review-and-metaanalysis-of-the-latest-research/A0B115B5D3AA60846799857B801D116E">reduced by vaccination</a>, but research is less certain for antivirals.</p>
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Read more:
<a href="https://theconversation.com/vaccination-testing-clean-air-covid-hasnt-gone-away-heres-where-australia-needs-to-do-better-222889">Vaccination, testing, clean air: COVID hasn't gone away – here's where Australia needs to do better</a>
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<p>But growing pandemic complacency from political leaders and the public has changed things. Some of this apparent indifference can be put down to understandable fatigue with response measures. But it remains dangerous in the face of a continuing pandemic.</p>
<p>One way to keep a focus on prevention and control would be to include these measures in an <a href="https://nzmj.org.nz/journal/vol-136-no-1583/continued-mitigation-needed-to-minimise-the-high-health-burden-from-covid-19-in-aotearoa-new-zealand">integrated respiratory infectious disease strategy</a>. This would combine COVID-19 control measures with those used to protect against influenza, respiratory syncytial virus (RSV), and other respiratory infections. </p>
<p>Measles could be added to the list, given the rising <a href="https://www.phcc.org.nz/briefing/urgent-action-needed-prevent-measles-epidemic-aotearoa-new-zealand">threat to New Zealand</a> from a global resurgence of the disease. </p>
<p>This <a href="https://ojs.victoria.ac.nz/pq/article/view/7500">integrated strategy</a> would include vaccination, promoting testing and self-isolation when sick, and measures to reduce transmission in critical indoor environments such as healthcare, public transport and education settings. </p>
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Read more:
<a href="https://theconversation.com/long-covid-stemmed-from-mild-cases-of-covid-19-in-most-people-according-to-a-new-multicountry-study-195707">Long COVID stemmed from mild cases of COVID-19 in most people, according to a new multicountry study</a>
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<p>Such a programme would need to be supported with community engagement, education, surveillance and research.</p>
<p>Structural inequalities mean Māori, Pacific peoples, and those living in relative deprivation, are less vaccinated, less protected from infection, less tested and less likely to have antivirals. </p>
<p>Consequently, they are more likely to be hospitalised and <a href="https://www.health.govt.nz/publication/covid-19-mortality-aotearoa-new-zealand-inequities-risk#:%7E:text=Ethnicity%20and%20age,with%20European%20and%20Other%20groups.">die from COVID-19</a>. These inequities are currently not being systematically tracked and acted on.</p>
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Read more:
<a href="https://theconversation.com/covid-theres-a-strong-current-of-pandemic-revisionism-in-the-mainstream-media-and-its-dangerous-222934">COVID: there's a strong current of pandemic revisionism in the mainstream media, and it's dangerous</a>
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<h2>Ignoring it won’t make it go away</h2>
<p>As we enter the fifth pandemic year, we need a change in thinking about COVID-19. This infection has <a href="https://doi.org/10.3390/ijms242317039">pathological features</a> in common with the other severe coronaviruses (SARS and MERS). </p>
<p>It is wishful thinking to imagine it will suddenly transform into a common cold coronavirus. As a recent <a href="https://www.nature.com/articles/s41579-023-00878-2#Abs1">review article</a> concluded: </p>
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<p>Transition from a pandemic to future endemic existence of SARS-CoV-2 is likely to be long and erratic […] endemic SARS-CoV-2 is by far not a synonym for safe infections, mild COVID-19 or a low population mortality and morbidity burden. </p>
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<p>In the face of this continuing pandemic threat, we need a response that is evidence-informed rather than evidence-ignored.</p><img src="https://counter.theconversation.com/content/224047/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Baker is a member of the Ministry of Health's COVID-19 Technical Advisory Group (TAG). The University of Otago receives funding from the Health Research Council of New Zealand and the New Zealand Ministry of Health for his research on COVID-19 and other infectious diseases.</span></em></p><p class="fine-print"><em><span>The University of Otago receives funding from the Health Research Council of New Zealand and the New Zealand Ministry of Health for research on COVID-19 and other infectious diseases.</span></em></p><p class="fine-print"><em><span>Matire Harwood was a member of the Ministry of Health COVID-19 TAG. She receives research funding from Health Research Council, National Heart Foundation and National Science Challenge-Healthier Lives. She also works at Papakura Marae which received funding for COVID-19 testing, vaccination and management.</span></em></p>On the fourth anniversary of New Zealand’s first COVID case it’s clear this is not a normal pandemic. Despite fatigue and indifference, New Zealand must heed the evidence and improve its response.Michael Baker, Professor of Public Health, University of OtagoAmanda Kvalsvig, Associate Professor, Department of Public Health, University of OtagoMatire Harwood, Associate Professor, Department of General Practice and Primary Care, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2088552023-07-26T00:32:56Z2023-07-26T00:32:56ZRSV is everywhere right now. What parents need to know about respiratory syncytial virus<figure><img src="https://images.theconversation.com/files/538668/original/file-20230721-21-8jb0lp.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-baby-weakened-bronchitis-getting-oxygen-1022883532">Shutterstock</a></span></figcaption></figure><p>This winter, we’re having to get our heads around another respiratory virus – RSV.</p>
<p>It’s less well known than COVID or flu, but it’s also responsible for unplanned visits to the GP or emergency department, and days off school, childcare and work.</p>
<p>It’s the <a href="https://pubmed.ncbi.nlm.nih.gov/31383776/">most common</a> cause of hospitalisation in infants. Most children have at least one RSV infection by the age of three years and yet, many Australians have not heard of RSV or know little about this potentially serious winter virus.</p>
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Read more:
<a href="https://theconversation.com/mondays-medical-myth-you-can-catch-a-cold-by-getting-cold-2488">Monday's medical myth: you can catch a cold by getting cold</a>
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<h2>What is RSV?</h2>
<p>RSV stands for respiratory syncytial (pronounced sin-CITY-al) virus. This common respiratory virus usually causes a mild cold with symptoms such as a fever, runny nose, coughing, decreased appetite and a wheeze. </p>
<p>Adults can be infected with RSV but usually recover in a few days.</p>
<p>But in young babies RSV can cause more severe respiratory illnesses such as <a href="https://www.rch.org.au/kidsinfo/fact_sheets/pneumonia/">pneumonia</a> or <a href="https://www.rch.org.au/kidsinfo/fact_sheets/bronchiolitis/">bronchiolitis</a>. These cause babies to breathe rapidly, stop breathing for a few seconds (apnoeas) and/or feed poorly. RSV in infancy can also potentially affect a child’s long-term health, increasing their risk of asthma, wheezing and allergies. </p>
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<p>In Australia, a wave of RSV infections typically begins in late autumn (April-May) and peaks in June-July. Cases are <a href="https://nindss.health.gov.au/pbi-dashboard/">starting to decline</a> in Australia now.</p>
<p>Because health staff have to report cases of RSV, we can keep track of <a href="https://nindss.health.gov.au/pbi-dashboard/">known cases</a>. But we suspect most go unreported as they are mild and/or doctors don’t always test for the virus.</p>
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Read more:
<a href="https://theconversation.com/heard-of-kindy-flu-theres-no-such-thing-but-kids-are-at-risk-this-flu-season-for-one-simple-reason-207825">Heard of 'kindy flu'? There's no such thing. But kids are at risk this flu season for one simple reason</a>
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<h2>Who’s most at risk?</h2>
<p>Both young and old people are most at risk of severe disease. </p>
<p>For children, those <a href="https://adc.bmj.com/content/107/4/359.long">most at risk</a> of severe disease include babies under two months old, premature infants, those with other medical conditions, or ones infected with another virus at the same time. First Nations children are <a href="https://pubmed.ncbi.nlm.nih.gov/31066061/">three to six times</a> more likely to be hospitalised with bronchiolitis caused by RSV than non-First Nations children.</p>
<p>Otherwise healthy children under 12 months old (usually under six months old) are the ones most often admitted to hospital. Of children admitted to hospital, <a href="https://pubmed.ncbi.nlm.nih.gov/35168504/">about a quarter</a> (26%) will be admitted to intensive care.</p>
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<a href="https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C994%2C667&q=45&auto=format&w=1000&fit=clip"><img alt="Male toddler with oxygen mask over face in hospital bed" src="https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C994%2C667&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Young children and the elderly are most at risk.</span>
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<h2>Why are we seeing so many cases now?</h2>
<p>RSV is spread via coughing and sneezing so it’s easy to see how the virus can spread among children inside during winter months.</p>
<p>But measures earlier in the COVID pandemic limited the spread of RSV.</p>
<p>There was very little RSV circulating in 2020 during the harshest lockdowns. However, in New South Wales and Western Australia (in late 2020) and in Victoria (early 2021) there was an <a href="https://www.nature.com/articles/s41467-022-30485-3">out-of-season re-emergence</a> of RSV, overwhelming hospitals and health-care facilities.</p>
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<p>In 2022, RSV settled back into the usual winter peak. However, many states are experiencing a winter surge in cases and hospitalisations attributed to it this year – bigger than before the pandemic.</p>
<p>This may relate to <a href="https://www.health.gov.au/diseases/respiratory-syncytial-virus-rsv-infection">new reporting requirements</a> for RSV and more testing for it.</p>
<p>However, reduced immunity in young infants due to lower maternal and infant exposure may have contributed to the record number of cases.</p>
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Read more:
<a href="https://theconversation.com/ive-had-covid-and-am-constantly-getting-colds-did-covid-harm-my-immune-system-am-i-now-at-risk-of-other-infectious-diseases-188899">I've had COVID and am constantly getting colds. Did COVID harm my immune system? Am I now at risk of other infectious diseases?</a>
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<h2>Is there a vaccine?</h2>
<p>There are no vaccines to protect against RSV in Australia.</p>
<p>Australia’s only currently available preventative medicine is <a href="https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Palivizumab_for_at-risk_patients/">palivizumab</a>, which is a long-acting monoclonal antibody given monthly during the RSV season. Due to its cost, it is reserved for infants at highest risk for severe RSV infection and is usually given in hospital. </p>
<p>However, several new preventative agents are in the pipeline. </p>
<p><a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-respiratory-syncytial-virus-rsv-vaccine">In May this year</a>, the US Food and Drug Administration approved the RSV vaccine Arexvy for people aged 60 and over. It is being <a href="https://www.tga.gov.au/resources/prescription-medicines-under-evaluation/arexvy-glaxosmithkline-australia-pty-ltd">considered for use</a> in Australia.</p>
<p>Results from clinical trials for RSV vaccines given to pregnant women to protect their baby for the first six months are promising. The maternal Pfizer vaccine <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2216480">has demonstrated</a> greater than 80% effectiveness against severe lower respiratory tract illness in their infants for the 90 days after birth.</p>
<p>However, safety data is being closely examined, including a <a href="https://www.bmj.com/content/381/bmj.p1021">potential risk</a> of premature birth. </p>
<p>The long-acting monoclonal antibody nirsevimab, (given as a single injection at the beginning of the RSV season) has regulatory approval in Europe and the US. It is currently <a href="https://www.tga.gov.au/resources/prescription-medicines-under-evaluation/beyfortus-astrazeneca-pty-ltd">being considered</a> for Australian children.</p>
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Read more:
<a href="https://theconversation.com/fdas-approval-of-the-worlds-first-vaccine-against-rsv-will-offer-a-new-tool-in-an-old-fight-4-questions-answered-205111">FDA's approval of the world's first vaccine against RSV will offer a new tool in an old fight – 4 questions answered</a>
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<h2>How can I protect my children in the meantime?</h2>
<p>Parents can minimise the risk of RSV by using many of the measures we’ve been using during the COVID pandemic. Encourage children to cover their mouths and noses when coughing or sneezing, and regularly wash their hands.</p>
<p>Ensuring kids stay away from school, childcare or other children when sick helps prevent the spread of many viruses, including RSV.</p>
<p><a href="https://www.rch.org.au/kidsinfo/fact_sheets/Respiratory_syncytial_virus_RSV/">Viral symptoms</a> to watch out for include difficulty feeding, cough, irritability and/or rapid breathing. If parents notice these signs or are worried about their child they should seek urgent medical assessment and not delay.</p><img src="https://counter.theconversation.com/content/208855/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Tuckerman is an investigator on a project grant sponsored by Industry. Her institution has received funding from Industry (GSK) for investigator led research. She does not receive any personal payments from Industry. </span></em></p><p class="fine-print"><em><span>Ashleigh Rak receives funding from NHMRC and the Victorian Government.</span></em></p><p class="fine-print"><em><span>Danielle Wurzel receives funding from NHMRC, MRFF and has received honoraria and/or consultancy fees from MSD, Sanofi, GSK which have been paid into her research fund.</span></em></p><p class="fine-print"><em><span>Margie Danchin receives funding from NHMRC, MRFF, WHO, DFAT and the Victorian Government. She is chair, Australian Regional Immunisation Alliance. </span></em></p>Even otherwise healthy children can end up in hospital with this winter respiratory virus.Jane Tuckerman, Senior Research Officer, Murdoch Children's Research InstituteAshleigh Rak, Research Nurse Coordinator, Murdoch Children's Research InstituteDanielle Wurzel, Paediatric Respiratory Physician, and Honorary Fellow Manager, Murdoch Children's Research InstituteMargie Danchin, Paediatrician at the Royal Childrens Hospital and Associate Professor and Clinician Scientist, University of Melbourne and MCRI, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1982332023-02-26T19:06:02Z2023-02-26T19:06:02ZIs there a vaccine for RSV or respiratory syncytial virus? After almost 60 years, several come at once<figure><img src="https://images.theconversation.com/files/510804/original/file-20230217-22-p39gna.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C556&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-asian-little-baby-boy-treated-1589743531">Shutterstock</a></span></figcaption></figure><p>You might not have heard of respiratory syncytial virus, or RSV. But it caused more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00478-0/fulltext">100,000 global deaths</a> in 2019, making it a leading cause of death in children under one year old.</p>
<p>In Australia, child deaths are thankfully <a href="https://pubmed.ncbi.nlm.nih.gov/34845151/">rare</a>. But infection sends thousands to hospital each year, particularly <a href="https://www.mja.com.au/journal/2019/210/10/respiratory-syncytial-virus-associated-hospitalisations-australia-2006-2015">babies and young children</a>.</p>
<p>So for kids, this virus is a very big deal. And despite almost 60 years of research, there are no licensed vaccines to prevent it.</p>
<p>That may change soon. We’ve recently had results of late-stage clinical trials of RSV vaccines from <a href="https://www.statnews.com/2023/01/17/moderna-says-rsv-vaccine-worked-setting-stage-for-competition-with-gsk-and-pfizer/">Pfizer, Moderna and GSK</a>. These vaccines are being assessed (or will be shortly) for regulatory approval in the United States.</p>
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<p>However, these trials were conducted in adults and pregnant women, not children. So we still have a way to go before RSV vaccines are tested in children, shown to be safe and effective, are approved for use, then become widely available.</p>
<p>Here’s why it’s taken so long to develop a RSV vaccine and what we can expect next.</p>
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Read more:
<a href="https://theconversation.com/rsv-experts-explain-why-rates-of-this-virus-are-surging-this-year-194403">RSV: experts explain why rates of this virus are surging this year</a>
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<h2>What is RSV?</h2>
<p>RSV is a contagious virus causing respiratory infections in both adults and children.</p>
<p>The virus is transmitted from person to person by droplets when someone coughs or sneezes, or by touching their nose or eyes after touching contaminated surfaces.</p>
<p>Infections usually surge in winter, causing symptoms such as a runny nose, sneezing, sore throat, fever, headache and cough. Adults and children can be hospitalised with RSV and its complications, which include pneumonia and <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Bronchiolitis/">bronchiolitis</a>.</p>
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Read more:
<a href="https://theconversation.com/rsv-faq-what-is-rsv-who-is-at-risk-when-should-i-seek-emergency-care-for-my-child-195292">RSV FAQ: What is RSV? Who is at risk? When should I seek emergency care for my child?</a>
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<h2>We’ve had a few setbacks</h2>
<p>The <a href="https://journals.asm.org/doi/10.1128/CVI.00609-15">first RSV vaccine</a> was given to infants and children in the mid-1960s. </p>
<p>Although this inactivated vaccine (composed of dead RSV particles) seemed to be well tolerated, it later caused a rare side effect called vaccine-enhanced disease. This is where the vaccine caused more serious RSV symptoms when infants and toddlers caught the virus, instead of protecting them.</p>
<p>This was almost 60 years ago, and the science of vaccine development has come a long way. Even though scientists later found new vaccine strategies, this disaster has unfortunately slowed down RSV vaccine research and development.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/randomised-control-trials-what-makes-them-the-gold-standard-in-medical-research-78913">Randomised control trials: what makes them the gold standard in medical research?</a>
</strong>
</em>
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<h2>Newer technologies, fresh hope</h2>
<p>Advances in what we know about the virus, and newer vaccine technologies, mean researchers are now more optimistic about the prospect of a RSV vaccine.</p>
<p>Ten years ago, <a href="https://www.science.org/doi/10.1126/science.1234914">scientists identified</a> the structure of the RSV viral protein it uses to attach and enter human host cells. This allowed scientists to change strategies and develop protein-based RSV vaccines.</p>
<p>Protein-based vaccines consist of injecting a purified protein from the target virus that stimulates the immune cells. This technology is used in many existing vaccines, such as those for hepatitis B and pertussis (whooping cough).</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1605357061583147009"}"></div></p>
<p>But it’s not been plain sailing for protein-based vaccines either.</p>
<p>In 2019, Novavax <a href="https://ir.novavax.com/2019-02-28-Novavax-Announces-Topline-Results-from-Phase-3-PrepareTM-Trial-of-ResVax-TM-for-Prevention-of-RSV-Disease-in-Infants-via-Maternal-Immunization">announced</a> its prototype protein-based RSV vaccine (ResVax) failed to prevent “medically significant” RSV in babies born to mothers who had been given the vaccine as part of a late-stage clinical trial.</p>
<p>Although the vaccine was shown to be safe, and protected babies from severe RSV, including hospitalisations, the vaccine has not yet made it to market, and further clinical trials <a href="https://www.precisionvaccinations.com/vaccines/resvax-rsv-vaccine">are ongoing</a>.</p>
<p>In recent years, we’ve seen another major technology development – mRNA vaccines. These have proved effective and robust during the COVID pandemic. </p>
<p>These mRNA vaccines involve injecting the information required for the human host cells to produce the viral protein, to later stimulate immune cells.</p>
<p>The front-runner RSV candidate vaccines – from GSK, Pfizer and Moderna – are either protein-based or use mRNA technology.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-fascinating-history-of-clinical-trials-139666">The fascinating history of clinical trials</a>
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</em>
</p>
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<h2>The GSK vaccines</h2>
<p>GSK is going with protein-based technology for two of its candidate RSV vaccines.</p>
<p>One (known as RSVPreF3 OA), has had good results in late-stage clinical trials in adults 60 years or older, with data published <a href="https://www.nejm.org/doi/10.1056/NEJMoa2209604">in recent weeks</a>. The US Food and Drug Administration (FDA) <a href="https://www.gsk.com/en-gb/media/press-releases/gsk-s-rsv-oa-vaccine-candidate-granted-priority-review-by-us-fda/">is reviewing</a> the vaccine, with results expected in May.</p>
<p>Another of GSK’s candidate RSV vaccines (GSK3888550A, RSVPreF3) is taking a different approach. The idea is to vaccinate pregnant women to confer immunity to the unborn baby.</p>
<p>Results of late-stage trials in healthy pregnant women aged 18-49 years are <a href="https://www.gsk.com/en-gb/media/press-releases/gsk-starts-phase-3-study-of-rsv-maternal-candidate-vaccine/">set to report in 2024</a>. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9200160/">Earlier studies</a> in non-pregnant women showed the vaccine was well tolerated and activated a good immune response.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511905/original/file-20230223-24-5r593v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pregnant Muslim woman clutching belly looking at phone in hand in front of window" src="https://images.theconversation.com/files/511905/original/file-20230223-24-5r593v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511905/original/file-20230223-24-5r593v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511905/original/file-20230223-24-5r593v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511905/original/file-20230223-24-5r593v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511905/original/file-20230223-24-5r593v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511905/original/file-20230223-24-5r593v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511905/original/file-20230223-24-5r593v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Some candidate RSV vaccines are given to pregnant women to protect their babies.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-pregnant-arab-woman-hijab-using-1407599552">Shutterstock</a></span>
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<h2>The Pfizer vaccine</h2>
<p>Pfizer has also gone with a protein-based RSV vaccine (RSVpreF). But this time it’s a bivalent vaccine. It contains proteins to stimulate immune protection against two types of RSV – RSV A and B. Again, the idea again is to vaccinate pregnant women to immunise their babies in the womb.</p>
<p>In November 2022, Pfizer <a href="https://www.pfizer.com/news/press-release/press-release-detail/pfizer-announces-positive-top-line-data-phase-3-global">announced</a> interim results of its <a href="https://clinicaltrials.gov/ct2/show/NCT04424316?term=RSVpreF+pfizer&phase=2&draw=2&rank=2">late-stage clinical trial</a> showing 81.8% efficacy in protecting against severe disease in babies (one to 90 days old) of vaccinated pregnant women. Over time, that immunity decreased.</p>
<p>Final clinical trial results are expected <a href="https://www.pfizer.com/news/press-release/press-release-detail/us-fda-accepts-biologics-license-application-pfizers">any day now</a>, and the vaccine is being submitted to the FDA for priority review, with a result expected in August.</p>
<h2>The Moderna vaccine</h2>
<p>Moderna is using mRNA technology for its candidate RSV vaccine (called mRNA-1345). It uses similar technology to its COVID mRNA vaccines.</p>
<p>It has been tested in <a href="https://clinicaltrials.gov/ct2/results?term=mRNA-1345&age_v=&gndr=&type=&rslt=&Search=Apply">late-stage clinical trials</a> in people over the age of 60. The <a href="https://investors.modernatx.com/news/news-details/2023/Moderna-Announces-mRNA-1345-an-Investigational-Respiratory-Syncytial-Virus-RSV-Vaccine-Has-Met-Primary-Efficacy-Endpoints-in-Phase-3-Trial-in-Older-Adults/default.aspx">company announced</a> earlier this year that the vaccine was mostly well tolerated and had an efficacy of 83.7%.</p>
<p>The company is set to make a <a href="https://investors.modernatx.com/news/news-details/2023/Moderna-Granted-FDA-Breakthrough-Therapy-Designation-for-mRNA-1345-An-Investigational-Respiratory-Syncytial-Virus-RSV-Vaccine-Candidate/default.aspx">full submission</a> to the FDA in the first half of 2023.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/3-mrna-vaccines-researchers-are-working-on-that-arent-covid-157858">3 mRNA vaccines researchers are working on (that aren't COVID)</a>
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</em>
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<h2>Several hurdles ahead</h2>
<p>Another candidate vaccine, <a href="https://www.janssen.com/janssen-announces-respiratory-syncytial-virus-rsv-adult-vaccine-candidate-maintains-high-efficacy">from Janssen</a>, uses a different type of technology (adenovirus vector technology), and is not so far advanced through clinical trials as the others. But it has shown <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9417128/">promising preliminary results</a> <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2207566?query=recirc_curatedRelated_article">to date</a> in adults.</p>
<p>And that’s the sticking point with all the RSV vaccines mentioned. They’ve only been tested in adults. To have the greatest impact, the vaccines must also be evaluated in young children and infants. </p>
<p>The biggest question is what age should a baby be vaccinated against RSV once it loses the immunity from its mother?</p>
<p>While we wait for RSV vaccines, the best way of slowing the spread of this viral illness are measures we’ve become used to during COVID. If you or your children have RSV, make sure you wear a mask, wash your hands and maintain your distance from others.</p>
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<p><em>We would like to thank Masters (Doctor of Medicine) student Chloe Scott from Griffith University for her critical review and assistance with this article.</em></p><img src="https://counter.theconversation.com/content/198233/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lara Herrero receives funding from NHMRC
</span></em></p><p class="fine-print"><em><span>Wesley Freppel does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Here’s why it’s taken so long to develop a vaccine for respiratory syncytial virus and what we can expect next.Lara Herrero, Research Leader in Virology and Infectious Disease, Griffith UniversityWesley Freppel, Research Fellow, Institute for Glycomics, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1957002022-12-16T13:13:41Z2022-12-16T13:13:41ZRSV treatments for young children are lacking, but the record 2022 cold and flu season highlights the urgency for vaccines and other preventive strategies<figure><img src="https://images.theconversation.com/files/501170/original/file-20221214-15092-osjj0p.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7951%2C5297&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Only one antiviral medication is approved by the FDA for RSV treatment, and it is administered through a nebulizer.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/asian-boy-using-inhaler-containing-medicine-to-stop-royalty-free-image/1227487354?phrase=RSV&adppopup=true">BonNontawat/iStock via Getty Images Plus</a></span></figcaption></figure><p>For many parents, respiratory syncytial virus – or RSV – which has been causing <a href="https://theconversation.com/rsv-a-pediatric-disease-expert-answers-5-questions-about-the-surging-outbreak-of-respiratory-syncytial-virus-193275">record numbers of hospitalizations of children</a> during the fall of 2022, may sound like a relatively new and unheard-of threat. But in fact, RSV is a <a href="https://www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7140a1-H.pdf">common respiratory virus</a> that circulates every fall and winter and is a common cause of lung infections in young children.</p>
<p>RSV can be difficult to distinguish from other respiratory infections since the symptoms are common to other illnesses – runny nose, sneezing, congestion, coughing, fever, decreased appetite and wheezing. In most cases, RSV is mild and will improve at home. However, in certain cases, it can cause severe illness and require hospital treatment. </p>
<p>RSV can cause severe infections and pneumonia in anyone, including <a href="https://www.cdc.gov/rsv/high-risk/older-adults.html">adults 65 years and older</a> and those with chronic lung or heart conditions or weakened immune systems. But it is most commonly severe in young children.</p>
<p>We are <a href="https://scholar.google.com/citations?user=Pu3L9HkAAAAJ&hl=en">an epidemiologist</a> and a <a href="https://www.bcm.edu/people-search/flor-munoz-rivas-27227">pediatric infectious disease physician</a> and have seen the effects of RSV on children firsthand. </p>
<p>Unfortunately, although RSV is a very common respiratory threat, treatments for it are relatively limited, and as yet, there is no vaccine against it. However, 2023 is likely to be a pivotal year for RSV prevention strategies and treatments.</p>
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<figcaption><span class="caption">How to keep your child safe from RSV.</span></figcaption>
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<h2>Treating children for RSV</h2>
<p>Current guidelines <a href="https://www.cdc.gov/rsv/about/symptoms.html">recommend supportive</a> care, which essentially means managing symptoms and trying to make children as comfortable as possible until they are well again. This includes offering plenty of fluids to avoid dehydration and using over-the-counter medications such as acetaminophen to reduce any fever. </p>
<p>Antibiotics are not useful for treating RSV since they only target bacterial infections and RSV is caused by a virus. But sometimes, children with RSV can also develop secondary bacterial infections in the lungs, in which case antibiotics may be prescribed. </p>
<p>There are a range of medications that have been tried on children with RSV, but for the most part, they’ve shown little benefit. For example, many studies have <a href="https://www.cochrane.org/CD001266/ARI_bronchodilators-for-bronchiolitis-for-infants-with-first-time-wheezing">trialed the use of inhalers</a> and <a href="https://doi.org/10.1001/archpedi.158.2.127">corticosteroid medications</a>, but results have shown that neither significantly reduces the severity of RSV. These medications are therefore not routinely recommended for children to treat severe RSV.</p>
<p>The only drug approved by the Food and Drug Administration to treat RSV is <a href="https://medlineplus.gov/druginfo/meds/a605018.html">ribavirin</a>, an antiviral medication. It is aerosolized using a special nebulizing machine and needs to be given in the hospital for periods of eight to 24 hours over three to five days. The drug works by trying to stop the virus from replicating in the respiratory tract. </p>
<p>The trials evaluating ribavirin <a href="https://doi.org/10.1002/14651858.CD000181.pub3">have been small</a>, which means we can’t really be certain of its benefits. Because ribavirin is very expensive and its benefits uncertain, the American Academy of Pediatrics <a href="https://doi.org/10.5863/1551-6776-23.5.372">no longer routinely recommends</a> it for treatment of RSV, except for specific cases in very high-risk patients.</p>
<p>Fortunately, most babies and young children with RSV do not require treatment and recover well with supportive care. But some can become very ill and need substantial care from their doctors, parents and family members. </p>
<p>While RSV can result in <a href="https://doi.org/10.1542/peds.2019-3611">serious disease for any child</a>, children in <a href="https://www.cdc.gov/rsv/clinical/index.html">high-risk groups</a> face more serious threats from RSV. These include babies less than 6 months old, premature infants, children under 2 years old with chronic lung disease or congenital heart disease, children with suppressed immune systems and children with neuromuscular disorders.</p>
<p>Children may require hospital care if they are having difficulty breathing, have a fever that does not go away after two days, or have lost energy and no longer eat, drink or urinate. This is primarily so they can be monitored and receive intravenous fluids to keep hydrated and ventilators to help with breathing. Approximately <a href="https://www.cdc.gov/rsv/clinical/index.html">1%-2% of babies less than 6 months old</a> with RSV will be hospitalized. </p>
<p>It’s important to know that children infected with RSV might take a turn for the worse before they get better. This is because, in addition to severe nasal congestion that interferes with their feeding, the inflammation in their airways and lungs may prevent them from breathing properly and keeping a normal oxygen level in their blood. These are the children who end up in emergency rooms and hospitals during the respiratory virus season.</p>
<h2>The future of RSV treatment is prevention</h2>
<p>Since effective treatments for severe RSV in children are so limited, the primary goal is to prevent the disease from happening in the first place. </p>
<p>One prevention strategy is to treat infants and children who are at high risk of severe disease before they get sick. This includes very preterm infants and those with heart and lung conditions. </p>
<p>A <a href="https://doi.org/10.1002/14651858.CD006602.pub4">monoclonal antibody called palivizumab</a> can be given as a series of shots and is usually reserved for use during the RSV season. But since RSV has been so variable throughout the COVID-19 pandemic, and in response to the early increase in RSV hospitalizations in children this year, the American Academy of Pediatrics recently <a href="https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/interim-guidance-for-use-of-palivizumab-prophylaxis-to-prevent-hospitalization/">updated its guidelines</a> to allow administration of palivizumab whenever RSV is in high circulation.</p>
<p>But to really get ahead of the RSV threat, we believe the health care field needs prevention strategies that can protect all children from the disease from birth.</p>
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<figcaption><span class="caption">RSV, flu and COVID-19 cases continue to fill U.S. hospitals.</span></figcaption>
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<h2>The promise of vaccines</h2>
<p>Despite more than five decades of research, there is still no RSV vaccine available for children. This is because developing a vaccine that really works has been tricky. RSV vaccines target the <a href="https://microbiologycommunity.nature.com/posts/53435-rsv-f-protein-an-attractive-target-for-therapeutic-intervention">F protein</a>, the part of the virus that it uses to infect cells, and this protein has different forms before and after infecting the cells. <a href="https://doi.org/10.1016/j.smim.2013.04.011">RSV vaccines are in development</a> for three groups, including infants 4 to 6 months old, adults 65 years and older, and pregnant people. </p>
<p>RSV vaccination during pregnancy produces RSV-specific antibodies in the mother that can then <a href="https://doi.org/10.1016/j.ijid.2021.06.015">cross the placenta</a> to protect the baby. These maternal antibodies generally offer protection for the first six months of a baby’s life. A recent clinical trial showed that RSV vaccination during pregnancy <a href="https://www.pfizer.com/news/press-release/press-release-detail/pfizer-announces-positive-top-line-data-phase-3-global">reduced the risk of RSV hospitalization by 82%</a> in infants less than 3 months old. These are very promising results.</p>
<p>Another viable option for the prevention of RSV for all young babies is the use of long-acting RSV-specific antibodies that can be given either at birth or prior to the RSV season. These could provide immunity to infants for several months while RSV is in circulation. A recent clinical trial showed that one of these products, nirsevimab, <a href="https://doi.org/10.1056/NEJMoa2110275">reduced the risk of RSV hospitalization by 62%</a> in children less than 1 year old. </p>
<h2>Looking ahead</h2>
<p>One positive outcome of fall 2022’s record RSV season is that it has raised public awareness of RSV and created renewed urgency around the need to find more effective preventive strategies and RSV treatments.</p>
<p>The success of these tools and strategies will largely depend on their acceptance and utilization by well-informed parents and providers. </p>
<p>Usually, parents become aware of RSV only after having experienced it in their own family. But pediatric providers know all too well from caring for their patients what RSV can do to young bodies. When parents and providers share these stories, it becomes a powerful testament to the need for preventive strategies to fight RSV.</p><img src="https://counter.theconversation.com/content/195700/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annette Regan receives research funding from the National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the US Centers for Disease Control and Prevention.</span></em></p><p class="fine-print"><em><span>Flor Munoz-Rivas is a member of the Safety Monitoring Board for various vaccines under development with Pfizer, Moderna, Virometix, Meissa, Sanaria and the National Institutes of Health. She also has been part of Advisory Boards for topics related to respiratory pathogens and vaccines for Sanofi, Aztra-Zeneca, Moderna, Merck and GSK. She receives research funding from Pfizer, Gilead, the Centers for Disease Control and Prevention, and the National Institutes of Health. </span></em></p>While RSV can become severe for any child, it poses a particularly serious threat for the youngest babies and for high-risk children.Annette Regan, Assistant Professor of Epidemiology, University of San FranciscoFlor M. Munoz, Associate Professor of Pediatric Infectious Diseases, Baylor College of Medicine Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1895162022-09-22T12:39:51Z2022-09-22T12:39:51ZCOVID-19 can cause lasting lung damage – 3 ways long COVID patients’ respiration can suffer<figure><img src="https://images.theconversation.com/files/485402/original/file-20220919-12-mtp5y0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2944%2C2036&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lung disease can manifest in a number of ways.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/lung-3d-rendering-imaging-royalty-free-image/1214718462">Mr. Suphachai Praserdumrongchai/iStock via Getty Images Plus</a></span></figcaption></figure><p>“I just can’t do what I used to anymore.” </p>
<p>As <a href="https://uvahealth.com/findadoctor/profile/jeffrey-m-sturek">pulmonologists and</a> <a href="https://uvahealth.com/findadoctor/profile/alexandra-kadl">critical care doctors</a> treating patients with lung disease, we have heard many of our patients recovering from COVID-19 tell us this even months after their initial diagnosis. Though they may have survived the most life-threatening phase of their illness, they have yet to return to their pre-COVID-19 baseline, struggling with activities ranging from strenuous exercise to doing laundry. </p>
<p>These lingering effects, called <a href="https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html">long COVID</a>, have affected as many as <a href="https://www.statnews.com/2022/07/06/understanding-long-covid-estimates/">1 in 5 American adults diagnosed with COVID-19</a>. Long COVID includes a <a href="https://doi.org/10.1038/s41591-022-01909-w">wide range of symptoms</a> such as brain fog, fatigue, cough and shortness of breath. These symptoms can result from damage to or malfunctioning of <a href="https://doi.org/10.1038/s41591-021-01283-z">multiple organ systems</a>, and understanding the causes of long COVID is a special research focus of the <a href="https://www.hhs.gov/about/news/2022/08/03/biden-harris-administration-releases-two-new-reports-long-covid-support-patients-further-research.html">Biden-Harris administration</a>.</p>
<p>Not all breathing problems are related to the lungs, but in many cases the <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/what-coronavirus-does-to-the-lungs">lungs are affected</a>. Looking at the lungs’ basic functions and how they can be affected by disease may help clarify what is on the horizon for some patients after a COVID-19 infection.</p>
<h2>Normal lung function</h2>
<p>The <a href="https://www.ncbi.nlm.nih.gov/books/NBK539907/">main function of the lungs</a> is to bring oxygen-rich air into the body and expel carbon dioxide. When air flows into the lungs, it is brought into close proximity with the blood, where oxygen diffuses into the body and carbon dioxide diffuses out. </p>
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<figcaption><span class="caption">The lungs bring oxygen into and carbon dioxide out of the body.</span></figcaption>
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<p>This process, as simple as it sounds, requires an extraordinary coordination of air flow, or ventilation, and blood flow, or perfusion. There are <a href="https://www.ncbi.nlm.nih.gov/books/NBK537353/">over 20 divisions</a> in your airway, starting at the main windpipe, or the trachea, all the way out to the little balloons at the end of the airway, called alveoli, that are in close contact with your blood vessels. </p>
<p>By the time a molecule of oxygen gets down to the end of the airway, there are about <a href="https://doi.org/10.1164/rccm.200308-1107OC">300 million</a> of these little alveoli it could end up in, with a total surface area of <a href="https://www.healthline.com/health/alveoli-function#alveoli-structure">over 1,000 square feet (100 square meters)</a> where gas exchange occurs.</p>
<p>Matching ventilation and perfusion rates is critical for basic lung function, and damage anywhere along the airway can lead to difficulty breathing in a number of ways.</p>
<h2>Obstruction – decreased airflow</h2>
<p>One form of lung disease is obstruction of airflow in and out of the body.</p>
<p><a href="https://doi.org/10.1016/j.jaci.2010.01.003">Two common causes</a> of impairments like these are chronic obstructive pulmonary disease and asthma. In these diseases, the airways become narrowed because of either damage from smoking, as is common in COPD, or allergic inflammation, as is common in asthma. In either case, patients experience difficulty blowing air out of their lungs. </p>
<p>Researchers have observed ongoing airflow obstruction in <a href="https://doi.org/10.1148/radiol.212170">some patients who have recovered from COVID-19</a>. This condition is typically treated with inhalers that deliver <a href="https://doi.org/10.1016%2Fj.rmed.2021.106401">medications that open up the airways</a>. Such treatments may also be helpful while recovering from COVID-19.</p>
<h2>Restriction – reduced lung volume</h2>
<p>Another form of lung disease is referred to as <a href="https://www.ncbi.nlm.nih.gov/books/NBK560880/">restriction</a>, or difficulty expanding the lungs. Restriction decreases the volume of the lungs and, subsequently, the amount of air they can take in. Restriction often results from the formation of scar tissue, also called <a href="https://www.mayoclinic.org/diseases-conditions/pulmonary-fibrosis/symptoms-causes/syc-20353690">fibrosis</a>, in the lungs due to injury. </p>
<p>Fibrosis thickens the walls of the alveoli, which makes gas exchange with the blood more difficult. This type of scarring can occur in chronic lung diseases, such as <a href="https://www.nhlbi.nih.gov/health/idiopathic-pulmonary-fibrosis">idiopathic pulmonary fibrosis</a>, or as a result of severe lung damage in a condition called <a href="https://www.nhlbi.nih.gov/health/ards">acute respiratory distress syndrome</a>, or ARDS. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/485406/original/file-20220919-8366-ys0duh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care provider tests a ventilation helmet on a patient." src="https://images.theconversation.com/files/485406/original/file-20220919-8366-ys0duh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485406/original/file-20220919-8366-ys0duh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485406/original/file-20220919-8366-ys0duh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485406/original/file-20220919-8366-ys0duh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485406/original/file-20220919-8366-ys0duh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485406/original/file-20220919-8366-ys0duh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485406/original/file-20220919-8366-ys0duh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Patients with acute respiratory distress syndrome due to COVID-19 may be treated with a helmet that provides oxygen, reducing the need for intubation.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/health-workers-test-a-helmet-that-allows-injecting-oxygen-news-photo/1297081646">Guillermo Legaria/Stringer via Getty Images News</a></span>
</figcaption>
</figure>
<p>ARDS can be caused by injuries originating in the lungs, like pneumonia, or severe disease in other organs, like pancreatitis. Around <a href="https://advances.massgeneral.org/research-and-innovation/article.aspx?id=1238">25% of patients</a> who recover from ARDS go on to develop restrictive lung disease. </p>
<p>Researchers have also found that patients who have <a href="https://doi.org/10.1038/s41591-021-01283-z">recovered from COVID-19</a>, especially those who had <a href="https://doi.org/10.1016%2Fj.chest.2021.02.062">severe disease</a>, can later develop restrictive lung disease. COVID-19 patients who require a ventilator may also have recovery rates similar to those who require a ventilator for <a href="https://doi.org/10.1164/rccm.202110-2335oc">other conditions</a>. Long-term recovery of lung function in these patients is still unknown. Drugs treating fibrotic lung disease after COVID-19 are currently undergoing <a href="https://clinicaltrials.gov/ct2/show/NCT04856111">clinical trials</a>.</p>
<h2>Impaired perfusion – decreased blood flow</h2>
<p>Finally, even when air flow and lung volume are unaffected, the lungs cannot complete their function if blood flow to the alveoli, where gas exchange occurs, is impaired. </p>
<p>COVID-19 is associated with an <a href="https://doi.org/10.1001/jama.2022.13072">increased risk for blood clots</a>. If blood clots travel to the lungs, they can cause a life-threatening <a href="https://www.healthline.com/health/pulmonary-embolus">pulmonary embolism</a> that restricts blood flow to the lungs. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/485407/original/file-20220919-6421-eq9toa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram of alveolus and gas exchange, where oxygen diffuses into the bloodstream and carbon dioxide diffuses out" src="https://images.theconversation.com/files/485407/original/file-20220919-6421-eq9toa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485407/original/file-20220919-6421-eq9toa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485407/original/file-20220919-6421-eq9toa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485407/original/file-20220919-6421-eq9toa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485407/original/file-20220919-6421-eq9toa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485407/original/file-20220919-6421-eq9toa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485407/original/file-20220919-6421-eq9toa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The alveoli of the lungs are where oxygen diffuses into the bloodstream and carbon dioxide diffuses out.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/alveolus-gas-exchange-royalty-free-illustration/530484347">ttsz/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>In the long term, blood clots can also cause chronic problems with blood flow to the lungs, a condition called <a href="https://foundation.chestnet.org/lung-health-a-z/chronic-thromboembolic-pulmonary-hypertension-cteph/">chronic thromboembolic pulmonary hypertension</a>, or CTEPH. Only <a href="https://doi.org/10.1183/13993003.01792-2016">0.5% to 3% of patients</a> who develop a pulmonary embolism for reasons other than COVID-19 go on to develop this chronic problem. However, there is evidence that severe COVID-19 infections can <a href="https://doi.org/10.1056/NEJMoa2015432">damage the blood vessels of the lung</a> directly and <a href="https://doi.org/10.1111/resp.14101">impair blood flow</a> during recovery.</p>
<h2>What’s next?</h2>
<p>Lungs can work less optimally in these three general ways, and COVID-19 can lead to all of them. Researchers and clinicians are still figuring out ways to best treat the long-term lung damage seen in long COVID. </p>
<p>For clinicians, closely following up with patients who have recovered from COVID-19, particularly those with persistent symptoms, can lead to quicker diagnoses of long COVID. Severe cases of COVID-19 are associated with <a href="https://www.ncbi.nlm.nih.gov/books/NBK570608/">higher rates of long COVID</a>. <a href="https://doi.org/10.1016/j.cell.2022.01.014">Other risk factors</a> for development of long COVID include preexisting Type 2 diabetes, presence of virus particles in the blood after the initial infection and certain types of abnormal immune function.</p>
<p>For researchers, long COVID is an opportunity to study <a href="https://theconversation.com/long-covid-19-and-other-chronic-respiratory-conditions-after-viral-infections-may-stem-from-an-overactive-immune-response-in-the-lungs-186970">the underlying mechanisms</a> of how different types of lung-related conditions that result from COVID-19 infection develop. Uncovering these mechanisms would allow researchers to develop targeted treatments to speed recovery and get more patients feeling and breathing like their pre-pandemic selves once again.</p>
<p>In the meantime, everyone can <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html">stay up to date on recommended vaccinations</a> and use <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html">preventive measures</a> such as good hand hygiene and masking when appropriate.</p><img src="https://counter.theconversation.com/content/189516/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeffrey M. Sturek has received funding from the National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Alexandra Kadl does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Understanding how injury and disease, including COVID-19, can impair lung function can help researchers and clinicians better help patients who are experiencing chronic conditionsJeffrey M. Sturek, Assistant Professor of Medicine, University of VirginiaAlexandra Kadl, Assistant Professor of Medicine and Pharmacology, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1869702022-08-04T12:23:36Z2022-08-04T12:23:36ZLong COVID-19 and other chronic respiratory conditions after viral infections may stem from an overactive immune response in the lungs<figure><img src="https://images.theconversation.com/files/477255/original/file-20220802-23-r6z7fj.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2297%2C1292&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The immune system usually stays dormant in the lungs in times of health.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/lung-virus-infection-royalty-free-image/1205199983">wildpixel/iStock via Getty Images</a></span></figcaption></figure><p>Viruses that cause respiratory diseases like the flu and COVID-19 can lead to mild to severe symptoms within the first few weeks of infection. These symptoms typically resolve within a few more weeks, sometimes with the help of treatment if severe. However, some people go on to experience persistent symptoms that last several months to years. Why and how respiratory diseases can develop into chronic conditions like <a href="https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html">long COVID-19</a> are still unclear.</p>
<p>I am a <a href="https://scholar.google.com/citations?hl=en&user=BNGZA1MAAAAJ">doctoral student</a> working in the <a href="https://www.immunology.virginia.edu/Sun/">Sun Lab</a> at the University of Virginia. We study how the immune system sometimes goes awry after fighting off viral infections. We also develop ways to target the immune system to prevent further complications without weakening its ability to protect against future infections. Our <a href="https://doi.org/10.1126/sciimmunol.abm7996">recently published review</a> of the research in this area found that it is becoming clearer that it might not be an active viral infection causing long COVID-19 and similar conditions, but an overactive immune system.</p>
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<figcaption><span class="caption">Long COVID-19 patients can experience persistent respiratory, cognitive and neurological symptoms.</span></figcaption>
</figure>
<h2>The lungs in health and disease</h2>
<p>Keeping your immune system dormant when there isn’t an active infection is essential for your lungs to be able to function optimally. </p>
<p>Your respiratory tract is in constant contact with your external environment, sampling around <a href="https://www.acepnow.com/article/avoid-airway-catastrophes-extremes-minute-ventilation/">5 to 8 liters (1.3 to 2 gallons) of air</a> – and the toxins and microorganisms in it – every minute. Despite continuous exposure to potential pathogens and harmful substances, your body has evolved to <a href="https://doi.org/10.1164/ajrccm.162.supplement_3.15tac6">keep the immune system dormant in the lungs</a>. In fact, allergies and conditions such as asthma are byproducts of an <a href="https://doi.org/10.1513/AnnalsATS.201401-028AW">overactive immune system</a>. These excessive immune responses can cause your airways to constrict and make it difficult to breathe. Some severe cases may require treatment to suppress the immune system. </p>
<p>During an active infection, however, the immune system is absolutely essential. When viruses infect your respiratory tract, immune cells are recruited to your lungs to fight off the infection. Although these cells are crucial to eliminate the virus from your body, their activity often results in collateral damage to your lung tissue. After the virus is removed, your body <a href="https://doi.org/10.1007%2Fs00281-016-0560-6">dampens your immune system</a> to give your lungs a chance to recover.</p>
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<figcaption><span class="caption">An overactive immune system, as in the case of asthma, can damage the lungs.</span></figcaption>
</figure>
<p>Over the past decade, researchers have identified a variety of <a href="https://doi.org/10.1016/j.stem.2020.03.009">specialized stem cells in the lungs</a> that can help regenerate damaged tissue. These stem cells can turn into almost all the different types of cells in the lungs depending on the signals they receive from their surrounding environment. <a href="https://doi.org/10.1126/scitranslmed.abo5254">Recent</a> <a href="https://doi.org/10.1016/j.stem.2020.06.020">studies</a> <a href="https://doi.org/10.1016/j.stemcr.2019.02.013">have highlighted</a> the prominent role the immune system plays in providing signals that facilitate lung recovery. But these signals can produce more than one effect. They can not only activate stem cells, but also perpetuate damaging inflammatory processes in the lung. Therefore, your body tightly regulates when, where and how strongly these signals are made in order to prevent further damage.</p>
<p>While the reasons are still unclear, some people are unable to turn off their immune system after infection and <a href="https://doi.org/10.1126/sciimmunol.abk1741">continue to produce tissue-damaging molecules</a> <a href="https://doi.org/10.1038/s41590-021-01113-x">long after</a> the virus has been flushed out. This not only further damages the lungs, but also interferes with regeneration via the lung’s resident stem cells. This phenomenon can result in chronic disease, as seen in several respiratory viral infections including <a href="https://doi.org/10.1016/j.immuni.2022.01.017">COVID-19</a>, <a href="https://doi.org/10.2340/16501977-2694">Middle East Respiratory Syndrome (MERS)</a>, <a href="https://doi.org/10.1056/NEJMoa1211917">respiratory syncytial virus (RSV)</a> and the <a href="https://doi.org/10.1016/j.jaci.2005.06.024">common cold</a>.</p>
<h2>The immune system’s role in chronic disease</h2>
<p>In our review, my colleagues and I found that many <a href="https://doi.org/10.1126/sciimmunol.abm7996">different types of immune cells</a> are involved in the development of chronic disease after respiratory viral infections, including long COVID-19.</p>
<p>Scientists so far have identified one particular type of immune cells, <a href="https://doi.org/10.1126/sciimmunol.abk1741">killer T cells</a>, as potential contributors to chronic disease. Also known as cytotoxic or CD8+ T cells, they specialize in killing infected cells either by interacting directly with them or by producing damaging molecules called cytokines. </p>
<p>Killer T cells are essential to curbing the virus from spreading in the body during an active infection. But their persistence in the lungs after the infection has resolved is linked to extended <a href="https://doi.org/10.1126/sciimmunol.abc4557">reduced respiratory function</a>. Moreover, animal studies have shown that <a href="https://doi.org/10.1126/sciimmunol.abk1741">removing killer T cells from the lungs</a> after infection may improve lung function and tissue repair.</p>
<figure>
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<figcaption><span class="caption">A legion of immune cells work together to remove invading pathogens.</span></figcaption>
</figure>
<p>Another type of immune cells called monocytes are also involved in fighting respiratory infections, serving among the first responders by producing virus- and tissue-damaging cytokines. Research has found that these cells also <a href="https://doi.org/10.1016/j.immuni.2022.01.017">continue to accumulate</a> in the lungs of long COVID-19 patients and promote a pro-inflammatory environment that can cause further damage.</p>
<p>Understanding the immunological mechanisms underlying long COVID-19 is the first step to addressing a <a href="https://www.kff.org/policy-watch/what-are-the-implications-of-long-covid-for-employment-and-health-coverage/">quickly worsening public health problem</a>. Identifying the subtle differences in how the same immune cells that protect you during an active infection can later become harmful could lead to earlier diagnosis of long COVID-19. Moreover, based on our findings, my team and I believe treatments that target the immune system could be an effective approach to manage long COVID-19 symptoms. We believe that this strategy may turn out to be useful not only for COVID-19, but also for other respiratory viral infections that lead to chronic disease as well.</p><img src="https://counter.theconversation.com/content/186970/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harish Narasimhan does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While a strong immune response is essential to fight against viral infection, an immune system that continues to stay active long after the virus has been cleared can lead to lung damage.Harish Narasimhan, PhD Candidate in Immunology, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1806022022-05-08T08:06:06Z2022-05-08T08:06:06ZAntibiotic use in Uganda is high: action is needed<figure><img src="https://images.theconversation.com/files/459424/original/file-20220425-21-kmqqqw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Even before the COVID crisis, excessive use and misuse of lifesaving antibiotics had contributed to the emergence of resistant strains of disease-causing organisms. This has rendered many of the most powerful treatments in modern medicine ineffective. </p>
<p>It’s <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext">estimated</a> that drug-resistant infections caused more than <a href="https://www.ox.ac.uk/news/2022-01-20-estimated-12-million-people-died-2019-antibiotic-resistant-bacterial-infections#:%7E:text=First%20comprehensive%20analysis%20of%20global,role%20in%204.95%20million%20deaths.">1.2 million</a> deaths in 2019. That is more than malaria and AIDS combined. And resistance contributed to about <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext">5 million</a> additional deaths.</p>
<p>There’s <a href="https://www.cdc.gov/drugresistance/covid19.html">some evidence</a> that the COVID-19 pandemic made matters worse.</p>
<p>COVID-19 is caused by a virus. And viruses are not treated with antibiotics. But early treatment guidelines for COVID-19 assumed that patients admitted to hospitals would develop bacterial superinfections that required antibiotics. The sheer volume of people who were sick with respiratory infections also <a href="https://www.youtube.com/watch?v=lFpLIDQcdyQ">seemed to encourage additional use of antimicrobial drugs</a>. </p>
<p>Antimicrobials are drugs that treat <a href="http://www.emro.who.int/health-topics/drug-resistance/what-is-the-difference-between-antibiotic-and-antimicrobial-resistance.html">bacterial, viral or other microbial infections</a>. Antimicrobial resistance, the drop in effectiveness of this broader class of drugs, was already a rising threat to global public health before December 2019. </p>
<p>In general, sub-Saharan Africa suffers from the highest rate of <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext">drug resistance-related deaths</a>. But the prevalence varies by country. In our recent research we set out to <a href="https://www.mdpi.com/2079-6382/11/2/199/htm">document</a> the magnitude of antimicrobial use, a known driver of antimicrobial resistance, in selected healthcare facilities in Uganda. </p>
<p>We found a high use of antibiotics across all surveyed health facilities. And compliance to Uganda’s clinical guidelines among healthcare workers was low. Also, men were more likely to be on antibiotics than women. In addition, antibiotic use was two times higher in public health facilities than in the private sector. But this could be attributed to the higher proportion of public healthcare facilities in our study sample. </p>
<p>Our results highlight areas for intervention to address antimicrobial resistance. These findings also provide a baseline against which we can compare the impact of such interventions. </p>
<h2>Trends in antibiotic use</h2>
<p>We surveyed antibiotic use in 13 hospitals in Uganda. Our analysis included nearly 1,100 patients and was done between December 2020 and April 2021. </p>
<p>Nearly three-quarters of all patients in our study were taking at least one antibiotic. This is high and could indicate overuse, some of which may be unnecessary. In addition less than 30% of the antibiotic prescriptions complied with Uganda’s <a href="http://library.health.go.ug/publications/guidelines/uganda-clinical-guidelines-2016">clinical guidelines</a> for choice of drugs. </p>
<p>Ceftriaxone is a drug used to manage a wide range of infections. It was among the most prescribed antimicrobials. But it’s not recommended for first-line use. A possible explanation for this is convenience and ease of its use as compared to the current first-line medicines.</p>
<p>In a first, we looked at differences in antibiotic use among males and females as a preliminary indication of gender differences in adequate access to antibiotics. We found that men had 15% greater odds of antibiotic use. Reasons for this observation were not obvious. But other <a href="https://openknowledge.worldbank.org/handle/10986/35134#:%7E:text=There%20are%20no%20gender%20differences,with%20an%20educated%20household%20head">studies</a> have attributed it to differences in access to healthcare between men and women. In those studies, boys were more likely to take antimicrobials for longer periods and to complete the regimen.</p>
<p>We also found antibiotic use substantially higher in public and nonprofit hospital settings compared with private ones. This contradicts our expectations that the profit motive typically drives the overuse of antibiotics in private hospitals and should be examined further. </p>
<p>We are concerned about the observed levels of use of antibiotics in Uganda. Efforts to examine whether this use is appropriate or necessary or not are compromised by inadequate patient record systems and diagnostic capacity. Proper and complete patient records and diagnostic capacity are the minimum requirements for the desired antimicrobial consumption and use surveillance. And for better quality of healthcare in these healthcare facilities. </p>
<p>On a positive note, Uganda has been strengthening the antibiotic consumption and use surveillance system and health facility diagnostic capacity at higher levels. Efforts are being made to address policy gaps, and training of healthcare workers at both undergraduate and graduate levels. </p>
<p>Our findings should be used to accelerate implementation of ongoing strategies to reduce misuse of medicines, and guide research in other sub-Saharan countries.</p>
<h2>Recommendations</h2>
<p>What’s needed next are sustained investments from government and development partners. Here are a few places to start:</p>
<ul>
<li><p>Invest in new, better, and easier-to-administer single-dose antibiotics that target a narrow range of bacteria, known as narrow spectrum antibiotics. So-called broad spectrum antibiotics are associated with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232501/#:%7E:text=Increased%20antimicrobial%20resistance%20is%20the,medicalization%20of%20self%2Dlimiting%20condition">more resistance</a>. This will enable health workers to treat infections better and comply with guidelines. </p></li>
<li><p>Improve laboratory infrastructure and technologies. Clinicians must be able to identify the microorganism that caused the infection, so they can choose the appropriate antimicrobial to administer. Current capacity for diagnosing bacterial infections in <a href="https://www.cddep.org/wp-content/uploads/2017/06/uganda_antibiotic_resistance_situation_reportgarp_uganda_0-1.pdf">Uganda is minimal</a>. </p></li>
<li><p>Strengthen the health workforce with more staff and training in infection prevention and control. Better infection control will reduce the incidence of bacterial infections, hence reduced need for antibiotic use.</p></li>
<li><p>Implement and enforce policies on the use of antibiotics including proper patient record keeping which can act as an indirect force to improve quality of healthcare. Lessons for proper patient record systems use can be borrowed from the health insurance industry. </p></li>
</ul>
<p>Uganda is only one country that needs to improve its stewardship of antimicrobial resistance. Without a coordinated global response, drug-resistant infections will cost the global economy <a href="https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf">US$100 trillion</a> in economic output by 2050, and lead to more disease and mortality than all noncommunicable diseases combined.</p><img src="https://counter.theconversation.com/content/180602/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Reuben Kiggundu is affiliated with the NGO Management Sciences for Health.</span></em></p><p class="fine-print"><em><span>Freddy Eric Kitutu does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nearly three-quarters of all patients in the study were taking at least one antibiotic. This is high and could indicate overuse.Freddy Eric Kitutu, Senior Lecturer of Health Systems Pharmacy and Researcher, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1762492022-02-10T03:12:54Z2022-02-10T03:12:54ZAt home with COVID? 5 easy tips to help you breathe more easily<figure><img src="https://images.theconversation.com/files/445551/original/file-20220210-23-3b49ib.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C660&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-calm-african-female-rest-leaned-1733456774">Shutterstock</a></span></figcaption></figure><p>Shortness of breath, persistent cough and fatigue are common COVID signs and symptoms. And the <a href="https://www.health.gov.au/health-alerts/covid-19/case-numbers-and-statistics">vast majority</a> of people will be managing their symptoms at home.</p>
<p>As a cardiorespiratory physiotherapist, I help people with heart and breathing problems manage and recover from a range of illnesses. </p>
<p>Here are some simple exercises to help you navigate COVID at home.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ive-tested-positive-to-covid-what-should-i-do-now-174458">I've tested positive to COVID. What should I do now?</a>
</strong>
</em>
</p>
<hr>
<h2>Why should I exercise when I have COVID?</h2>
<p>Your body does need some rest when you are sick. However, doing simple, gentle exercises while convalescing with COVID can <a href="https://www.sciencedirect.com/science/article/pii/S1744388121000633?casa_token=DtZHFwAh5-8AAAAA:dmR3Lcvu331IedCvgbEioJ6eJTOSD2jGRD7L3sobJRJBvERfvl2xZfc5InNPZktW--YkUmYH">help improve</a> your symptoms.</p>
<p>People who are older, overweight, or have a chronic condition, such as diabetes, or cardiovascular (heart/circulation) and respiratory (lung) disease, are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543371/">more likely</a> to have COVID symptoms.</p>
<p>So these groups are among those who would particularly benefit from simple, gentle exercise at home.</p>
<h2>1. Relaxed breathing</h2>
<p>This exercise is particularly useful if you feel short of breath:</p>
<ul>
<li><p>get into a stable and comfortable position. Drop your shoulders and breathe in slowly</p></li>
<li><p>purse your lips (as if you’re blowing through a straw)</p></li>
<li><p>breathe out slowly and steadily through your mouth</p></li>
<li><p>repeat the exercise for a minute.</p></li>
</ul>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/dDpX7pGdPR4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Here’s what relaxed breathing looks like.</span></figcaption>
</figure>
<p>You can perform this exercise as often as you like. But <strong>stop if you feel dizzy</strong> as taking too many breaths in a row will cause light headiness. </p>
<p>Perform the exercise in a room with windows open. If you are feeling hot, you can cool your face with a damp towel while doing it.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/445543/original/file-20220209-18418-18fi99b.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person lying on their side on the bed" src="https://images.theconversation.com/files/445543/original/file-20220209-18418-18fi99b.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/445543/original/file-20220209-18418-18fi99b.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445543/original/file-20220209-18418-18fi99b.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445543/original/file-20220209-18418-18fi99b.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445543/original/file-20220209-18418-18fi99b.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445543/original/file-20220209-18418-18fi99b.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445543/original/file-20220209-18418-18fi99b.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some people will need to lie on their side for this exercise.</span>
<span class="attribution"><a class="source" href="https://apps.who.int/iris/bitstream/handle/10665/344472/WHO-EURO-2021-855-40590-59892-eng.pdf?sequence=1&isAllowed=y">WHO</a></span>
</figcaption>
</figure>
<p>Adopting a comfortable position is key to this exercise. Sitting in a supportive chair may be the easiest for most people. </p>
<p>However, for some people with COVID, sitting in a chair is too strenuous. In these instances, try this exercise in other positions such as lying on your side, as <a href="https://www.euro.who.int/en/health-topics/Life-stages/disability-and-rehabilitation/publications/support-for-rehabilitation-self-management-after-covid-19-related-illness,-2nd-ed">recommended</a> by the World Health Organization.</p>
<h2>2. Deep breathing</h2>
<p>This can improve oxygen intake and calm your nerves:</p>
<ul>
<li><p>get into an upright position. Relax your shoulders</p></li>
<li><p>breathe in deeply through your nose for two to three seconds. Hold your breath for three seconds, if able</p></li>
<li><p>breathe out through your nose or mouth, whichever is more comfortable</p></li>
<li><p>repeat the exercise for a minute. </p></li>
</ul>
<p>Again, <strong>stop if you feel dizzy.</strong> You may cough and bring up some phelgm after this exercise. If you do have to cough, cover your mouth with a tissue and dispose of the tissue immediately in a sealed bag after each use. Wash your hands thoroughly after.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-look-after-your-mental-health-if-youre-at-home-with-covid-174536">How to look after your mental health if you're at home with COVID</a>
</strong>
</em>
</p>
<hr>
<h2>3. Lie on your tummy (if you can)</h2>
<p>You may have heard from others, such as Harry Potter author <a href="https://www.health.com/condition/infectious-diseases/coronavirus/jk-rowling-breathing-technique-covid-19">JK Rowling</a>, about the benefits of lying on your stomach (proning) during breathing exercises to improve oxygenation.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/445545/original/file-20220209-19-f58vmq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person lying on their front on the bed" src="https://images.theconversation.com/files/445545/original/file-20220209-19-f58vmq.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/445545/original/file-20220209-19-f58vmq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=274&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445545/original/file-20220209-19-f58vmq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=274&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445545/original/file-20220209-19-f58vmq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=274&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445545/original/file-20220209-19-f58vmq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=344&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445545/original/file-20220209-19-f58vmq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=344&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445545/original/file-20220209-19-f58vmq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=344&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Lying on your front isn’t for everyone and can be painful.</span>
<span class="attribution"><a class="source" href="https://apps.who.int/iris/bitstream/handle/10665/344472/WHO-EURO-2021-855-40590-59892-eng.pdf?sequence=1&isAllowed=y">WHO</a></span>
</figcaption>
</figure>
<p>Proning is common in hospital for people who need extra oxygen. However, the evidence for proning at home is unclear and it is not for everyone.</p>
<p>As you need to stay on your stomach for at least 30 minutes, some people may find this extremely uncomfortable, especially if they have neck and lower back pain. For these people, sitting upright or lying on their side while doing breathing exercises may be better alternatives.</p>
<p>Nonetheless, if you would like to try proning, here are some tips:</p>
<ul>
<li><p>do not try proning after a meal</p></li>
<li><p>choose a firm surface to lie on. Soft beds can make lying on your stomach even more uncomfortable for your back</p></li>
<li><p>turn your head to the side. Place a pillow under your stomach, feet, arms and head for comfort</p></li>
<li><p>ensure you have someone with you at all times, especially when trying this for the first time. Both you and your helper should wear a mask to minimise cross-infection </p></li>
<li><p>do not attempt proning with children under one year old.</p></li>
</ul>
<h2>4. Move regularly</h2>
<p>Even people with relatively mild COVID symptoms may continue to be fatigued after other symptoms have resolved. </p>
<p>Doing simple exercises regularly throughout the day while in isolation can help minimise the effects of reduced mobility during COVID.</p>
<p>You can try sitting on a chair and standing, then repeating that for a minute. Or you could march on the spot for two minutes. </p>
<p><a href="https://www.euro.who.int/en/health-topics/Life-stages/disability-and-rehabilitation/publications/support-for-rehabilitation-self-management-after-covid-19-related-illness,-2nd-ed">Pacing and prioritising</a> your activities to ensure you do regular activities throughout the day can also help manage your fatigue.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-a-pulse-oximeter-should-i-buy-one-to-monitor-covid-at-home-174457">What's a pulse oximeter? Should I buy one to monitor COVID at home?</a>
</strong>
</em>
</p>
<hr>
<h2>5. Know when to seek further medical attention</h2>
<p>If you or a family member experience chest pain, difficulty breathing despite home management, dizziness, new weakness in your face, arm or leg, increased confusion, difficulty staying awake, or have thoughts of self-harm, you will need to seek <a href="https://theconversation.com/covid-can-worsen-quickly-at-home-heres-when-to-call-an-ambulance-166889">urgent medical attention</a>. </p>
<p>You can also use online <a href="https://www.healthdirect.gov.au/symptom-checker/tool/basic-details">symptom checkers</a> for advice on your next immediate action, including when to call an ambulance.</p>
<p>If your COVID symptoms last longer than two weeks, see your local doctor. They may be able to <a href="https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/605525/ACI-Respiratory-Rehab-Following-COVID-19.pdf">refer you</a> to a pulmonary (lung) rehabilitation service or physiotherapist who specialises in lung conditions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-can-worsen-quickly-at-home-heres-when-to-call-an-ambulance-166889">COVID can worsen quickly at home. Here's when to call an ambulance</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/176249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clarice Tang receives funding from Multicultural NSW, Department of Health and Maridulu Budyari Gumal. She is affiliated with Western Sydney University and is a member of the Australian Physiotherapy Association, Thoracic Society of Australia and New Zealand and the American Thoracic Society. </span></em></p>Exercise might be the last thing on your mind if you’re at home with COVID. But these gentle breathing exercises can help.Clarice Tang, Senior lecturer in Physiotherapy, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1714902021-11-15T19:06:29Z2021-11-15T19:06:29ZWhat is ECMO? Doctors are shocked so many ICU patients are on this advanced life support right now<figure><img src="https://images.theconversation.com/files/430974/original/file-20211109-17-1lhz6bb.jpg?ixlib=rb-1.1.0&rect=43%2C7%2C4830%2C3239&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/working-ecmo-machine-intensive-care-260nw-1131769238.jpg">Shutterstock</a></span></figcaption></figure><p>Doctors and health experts have expressed <a href="https://twitter.com/alfredhealth/status/1456418217681850376?s=12">shock on social media</a> recently about the number of ICU patients on ECMO treatment, especially in Victoria. </p>
<p><a href="https://www.svhlunghealth.com.au/procedures/procedures-treatments/ecmo-extracorporeal-membrane-oxygenation">ECMO</a>, which stands for extra corporeal membrane oxygenation, is the life support of last resort for patients with severe heart and lung failure. </p>
<p>At any one time, a busy ECMO hospital would normally have three to five patients supported with ECMO. The number of patients on ECMO at the Alfred Hospital in Melbourne is hovering around 20, almost all because of COVID. In the US, hospitals <a href="https://www.npr.org/sections/health-shots/2021/09/06/1033832562/covid-icu-ecmo-life-support-shortage-hospitals">report</a> more requests for ECMO for teenagers and young adults and severely stretched resources. </p>
<p>ECMO is a vital tool but it requires highly trained staff and a huge amount of hospital resources. Patients who survive ECMO support may have long term health complications related to their critical illness.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1457571409962491908"}"></div></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/were-two-frontline-covid-doctors-heres-what-we-see-as-case-numbers-rise-167195">We're two frontline COVID doctors. Here's what we see as case numbers rise</a>
</strong>
</em>
</p>
<hr>
<h2>Outsourcing the heart and lungs</h2>
<p>In lay terms, ECMO is a heart or lung bypass machine. A pump and artificial lung, both sitting outside the body, provide a level of support the sick organs can no longer provide. This way, the rest of the body’s functions are maintained. </p>
<p>The meaning of each of the letters of the ECMO acronym is:</p>
<ul>
<li><p>Extracorporeal: outside the body</p></li>
<li><p>Membrane: the artificial lung is referred to as a “membrane”, or thin layer of material that keeps blood flowing on one side and oxygen on the other. This thin and porous membrane allows oxygen in and carbon dioxide out </p></li>
<li><p>Oxygenation: when oxygen enters the blood it is equivalent to breathing in. The process equivalent to breathing out, the removal of carbon dioxide, also occurs.</p></li>
</ul>
<p>As well as the oxygenator, the ECMO machine includes cannulae – or tubing – to drain the blood from the patient and return it once oxygen has been added and carbon dioxide removed, a pump and a control panel.</p>
<p>ECMO evolved from cardiopulmonary bypass (heart-lung bypass) machines used to perform open heart surgery. But ECMO equipment is optimised for support lasting days to weeks rather than hours.</p>
<p>ECMO can be connected to the patient in two main ways: veno-venous (to replace just the function of the patient’s lungs) and veno-arterial (to do the work of both the heart and lungs). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/430975/original/file-20211109-27-1pb5vk7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="diagram of blood pumping ECMO machine" src="https://images.theconversation.com/files/430975/original/file-20211109-27-1pb5vk7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/430975/original/file-20211109-27-1pb5vk7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/430975/original/file-20211109-27-1pb5vk7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/430975/original/file-20211109-27-1pb5vk7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/430975/original/file-20211109-27-1pb5vk7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=534&fit=crop&dpr=1 754w, https://images.theconversation.com/files/430975/original/file-20211109-27-1pb5vk7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=534&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/430975/original/file-20211109-27-1pb5vk7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=534&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Two types of ECMO transfusion.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-vector/extracorporeal-membrane-oxygenation-ecmo-life-260nw-1810163056.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-covid-patients-are-intubated-in-icu-the-trauma-can-stay-with-them-long-after-this-breathing-emergency-167361">When COVID patients are intubated in ICU, the trauma can stay with them long after this breathing emergency</a>
</strong>
</em>
</p>
<hr>
<h2>A heavy load</h2>
<p>ECMO is the highest level of life support that can be provided, with a machine wholly or partly replacing the function of the patient’s own heart and/or lungs. </p>
<p>Only a small number of facilities in the world, and in Australia, are able to provide ECMO. In Australia, all ECMO services are located in large city intensive care units (ICUs), though some ECMO retrieval services can initiate ECMO support in smaller hospitals before moving patients to an ECMO ICU for ongoing care.</p>
<p>Highly specialised equipment and staff are required to provide ECMO. </p>
<p>Around-the-clock care is provided by highly trained ECMO nurses. Many ECMO ICUs have one nurse to look after the ECMO machine and another to look after the patient, who remains critically ill and usually on a full suite of other life support measures in addition to ECMO. These might include a ventilator to support the lungs, a dialysis machine to support the kidneys and many different types of drugs continuously delivered to keep the patient alive.</p>
<p>Medical care in the ICU is provided by large specialised teams. A broader allied health team including physiotherapists, dietitians, social workers and pharmacists help provide holistic care. Perfusionists, who specialise in extracorporeal life support, provide vital expert guidance.</p>
<p>Life-threatening problems with bleeding, clotting and infection are common when managing ECMO patients. Patients frequently require highly specialised support from cardiothoracic surgical teams, haematology and specialised blood bank services, radiology and interventional radiology, general surgical services, infectious diseases, cardiology, and respiratory medicine.</p>
<p>Some patients require weeks to months of ECMO support, which can raise ethical issues regarding <a href="https://www.sciencedaily.com/releases/2021/09/210929212156.htm">resources, allocation and deaths</a>. Some COVID patients are on ECMO for <a href="https://twitter.com/AlfredHealth/status/1453591376545783811">more than 100 days</a>. The COVID pandemic has severely tested the ability of our health-care services to provide ECMO care.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1458497413812035594"}"></div></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/if-covid-hospitalisations-increase-its-still-not-clear-how-patients-will-be-prioritised-for-icu-beds-169948">If COVID hospitalisations increase, it's still not clear how patients will be prioritised for ICU beds</a>
</strong>
</em>
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<hr>
<h2>Often just the beginning</h2>
<p>A patient’s time on ECMO represents only one early phase of their critical illness recovery and, even if they survive their initial illness, <a href="https://www.abc.net.au/news/2021-11-09/covid-patients-get-symptoms-months-after-infection-study-finds/100346554">most require ongoing hospital care and rehabilitation</a> for many months afterwards. It is vital that a full suite of specialised hospital and rehabilitation services are available to maximise the patient’s chances of good quality survival.</p>
<p>Despite ECMO being the most complex form of life support available, the simple maxim that “prevention is better than cure” still applies. </p>
<p>Avoiding COVID infection by getting vaccinated, wearing a mask and paying attention to <a href="https://ozsage.org/media_releases/beware-the-air-you-share-ozsage-advice-on-safe-indoor-air-ventilation-for-australia-september-6th/">ventilation and air quality</a> all remain vitally important to protect yourself and our healthcare system.</p><img src="https://counter.theconversation.com/content/171490/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Greg Kelly is a Staff Specialist, Paediatric Intensive Care, Sydney Children’s Hospital Network and affiliated with OzSAGE. </span></em></p><p class="fine-print"><em><span>Josh Ihle is Senior Intensive Care Physician and Deputy Head of Cardiothoracic ICU at the Alfred Hospital.</span></em></p>ECMO uses an artificial heart and lung to replace the entire function of the person’s own heart and lungs outside the body. And COVID is demanding more ECMO than we’ve ever used before.Greg Kelly, Senior lecturer, The University of QueenslandJosh Ihle, Senior lecturer, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1713272021-11-10T14:43:18Z2021-11-10T14:43:18ZExtreme heat hurts human health. Its effects must be mitigated – urgently<figure><img src="https://images.theconversation.com/files/430752/original/file-20211108-19-1tn54mx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Higher temperatures cause drought, and can lead to food insecurity
</span> <span class="attribution"><span class="source">Guido Dingemans, De Eindredactie/GettyImages</span></span></figcaption></figure><p>The African continent is heating up more, and faster, than other regions in the world according to the recently released <a href="https://www.uneca.org/stories/state-of-climate-in-africa-report-2020">State of Climate in Africa Report</a>. By 2030, the report says up to 118 million extremely poor people will be subject to the devastating impacts of drought and intense heat.</p>
<p>Many of the temperatures presently being recorded in Africa, and those projected in the next decade, are <a href="https://doi.org/10.1038/s41558-018-0145-6">already close</a> to the limits of human survival, or “liveability”. </p>
<p>The general limit of heat we should live in is 35°C wet-bulb temperature, which is a measure of both air temperature and humidity. Beyond this, the body struggles to cool itself.</p>
<p>In northern Mali, for example, many communities <a href="https://www.cifor.org/knowledge/publication/3524/">have to make do</a> with a rainy season of just three months, from July to September. For the rest of the year, temperatures approach 50°C. The consequences have been catastrophic, impacting health and agriculture and livestock activities. Younger generations have no option but to leave as they cannot survive in these conditions.</p>
<p>Extreme heat is a serious health hazard. It can have very negative health effects on the human body. The body responds to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01208-3/fulltext">heat stress by</a> redistributing blood flow to the skin and producing sweat, thus cooling the body. These blood flow changes increase the demand on the heart, making it work harder. Additional sweat production can also lead to dehydration, reducing blood volume which strains the heart further and also causes damage to organs such as the kidney.</p>
<p>Despite this, extreme heat has drawn less attention than other climate risks, such as flooding and drought. </p>
<p>The 26th UN Climate Change Conference of the Parties (COP26) provides an opportunity to focus in more detail on the health effects of extreme heat in African countries and elsewhere. Particular attention should be paid to how vulnerable groups like women, newborn children and poorer people can be helped to deal with or mitigate against these effects.</p>
<h2>How heatwaves affect people</h2>
<p>There are various ways in which rising temperatures will affect people. </p>
<p>Heatwaves – generally considered to be several days of excessively hot weather, which may be accompanied by high humidity – <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30274-6/fulltext">worsen</a> the risk of death from heatstroke. This happens when the body is unable to control its temperature which then rises rapidly to 40°C or more causing internal organ damage. </p>
<p>It also means more people with certain ailments – such as kidney or respiratory diseases – are at a higher risk of dying.</p>
<p>As temperatures rise, there’ll be an <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-51962100132-7/fulltext">increased spread</a> of infectious diseases, such as malaria and dengue fever. This is because more areas will become suitable for vectors, like mosquitoes that carry malaria.</p>
<p>Increased heat will also result in more drought which will result in crop failure and livestock deaths. This will lead to under- and malnutrition, especially in children, with higher rates of stunting or worse a result. Projections using temperature changes in sub-Saharan Africa <a href="https://pubmed.ncbi.nlm.nih.gov/33139856/">suggest</a> considerable increases in malnutrition. For instance, it’s expected that by 2100 there’ll be an increase in prevalence of wasting in western Africa by 37%, and 25% for central and eastern Africa. </p>
<p>More heat also means <a href="https://icpac.medium.com/wildfires-in-eastern-africa-will-climate-change-increase-the-intensity-of-wildfires-573ba35a5e10">more wildfires</a>. Wildfires affect humans in several ways including burns, pollutants from smoke and psychological trauma. Increased vulnerability to wildfires is <a href="https://icpac.medium.com/wildfires-in-eastern-africa-will-climate-change-increase-the-intensity-of-wildfires-573ba35a5e10">expected</a> in East Africa due to a combination of temperature change and unsustainable land management practices, such as clearing and setting fire to land to plant crops.</p>
<h2>Most at risk</h2>
<p>It is important to understand which groups are most at risk from the negative effects of extreme heat. </p>
<p><a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30274-6/fulltext">A review</a> of climate change and health literature earlier this year found a greater mortality risk from heatwaves for children, especially infants. Children are more at risk as they have smaller surface to body ratios than adults (increasing dehydration and heat stress risk) and they are still growing with underdeveloped systems, such as respiratory and immune systems.</p>
<p>Older people are more vulnerable to heat stress because their bodies are less able to adapt to changes in body temperature and they may have chronic medical conditions.</p>
<p>Extreme heat is also a high risk factor for pregnant women and their babies. A summary of evidence on the obstetric risks of heat reported many associated adverse effects <a href="https://www.bmj.com/content/371/bmj.m3811.long">including</a> maternal hypertension <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.13958">and</a> placental abruption (the separation of the placenta from the uterus which can cause pregnancy complications), stillbirths, preterm birth, and low birth weight. Some of these complications could be because extreme heat causes dehydration and may lead to contractions and fainting. Exposure to extreme heat in a woman’s first trimester may also cause foetal heart and neural tube defects.</p>
<p>Finally, heat is expected to have worse outcomes for more vulnerable members of society. </p>
<p>A <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1908064">review</a> of the effects of climate change – in low- and middle-income countries found that residents of informal urban settlements are particularly at risk. That’s because of vulnerabilities like limited access to healthcare, poor sanitation and overcrowding. A <a href="https://www.sciencedirect.com/science/article/abs/pii/S0048969720348841?via%3Dihub">case study</a> of informal settlements in Dar es Salaam, Tanzania, reinforces the review’s findings: it shows that higher temperatures pose a significant risk to health – for instance because tin roofs exacerbate heat stress – even if the city doesn’t reach extreme temperatures.</p>
<p>As for those living in rural areas, such as pastoralists, aside from the stress extreme heat puts on their bodies, pastoralists will be vulnerable to drought and food insecurity. </p>
<h2>Moving forward</h2>
<p>These are not problems for the future. As the examples above and many others highlight, Africa is already feeling the reality of heat stress. All the projections suggest it will only get worse, yet nearly all heat-related adverse health outcomes and deaths are preventable. </p>
<p>But the continent has limited research capacity to examine these challenges and inform policy. Most of the research has focused on current impacts and that risks will continue to increase with additional climate change. Moving beyond this to identify solutions that are effective in the African context is an essential step.</p>
<p>There’s <a href="http://www.mdpi.com/2071-1050/13/9/5312">low scientific growth</a> in publications output and a large evidence gap both in understanding heat stress and relevant interventions to adapt to these changing environmental circumstances. </p>
<p>The research that needs to be done includes vulnerability assessments, urban heat island evaluation and studies that focus on heat adaptation measures that might prevent the worst effects of extreme heat.</p>
<p>In addition to more research, the continent needs immediate financial and technological assistance to adapt to the warming environment and to support research. </p>
<p>Heat risks are complex. They require strong research foundations and integrated planning, for example across health systems and urban planning. Early warning systems are also needed that actively involve communities to avoid or mitigate at least some adverse effects.</p>
<p>It is imperative that people from different disciplinary backgrounds work on climate and health issues together, coordinate, and develop new ideas together. One example is the new network – <a href="https://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.enbel-project.eu%2Fevents-page%2Fchance-a-new-network-for-climate-and-health-in-africa&data=04%7C01%7CAbdu.Mohiddin%40aku.edu%7Cacbe54b343f94fe4726c08d99916dbc1%7Ca5d4252a02f94e6096f09733baae4919%7C0%7C0%7C637709145716788230%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=VWDh8MSO5qIxtQ34DTNHgCSqnfZeGcnj7Lj%2F2IYkNpE%3D&reserved=0">CHANCE (Climate-Health Africa Network for Collaboration and Engagement)</a> – which is funded by the European Commission EU’s Horizon 2020 programme. It aims to facilitate interactions and create greater coherence between these, sometimes, siloed communities of practice. </p>
<p>It’s imperative that all of this happens fast. People are already living with the effects of a warming environment, with devastating effects. </p>
<p>_Caroline Gichuki, an emerging researcher in the field of climate change and health, helped in the writing of this article. _</p><img src="https://counter.theconversation.com/content/171327/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Jack receives funding from NERC, EU Commission, and the NIH</span></em></p><p class="fine-print"><em><span>Evans Kituyi consults for UNEP and GIZ.</span></em></p><p class="fine-print"><em><span>Kristie Ebi receives funding from the World Health Organization and the US National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Matthew Chersich receives funding from the EU, NIH and Belmont Forum </span></em></p><p class="fine-print"><em><span>Stanley Luchters receives funding from the Belmont Forum, European Commission and the US NIH.</span></em></p><p class="fine-print"><em><span>Abdu Mohiddin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many of the temperatures presently being recorded in Africa, and those projected in the next decade, are already close to the limits of human survival, or “liveability”.Abdu Mohiddin, Assistant Professor, Aga Khan University Christopher Jack, Researcher, University of Cape TownEvans Kituyi, Associate, Institute for Climate Change & Adaptation, University of NairobiKristie Ebi, Professor of Global Health and Environmental and Occupational Health Sciences, University of WashingtonMatthew Chersich, Professor, University of the WitwatersrandStanley Luchters, Professor, Aga Khan University HospitalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1696152021-10-12T04:35:15Z2021-10-12T04:35:15ZMany e-cigarette vaping liquids contain toxic chemicals: new Australian research<figure><img src="https://images.theconversation.com/files/425827/original/file-20211012-15-1dvcfrn.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2400%2C1637&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Toan Nguyen/Unsplash</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>From October 1, it’s been <a href="https://www.9news.com.au/national/federal-politics-news-fears-tough-new-vaping-laws-will-drive-people-back-to-smoking/2c6c8e54-1b65-4231-8c12-5b60c9065580">illegal to buy e-liquids containing nicotine without a prescription from a doctor</a> everywhere in Australia, except South Australia.</p>
<p>But vaping with nicotine-free e-liquids is not illegal in Australia (though in some jurisdictions the e-cigarette devices themselves are illegal).</p>
<p>Vaping is <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">increasing in popularity in Australia</a>, particularly among young people. </p>
<p>I co-led a research team that wanted to find out what’s in the nicotine free e-liquids that vapers inhale, and their potential health effects.</p>
<p>Our study, published this week in The Medical Journal of Australia, found most e-liquids contained <a href="https://www.mja.com.au/journal/2021/216/1/chemical-analysis-fresh-and-aged-australian-e-cigarette-liquids">chemicals known to cause respiratory issues and lung damage when inhaled</a>. Most contained ingredients that have since been banned by Australia’s drug regulator, the Therapeutic Goods Administration (TGA).</p>
<p>We also found all e-liquids contained substances for which the health effects of inhalation exposure are unknown.</p>
<p>It’s clear vaping isn’t safe, and e-cigarettes haven’t been approved as smoking cessation devices.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaping-as-an-imaging-scientist-i-fear-the-deadly-impact-on-peoples-lungs-123435">Vaping: As an imaging scientist I fear the deadly impact on people’s lungs</a>
</strong>
</em>
</p>
<hr>
<h2>What did we study?</h2>
<p>A few years ago, we conducted a small study which involved chemically analysing ten e-liquids purchased in Australia. All of them were labelled “nicotine free”.</p>
<p>Our research, published in The Medical Journal of Australia in 2019, was surprising and concerning. We found <a href="https://www.mja.com.au/journal/2019/210/3/nicotine-and-other-potentially-harmful-compounds-nicotine-free-e-cigarette">60% of the liquids contained nicotine</a>. In some instances, this was at levels high enough not to be just trace contamination.</p>
<p>We also found all ten e-liquids contained a chemical called “2-chlorophenol”, which is often used in pesticides and disinfectants and is a <a href="https://pubchem.ncbi.nlm.nih.gov/compound/2-Chlorophenol">known irritant to the skin and lungs</a>.</p>
<p>Most of the e-liquids also contained “<a href="https://hmdb.ca/metabolites/HMDB0000991">2-aminooctanoic acid</a>, which is an amino acid found in the biological products of mammals, including faeces, urine and blood. Its presence was potentially a result of contamination with one of these substances during the manufacturing or packaging processes.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1084539220658577408"}"></div></p>
<p>Our findings prompted us to expand on our previous study. </p>
<p>This time we analysed 65 Australian e-liquids, including using a method aimed at better understanding how heating the e-liquids for vaping might change their chemical components.</p>
<p>This was the most expansive analysis of Australian e-liquids to date, and was led by Curtin University and the Wal-yan Respiratory Research Centre, in conjunction with Lung Foundation Australia, the Minderoo Foundation, and Cancer Council Western Australia.</p>
<p>All of the e-liquids we studied were purchased online or from brick-and-mortar stores across Australia. All were advertised as being "best-sellers”, Australian made, and nicotine free, so it’s likely they’re representative of what many Australian vapers might be using.</p>
<p>None of the e-liquids were labelled with a comprehensive ingredient list, so it’s impossible for users to know what chemicals they’re inhaling. It also means all the e-liquids we tested <a href="https://ec.europa.eu/health/tobacco/ecigarettes_en">wouldn’t be compliant with European Union labelling regulations</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaping-is-glamourised-on-social-media-putting-youth-in-harms-way-159436">Vaping is glamourised on social media, putting youth in harm's way</a>
</strong>
</em>
</p>
<hr>
<h2>What else did we find?</h2>
<p>Many of the flavouring chemicals we detected are “generally regarded as safe” by the United States Food and Drug Administration (FDA) when used in foods and drinks. But there’s a big difference between a chemical that’s safe to ingest and one which is safe to inhale long-term.</p>
<p>We also detected nicotine in some e-liquids, however, it was found much less frequently and at much lower concentrations than in our previous study. This may be indicative of a cleaner manufacturing process.</p>
<p>We only tested for “freebase” nicotine, which is typically used in both conventional cigarettes and nicotine replacement therapies. So, the e-liquids may have contained a different type of nicotine, called nicotine salts, which are much more commonly used now than they were a few years ago.</p>
<p>We also found 2-chlorophenol again, although it was only in about half of the e-liquids tested. Regardless, the contamination of e-liquids with this known toxic chemical, which has no valid reason for being present, remains a significant problem.</p>
<figure class="align-center ">
<img alt="A shelf of e-liquids for vaping" src="https://images.theconversation.com/files/425826/original/file-20211012-23707-hhp40c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/425826/original/file-20211012-23707-hhp40c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/425826/original/file-20211012-23707-hhp40c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/425826/original/file-20211012-23707-hhp40c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/425826/original/file-20211012-23707-hhp40c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/425826/original/file-20211012-23707-hhp40c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/425826/original/file-20211012-23707-hhp40c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Most e-liquids studied had chemicals known to cause respiratory issues in humans.</span>
<span class="attribution"><span class="source">E-Liquids UK/Unsplash</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>A range of other chemicals of concern were commonly detected, including benzaldehyde, trans-cinnamaldehyde and menthol. These chemicals are added for their almond, cinnamon and mint flavours, respectively.</p>
<p>Benzaldehyde was found in every e-liquid except four, while menthol and trans-cinnamaldehyde were found in about three-quarters of the e-liquids. The presence of these chemical flavourings was concerning for a number of reasons.</p>
<p>Firstly, they’re all known to alter the effects of nicotine. <a href="https://pubmed.ncbi.nlm.nih.gov/15084646/">Menthol makes nicotine more addictive</a>.</p>
<p>Benzaldehyde and trans-cinnamaldehyde are known to inhibit an enzyme called “CYP2A6”. CYP2A6 is responsible for metabolising and detoxifying many drugs humans are exposed to, including nicotine. </p>
<p>When its function is impaired by these flavouring chemicals, it means a vaper using e-liquids containing nicotine is going to have nicotine in their body for a longer period of time before it’s processed by the body.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1447368350535925761"}"></div></p>
<p>Benzaldehyde is also a <a href="https://pubmed.ncbi.nlm.nih.gov/31117350/">respiratory irritant</a> and can reduce a person’s ability to fight off lung infections. Trans-cinnamaldehyde has even more severe effects <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582929/">on the immune cells in the lung</a>.</p>
<p>Both of these chemicals are now included on the TGA’s <a href="https://www.tga.gov.au/sites/default/files/nicotine-vaping-products-and-vaping-devices_0.pdf">list of prohibited e-liquid ingredients</a>, meaning they’re banned in Australian e-liquids. Menthol isn’t banned by the TGA, but it’s prohibited in tobacco cigarettes in some countries. In this study, the e-liquids were analysed before the ban came into force. </p>
<p>This research clearly shows Australian e-liquids contain a range of chemicals that are either known to negatively impact health, or for which the potential health impacts of inhalation exposure are unknown.</p>
<p>A lot more research is needed in this space before informed decisions on both nicotine free and nicotine e-cigarette usage can be made, and to better understand how vaping impacts our health.</p>
<hr>
<p><em>The author would like to acknowledge Professor Ben Mullins and Dr Sebastien Allard, of Curtin University, who were co-leads on this research project.</em></p><img src="https://counter.theconversation.com/content/169615/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>For this study Alexander Larcombe, Ben Mullins and Sebastien Allard received funding from Lung Foundation Australia, Minderoo Foundation and Cancer Council WA. Alexander Larcombe is affiliated with ACOSH - the Australian Council on Smoking and Health. </span></em></p>Most e-liquids we studied contained chemicals known to cause respiratory issues and lung damage when inhaled.Alexander Larcombe, Associate Professor and Head of Respiratory Environmental Health, Telethon Kids InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1653032021-08-08T21:03:08Z2021-08-08T21:03:08ZTuberculosis, the forgotten pandemic relying on a 100-year-old vaccine<figure><img src="https://images.theconversation.com/files/414927/original/file-20210806-19-w40utz.jpg?ixlib=rb-1.1.0&rect=1%2C1%2C997%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/adult-child-hands-holding-lung-world-1653122248">from www.shutterstock.com</a></span></figcaption></figure><p>By some estimates, <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002152">2 billion people</a> are now infected worldwide, and in 2019, around <a href="https://www.who.int/publications/i/item/9789240013131">1.4 million people</a> died from it.</p>
<p>It’s a pandemic infection, spread through the air — but it’s not COVID. It’s tuberculosis (or TB). Yet we’re not in lockdown for it. And we’re not queuing up for a vaccine.</p>
<p>Some people call TB “<a href="https://www.the-scientist.com/features/tuberculosis-the-forgotten-pandemic-68894">the forgotten pandemic</a>”. But our knowledge of one pandemic is helping us manage the other.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-tb-and-am-i-at-risk-of-getting-it-in-australia-75290">Explainer: what is TB and am I at risk of getting it in Australia?</a>
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</em>
</p>
<hr>
<h2>They’re similar in some ways …</h2>
<p>TB is caused by the bacterium <em><a href="https://theconversation.com/explainer-what-is-tb-and-am-i-at-risk-of-getting-it-in-australia-75290">Mycobacterium tuberculosis</a></em>. And COVID is caused by SARS-CoV-2, a virus. They’re quite different microorganisms. But it’s easy for them to overlap in people’s minds. </p>
<p>Both TB and COVID are infectious diseases that generally affect the lungs. Both are passed between people mainly by aerosols, when infected people cough, sing or otherwise release them into the surrounding air.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/414928/original/file-20210806-25-1o0xxea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Mycoplasma tuberculosis" src="https://images.theconversation.com/files/414928/original/file-20210806-25-1o0xxea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414928/original/file-20210806-25-1o0xxea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414928/original/file-20210806-25-1o0xxea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414928/original/file-20210806-25-1o0xxea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414928/original/file-20210806-25-1o0xxea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414928/original/file-20210806-25-1o0xxea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414928/original/file-20210806-25-1o0xxea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">TB is caused by <em>Mycobacterium tuberculosis</em>.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/bacteria-mycobacterium-tuberculosis-causative-agent-3d-1013219203">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>So some of the things we’re used to doing for COVID-19 – like wearing masks and good ventilation – also work for preventing the spread of TB. </p>
<p>However, there are some important differences between them, which mean our public health responses can look quite different.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/kissing-can-be-dangerous-how-old-advice-for-tb-seems-strangely-familiar-today-140172">'Kissing can be dangerous': how old advice for TB seems strangely familiar today</a>
</strong>
</em>
</p>
<hr>
<h2>… but not in others</h2>
<p>We are all so familiar with COVID. So when I’m talking with people about TB, I’ve started highlighting three key differences between the infections.</p>
<p><strong>1. TB is less infectious</strong></p>
<p>TB is much less infectious. While COVID (especially strains like the <a href="https://science.sciencemag.org/content/372/6549/1375.summary">Delta variant</a>) may be transmitted after brief or “fleeting” contact, this is rare for TB. </p>
<p>As a rule of thumb, <a href="https://www.thermh.org.au/tb">TB programs</a> around the world often suggest you need to be in close contact with an infectious person for more than eight hours before that risk builds up to the point where you need to be tested for it.</p>
<p>This means people are more likely to spread the infection within their household or immediate family rather than at the shops. </p>
<p><strong>2. TB symptoms take longer to show up</strong></p>
<p>With TB, the “window” between being exposed and becoming unwell, known as the incubation period, is much longer.</p>
<p>Infections can stay dormant (or “latent”) in the body for many months or years before people become unwell. But almost everyone who becomes unwell with COVID has been infected within the past two weeks.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1397504069917319170"}"></div></p>
<p>We don’t ask contacts of TB to isolate at home as we can’t predict when they might become unwell. It certainly wouldn’t be ethical or realistic to isolate people for months or years, just in case. Fortunately, people who have dormant TB cannot pass infection on to others in the meantime.</p>
<p><strong>3. We have TB treatments to help curb the spread</strong></p>
<p>As we’re uncertain about how long it takes between someone becoming infected and becoming unwell with TB, you’d think that would be a big problem.</p>
<p>But we have effective treatments to give people with dormant TB. These help prevent them developing active disease.</p>
<p>These treatments, particularly antibiotics such as <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1714283">isoniazid or rifampicin</a>, can greatly reduce the risk of contacts becoming sick.</p>
<p>For COVID, we don’t yet have any treatments for people who are infected but who are not showing symptoms (known as post-exposure treatments) to minimise the chance of them spreading the virus. </p>
<p>Some have been tried, but so far none have convincingly been shown <a href="https://www.covid19treatmentguidelines.nih.gov/overview/prevention-of-sars-cov-2/">to be effective</a>.</p>
<h2>How about vaccines?</h2>
<p>Perhaps the biggest difference in our response to these pandemics is we have a variety of effective vaccines against COVID.</p>
<p>For TB, we are relying on a <a href="https://www.the-scientist.com/features/tuberculosis-the-forgotten-pandemic-68894">100-year-old vaccine, known as BCG</a> (short for Bacille Calmette-Guerin), which is still one of the <a href="https://www.who.int/teams/health-product-policy-and-standards/standards-and-specifications/vaccines-quality/bcg">most widely used</a> vaccines globally.</p>
<p>While it <a href="https://www.sciencedirect.com/science/article/pii/S0140673606685073?casa_token=COyGuPY0ZQUAAAAA:JHAoRMZxvaZPO-hlHPKZiqSRsaLPXtcZzYZwrnDR5H6MtmJbA9mliwX0NbTKXZwUFzARGRAQlp9a">protects young children</a> from the most severe forms of TB, the vaccine seems to give <a href="https://academic.oup.com/jid/article-abstract/221/1/146/5556484">much less protection for adults</a>. </p>
<p>The BCG vaccine, unlike COVID vaccines, is a live vaccine, meaning it contains live (but weakened) bacteria. So it can’t be given safely to people with immune suppressing conditions, like HIV, because they could get infected from it. This means its use is limited in some people who most need protection.</p>
<h2>TB vaccine may protect against COVID</h2>
<p>Perhaps the BCG vaccine and COVID will come full circle. The <a href="https://www.mcri.edu.au/brace">BRACE trial</a>, launched from Melbourne’s Murdoch Children’s Research Institute, is studying whether the BCG vaccine might protect against COVID infection. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1243299284243509248"}"></div></p>
<p>This investigation has been prompted by a long history of research showing the vaccine also <a href="https://www.sciencedirect.com/science/article/pii/S1198743X19301971">improves our immune responses to other conditions</a> such as viral infections.</p>
<p>We don’t know yet whether this will work, as the study is ongoing. Almost 7,000 health-care workers around the world at risk of COVID exposure have been recruited to the trial.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/could-bcg-a-100-year-old-vaccine-for-tuberculosis-protect-against-coronavirus-138006">Could BCG, a 100-year-old vaccine for tuberculosis, protect against coronavirus?</a>
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</em>
</p>
<hr>
<p>Whether or not BCG turns out to prevent COVID, there’s no question we need new and more effective vaccines for TB.</p>
<p>While we have an increasing number of <a href="https://www.tbvi.eu/what-we-do/pipeline-of-vaccines/">potential vaccine candidates</a>, right now there is still no alternative to our 100-year-old BCG. </p>
<p>The massive amount of activity globally in developing COVID vaccines has also stimulated calls for <a href="https://theunion.org/news/bcg-100th-anniversary-statement-close-the-funding-gap">greater efforts and funding</a> to develop new TB vaccines. </p>
<p>We hope these will lead to more effective and safer options, and be powerful tools for eliminating TB. Let’s hope we’re not left waiting another 100 years.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/tuberculosis-kills-as-many-people-each-year-as-covid-19-its-time-we-found-a-better-vaccine-151590">Tuberculosis kills as many people each year as COVID-19. It's time we found a better vaccine</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/165303/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justin Denholm is the Medical Director of the Victorian Tuberculosis Program.</span></em></p>COVID has shown us we can develop a range of safe and effective vaccines. Now we need to do the same for TB.Justin Denholm, Associate Professor, Melbourne HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1480312020-10-16T14:16:45Z2020-10-16T14:16:45ZDrive-throughs are busier than ever during the pandemic – but they’re hotspots for air pollution<figure><img src="https://images.theconversation.com/files/363716/original/file-20201015-23-1cid3ja.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4592%2C3056&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In the US, the average time spent waiting in fast food drive-throughs has risen by half a minute during the pandemic.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drive-thru-fast-food-restaurantmotion-blur-38753656">Ministr-84/Shutterstock</a></span></figcaption></figure><p>Over <a href="https://www.euro.who.int/en/media-centre/sections/press-releases/2015/04/air-pollution-costs-european-economies-us%24-1.6-trillion-a-year-in-diseases-and-deaths,-new-who-study-says">90% of EU citizens</a> each year are exposed to levels of outdoor air pollution that are above the World Health Organization’s air quality guidelines. In Birmingham, the UK’s second largest city, air quality <a href="https://www.birmingham.gov.uk/downloads/file/11938/air_quality_annual_status_report_2018_containing_data_for_2017">in 2018</a> breached both national air quality limits for nitrogen dioxide (NO₂) and the WHO guideline for particulate matter. Children who live in Birmingham could have their lives <a href="https://www.uk100.org/wp-content/uploads/2019/05/KCL-UK100-Birmingham-City-Health-and-Economic-Impact-2019.pdf">cut short</a> by an average of up to seven months because of poor air quality alone. </p>
<p>Air pollution is a public health crisis, but it’s currently overshadowed by coronavirus. As the virus has restricted our access to cafes and restaurants, drive-through services have swollen. They might allow a semblance of normal life to continue, but what might it mean for the air we breathe?</p>
<p>In research conducted at the outset of the pandemic, my colleagues and I discovered that many drive-throughs in the UK are air pollution hotspots. Without measures to limit exposure, these sites could contribute to chronic health problems among drive-through workers and the people they serve.</p>
<figure class="align-center ">
<img alt="A car exhaust surrounded by fumes." src="https://images.theconversation.com/files/363717/original/file-20201015-17-1nsyyzf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363717/original/file-20201015-17-1nsyyzf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363717/original/file-20201015-17-1nsyyzf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363717/original/file-20201015-17-1nsyyzf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363717/original/file-20201015-17-1nsyyzf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363717/original/file-20201015-17-1nsyyzf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363717/original/file-20201015-17-1nsyyzf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Air pollution is a leading cause of illness worldwide.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/car-exhaust-pipe-which-comes-out-574315432">Jarhe Photography/Shutterstock</a></span>
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</figure>
<h2>Convenience at a cost</h2>
<p>In February 2020, mere weeks before lockdown began in the UK, we published <a href="https://www.coventry.ac.uk/news/2020/coventry-university-research-reveals-high-levels-of-air-pollution-which-could-harm-health-of-drive-thru-staff-and-customers/">a study</a> on air pollution around the drive-through windows of fast food outlets in 10 major cities throughout the UK. To find out how it might be affecting customers and employees, we used <a href="https://www.aqmesh.com/">monitors</a> to measure levels of pollution every 15 minutes for two weeks.</p>
<p>At a drive-through in Erith, south-east London, 61% of NO₂ measurements exceeded the UK’s safe limit. In Hull, 27% of measurements revealed unsafe levels of NO₂ and in Birmingham, 19% exceeded the limit. NO₂ levels seemed to peak during lunch and in the evening, while concentrations of particulate matter were highest in the morning during the breakfast rush.</p>
<p>In all of these places, drive-through employees were regularly exposed to toxic fumes that can have long-term health effects. Customers in their cars weren’t much safer either. Rather than being protected from emissions inside a vehicle, <a href="https://airqualitynews.com/2019/10/07/drivers-are-exposed-to-the-highest-levels-of-harmful-air-pollution-and-taxi-drivers-are-most-at-risk/">studies</a> show that pollutants can accumulate <a href="https://www.berkeleywellness.com/healthy-community/environmental-health/article/pollution-inside-your-car">within your car</a> while you’re sat inside, often to higher levels in the confined space than outside it.</p>
<h2>Clearing the air</h2>
<p>Ours was the first study to investigate pollution levels at drive-throughs. Since then, drive-through <a href="https://www.bbc.co.uk/news/av/health-51660561">coronavirus testing sites</a> have sprung up across the UK and in the US, a “<a href="https://www.cnbc.com/2020/08/05/coronavirus-pandemic-sparks-a-building-boom-for-restaurant-drive-thrus.html">building boom</a>” for restaurant drive-throughs is underway.</p>
<p>Traffic pollution contains a number of harmful substances. Nitrogen dioxide (<a href="https://www.epa.gov/no2-pollution/basic-information-about-no2">NO₂</a>) is a noxious gas found in exhaust fumes that has been linked to asthma and birth complications. <a href="https://pubs.rsc.org/en/content/articlelanding/2020/MT/C9MT00253G#!divAbstract">Particulate matter</a> is another form of air pollution that’s like a fine dust, shed during combustion in the engine or from the <a href="https://theconversation.com/how-your-car-sheds-microplastics-into-the-ocean-thousands-of-miles-away-142614">wear and tear of brakes</a>. </p>
<p>These tiny fragments often measure less than 2.5 thousandths of a millimetre, or one-thirtieth the width of a human hair. <a href="https://www.epa.gov/pm-pollution/health-and-environmental-effects-particulate-matter-pm#:%7E:text=Exposure%20to%20such%20particles%20can,a%20variety%20of%20problems%2C%20including%3A&text=decreased%20lung%20function,airways%2C%20coughing%20or%20difficulty%20breathing.">But when inhaled</a>, they can infiltrate the bloodstream and weaken the lungs or contribute to heart disease.</p>
<p>Although there are permissible standards for these substances that are set by the government, no studies can claim that a harmless level of air pollution exists. People with underlying health problems can be affected even at very low levels of exposure.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/air-pollution-your-exposure-and-health-risk-could-depend-on-your-class-ethnicity-or-gender-128272">Air pollution: your exposure and health risk could depend on your class, ethnicity or gender</a>
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<p>Employers have a duty to protect drive-through workers from air pollution. <a href="https://www.researchgate.net/publication/305273924_An_Evaluation_of_the_Effects_of_Drive-Through_Configurations_on_Air_Quality_at_Fast_Food_Restaurants">Proper precautionary measures</a> to minimise their exposure could also benefit the public. Using a reverse-flow fan system to prevent exhaust from entering the drive-through windows, encouraging stationary drivers to turn off their engines while waiting and preventing pregnant staff from working on the drive-through are just a few small steps that could make a big difference.</p>
<p>Scientists have found that hospital admissions for COVID-19 tend to flare up <a href="https://theconversation.com/air-pollution-exposure-linked-to-higher-covid-19-cases-and-deaths-new-study-141620">where air pollution</a> is most severe, as chronic exposure to airbone pollutants can make people <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7128509/">more vulnerable</a>. Using drive-through services instead of eating inside cafes and restaurants might limit your contact with coronavirus, but the hidden health consequences of air pollution should not be ignored.</p><img src="https://counter.theconversation.com/content/148031/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anitha Chinnaswamy received support from BBC West Midlands to conduct this research.</span></em></p>Staff and customers with underlying health conditions are likely to be most at risk at drive-through windows.Anitha Chinnaswamy, Assistant Professor of Environment and Computing, Coventry UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1401722020-06-26T04:20:20Z2020-06-26T04:20:20Z‘Kissing can be dangerous’: how old advice for TB seems strangely familiar today<figure><img src="https://images.theconversation.com/files/343646/original/file-20200624-56949-8sqb0c.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C1016%2C761&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/kissing-couple-antiviral-medical-mask-style-1667403004">Shutterstock</a></span></figcaption></figure><p>We’ve been reminded about avoiding hugging or kissing, especially among large family groups, in light of the recent <a href="https://www.9news.com.au/national/coronavirus-victoria-large-family-gatherings-behind-latest-covid19-outbreak/64580fd0-d6c0-428c-a348-0ee4001bb5f6">Melbourne coronavirus clusters</a>.</p>
<p>But alerting the public to the potential for kissing to spread infectious diseases isn’t new. It’s been a feature of past pandemics, including the scourge of tuberculosis (or TB) in Australia a century ago.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/this-isnt-the-first-global-pandemic-and-it-wont-be-the-last-heres-what-weve-learned-from-4-others-throughout-history-136231">This isn't the first global pandemic, and it won't be the last. Here's what we've learned from 4 others throughout history</a>
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<p>In the first half of the 20th century, people with TB were advised to stop kissing to protect their friends and family from contracting the dreaded disease.</p>
<p>In 1905, delegates at an International Congress on Tuberculosis in Paris <a href="https://trove.nla.gov.au/newspaper/article/89226774">described</a> kissing as “dangerous, detrimental and responsible for countless diseases”.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/340258/original/file-20200608-176564-1xzu429.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/340258/original/file-20200608-176564-1xzu429.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/340258/original/file-20200608-176564-1xzu429.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=898&fit=crop&dpr=1 600w, https://images.theconversation.com/files/340258/original/file-20200608-176564-1xzu429.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=898&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/340258/original/file-20200608-176564-1xzu429.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=898&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/340258/original/file-20200608-176564-1xzu429.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1128&fit=crop&dpr=1 754w, https://images.theconversation.com/files/340258/original/file-20200608-176564-1xzu429.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1128&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/340258/original/file-20200608-176564-1xzu429.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1128&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">TB is everyone’s business, according to literature circulated at the time, and was clearly pegged as a public health issue.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>A minority of overly enthusiastic public health physicians suggested banning kissing altogether. </p>
<p>In Western Australia in 1948 an article in the Tuberculosis Association pamphlet <a href="https://uwap.uwa.edu.au/products/kissing-can-be-dangerous-the-public-health-campaigns-to-prevent-and-control-tuberculosis-in-western-australia-1900-1960">warned</a> “Kissing can be Dangerous: Doctors and Married Men are agreed on this”.</p>
<p>Showing bodily restraint was one of the few weapons against TB before <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(45)91574-1/fulltext">the antibiotic streptomycin</a> and other drugs became widely available after the end of the second world war and into the 1950s.</p>
<p>Other measures, with which we are familiar today, included sanitation and social distancing.</p>
<p>Laws and by-laws prohibiting spitting in public were introduced. Publicans had to provide spittoons for customers to prevent the spread of the disease. And people with TB had to spit into a jar, which they carried with them, or a tissue (known as Japanese paper), which they burnt after each use.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/343939/original/file-20200625-33550-ndhcho.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/343939/original/file-20200625-33550-ndhcho.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/343939/original/file-20200625-33550-ndhcho.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=772&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343939/original/file-20200625-33550-ndhcho.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=772&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343939/original/file-20200625-33550-ndhcho.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=772&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343939/original/file-20200625-33550-ndhcho.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=970&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343939/original/file-20200625-33550-ndhcho.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=970&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343939/original/file-20200625-33550-ndhcho.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=970&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">By-laws were introduced to ban spitting in public.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>“Consumptives” (people with TB) were advised to cover their mouth when coughing or sneezing and not to speak near other people’s faces.</p>
<p>They were cautioned against drinking alcohol because even mild inebriation could make them careless in their behaviour and a danger to friends and family.</p>
<p>The message was clear. TB was a disease of the individual and any reckless or insanitary behaviour could infect others.</p>
<p>Extra cleanliness at home was encouraged. Regular dusting with a damp cloth kept surfaces clean and safe. Housewives were instructed to dampen the floor with wet tea leaves to prevent infected dust from contaminating the air and endangering family members. </p>
<p>An infected person used separate plates, cups and utensils that were boiled to sterilise them. </p>
<p>They separated themselves from their family, sleeping outside in an airy shelter or on the verandah or sleep-out. </p>
<p>If a person died from the disease, public health officials burnt their clothing and bedding. Their books were possible sources of contamination and had to be aired in sunlight to kill any remaining germs.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/xeixTj-Tu8Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">This 1950 health department video advises people to act on TB symptoms, go and get tested and to practise personal hygiene (Libraries Tasmania).</span></figcaption>
</figure>
<h2>Contact tracing and mass testing</h2>
<p>Public health officials conducted contact tracing to identify people carrying or having been exposed to TB.</p>
<p>People gave a sputum (spit) sample, which was then sent for analysis. They were warned to isolate themselves until the results were known.</p>
<p>Having a chest x-ray <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiC67H3mJzqAhXLyDgGHYFKAiMQFjAJegQIAxAB&url=http%3A%2F%2Fflex.flinders.edu.au%2Ffile%2F021d4329-a490-4bde-96fa-4073bdd95d58%2F1%2FThesis-Putland-2013-01Abstract.pdf&usg=AOvVaw1mFUU60q7M_JzV-NvNIXIK">became compulsory</a> for all Western Australians aged 14 years and over from 1950. The population was x-rayed at special clinics set up in every city or by mobile x-ray vans that went to every country town. Other states had different policies. By the early 1960s, x-rays were compulsory around Australia.</p>
<p>Only those who had had their x-ray and complied with public health requirements were deemed “safe”. If they didn’t comply they were called a public health menace and a danger to society.</p>
<p>Anyone refusing to be x-rayed could be sent to jail, where they were x-rayed.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/343647/original/file-20200624-56963-2z77nb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/343647/original/file-20200624-56963-2z77nb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343647/original/file-20200624-56963-2z77nb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343647/original/file-20200624-56963-2z77nb.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343647/original/file-20200624-56963-2z77nb.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343647/original/file-20200624-56963-2z77nb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343647/original/file-20200624-56963-2z77nb.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343647/original/file-20200624-56963-2z77nb.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">X-rays in the outback, part of mass screening for TB.</span>
<span class="attribution"><span class="source">Alan King</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Isolation housed the sick, often for years</h2>
<p>If people weren’t at home convalescing, they were sent to specially built isolation hospitals, known as sanatoria, to be treated with rest and fresh air. Sanatoria were regarded as a last resort because until 1947, and the advent of antibiotics, there was no cure for the disease.</p>
<p>In Western Australia from 1904 people went to the <a href="https://archive.sro.wa.gov.au/index.php/coolgardie-sanatorium-au-wa-a1141">Coolgardie Sanatorium</a> and from 1914 to <a href="https://archive.sro.wa.gov.au/index.php/wooroloo-sanatorium-au-wa-a1140">Wooroloo Sanatorium</a>, where they slept in the open air to disperse infection. </p>
<p>Incarceration in the sanatorium might last years or even a lifetime. Patients were unable to have close contact with visitors or see their children, except from a distance. Their incarceration was intended to protect the public from infection.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/343650/original/file-20200624-56973-1ygngwb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/343650/original/file-20200624-56973-1ygngwb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343650/original/file-20200624-56973-1ygngwb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=348&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343650/original/file-20200624-56973-1ygngwb.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=348&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343650/original/file-20200624-56973-1ygngwb.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=348&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343650/original/file-20200624-56973-1ygngwb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=437&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343650/original/file-20200624-56973-1ygngwb.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=437&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343650/original/file-20200624-56973-1ygngwb.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=437&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Special isolation hospitals or sanatoria were built to house people with TB and protect the wider community from infection.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In the 1950s, special chest hospitals were built in cities offering a more modern approach to the disease, although sanatoria remained open. Patients could still spend more than a year in hospital even after a cure became available. </p>
<p>By 1958, as the TB pandemic waned and was eradicated, chest hospitals began to treat patients with other diseases.</p>
<h2>What can we learn?</h2>
<p>COVID-19 and tuberculosis are both branded as public enemies, wreaking havoc on the fabric of society and destroying lives. But unlike COVID-19, TB is caused by a bacterium, can be treated with antibiotics, and we have a vaccine against it.</p>
<p>Still, the World Health Organisation <a href="https://www.who.int/news-room/fact-sheets/detail/tuberculosis">reported</a> 1.5 million people worldwide died from TB in 2018. </p>
<p>Until we have a vaccine or treatment for COVID-19, social distancing, good hand hygiene, contact tracing, testing and self-isolation are among our chief weapons during this latest pandemic. And yes, kissing can still be dangerous.</p><img src="https://counter.theconversation.com/content/140172/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Criena Fitzgerald does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A century ago, Australians were battling another pandemic, tuberculosis, with public health measures many will find familiar today.Criena Fitzgerald, Honorary Research Fellow, Faculty of Arts, Business, Law and Education, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1399292020-06-18T12:36:08Z2020-06-18T12:36:08ZOne metre or two? The science behind social distancing<figure><img src="https://images.theconversation.com/files/342258/original/file-20200616-23217-1yqvxka.jpg?ixlib=rb-1.1.0&rect=51%2C510%2C5776%2C3328&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/social-distancing-people-keep-distance-public-1684207930">eamesBot/Shutterstock</a></span></figcaption></figure><p>What constitutes a safe distance when it comes to the spread of COVID-19? The answer <a href="https://www.bbc.com/news/science-environment-52522460">depends on where you live</a>. </p>
<p>China, Denmark and France recommend social distancing of one metre; Australia, Germany and Italy recommend 1.5 metres, and the US recommends six feet, or 1.8 metres. The UK, meanwhile, has announced that it will relax its <a href="https://www.theguardian.com/science/2020/jun/14/scientists-report-flaws-in-who-study-on-two-metre-distancing">attracted criticism</a> from top scientists for doing so. </p>
<p>The truth is, we don’t yet know how far is far enough when it comes to coronavirus. A recent study found the virus in air as far as <a href="https://wwwnc.cdc.gov/eid/article/26/7/20-0885_article">four metres away from infected patients</a> in a COVID-19 ward. But another <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext">study</a>, touted by the WHO, concluded that the risk of transmission becomes significantly lower with a distance of one metre or more from an infected person, reducing further with increased distance.</p>
<p>Why such a range of “safe” distances? That’s because social distancing is a complex problem with many variable influencing factors. Here are four of the most important ones. </p>
<h2>Respiratory droplets</h2>
<p>When we breathe, talk, cough and sneeze, thousands of droplets are expelled from our mouth and nose. The size of these droplets varies – some may be millimetres in size and some might be many thousands of times smaller. The larger droplets, which carry more virus particles, settle more quickly due to gravity. The smaller droplets, carrying fewer particles, can remain suspended in the air for hours. </p>
<p>The number and size of droplets vary <a href="https://www.sciencedirect.com/science/article/pii/S0021850208002036">depending on the activity</a>. A cough produces more droplets overall and a greater proportion of them are larger. Breathing produces fewer droplets overall and they are generally smaller. The speed with which the droplets leave your mouth and nose also influences how far they travel – sneeze droplets will travel furthest. </p>
<h2>Viral load</h2>
<p>Viral load refers to the number of copies of the virus in a sample (for example, in the droplets that leave our mouth and nose). We know the number of <a href="https://www.bmj.com/content/369/bmj.m1443">virus copies</a> in the respiratory samples of COVID-19 patients can vary from a few thousand to <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30113-4/fulltext">hundreds of billions per millilitre</a>. </p>
<p>The viral load varies from one person to another, but also depends on what stage of the illness the patient is at. We also know that people without symptoms can shed the virus. </p>
<p>Knowing the viral load in respiratory droplets allows us to calculate how many virus particles people may be exposed to and whether this might be enough for them to become infected.</p>
<h2>Infectious dose</h2>
<p>The infectious dose is the number of copies of the virus that your body needs to be exposed to in order to develop an infection. When it comes to calculating a safe distance, the closer you are to an infected person, the more likely you are to be exposed to the infectious dose by breathing in virus-laden droplets.</p>
<p>The infectious dose for influenza strains varies from <a href="https://link.springer.com/article/10.1007/s12560-011-9056-7">thousands to millions</a> of copies. We do not yet know this number for SARS-CoV-2. </p>
<p>In time, further research on how the virus behaves in humans and other animals, and comparisons to other viruses will help to hone this number. In any case, we can be certain that the infectious dose will vary between different people. </p>
<h2>The environment</h2>
<p>Whether we are indoors or outdoors, in school, at work, on public transport or in the supermarket, the flow of air, ventilation, temperature and humidity will influence what happens to respiratory droplets. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/342263/original/file-20200616-23276-xhcz40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/342263/original/file-20200616-23276-xhcz40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/342263/original/file-20200616-23276-xhcz40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/342263/original/file-20200616-23276-xhcz40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/342263/original/file-20200616-23276-xhcz40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/342263/original/file-20200616-23276-xhcz40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/342263/original/file-20200616-23276-xhcz40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A lot depends on our environment when it comes to how water droplets spread.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/three-asian-people-wearing-mask-standing-1680627379">TravelerPix/Shutterstock</a></span>
</figcaption>
</figure>
<p>Air currents will blow droplets around in various directions. Good ventilation will dilute the number of droplets in the air. Temperature and humidity will affect the rate at which water evaporates from droplets. All this will affect our understanding of how much distance to keep in different types of space.</p>
<h2>Complex scenarios</h2>
<p>With these four elements, we can begin to put together what makes a safe distance. </p>
<p>Let’s start with this scenario: three people are in a room that is not ventilated. One of them is infected and two are not. One of the healthy people is standing closer to the infected person – for example, 80 centimetres away – and one is further away, say two metres. </p>
<p>The infected person coughs, producing a cloud of droplets. The larger droplets carrying more virus particles settle more quickly due to gravity. The smaller droplets carrying less virus travel further. So the person standing closer to the infected patient is at higher risk of being exposed to infectious droplets than the one standing further away. </p>
<p>Of course, the above scenario is overly simple. People move around. An open window may blow air in a particular direction. The infected person may cough repeatedly during a period of time. An air conditioner might recirculate air around a room. Room temperature and humidity may result in drying leading to smaller particles carrying higher concentrations of virus. Exposure to many smaller droplets over a longer period of time may be equivalent to exposure to a few larger ones in a short period. </p>
<p>There is an infinite number of scenarios and having one rule that applies to them all is impossible. </p>
<p>This means that different countries’ rules are, ultimately, best guesses made on the basis of some of the factors described above. They cannot apply in all contexts. </p>
<p>It is very unlikely that you would be exposed to infectious droplets outdoors because of rapid air flow and dilution, but enclosed crowded indoor spaces are much more of a risk. We all need to do our bit to stop the spread of coronavirus, so keep your distance, preferably as far as you can.</p><img src="https://counter.theconversation.com/content/139929/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lena Ciric receives funding from UKRI. </span></em></p>France says one metre, Spain says two. But what really constitutes a safe distance when it comes to COVID-19?Lena Ciric, Associate Professor in Environmental Engineering, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1395132020-06-08T14:14:22Z2020-06-08T14:14:22ZWill flu or cold viruses push the new coronavirus out of circulation this winter?<figure><img src="https://images.theconversation.com/files/339517/original/file-20200603-130940-laazfr.jpg?ixlib=rb-1.1.0&rect=6%2C6%2C4259%2C2833&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-coughing-into-his-fist-isolated-1212571078">Kleber Cordeiro/Shutterstock</a></span></figcaption></figure><p>SARS-CoV-2, the virus that causes COVID-19, is here to stay for the summer. What happens next, though, is unclear. One possibility is a major <a href="https://www.cidrap.umn.edu/sites/default/files/public/downloads/cidrap-covid19-viewpoint-part1_0.pdf">second wave</a> in the autumn or winter. This scenario would reflect the behaviour of the 2009 H1N1 “swine flu” pandemic and its deadlier predecessor in <a href="https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/three-waves.htm">1918</a>, the so-called Spanish flu. </p>
<p>If SARS-CoV-2 resurges in the winter, it will be one in a crowded field of wintertime respiratory viruses, including influenza, rhinovirus, respiratory syncytial virus (RSV), and four other coronavirus strains that normally cause common cold-like symptoms. </p>
<p>What effect might these other viruses have on the spread of SARS-CoV-2? Will they coexist harmoniously, or could they push SARS-CoV-2 out of circulation? We can’t yet be certain, but we can look to the historical interactions between these and other well-known viruses to outline the possibilities. </p>
<h2>Cross protection</h2>
<p>Near the end of the 18th century, the English physician <a href="https://www.cdc.gov/smallpox/history/history.html">Edward Jenner observed</a> that milkmaids rarely fell victim to the deadly and debilitating smallpox. He correctly guessed that exposure to cowpox – a related virus that causes much milder illness – protected them. </p>
<p>Jenner’s breakthrough is normally associated with the invention of the first vaccine, but his discovery illustrated an even more fundamental concept: pathogens exist in relation to one another, and sometimes they can inhibit one another’s ability to spread. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/339519/original/file-20200603-130934-1o21ykl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339519/original/file-20200603-130934-1o21ykl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339519/original/file-20200603-130934-1o21ykl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339519/original/file-20200603-130934-1o21ykl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339519/original/file-20200603-130934-1o21ykl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339519/original/file-20200603-130934-1o21ykl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339519/original/file-20200603-130934-1o21ykl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Edward Jenner performing his first vaccination on James Phipps.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=90129751">Ernest Board/Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>The cross protection that cowpox offers against smallpox is a result of the two virus’s structural similarity. When a person becomes infected with cowpox, the immune system mounts a fast, broad-spectrum response followed by a slower, more targeted response that is tailored to the virus. </p>
<p>After clearing the infection, the body keeps a biological template of the virus’s shape so that it can quickly recognise and respond to any future exposures. The structure of smallpox is so similar to the structure of cowpox that the body is able to fight off a smallpox infection, even if it has only been exposed previously to its milder cousin. </p>
<p>Cross protection explains the effectiveness of flu vaccines. Each year, scientists guess which influenza strains will be the most common in the coming season. The guess is <a href="https://www.cdc.gov/flu/prevent/vaccine-selection.htm">invariably “wrong”</a>, but the vaccine is close enough to prevent many infections. </p>
<p>Cross protection also explains why elderly people fared unexpectedly well during the 2009 flu pandemic: H1N1 flu strains also circulated during the <a href="https://www.jimmunol.org/content/185/3/1642.short">first half of the 20th century</a>, and anyone who was exposed to them retained the biological memory for decades. </p>
<p>Cross protection also regulates the <a href="https://science.sciencemag.org/content/368/6493/860">boom-bust cycle</a> of seasonal coronavirus transmission. The four mild coronaviruses are divided into two genetically related pairs, the alphas and the betas, which cause large outbreaks in alternating years. Each strain inhibits the spread of its closest relative, leading to a consistent two-year cycle. SARS-CoV-2 is a beta-coronavirus, meaning that it might have to compete with two close relatives during an autumn or winter wave. </p>
<p>A <a href="https://www.cell.com/cell/pdf/S0092-8674(20)30610-3.pdf">recent study</a> showed that SARS-CoV-2 can be recognised by the immune systems of people previously infected with one of the milder alpha- or beta-coronaviruses. This does not guarantee cross protection, but it is one of the necessary conditions.</p>
<p>Sometimes even unrelated viruses induce cross protection. In 2009, the H1N1 flu pandemic <a href="https://academic.oup.com/jid/article/218/3/406/4994087">delayed the peak of the RSV season</a> by a few weeks. Similar shifts in peak outbreak timing have been documented for a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5732536/">variety of respiratory illnesses</a>. This probably has to do with the faster, broader part of the immune response. When the immune system is already in high gear, it is able to fight off infection from other possible intruders. </p>
<h2>Exacerbating harm</h2>
<p>Cross protection is only half of the story. Viruses can also exacerbate the harm caused by one another. For example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697435/">HIV</a> and <a href="https://science.sciencemag.org/content/348/6235/694">measles</a> directly attack the immune system, weakening the body’s defences and leaving a person vulnerable to other pathogens. </p>
<p>But there is also another, stranger pathway. Sometimes a previous infection with one viral strain can actively help a closely related strain to invade. <a href="https://www.nature.com/scitable/content/model-of-antibody-dependent-enhancement-of-dengue-22403433/">Dengue virus</a> is the most famous example. A person’s first infection with dengue is likely to be mild, but the second can be life-threatening. The dengue strain that causes the second infection can hitch a ride on the antibodies that were produced to clear the first, helping the second strain to enter cells and cause a more severe infection. </p>
<p><a href="https://www.pnas.org/content/117/15/8218">Similar processes</a> could be in play for SARS-CoV-2. If so, a previous infection with SARS-CoV-2 or another coronavirus could make an infection more severe, not less. </p>
<h2>Looking ahead</h2>
<p>It’s too soon to say for sure what will happen in the coming months, but important evidence should start coming in soon. The earliest information about viral interactions will come from the southern hemisphere, which is just entering its peak respiratory illness season. </p>
<p>Second, various studies are underway, including one in <a href="https://bedford.io/papers/chu-sfs-protocol/">Seattle</a> and one in <a href="https://www.earth.columbia.edu/projects/view/1769">New York City</a> to identify the full range of respiratory viruses in densely populated settings. Combining the findings from these studies with SARS-CoV-2 surveillance will help us to get an early glimpse into interactions between respiratory viruses. </p>
<p>Still, models and historical experience with flu pandemics suggest that SARS-CoV-2 is probably <a href="https://www.cidrap.umn.edu/sites/default/files/public/downloads/cidrap-covid19-viewpoint-part1_0.pdf">here to stay for the foreseeable future</a>, even if some cross protection is in play. The field might seem crowded for respiratory viruses, but there’s ample room for one more.</p><img src="https://counter.theconversation.com/content/139513/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Kissler does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This winter, the field of respiratory viruses will be crowded.Stephen Kissler, Postdoctoral Researcher, Immunology and Infectious Diseases, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1390592020-06-04T11:18:55Z2020-06-04T11:18:55ZAfter coronavirus, another hidden respiratory disease lurks in the buildings we left behind<figure><img src="https://images.theconversation.com/files/339276/original/file-20200602-133910-1mky30d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/view-old-buildings-water-towers-midtown-1280896291">Charlotte Raboff/Shutterstock</a></span></figcaption></figure><p>Global outbreaks of coronavirus have forced the closing of schools, gyms, offices and other buildings at a scale never seen before. Now, as countries start reopening after lockdown, those previously abandoned buildings could have become a breeding ground for another infection – Legionnaires’ disease.</p>
<p>Legionnaires’ disease is caused by inhaling water droplets that contain the <em>Legionella pneumophilia</em> bacteria. It’s quite rare, but the long periods of inactivity in buildings during lockdown greatly increases the risk of outbreaks. </p>
<h2>What is Legionnaires’ disease?</h2>
<p>Legionnaires’ disease causes severe pneumonia. In fact its <a href="https://www.cdc.gov/legionella/about/signs-symptoms.html">symptoms</a> could easily be mistaken for COVID-19. They include fever, dry cough, shortness of breath and muscle pain. This means the potential for increased incidence of Legionnaires’ due to missed diagnosis cannot be overstated. </p>
<p>Unlike COVID-19, Legionnaires’ does not spread from person to person but causes <a href="https://www.ncbi.nlm.nih.gov/pubmed/28141970">large community outbreaks</a> through contaminated airborne water droplets from sources including showerheads, taps, cooling towers, air-conditioning systems, spa pools, hot tubs and water fountains.</p>
<p>The disease can be deadly, and infects multiple people at once. A recent outbreak in North Carolina saw <a href="https://www.npr.org/2019/10/04/767210215/n-c-officials-trace-124-legionnaires-disease-cases-to-hot-tub-at-a-fair">124 people</a> contract the disease and <a href="https://www.buzzfeednews.com/article/olivianiland/hot-tub-north-carolina-legionnaires-disease-outbreak">four people die</a> after walking past a infected hot tub display.</p>
<p>The bacteria live in warm environments, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3856027/">surviving in biofilm</a> – clusters of microbial life that gather on surfaces – and feeding on pipework sludge and sediment. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/336523/original/file-20200520-152302-54g3sl.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/336523/original/file-20200520-152302-54g3sl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336523/original/file-20200520-152302-54g3sl.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=326&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336523/original/file-20200520-152302-54g3sl.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=326&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336523/original/file-20200520-152302-54g3sl.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=326&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336523/original/file-20200520-152302-54g3sl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=410&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336523/original/file-20200520-152302-54g3sl.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=410&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336523/original/file-20200520-152302-54g3sl.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=410&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Factors that lead to Legionella growth in biofilm,</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/legionella/wmp/overview/growth-and-spread.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fwater-system-maintenance%2Fgrowth-and-spread.html">CDC</a></span>
</figcaption>
</figure>
<p>All water systems are at risk of this foreseeable and preventable contamination, but dormant and decommissioned buildings are especially at risk. That’s because intermittent use of buildings and equipment and the interruption of cleaning regimes increase the likelihood of water stagnation, which in turn increases the likelihood of a <em>Legionella</em> outbreak. </p>
<h2>What is the risk?</h2>
<p>The end of lockdown could not come at a worse time for potential Legionnaires’ outbreaks. The <em>Legionella</em> bacteria <a href="https://www.ecdc.europa.eu/en/publications-data/figure-2-number-legionnaires-disease-cases-month-eueea-2011-2014-0">flourishes</a> in summer months, as the optimum range for the bacteria is between 20-45°C. </p>
<p>Even more worryingly, countries that have had some of the most stringent lockdowns – and which as a result will have large numbers of disused buildings – are the countries where this disease is most common. France, Germany, Italy, Spain, the UK and Netherlands accounted for 70% of all <a href="https://www.ecdc.europa.eu/en/publications-data/legionnaires-disease-annual-epidemiological-report-2017">cases reported in Europe</a> in 2017. Of those, 10-15% of cases report a fatal outcome. </p>
<p>Meanwhile, the US, which has had widespread lockdowns, has experienced an <a href="https://aem.asm.org/content/early/2019/09/09/AEM.01776-19/article-info?versioned=true">800% increase</a> in reported cases over the past 20 years, probably because environmental impacts such as increased rainfall and warmer temperatures benefit the growth of <em>Legionella</em>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/336521/original/file-20200520-152311-1iankje.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/336521/original/file-20200520-152311-1iankje.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336521/original/file-20200520-152311-1iankje.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336521/original/file-20200520-152311-1iankje.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336521/original/file-20200520-152311-1iankje.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336521/original/file-20200520-152311-1iankje.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=579&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336521/original/file-20200520-152311-1iankje.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=579&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336521/original/file-20200520-152311-1iankje.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=579&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Distribution of Legionnaires’ disease cases in the EU/EEA, 2016.</span>
<span class="attribution"><a class="source" href="https://www.ecdc.europa.eu/sites/default/files/documents/AER_for_2017-Legionnaires-disease_1.pdf">European Centre for Disease Prevention and Control</a></span>
</figcaption>
</figure>
<p>As well as the risk in public buildings, there is also potential for increased domestic exposure as a result of the coronavirus pandemic. </p>
<p>Consumer buying trends report hot tub sales are surging – one online seller reported a <a href="https://www.businesscloud.co.uk/news/online-hot-tub-business-sees-1600-uk-surge-during-lockdown">1600% increase</a> in demand during lockdown. As the North Carolina example shows, hot tubs can become a breeding ground for Legionnaires’ when they are not cleaned or disinfected properly. </p>
<h2>COVID-19 vs Legionnaires’ disease</h2>
<p><a href="https://wwwnc.cdc.gov/eid/article/20/11/13-1872_article">At-risk groups</a> for Legionnaires’ disease are largely the same as for COVID-19 – 90% of cases affect people over 45, and two-thirds are male. Having chronic lung disease and other illnesses such as diabetes increases your risk of severe illness from Legionnaires’ disease, just as it does for COVID-19. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/339278/original/file-20200602-133919-1oiepng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/339278/original/file-20200602-133919-1oiepng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/339278/original/file-20200602-133919-1oiepng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339278/original/file-20200602-133919-1oiepng.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339278/original/file-20200602-133919-1oiepng.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339278/original/file-20200602-133919-1oiepng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=976&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339278/original/file-20200602-133919-1oiepng.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=976&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339278/original/file-20200602-133919-1oiepng.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=976&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The Legionella pneumophila bacterium causes the majority of Legionnaires’ disease outbreaks.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/legionella/images/materials-illustration.jpg">CDC</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p>But the strategy for fighting COVID-19 is not the one to adopt for Legionnaires’ disease. </p>
<p>People suspected of illness with COVID-19 are typically asked to self-isolate for a period of 14 days to prevent passing on the disease to others. But Legionnaires’ disease cannot be passed from person to person, and the symptoms worsen significantly over a seven-day period. As Legionnaires’ is caused by a bacteria, prompt treatment with antibiotics is vital. Delaying treatment can result in severe respiratory failure. </p>
<p>The additional risk of Legionnaires’ disease to recovered COVID-19 patients is currently unknown. <a href="https://www.medrxiv.org/content/10.1101/2020.02.29.20027698v2">Pre-print studies</a> of coronavirus cases in China and Japan found that 20% of COVID-19 patients were also infected with the <em>Legionella</em> bacteria. So it seems that coronavirus patients are more vulnerable to other community-acquired infections such as a Legionnaires’ and are at risk of acquiring it in hospital, as it can easily breed in medical facilities and equipment.</p>
<p>In the coming months as countries re-open, negative test results for coronavirus in those presenting with influenza and severe respiratory symptoms should be immediately referred for Legionnaires’ disease testing and not simply encouraged to recuperate alone. This could have a major impact on survival and recovery rates.</p>
<h2>How your employer should keep you safe</h2>
<p><em>Legionella</em> can rapidly become a public health problem in everyday places such as offices, schools, colleges, <a href="https://www.gov.uk/government/collections/legionnaires-disease-guidance-data-and-analysis">healthcare settings</a>, and factories. Employers are legally required to protect worker health from <em>Legionella</em> infection in <a href="http://www.bohs.org/return-to-work-guidance/">most jurisdictions</a>. </p>
<p>As countries exit lockdown, a comprehensive assessment must be made of all water systems in premises before anyone returns to work. <a href="https://www.hse.gov.uk/healthservices/legionella.htm">Effective water management programmes</a> in buildings, facilities and plant will eliminate this public health threat. </p>
<p>Increasing commercial and public awareness of <em>Legionella</em> controls is critical in long-term disease prevention. National and local publicity on Legionnaires’ disease risks when returning to work and leisure, along with guidance on the <a href="https://www.cieh.org/media/4208/legionella-guidance-covid-19.pdf">safe re-opening of buildings</a> should help to reduce the likelihood of disease outbreaks.</p><img src="https://counter.theconversation.com/content/139059/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anne Clayson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It causes fever, a dry cough, shortness of breath. Outbreaks are frequently deadly. It’s not COVID-19, and it could be waiting in your workplace after lockdown.Anne Clayson, Programme Director, Associate Professor in Occupational Hygiene and Occupational Health, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1384642020-05-13T14:38:56Z2020-05-13T14:38:56ZCOVID-19 has blown away the myth about ‘First’ and ‘Third’ world competence<figure><img src="https://images.theconversation.com/files/334609/original/file-20200513-156675-28cwm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Donald Trump has been widely slammed for mishandling the COVID-19 crisis, costing the US dearly. </span> <span class="attribution"><span class="source">Drew Angerer/Getty Images</span></span></figcaption></figure><p>One of the planet’s – and Africa’s – deepest prejudices is being demolished by the way countries handle COVID-19.</p>
<p>For as long as any of us remember, everyone “knew” that “First World” countries – in effect, Western Europe and North America – were much better at providing their citizens with a good life than the poor and incapable states of the “Third World”. “First World” has become shorthand for competence, sophistication and the highest political and economic standards.</p>
<p>So deep-rooted is this that even critics of the “First World” usually accept it. They might argue that it became that way by exploiting the rest of the world or that it is not morally or culturally superior. But they never question that it knows how to offer (some) people a better material life. Africans and others in the “Third World” often aspire to become like the “First World” – and to live in it, because that means living better.</p>
<p>So we should have expected the state-of-the-art health systems of the “First World”, spurred on by their aware and empowered citizens, to handle COVID-19 with relative ease, leaving the rest of the planet to endure the horror of buckling health systems and mass graves.</p>
<p>We have seen precisely the opposite. </p>
<h2>Fatal errors</h2>
<p>“First World” is often code for countries run by Europeans or people of European descent; some of the worst health performers on the globe in recent weeks have been “First World”. For Anglophone Africans, it is doubly interesting that two of the greatest failures in handling COVID-19 are the former coloniser, Britain, and the English-speaking superpower, the United States of America.</p>
<p>Both countries’ national governments have made just about every possible mistake in tackling COVID-19. </p>
<p>They <a href="https://www.tehrantimes.com/news/446660/U-S-UK-first-ignored-corona-now-they-are-failing-to-contain">ignored the threat</a>. When they were forced to act, they <a href="https://www.nbcnews.com/politics/white-house/mixed-white-house-messaging-coronavirus-sparks-internal-frustration-n1152606">sent mixed signals</a> to citizens which encouraged many to act in ways which <a href="https://www.theguardian.com/world/2020/apr/18/how-did-britain-get-its-response-to-coronavirus-so-wrong">spread the infection</a>. Neither did anything like the testing needed to control the virus. Both failed to equip their hospitals and health workers with the equipment they needed, triggering many avoidable deaths.</p>
<p>The failure was political. The US is the only rich country with no national health system. An attempt by former president Barack Obama to <a href="https://www.thebalance.com/obamacare-definition-3306077">extend affordable care</a> was watered down by right-wing resistance, then <a href="https://www.bbc.com/news/world-us-canada-24370967">further gutted by the current president and his party</a>. Britain’s much-loved <a href="https://www.nhs.uk/">National Health Service</a> has been <a href="https://www.theguardian.com/commentisfree/2019/oct/25/boris-johnson-conservatives-nhs-funding">weakened by spending cuts</a>. Both governments failed to fight the virus in time because they had other priorities.</p>
<p>And yet, in Britain, the government’s <a href="https://ukpollingreport.co.uk/">popularity ratings are sky high</a> and it is expected to win the next election comfortably. The US president is behind in the polls but the contest is close enough to <a href="https://www.realclearpolitics.com/epolls/latest_polls/">make his re-election a real possibility</a>. Can there be anything more typically “Third World” than citizens supporting a government whose actions cost thousands of lives?</p>
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Read more:
<a href="https://theconversation.com/what-south-africa-needs-to-forge-a-resilient-social-compact-for-covid-19-138171">What South Africa needs to forge a resilient social compact for Covid-19</a>
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<p>Western European countries such as <a href="https://www.aljazeera.com/news/2020/04/spain-coronavirus-spreading-month-lockdown-200424085528959.html">Spain</a>, <a href="https://www.nytimes.com/interactive/2020/world/europe/italy-coronavirus-cases.html">Italy</a> and Africa’s other wholesale coloniser, <a href="https://www.bbc.com/news/world-europe-52615733">France</a>, also battled to contain the virus. Some European countries have coped reasonably well, as have some run by the descendants of Europeans such as <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31097-7/fulltext">New Zealand</a> and <a href="https://www.bbc.com/news/av/world-australia-52616232/coronavirus-crowd-concerns-as-australia-s-restrictions-ease">Australia</a>. But the star performers are not in the historical “First World”.</p>
<h2>Effective responses</h2>
<p>The most effective response was probably South Korea’s, followed by other East Asian states and territories. This is partly because they are used to dealing with coronavirus outbreaks. But it is also because they learned from experience: South Korea’s success is due to <a href="https://theconversation.com/how-south-korea-flattened-the-coronavirus-curve-with-technology-136202">very effective testing and tracing of infected people</a>. Whatever the reason, it is East Asia, not “the West”, which has done what the “First World” is expected to do.</p>
<p>Some would reply that East Asia is now “First World”. So, it is still superior; it has simply changed its address. This is debatable. But, even if it is accepted, some places have contained the virus in distinctly “Third World” conditions.</p>
<p>Kerala was the first Indian state to encounter the virus but <a href="https://www.theguardian.com/commentisfree/2020/apr/21/kerala-indian-state-flattened-coronavirus-curve">has kept deaths down to three</a>. It had largely curbed COVID-19 but is now dealing with nearly 200 cases, all people arriving from other parts of India. Judging by its record so far, it will contain this outbreak too.</p>
<p>Kerala, too, has learnt from handling previous epidemics. It also has a strong health system. But one of its key tools is <a href="http://www.ipsnews.net/2020/04/kerala-covid-19-response-model-emulation/">citizen participation</a>: it has worked with neighbourhood watches and citizen volunteers to track the contacts of infected people. Students were recruited to build kiosks at which citizens were tested. Kerala also had the capacity to ensure that all children entitled to school meals received them after schools were closed: non-governmental organisations were mostly responsible, emphasising the partnership between the government and citizens.</p>
<p>Kerala’s performance is not a fluke: it has, for years, produced better health outcomes and literacy rates than the rest of India.</p>
<p>Nor has Africa’s response to the virus confirmed prejudices. When COVID-19 began spreading, it became almost routine for reports, <a href="https://theconversation.com/coronavirus-an-existential-threat-to-africa-and-her-crowded-slums-135829">commentaries</a> – and Melinda Gates, who, with her husband Bill, heads the couple’s development foundation – to predict that Africa would be engulfed in death as the virus ripped through its weak health systems. This is, after all, what is meant to happen in the “Third World” and particularly in Africa, which is always considered the least capable continent on the planet.</p>
<p>So far, it has not happened. It still might but, even if it does, some countries are coping better than the dire predictions claimed (and, perhaps, better than the “First World”). One stand-out is Senegal, which has devised a <a href="https://www.aljazeera.com/programmes/countingthecost/2020/04/senegal-1-covid-19-test-kit-race-vaccine-200425131112353.html">cheap test for the virus</a> and has used 3-D printing to produce ventilators at a fraction of the going price. Africa, too, has experienced recent outbreaks, notably of Ebola, and seems to have learned valuable lessons from them.</p>
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Read more:
<a href="https://theconversation.com/why-africa-needs-to-battle-unique-challenges-to-keep-coronavirus-numbers-down-136001">Why Africa needs to battle unique challenges to keep coronavirus numbers down</a>
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<h2>Inspiring</h2>
<p>The “First World” is still far richer than the rest of the planet and may well remain so. So its politicians, academics and journalists will probably still believe they are better than the rest.</p>
<p>But the COVID-19 experience may just trigger new thinking in the “Third World”. The most basic function of a government is to protect the safety of its citizens. Ensuring that people remain healthy is at least as important a guarantee of safety as protecting them from violence.</p>
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Read more:
<a href="https://theconversation.com/explainer-why-covid-19-provides-a-lesson-for-africa-to-fund-social-assistance-137175">Explainer: why COVID-19 provides a lesson for Africa to fund social assistance</a>
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<p>Reasonable people would surely much rather be living in Kerala or Senegal (or East Asia) right now than in Europe and North America, raising obvious questions about who really does offer a better life.</p>
<p>That should inspire Africans and others in the “Third World” to ask themselves whether it makes sense to want to be America, Britain or France. COVID-19 has made a strong argument for wanting to be East Asia – or, given Africa’s circumstances, Kerala.</p><img src="https://counter.theconversation.com/content/138464/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steven Friedman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some of the worst health performers in recent weeks have been ‘First World’.Steven Friedman, Professor of Political Studies, University of JohannesburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1346852020-04-15T11:11:15Z2020-04-15T11:11:15ZCoronavirus: lockdown’s effect on air pollution provides rare glimpse of low-carbon future<p>The COVID-19 pandemic has caused industrial activity to shut down and cancelled flights and other journeys, slashing greenhouse gas emissions and air pollution around the world. If there is something positive to take from this terrible crisis, it could be that it’s offered a taste of the air we might breathe in a low-carbon future.</p>
<p>The World Health Organisation (WHO) estimates that about <a href="https://www.nature.com/articles/nature15371">3 million people die each year</a> from ailments caused by air pollution, and that more than 80% of people living in urban areas are exposed to air quality levels that <a href="https://www.who.int/phe/publications/air-pollution-global-assessment/en/">exceed safe limits</a>. The situation is worse in low-income countries, where 98% of cities fail to meet WHO air quality standards.</p>
<p>Measurements from the European Space Agency’s Sentinel-5P satellite show that during late January and early February 2020, levels of nitrogen dioxide (NO₂) over cities and industrial areas in Asia and Europe were lower than in the same period in 2019, by as much as 40%.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/322870/original/file-20200325-168885-1ib1grk.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/322870/original/file-20200325-168885-1ib1grk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/322870/original/file-20200325-168885-1ib1grk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/322870/original/file-20200325-168885-1ib1grk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/322870/original/file-20200325-168885-1ib1grk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/322870/original/file-20200325-168885-1ib1grk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=571&fit=crop&dpr=1 754w, https://images.theconversation.com/files/322870/original/file-20200325-168885-1ib1grk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=571&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/322870/original/file-20200325-168885-1ib1grk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=571&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">As new daily cases of COVID-19 reached their peak in China, air pollution plummeted.</span>
<span class="attribution"><span class="source">ESA/NASA</span>, <span class="license">Author provided</span></span>
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<p>Two weeks after the nationwide lockdown was announced on March 23 in the UK, NO₂ pollution in some cities fell by as much as <a href="https://www.bbc.co.uk/news/uk-england-52202974">60% compared to the same period in 2019</a>. NASA revealed that NO₂ pollution over New York and other major metropolitan areas in north-eastern USA was <a href="https://www.nasa.gov/feature/goddard/2020/drop-in-air-pollution-over-northeast/">30% lower in March 2020</a>, compared to the monthly average from 2015 to 2019.</p>
<p>Most NO₂ comes from road transport and power plants, and it can exacerbate respiratory illnesses such as asthma. It also makes symptoms worse for those suffering from lung or heart conditions. NO₂ emissions have been a particularly thorny problem for Europe, with many countries <a href="https://www.eea.europa.eu/data-and-maps/indicators/exceedances-of-air-quality-objectives-7/assessment-2">in breach of EU limits</a>.</p>
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Read more:
<a href="https://theconversation.com/coronavirus-how-the-current-number-of-people-dying-in-the-uk-compares-to-the-past-decade-134420">Coronavirus: how the current number of people dying in the UK compares to the past decade</a>
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<p>In a sense, we are conducting the largest ever global air pollution experiment. Over a relatively short period of time, we’re turning off major air pollutant sources in industry and transport. In Wuhan alone, <a href="https://www.theguardian.com/world/2020/jan/24/wuhan-the-city-of-11-million-at-the-heart-of-the-coronavirus-outbreak">11 million people were in lockdown</a> at the height of the outbreak there. Across China, <a href="https://www.npr.org/sections/goatsandsoda/2020/02/21/806958341/restrictions-and-rewards-how-china-is-locking-down-half-a-billion-citizens">over half a billion</a>. China normally emits in excess of <a href="https://www.earth-syst-sci-data.net/10/1987/2018/essd-10-1987-2018.pdf">30 mega tonnes</a> of nitrogen oxides per year, with estimates for 2019 reaching <a href="https://www.atmos-chem-phys-discuss.net/acp-2019-1122/acp-2019-1122.pdf">40 mega tonnes</a>.</p>
<h2>Making air quality improvements permanent</h2>
<p>China emits over 50% of all the nitrogen dioxide in <a href="https://www.atmos-chem-phys-discuss.net/acp-2019-1122/acp-2019-1122.pdf">Asia</a>. Each tonne of NO₂ that isn’t emitted as a result of the pandemic is the equivalent of removing 62 cars per year from the road. So you could estimate that over China, even a moderate 10% reduction in NO₂ emissions is equivalent to taking 48,000 cars off the road. But the 40% drop in NO₂ on 2019 levels for January and February in some areas equates to removing a whopping 192,000 cars.</p>
<p>That’s an indication of what could be achieved permanently for air quality if car use was phased down and replaced with electrically powered mass transit. Electrifying transport in this way, with expanded train lines and more electric cars and charging stations, would slash tail pipe emission of air pollutants such as NO₂.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/322869/original/file-20200325-168889-tlgm35.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/322869/original/file-20200325-168889-tlgm35.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/322869/original/file-20200325-168889-tlgm35.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=255&fit=crop&dpr=1 600w, https://images.theconversation.com/files/322869/original/file-20200325-168889-tlgm35.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=255&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/322869/original/file-20200325-168889-tlgm35.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=255&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/322869/original/file-20200325-168889-tlgm35.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=320&fit=crop&dpr=1 754w, https://images.theconversation.com/files/322869/original/file-20200325-168889-tlgm35.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=320&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/322869/original/file-20200325-168889-tlgm35.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=320&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Surface concentrations of nitrogen dioxide over northern Italy, January 31 versus March 15 2020.</span>
<span class="attribution"><a class="source" href="http://www.esa.int/ESA_Multimedia/Videos/2020/03/Coronavirus_nitrogen_dioxide_emissions_drop_over_Italy">Copernicus Atmosphere Monitoring Service (CAMS); ECMWF</a>, <span class="license">Author provided</span></span>
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<p>But electric vehicles are only as clean as the electricity that powers them. The recent improvements in air quality could be made permanent by replacing fossil fuel generation with renewable energy and other low-carbon sources. <a href="https://www.atmos-chem-phys.net/12/4429/2012/acp-12-4429-2012.pdf">Reducing monthly NO₂ emissions</a> from electricity generation by 10% would be the equivalent of turning off 500 coal power stations for a year. </p>
<p>Ironically, by shutting down swaths of the global economy, COVID-19 has helped expose another respiratory health crisis. The ensuing lockdowns have shown the improvements to air quality that are possible when emissions are reduced on a global scale. </p>
<p>The pandemic could show us how the future might look with less air pollution, or it may just indicate the scale of the challenge ahead. At the very least, it should challenge governments and businesses to consider how things can be done differently after the pandemic, to hold on to temporary improvements in air quality.</p>
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<img alt="" src="https://images.theconversation.com/files/263883/original/file-20190314-28475-1mzxjur.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263883/original/file-20190314-28475-1mzxjur.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=140&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263883/original/file-20190314-28475-1mzxjur.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=140&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263883/original/file-20190314-28475-1mzxjur.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=140&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263883/original/file-20190314-28475-1mzxjur.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=176&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263883/original/file-20190314-28475-1mzxjur.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=176&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263883/original/file-20190314-28475-1mzxjur.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=176&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em><a href="https://theconversation.com/imagine-newsletter-researchers-think-of-a-world-with-climate-action-113443?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=Imagineheader1134685">Click here to subscribe to our climate action newsletter. Climate change is inevitable. Our response to it isn’t.</a></em></p><img src="https://counter.theconversation.com/content/134685/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Monks receives funding from Natural Environment Research Council. </span></em></p>As lockdowns have came into effect around the world, air pollution has plummeted.Paul Monks, Professor of Atmospheric Chemistry and Earth Observation Science, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1254052020-02-24T13:17:51Z2020-02-24T13:17:51ZLessons from Rwanda on tackling unsafe drinking water and household air pollution<figure><img src="https://images.theconversation.com/files/313085/original/file-20200131-41503-1sqp8rx.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tubeho Neza community distributions of household water filters and cookstoves in western Rwanda in 2014. </span> <span class="attribution"><span class="source"> Evan Thomas</span></span></figcaption></figure><p>Unsafe drinking water and household air pollution are major <a href="https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death">causes</a> of illness and death around the world. This is also the case in Rwanda, where <a href="https://www.sciencedaily.com/releases/2019/06/190603151705.htm">most people</a> living in rural areas drink untreated water and burn firewood on open stoves to cook their meals. <a href="https://www.sciencedaily.com/releases/2019/06/190603151705.htm">More than 80%</a> of Rwandans rely on firewood as their primary fuel source. </p>
<p>After neonatal disorders, pneumonia and diarrhoeal disease are the two <a href="http://www.healthdata.org/rwanda">leading killers</a> of children under five years of age in Rwanda. Unsafe drinking water is the <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.12329">leading cause</a> of diarrhoeal disease. And cooking indoors on open-fire stoves, with fuel such as wood and charcoal, has been <a href="https://link.springer.com/article/10.1007%2Fs40572-014-0021-0">linked</a> to pneumonia, low birth weight and impaired development in children. </p>
<p>There have been many <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012613/full">efforts</a> to address these environmental health issues, but they often lack the <a href="https://link.springer.com/chapter/10.1007/978-3-319-28643-3_2">financial support</a> to be sustained in the long term. </p>
<p>In 2011, we came together as government, implementers and independent evaluators to design and study a programme that would address these environmental health challenges in Rwanda. It would need to be both sustainable and scalable. </p>
<p>The programme was financed and led by <a href="https://www.delagua.org/">DelAgua</a>, a UK-based water test kit company, in partnership with the Rwanda Ministry of Health. It was branded “<a href="https://www.colorado.edu/center/mortenson/Tubeho%20Neza">Tubeho Neza</a>”, which translates to “live well” in Kinyarwanda an official language of Rwanda.</p>
<p>DelAgua and the Ministry of Health evaluated which technologies could most effectively reduce drinking water contamination and indoor air pollution. They needed to be technologies that people would adopt, were durable, and could be maintained easily by community health workers. </p>
<p>To become financially sustainable, we wanted the project to be eligible for carbon credits under the United Nations Clean Development Mechanism. By reducing wood fuel demands, the project could earn revenue through the generation and sale of these <a href="https://link.springer.com/chapter/10.1007/978-3-319-28643-3_8">carbon credits</a>. </p>
<p>DelAgua and the Ministry of Health, after certification by the Rwanda Bureau of Standards, decided to use the Vestergaard Frandsen <a href="https://www.vestergaard.com/lifestraw-family-2-0/">LifeStraw Family</a> 2.0 household water filter and the <a href="https://ecozoom.com/products/zoom-dura?variant=655681577">EcoZoom Dura</a> portable wood-burning cookstove. </p>
<p>A 2012 pilot <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0092403">demonstrated the viability and impact</a> of this programme: households started, and continued, to use the water filters and cookstoves. These findings led to a larger roll-out which started in 2014.</p>
<h2>The roll-out</h2>
<p>Working with the Rwanda National Police and the Ministry of Health, DelAgua reached over 101,000 households with the water filters and cookstoves. In 2015 they distributed an additional 250,000 cookstoves to nearly a million more people. </p>
<p>Community health workers advised communities and households about proper use of the products. They then visited each household regularly for a year after the distribution to encourage adoption and perform any repairs that were needed. </p>
<p>From 2012 to 2016, the London School of Hygiene and Tropical Medicine and Emory University evaluated the programme. They looked at the design, adoption rate and impacts on water quality, air quality, respiratory disease and diarrhoea, as well as the carbon credit financing mechanism.</p>
<p><a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002812">This project study</a> was published in 2019 and showed promising results. Among children under five years of age, the intervention reduced seven-day prevalence of reported diarrhoea by 29% and acute respiratory infection by 25%. </p>
<p>As expected, drinking water quality improved, probably explaining the impact on diarrhoea. But people’s exposure to fine particulate matter in the air (measured with personal exposure sensors) remained unchanged, despite increased outdoor cooking with the improved cookstoves. This is consistent with <a href="https://www.sciencedirect.com/science/article/pii/S0140673616325077?via%3Dihub">other research</a> that found no protective effect from cooking on improved biomass stoves, such as the Tubeho Neza. </p>
<p>But the study also found that people used the products less over time, as reinforcement by the community health workers became less frequent. As correct, consistent use is essential for achieving health benefits, it is unclear whether the protective effects can be sustained in the absence of regular visits and engagement with households. </p>
<p>Beyond the directly measured health impacts, the people who implement the products also <a href="https://www.sciencedirect.com/science/article/pii/S2352728519300491">analysed</a> the overall programme costs and benefits. There were savings in fuelwood - an estimated 65,000 tons, enough to reverse deforestation in the region for a few years. Over five years the total programme cost was nearly US$12 million and the total benefit was estimated at over $66 million. </p>
<p>These results suggest that the programme was cost-effective in reducing wood fuel use, improving drinking water quality, and reducing risk of diarrhoea and respiratory illness among children under five. </p>
<h2>Future challenges</h2>
<p>As long as these products are still in use, DelAgua earns carbon credits which are then <a href="http://pubdocs.worldbank.org/en/680521534357131570/pdf/PAD-FINAL.pdf">sold to the World Bank</a> and other buyers. The aim to is to benefit private sector investors and to support the programme’s continuation. </p>
<p>The water filters and stoves used in the trial are nearing the end of their lifetimes and it does not look as if they can be replaced, given the <a href="http://documents.worldbank.org/curated/en/191801559846379845/pdf/State-and-Trends-of-Carbon-Pricing-2019.pdf">weak carbon credit market</a>. As a result, DelAgua has transitioned to a focus on carbon-credit subsidised retail sales of these products in Rwanda. </p>
<p>Over the same years as this programme in Rwanda, there were several other large-scale trials of water, sanitation and hygiene interventions in low-income settings. They indicated little or no <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1410-x">impacts on health</a>. Similarly, a study of community hygiene clubs in Rwanda – designed to improve awareness without providing any products – <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30217-6/fulltext">showed no impact</a> on health. </p>
<p>Cleaner fuels, such as liquefied petroleum gas, may offer a potential solution to further improving air quality, and are being evaluated in a multi-country <a href="http://www.hapintrial.org/">trial</a> that includes Rwanda. But accessibility and affordability of such fuels will continue to be a challenge in many settings. </p>
<p>In contrast, the Tubeho Neza programme has showed that it is possible to provide interventions against major diseases to vulnerable households at scale and to secure their adoption and consistent use. It also demonstrated the efficiency of combining critical environmental interventions at the household level. This achievement can inform other national efforts.</p>
<p><em>Evan Thomas led a team in design and implementation of the programme, Jean de Dieu Ngirabega represented the Ministry of Health, while Thomas Clasen’s team independently studied its impacts.</em></p><img src="https://counter.theconversation.com/content/125405/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Evan Thomas was previously employed by DelAgua, and was responsible for designing and managing the program described. </span></em></p><p class="fine-print"><em><span>Thomas Clasen was employed by Emory University or LSTHM which received funding under a grant from Portland State University. </span></em></p><p class="fine-print"><em><span>Jean De Dieu Ngirabega does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Tubeho Neza programme has showed that it is possible to provide interventions against major diseases to vulnerable households.Evan Thomas, Associate Professor, University of Colorado BoulderJean De Dieu Ngirabega, Visiting lecturer, Research and Community Health, Ruli Higher Institute of HealthThomas Clasen, Professor, Emory UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1278732019-12-04T17:41:16Z2019-12-04T17:41:16ZRemove car lanes, restrict vehicles and improve transit to reduce traffic congestion<figure><img src="https://images.theconversation.com/files/304343/original/file-20191128-178135-10fwswo.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1349%2C665&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Montréal is one of the most congested cities in Canada. In 2018, a total of 145 hours per capita were lost by people stuck in rush hour traffic. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>During a trip to the United States, I was surprised to hear a transportation planner from a major American metropolis say that traffic congestion was not a problem because it was a sign of economic vitality.</p>
<p>Some even say that aspiring to less congestion is not desirable, as the road network is designed to absorb peak traffic during the morning rush hour. Not having congestion means there is more capacity within the network than demand.</p>
<p>Yet the environmental, social and economic costs associated with traffic congestion are real and affect the health, quality of life and wallet of all taxpayers and citizens on a daily basis.</p>
<p>The consequences of road congestion are generally measured in terms of additional travel time, and with the associated costs of additional vehicle use, such as fuel, depreciation and maintenance.</p>
<h2>Costs of $4.2 billion in Montréal</h2>
<p>Some studies also include greenhouse gas (GHG) emissions and additional accidents caused by more time spent in traffic. Congestion also leads to other direct and indirect costs such as premature wear and tear on roads and impact on the health of people.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/298156/original/file-20191022-55685-112pwlw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298156/original/file-20191022-55685-112pwlw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298156/original/file-20191022-55685-112pwlw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298156/original/file-20191022-55685-112pwlw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298156/original/file-20191022-55685-112pwlw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298156/original/file-20191022-55685-112pwlw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298156/original/file-20191022-55685-112pwlw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Heavy traffic flows across the Jacques-Cartier Bridge in Montréal.</span>
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<p>Montréal is the second <a href="http://inrix.com/scorecard/">most congested city in Canada</a>, with a total of 145 hours lost per capita in peak rush hour traffic in 2018. It comes after Toronto, which ranks first among Canadian cities (167 hours lost). Québec City ranks ninth (85 hours lost).</p>
<h2>Increase in greenhouse gas emissions</h2>
<p>Road congestion also increases the air pollution produced by the combustion of fossil fuels, leading to an increase in respiratory problems, premature deaths and several types of cancer, especially for <a href="https://www.emerald.com/insight/content/doi/10.1108/9781786359513-022/full/html">neighbouring populations, which are often disadvantaged</a>.</p>
<p>Gasoline and diesel vehicles also emit carbon dioxide, a powerful greenhouse gas responsible for global warming. In Canada, the entire transportation sector is the <a href="https://www.canada.ca/en/environment-climate-change/services/climate-change/greenhouse-gas-emissions/sources-sinks-executive-summary-2019.html">second largest source of greenhouse gases emissions , accounting for 28 per cent of total emissions</a>.</p>
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À lire aussi :
<a href="https://theconversation.com/when-it-comes-to-vehicles-canada-tops-the-charts-for-poor-fuel-economy-115213">When it comes to vehicles, Canada tops the charts for poor fuel economy</a>
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<p>In Québec, transportation accounted for <a href="http://www.environnement.gouv.qc.ca/changements/ges/2015/inventaire1990-2015.pdf">43 per cent of total greenhouse gases emissions in 2016</a>, of which 80 per cent came from road transportation. These emissions <a href="http://www.bv.transports.gouv.qc.ca/mono/1233551.pdf">increased by 52 per cent between 1990 and 2016</a>.</p>
<p>Although greenhouse gas emissions from road congestion are not systematically inventoried, they are often used to justify new road projects. But why does congestion persist, despite government interventions to reduce it?</p>
<h2>“Build it and they will come!”</h2>
<p>The government response to congestion problems has generally been to build new roads or widen existing ones. However, this measure is ineffective because increasing capacity only increases vehicle use.</p>
<p>New routes generate additional demand equivalent to the new capacity. This natural near balance between supply and demand explains why roads reach pre-expansion congestion levels between <a href="https://repository.upenn.edu/cgi/viewcontent.cgi?article=1087&context=real-estate_papers">five and 10 years after the construction of new routes</a>.</p>
<p>What American economist Anthony Downs called “<a href="https://www.citylab.com/transportation/2011/10/only-hope-reducing-traffic/315/">the fundamental law of highway congestion</a>” in 1962 has since been confirmed by a large number of scientific studies.</p>
<p>The new traffic caused by the increase in road capacity, commonly referred to as “induced demand,” comes from <a href="https://repository.upenn.edu/cgi/viewcontent.cgi?article=1087&context=real-estate_papers">four sources</a>: increased commercial traffic, changing travel patterns, population migration and, to a lesser extent, diversion of traffic from other routes.</p>
<h2>An increase in travel time</h2>
<p>In the short term, new road segments reduce travel time and therefore costs, which encourages individuals and businesses to travel more, change departure times or itineraries, choose cars over public transit or move further away from where they work.</p>
<p>This increase in demand therefore compensates proportionally for the new road supply in the medium term, and at the same time for the reduction in greenhouse gas emissions that could have been associated with a reduction in congestion.</p>
<p>In addition, the road network may not be used to its optimal capacity because users make an individual decision about the fastest route for their travel, regardless of the choices of others. These decisions may not correspond to the social optimal. Thus, the addition of a road can increase the total travel time over the entire network (and vice versa), making it necessary to coordinate individual trips.</p>
<h2>Adding roads does not improve the economy</h2>
<p>Another argument often used to justify increasing road capacity is that of job creation and economic development. Although road infrastructure creates employment during its construction, most studies have not found a link between increased road capacity and economic activity. Indeed, it is rather a <a href="https://repository.upenn.edu/cgi/viewcontent.cgi?article=1031&context=real-estate_papers">displacement of economic activity</a> across the same metropolitan region that is observed.</p>
<p>For example, exporting companies will be located along the new road infrastructure, but this will <a href="https://repository.upenn.edu/cgi/viewcontent.cgi?article=1031&context=real-estate_papers">not have a significant effect</a> on the total value of their production.</p>
<h2>Increasing public transit is not enough</h2>
<p>Increasing public transit is often promoted as the main alternative to building additional lanes or new roads. However, in accordance with the fundamental law of congestion, the space freed up by the use of public transport is ultimately compensated for by the additional demand it creates. Thus, <a href="https://repository.upenn.edu/cgi/viewcontent.cgi?article=1087&context=real-estate_papers">public transport is not enough</a> to reduce congestion.</p>
<p>In fact, if the objective is to reduce car traffic, the only effective method on the supply management side is <a href="https://nacto.org/docs/usdg/disappearing_traffic_cairns.pdf">reduction in road capacity</a>, because the law of road congestion also works in the opposite direction: what we refer to as “reduced demand.” In addition to reducing travel demand, lane removal and traffic restriction also have measurable and documented social, environmental and economic benefits.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/298169/original/file-20191022-55701-2gsrso.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298169/original/file-20191022-55701-2gsrso.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298169/original/file-20191022-55701-2gsrso.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298169/original/file-20191022-55701-2gsrso.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298169/original/file-20191022-55701-2gsrso.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298169/original/file-20191022-55701-2gsrso.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298169/original/file-20191022-55701-2gsrso.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Adding new modes of public transit will not solve congestion problems.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Ecofiscal measures</h2>
<p>Other measures are used to manage transport demand. First, the imposition of eco-tax measures, such as the gas tax and the parking tax, can help reduce vehicle use.</p>
<p><a href="http://www.bv.transports.gouv.qc.ca/mono/1233551.pdf">A Québec study</a> reveals that increasing the gas tax to $0.46/L in Québec and introducing a road use tax of $0.15/km in greater Montréal area would make it possible to reach a quarter of Québec’s target for reducing greenhouse gas emissions from transportation, in addition to increasing the use of public transit by almost 40 per cent.</p>
<p>Eco-taxation also encourages motorists to use public and active modes of transport, provided that these choices are available to them.</p>
<p>Teleworking, flexible working hours, parking management and so-called smart growth policies also reduce travel distances and the need or willingness to travel by car. These measures have positive consequences on public health, urban quality of life, land values, local consumption, etc.</p>
<p>The most effective planning choices are not always the most popular. To <a href="http://www.transformingurbantransport.com/strategies-and-tactics">get them accepted</a>, decision-makers must act at the right time, use technical expertise, conduct pilot projects, find allies, compensate for inconveniences and work with the various levels of government.</p>
<p><em>This text is an abridged version of a text originally published in the journal <a href="http://www.climatoscope.ca/">Le Climatoscope</a>.</em></p>
<p>[ <em><a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/127873/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fanny Tremblay-Racicot has received financing from le Fonds de Recherche du Québec - Société et culture and Transition Énergétique Québec. </span></em></p>Traffic congestion causes more problems than just being stuck in traffic. There are real effects on the health, quality of life and wallets of taxpayers.Fanny Tremblay-Racicot, Professeure adjointe, administration municipale et régionale, École nationale d'administration publique (ENAP)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1218622019-08-16T12:52:36Z2019-08-16T12:52:36ZWhy are people still dying from Legionnaires’ disease?<figure><img src="https://images.theconversation.com/files/288192/original/file-20190815-136208-s9lota.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Inhaling mist contaminated with _Legionella pneumophila_ can lead to Legionnaires' disease.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/girl-shower-behind-misted-glass-takes-1227823831">Denis Klimov 3000/Shutterstock.com</a></span></figcaption></figure><p>In the nearly 50 years since epidemiologists first discovered Legionnaires’ disease, we have learned how to test for it, treat it and prevent it. So why are people still dying from it and why are more and more people becoming sick with it every single year?</p>
<p>Most recently, <a href="https://www.nytimes.com/2019/08/07/us/legionnaires-disease-atlanta-death.html">one woman died</a> and over 70 other people were infected in the largest outbreak of the disease in Georgia history after staying at the Sheraton Atlanta Hotel in mid-July. </p>
<p>From 2000 through 2017, the number of reports of Legionnaires’ disease <a href="https://www.cdc.gov/legionella/about/history.html">increased over 500% in the United States</a>. Many factors contribute to this increase: a true increase in cases, an older population at higher risk, better diagnosis, improved disease reporting and more thorough investigation of outbreaks by health departments. However, the fact remains that each year over 6,000 people are infected and over 250 people die from a disease that is <a href="http://www.cidrap.umn.edu/news-perspective/2017/06/cdc-most-healthcare-acquired-legionnaires-cases-could-be-prevented">largely preventable</a>.</p>
<p>I am an infectious disease epidemiologist at the University of Nevada, Las Vegas School of Public Health. For nearly 15 years, I investigated outbreaks of disease for the health department in Las Vegas and I dealt with Legionnaires’ disease in Las Vegas Strip hotels <a href="https://vegasinc.lasvegassun.com/business/2011/aug/23/aria-guests-sue-after-acquiring-legionnaires-disea/">on</a> <a href="https://lasvegassun.com/news/2012/jan/30/guest-who-stayed-luxor-dies-legionnaires-disease/">numerous</a> <a href="https://knpr.org/knpr/2012-02/legionnaires-strikes-again-mgm-hotels">occasions</a>, including repeatedly investigating one resort that spent <a href="https://doi.org/10.1017/S0950268811002779">eight years fighting the pathogen</a>. </p>
<h2>What is Legionnaires’ disease?</h2>
<p>Legionnaires’ disease is a respiratory disease that occurs when the bacteria <em>Legionella pneumophila</em> infect the lungs. In order to become sick, you have to inhale microscopic droplets of water that are contaminated with the bacteria. Simply drinking contaminated water is not enough to make you sick, and you cannot catch the disease from someone else who is sick. </p>
<p>It can take up to 10 days for symptoms to appear, and when they do, they initially look like a bad case of flu. The illness typically begins with a high fever, a cough, shortness of breath, muscle ache and headache. After a couple of days, these symptoms progress to pneumonia, a buildup of fluid in the lungs that makes it difficult to breathe. In <a href="https://www.cdc.gov/legionella/health-depts/surv-reporting/2014-15-surv-report-508.pdf">2014 and 2015</a>, more than 95% of people with Legionnaires’ disease wound up being hospitalized. While the disease is treatable with antibiotics, about 1 in 8 still died from their infection. </p>
<p>Although the bacteria can infect people of all ages, more than 80% of <a href="https://www.cdc.gov/legionella/health-depts/surv-reporting/2014-15-surv-report-508.pdf">reported cases</a> were 50 years old or older and about 60% were men. Smokers and people with underlying lung diseases – such as emphysema or chronic obstructive pulmonary disease – or weakened immune systems, due to medicines or health problems such as cancer or diabetes, are also at higher risk of infection.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/288195/original/file-20190815-136230-e48t2j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/288195/original/file-20190815-136230-e48t2j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288195/original/file-20190815-136230-e48t2j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288195/original/file-20190815-136230-e48t2j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288195/original/file-20190815-136230-e48t2j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288195/original/file-20190815-136230-e48t2j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288195/original/file-20190815-136230-e48t2j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288195/original/file-20190815-136230-e48t2j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Symptoms of Legionnaires’ disease resemble the flu.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/legionnaires-disease-legionellosis-legion-fever-signs-302169239?src=CuKPbXkOCKSoAr3Ynyy-Cw-1-5">Designua/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>How does it spread?</h2>
<p>We have learned a lot about the disease and how it spreads since it was discovered and named nearly 50 years ago. In 1976, an estimated 180 attendees of American Legion convention in Philadelphia developed a mysterious respiratory illness and <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00045731.htm">29 died within days of the event</a>. It wasn’t until months after that outbreak that the responsible organism, <em>Legionella pneumophila</em>, <a href="https://wwwnc.cdc.gov/eid/article/23/11/ET-2311_article">was first discovered</a>. The bacteria was found growing in the hotel’s cooling tower and was spread throughout the hotel via the air conditioning system.</p>
<p>We now know that <em>Legionella pneumophila</em> can be regularly found in fresh water all over the world, which makes preventing disease a particular challenge. We also know that man-made water systems, including <a href="https://abcnews.go.com/Health/legionnaires-outbreak-traced-back-playboy-mansion/story?id=12924405">hot tubs</a>, <a href="https://dx.doi.org/10.1097%2FPHH.0000000000000558">cooling towers</a>, <a href="https://www.nytimes.com/1990/01/11/us/mist-in-grocery-s-produce-section-is-linked-to-legionnaires-disease.html">misters</a>, <a href="https://wwwnc.cdc.gov/eid/article/8/1/01-0176_article">fountains</a>, hot water tanks, and even the complex plumbing systems in big buildings can grow and spread <em>Legionella</em>. </p>
<p>Two things have to happen for a person to develop Legionnaires’ disease. First, a person has to be exposed to the bacteria through inhaling small droplets of water. Then the bacteria has to multiply until there are enough of them to cause disease. The first factor is impossible to control, as exposure occurs through breathing contaminated water. For example, if you take a shower, there is no way to prevent breathing in the fine mist created by the shower head. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/288197/original/file-20190815-136203-1gcvhbz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/288197/original/file-20190815-136203-1gcvhbz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288197/original/file-20190815-136203-1gcvhbz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288197/original/file-20190815-136203-1gcvhbz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288197/original/file-20190815-136203-1gcvhbz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288197/original/file-20190815-136203-1gcvhbz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288197/original/file-20190815-136203-1gcvhbz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288197/original/file-20190815-136203-1gcvhbz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Legionnaires’ disease was named for an outbreak at a conference of the American Legion.</span>
<span class="attribution"><span class="source">Glynnis Jones/Shutterstock.com</span></span>
</figcaption>
</figure>
<h2>High risk times for <em>Legionella</em></h2>
<p>Because these bacteria are found everywhere in fresh water, it is impossible to keep them from being introduced into a water system. That leaves society with the challenge of controlling the number of bacteria. The bacteria can live a long time in the pipes that are part of a larger water system, such as those that are in hotels and nursing homes, and when a person turns on the shower in a hotel, <em>Legionella</em> comes tumbling out, too.</p>
<p>The most important factor in preventing <em>Legionella</em> growth in pipes and the water system is to control the temperature of the water. These bacteria grows best at temperatures between <a href="https://www.who.int/water_sanitation_health/emerging/legionella.pdf">77 and 108 degrees Fahrenheit</a>. The longer water sits in pipes, such as those in a hotel room that is unoccupied for several days, the more likely it is that it will be in that temperature danger zone and the bacteria will flourish. This is why Legionnaires’ disease cases spike in the <a href="https://www.cdc.gov/legionella/health-depts/surv-reporting/2014-15-surv-report-508.pdf">summer and early fall</a> when it is harder to keep the water out of that temperature danger zone. </p>
<p>Ultimately, the responsibility for preventing Legionnaires’ disease falls on the shoulders of the building owners and managers to implement a comprehensive <a href="https://www.cdc.gov/legionella/wmp/index.html">water management program</a> of the complex water systems in their facility. Unlike private homes, commercial buildings have miles of pipe where water may sit for long periods of time, water-based cooling systems, large spas and decorative fountains – and these all have to be properly maintained to prevent <em>Legionella</em> growth. This is particularly important for hospitals and nursing homes, as 20% of Legionnaires’ cases are acquired in health care settings by people who are at high risk for infection. However, as we have seen in the outbreak in Atlanta, and in hundreds of other outbreaks over the years, Legionnaires’ disease can affect anyone at any time. </p>
<p>As we start to understand <a href="https://www.ajc.com/news/officials-confirm-first-legionnaires-death-linked-atlanta-outbreak/qlcU6tCtW4hA3LRQThlfiK/">what went wrong in Atlanta</a>, public health experts might learn more about how to prevent Legionnaires’ disease. It’s then up to building owners and operators to put the necessary protections in place throughout the country. Unfortunately the public can’t do much more than hold their breath. </p>
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<p class="fine-print"><em><span>Brian Labus was previously funded by grants from the Centers for Disease Control and Prevention for disease surveillance and outbreak investigation activities, including Legionnaires' disease.</span></em></p>A woman recently died from Legionnaires’ disease at an Atlanta hotel. Why? The cause is known and the disease is largely preventable. Yet the number of cases in the US continue to rise.Brian Labus, Assistant Professor of Epidemiology and Biostatistics, University of Nevada, Las VegasLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1152022019-04-15T10:53:19Z2019-04-15T10:53:19ZMapping the US counties where traffic air pollution hurts children the most<figure><img src="https://images.theconversation.com/files/268491/original/file-20190409-2898-19ixlz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pollutants not shown.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/traffic-jam-rush-hour-554001493?src=OS7lXoMorMrlQ7qX8PxqKA-1-16">bibiphoto/shutterstock.com</a></span></figcaption></figure><p>In the U.S., <a href="https://dx.doi.org/10.15585%2Fmmwr.mm6705e1">over 6 million children had ongoing asthma in 2016</a>. Globally, <a href="http://www.globalasthmareport.org/">asthma kills around 1,000 people every day</a> – and its prevalence is rising. </p>
<p>This condition has a high economic cost. Each year in the U.S., <a href="https://doi.org/10.1513/AnnalsATS.201703-259OC">more than US$80 billion is lost because of asthma</a>. This is mainly due to premature deaths, medical payments and missed work and school days. The burden is higher for families with asthmatic children, who, on average, spend $1,700 more on health care than families with healthy children.</p>
<p>One major <a href="https://dx.doi.org/10.1136%2Foem.2004.019216">environmental factor</a> that might contribute to the development of asthma is air pollution from traffic. <a href="https://doi.org/10.1016/j.envint.2019.03.041">In our study</a>, published on April 3, our team mapped where in the U.S. children are most at risk for developing asthma from this type of pollution.</p>
<h2>Traffic and asthma</h2>
<p>Asthma is likely the <a href="https://www.who.int/respiratory/asthma/en/">most common chronic disease in childhood</a>, according to the World Health Organization. </p>
<p>Asthma presents as episodes of wheezing, coughing and shortness of breath due to the reversible, or partially reversible, obstruction of airflow. Six in 10 of children with asthma worldwide had <a href="https://www.cdc.gov/asthma/asthma_stats/severity_child.htm">a form of persistent asthma</a>, meaning that either they were on long-term medication or their condition could not be controlled even with medication. </p>
<p>Traffic pollution contains a mixture of harmful pollutants like nitrogen oxides, carbon monoxide, particulate matter, benzene and sulfur. These pollutants are known to harm health in many ways, causing a number of cardiovascular, respiratory and neurological diseases.</p>
<p>One 2013 review suggested that long-term exposure to common traffic-related air pollutants is linked to the <a href="https://doi.org/10.1007/s11869-011-0144-5">development of asthma in children and adults</a>. </p>
<p>A much larger meta-analysis in 2017, which focused on children and included more recently published studies, <a href="https://doi.org/10.1016/j.envint.2016.11.012">found consistent connections between this type of pollution and childhood asthma development</a>. The researchers concluded that there is now sufficient evidence showing a relationship between this type of pollution and the onset of childhood asthma.</p>
<p>Studies from the nonprofit research group <a href="https://www.healtheffects.org/publication/traffic-related-air-pollution-critical-review-literature-emissions-exposure-and-health">Health Effects Institute</a> and the <a href="https://cfpub.epa.gov/ncea/isa/recordisplay.cfm?deid=310879">U.S. Environmental Protection Agency</a> have concluded along these lines.</p>
<h2>Mapping the problem</h2>
<p>Despite this emerging evidence, the burden of childhood asthma due to traffic-related air pollution is poorly documented. Very few studies explore the geographic and spatial variations.</p>
<p>My research team wanted to quantify the connection between exposure to traffic pollution and the onset of childhood asthma across 48 U.S. states and the District of Columbia. We also wanted to make these data open to the public. </p>
<p>In our analysis, we looked at 70 million kids and conducted all calculations at the census block level, the smallest available geographical unit for census data. We collaborated with researchers from the <a href="https://depts.washington.edu/airqual/">University of Washington</a>, who modeled the concentrations of nitrogen dioxide, a strong sign of traffic-related air pollution, using satellite imagery combined with environmental ground monitoring data.</p>
<p>We then took data extracted <a href="https://doi.org/10.3109/02770903.2011.637594">from surveys by the Centers for Disease Control and Prevention</a>, estimating childhood asthma incidence in the U.S. Alongside data from our air pollution models, we used these data to estimate the number of childhood asthma cases caused by exposure to traffic pollution. </p>
<p>We then created a first-of-its-kind, <a href="https://carteehdata.org/library/webapp/trap-asthma-usa">county-by-county interactive heat map and city-by-city table</a> detailing the distribution of childhood asthma due to nitrogen dioxide across the U.S. in both 2000 and 2010. Each county is represented, and users can explore the data to see the findings for a particular county. </p>
<p><iframe id="tc-infographic-383" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/383/231cc977a0a7b70aad241d8beb0a5d097c37f667/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>A win for public health</h2>
<p>Our analysis found that childhood asthma cases attributable to traffic pollution across the U.S. decreased, on average, by 33% between 2000 and 2010. In 2000, we estimated that 209,100 childhood asthma cases could be attributed to traffic pollution, while this number dropped to 141,900 cases in 2010. That’s a major win for public health. </p>
<p>What caused the decline in traffic-related asthma cases? There may be multiple causes, including more fuel-efficient vehicles, <a href="https://blogs.lse.ac.uk/usappblog/2019/03/02/us-factories-are-polluting-less-but-regulation-rollbacks-threaten-air-quality/">more stringent regulation</a> on <a href="https://gispub.epa.gov/air/trendsreport/2018/#naaqs_trends">nitrogen oxide emissions</a> and, potentially, reductions in total vehicle miles traveled <a href="https://dx.doi.org/10.1289%2Fehp.1409567">due to the recession</a>.</p>
<p>Despite this encouraging decrease in air pollution and its associated health burden, there were 141,900 childhood asthma cases due to traffic-related air pollution in the U.S. That’s 18% of all childhood asthma cases. </p>
<p>Moreover, we found that children living in urban areas had twice the percentage of asthma cases attributable to nitrogen dioxide exposures as compared to children living in rural areas.</p>
<p>Our estimates underline an urgent need to reduce children’s exposure to air pollution. We hope that our analyses and heat maps will better inform policymakers, transportation agencies, medical associations and anyone else interested in learning more about the burden of childhood asthma due to air pollution.</p><img src="https://counter.theconversation.com/content/115202/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Haneen Khreis receives funding from the U.S. Department of Transportation's University Transportation Center. She is also affiliated with The Barcelona Institute for Global Health. </span></em></p>Childhood asthma cases caused by traffic pollution are on the decline. But children in some parts of the country are faring better than others.Haneen Khreis, Assistant Research Professor, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1121252019-03-26T22:34:28Z2019-03-26T22:34:28ZA new drug promises to lower risks of asthma attack<figure><img src="https://images.theconversation.com/files/265940/original/file-20190326-36267-183atex.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research published in Science Translational Medicine in February 2019 used a virtual patient to test the drug, Fevipiprant.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>A <a href="http://stm.sciencemag.org/content/11/479/eaao6451">recent study</a> shows that a gamechanger drug called Fevipiprant <a href="https://www.theguardian.com/society/2016/aug/06/fevipiprant-asthma-drug-trial-treatment">promises to lower patients’ risks of suffering an asthma attack and being admitted to a hospital</a>. </p>
<p>This is the <a href="https://www.eurekalert.org/pub_releases/2019-02/uol-apt021119.php">first time a drug reducing airway smooth muscle mass</a> — a key clinical indicator of disease severity that increases the likelihood of more frequent asthma attacks and even deaths — has been reported.</p>
<p>Along with <a href="https://www.sheffield.ac.uk/dcs/people/academic/rsmallwood">Rod Smallwood,</a> fellow of the British Royal Academy of Engineering, I developed computer models that allowed us to simulate results from a <a href="https://doi.org/10.1016/S2213-2600(16)30179-5">Phase 2 clinical trial</a> — to predict therapy outcomes in patients.</p>
<p>The original trial was led by <a href="https://www2.le.ac.uk/departments/iii/people/brightling">Christopher Brightling</a>, clinical professor in respiratory medicine at the University of Leicester and the principal co-ordinator of the European Lung Foundation <a href="https://www.europeanlung.org/en/projects-and-research/projects/airprom/home">AirPROM</a>. </p>
<h2>Asthma is increasingly common</h2>
<p>Asthma affects around 339 million people worldwide, killing as many as 1,000 people every day, according to the <a href="http://www.globalasthmareport.org/Global%20Asthma%20Report%202018.pdf">Global Asthma Report 2018</a>. </p>
<p>The prevalence of asthma is on the rise, with low- and middle-income countries suffering most — in part, because essential medicines are unavailable, unaffordable or are of unreliable quality.</p>
<p>Asthma is caused by complex set of interactions between a patient’s genes, cells and environment that lead to an increase in airway smooth muscle mass: a process referred to as “remodelling.”</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/265935/original/file-20190326-36256-1ha1vsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/265935/original/file-20190326-36256-1ha1vsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/265935/original/file-20190326-36256-1ha1vsh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/265935/original/file-20190326-36256-1ha1vsh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/265935/original/file-20190326-36256-1ha1vsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/265935/original/file-20190326-36256-1ha1vsh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/265935/original/file-20190326-36256-1ha1vsh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man wears a health mask on the skytrain in Bangkok, Thailand, in February 2019, to guard against air and dust pollution.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Our airways are composed of <a href="http://stm.sciencemag.org/content/11/479/eaao6451.full">several different cell types</a> that exist together in a highly ordered state. The airway lumen is lined by epithelial cells and, further inside, the mesenchyme. The latter contains muscle cells that increase in mass during asthma. Another crucial feature of the airway are the inflammatory cells that are recruited in the event of a foreign challenge (such as an allergen or virus).</p>
<p>In health, these three elements work in harmony to ensure effective airflow and appropriate response to external challenges. In asthma, these harmonic interactions are compromised, resulting in increased muscle mass.</p>
<p>Developing a sound strategy to treat asthma requires a precise understanding of the factors that contribute to the emergence of the disease. We cannot achieve this through experimentation alone because so many factors contribute to the disease. With mathematical models, we can use hypotheses to help reduce the complexity of the system. </p>
<h2>We made a ‘virtual patient’</h2>
<p>In the clinical trial, Fevipiprant was observed to <a href="https://doi.org/10.1016/S2213-2600(16)30179-5">reduce the number of inflammatory cells</a> and muscle mass. </p>
<p>To understand how, <a href="https://leicester.figshare.com/articles/Clinical_level_agent-based_model_of_pathological_airway_remodeling_in_asthma/7610933">I developed a mathematical model</a> that combined the epithelial, mesenchymal and inflammatory elements — to understand what is responsible for airway remodelling during asthma. </p>
<p>I used something called <a href="https://doi.org/10.1093/bib/bbt077">“agent-based modeling”</a> — a mathematical approach that relies on rule-sets governing interactions between various model elements.</p>
<p>I developed a “virtual patient” with severe asthma and gave them virtual drugs. I made sure that the model was capturing biological reality by first administering virtual Mepolizumab, which killed inflammatory cells in the airways. The virtual patient performance was <a href="https://doi.org/10.1164/rccm.200208-789OC">consistent with clinical results</a>. </p>
<p>I then gave the virtual patient Fevipiprant. While it showed the same amount of reduction in inflammatory cells as the clinical trial, it failed to show the same amount of reduction in muscle mass as observed clinically.</p>
<p>This led to the conclusion that Fevipiprant acted not by reducing the inflammation alone, but by also directly impacting muscle mass. Experiments conducted by <a href="https://www2.le.ac.uk/departments/iii/existing-staff-and-students/researcher-forum/biographies/dr-ruth-saunders">Ruth Saunders</a> at the University of Leicester, with muscle cells taken from patients suggested that Fevipiprant reduced the recruitment of cells called myofibroblasts, which add to muscle mass during remodelling. </p>
<p>When this secondary feature was added to the model, the observed reduction in the muscle mass of the virtual patient was consistent with clinical data.</p>
<h2>Reduced dependence on steroids</h2>
<p>Fevipiprant could be a potential therapy to improve airway remodelling in asthma. </p>
<p>Using this drug could allow patients to reduce their dependence on high-dose steroids, whose side-effects include weight gain, diabetes and high blood pressure. </p>
<p>Secondly, the “virtual patient” can play a role in drug design and optimization, potentially lowering drug-development costs. </p>
<p>While this does need more testing with other therapies, it is a milestone in patient-specific models and promises a new era of precision within respiratory medicine.</p><img src="https://counter.theconversation.com/content/112125/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The research discussed in this article was funded by Airway Disease Predicting Outcomes through Patient Specific Computational Modelling (AirPROM) via the Seventh European Union Framework, the National Institute for Health Research (NIHR) Leicester Biomedical Research Centre and the Swiss pharmaceutical company, Novartis.</span></em></p>Asthma affects around 339 million people worldwide. A new drug promises to lower risks of asthma attack and may eventually allow patients to reduce their dependence on steroids.Himanshu Kaul, Postdoctoral Fellow, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/995122018-08-10T02:07:43Z2018-08-10T02:07:43ZA strong immune system helps ward off colds and flus, but it’s not the only factor<figure><img src="https://images.theconversation.com/files/231212/original/file-20180809-30446-72yohm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Winter bugs are impossible to escape.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-holding-handle-on-train-taiwan-1135859891?src=uZJW9VVKeaZjAFi8ngnyoQ-2-53">Shutterstock</a></span></figcaption></figure><p>It’s peak flu season. You’re cold, rugged up and squashed on public transport or in the lift at work. You hear a hacking cough, or feel the droplets of a sneeze land on your neck. Will this turn into your third cold this year?</p>
<p>No matter how much we try to minimise our exposure to respiratory viruses, it’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5187459/">far more difficult</a> in winter when we spend so much time in close proximity to other people. </p>
<p>On top of this, viruses tend to be more stable in colder and drier conditions, which means they <a href="https://www.nih.gov/news-events/nih-research-matters/flu-virus-fortified-colder-weather">stick around longer</a>. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-how-long-should-you-stay-away-when-you-have-a-cold-or-the-flu-98702">Health Check: how long should you stay away when you have a cold or the flu?</a>
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<p>The common cold is caused by more than <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/colds">200 different viruses</a>, the most common of which are rhinoviruses (rhino meaning nose). Rhinovirus infections tend to be mild; you might get a sore throat and a head cold lasting just a few days. </p>
<p>Influenza, or the flu, is generally caused by type A or B <a href="https://www.webmd.com/cold-and-flu/advanced-reading-types-of-flu-viruses">influenza viruses</a>. The flu is far more aggressive and often includes a fever, fatigue and body aches, in addition to all the classic cold symptoms. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231207/original/file-20180809-30476-1pivwfn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231207/original/file-20180809-30476-1pivwfn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=379&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231207/original/file-20180809-30476-1pivwfn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=379&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231207/original/file-20180809-30476-1pivwfn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=379&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231207/original/file-20180809-30476-1pivwfn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=477&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231207/original/file-20180809-30476-1pivwfn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=477&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231207/original/file-20180809-30476-1pivwfn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=477&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The flu tends to be more severe than the common cold.</span>
<span class="attribution"><a class="source" href="https://www.healthdirect.gov.au/cold-or-flu-infographic">healthdirect</a></span>
</figcaption>
</figure>
<p>When it comes to getting sick, there’s always an element of bad luck involved. And some people, particularly those with young children or public transport commuters, are likely to come into contact with more viruses. </p>
<p>But you may have noticed that illness often strikes when you’re stressed at work, not sleeping properly, or you’ve been out partying a little too much. The health of our immune system plays an important role in determining how we can defend against invading cold and flu viruses.</p>
<h2>How the immune system fights viruses</h2>
<p>Your skin and saliva are key barriers to infection and form part of your immune system, along with cells in every tissue of your body, including your blood and your brain. </p>
<p>Some of these cells migrate around to fight infection at specific sites, such as a wound graze. Other cells reside in one tissue and regulate your body’s natural state of health by monitoring and helping with the healing process.</p>
<p>The cells that make up your immune system need energy too, and when you’re low on juice, they’ll be on low-battery mode. This is when our natural immune defences are weakened and normally innocuous bugs can begin to cause strife. </p>
<p>Our immune system requires a lot of energy to defend our bodies. Feeling tired and achy, overheating, and glands swelling are all signs that our immune system is busy fighting something.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-how-does-the-immune-system-work-27163">Explainer: how does the immune system work?</a>
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</em>
</p>
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<h2>Boosting our natural defence system</h2>
<p>Our immune system has evolved to naturally detect and eliminate viral infections. And we can actively <a href="https://www.health.harvard.edu/staying-healthy/how-to-boost-your-immune-system">strengthen our immunity and natural defences</a> by looking after ourselves. This means:</p>
<ul>
<li><p>getting adequate sleep. Sleep deprivation <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132857/">increases the hormone cortisol</a>, which suppresses immune function when its levels are elevated</p></li>
<li><p>exercising, which <a href="https://medlineplus.gov/ency/article/007165.htm">helps the lymphatic system</a>, where our immune cells circulate, and lowers levels of stress hormones </p></li>
<li><p>eating well and drinking enough water. Your immune system needs energy and nutrients obtainable from food. And staying well hydrated helps the body to flush out toxins</p></li>
</ul>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231242/original/file-20180809-30458-qhpcs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231242/original/file-20180809-30458-qhpcs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231242/original/file-20180809-30458-qhpcs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231242/original/file-20180809-30458-qhpcs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231242/original/file-20180809-30458-qhpcs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231242/original/file-20180809-30458-qhpcs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231242/original/file-20180809-30458-qhpcs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Good food feeds your immune system.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/IGfIGP5ONV0">Anna Pelzer</a></span>
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<ul>
<li>not smoking. Smoking, or even secondary smoke, damages our lungs and increases the vulnerability of our respiratory system to infection.</li>
</ul>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-should-i-take-vitamin-c-or-other-supplements-for-my-cold-98309">Health Check: should I take vitamin C or other supplements for my cold?</a>
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<h2>Educating our immune system</h2>
<p>Natural defences aren’t always enough to keep us safe and we need the help of flu vaccinations.</p>
<p>Vaccines are designed to educate an army of B and T cells which make up your adaptive immune system. This arm of your immune system learns by exposure and provides long-term immunity. </p>
<p>These T and B cells need a bit of time from the initial influenza exposure before they can be activated. This activation lag time is when you feel the brunt of the flu infection: lethargy, body aches, extreme fatigue and unable to get off the couch for a day or two. </p>
<p>To overcome this delay and protect people before they are exposed to potentially harmful flu strains, flu vaccination introduces fragments of the influenza virus into the body, which acts like prior exposure to the bug (without actual infection).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231241/original/file-20180809-30458-wgcdo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231241/original/file-20180809-30458-wgcdo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231241/original/file-20180809-30458-wgcdo7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231241/original/file-20180809-30458-wgcdo7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231241/original/file-20180809-30458-wgcdo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231241/original/file-20180809-30458-wgcdo7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231241/original/file-20180809-30458-wgcdo7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">You can still get the flu if you’ve been vaccinated but you might not get as sick.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/caring-man-made-tea-cute-sick-1151493122?src=T6GHODDflT-C25W6avSXHA-1-99">VGstockstudio/Shutterstock</a></span>
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<p>Seasonal vaccines are designed to match currently circulating strains and target those strains before you’re infected. </p>
<p>You can still catch the influenza virus if you are vaccinated. But because of this pre-education, the symptoms will likely be milder. The immune system has been trained and the army of B and T cells can move into action quicker. </p>
<h2>Already have a cold or the flu?</h2>
<p>If you’ve been sniffling and sneezing your way through winter, be comforted by the fact that these bugs are strengthening your immune system. Our body remembers the particular strain of rhinovirus or influenza we get, so it can recognise and mount a stronger defence if we encounter it again. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-whats-new-about-the-2018-flu-vaccines-and-who-should-get-one-94514">Explainer: what's new about the 2018 flu vaccines, and who should get one?</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/99512/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Illness often strikes when you’re stressed at work, not sleeping properly, or you’ve been out partying a little too much. Here’s why.Hui-Fern Koay, Research Fellow in Immunology, The University of MelbourneJesseka Chadderton, PhD Candidate, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.