Tears in Heaven: Religiously and Culturally Sensitive Laws for Preventing the Next Pandemic

In February 2016, the World Health Organization (WHO) declared a “public health emergency of international concern” due to the increased clusters of microcephaly, Guillain-Barré Syndrome, and other neurological disorders in areas affected by the Zika virus. That declaration came in the wake of the West Africa Ebola crisis. Back to back declarations by WHO of the highest threat level for an international public health emergency underscores how quickly pathogens can now spread and cause devastation across borders. It also highlights the need to implement lessons learned from each pandemic crisis without delay. These crises demonstrate that laws to curtail the spread of deadly contagious diseases need to be drafted and implemented in ways to maximize community acceptance. Without prudently crafted laws in place that are as consistent as possible with community mores, threats from deadly diseases may cause anxiety and panic, and governments may react to political and public pressures and mandate rules that may unnecessarily impinge on personal rights and deeply held religious beliefs. Infringing upon ideological or religious beliefs could lead to increased distrust of government and civil disobedience and could also, paradoxically, undermine the goal of preventing the spread of infectious disease. This article focuses on applying to future pandemics a critical lesson from prior crises — the need for public health officials to accommodate religious and cultural practices of the community to more effectively implement emergency measures. Further, the article proposes an interdisciplinary and proactive approach to development of laws and regulations to create a system that is adaptable, acceptable to the community, and scientifically sound

COVID-19 and globalization

The world is experiencing a major pandemic caused by SARS-CoV-2, the Coronavirus causing COVID-19. This disease first entered the human population in Hubei province, China, in mid-November 2019 and manifested in Wuhan, the largest metropolitan area of Hubei, when a cluster of patients were admitted to hospital with a ‘severe pneumonia of unknown cause’ in early December. Although humanity has survived previous pandemics by infectious agents, the present one is unprecedented in its capacity to take advantage of modern globalization allowing for massive transborder spread at a surprising speed. When writing these lines, the pandemic affects 181 countries and territories, with around 1,084,000 infected subjects, more than 58,000 deaths and 225,000 recovered patients, according to the Johns Hopkins University

Whole Genome Characterization of the Mechanisms of Daptomycin Resistance in Clinical and Laboratory Derived Isolates of Staphylococcus aureus

Background: Daptomycin remains one of our last-line anti-staphylococcal agents. This study aims to characterize the genetic evolution to daptomycin resistance in S. aureus. Methods: Whole genome sequencing was performed on a unique collection of isogenic, clinical (21 strains) and laboratory (12 strains) derived strains that had been exposed to daptomycin and developed daptomycin-nonsusceptibility. Electron microscopy (EM) and lipid membrane studies were performed on selected isolates. Results: On average, six coding region mutations were observed across the genome in the clinical daptomycin exposed strains, whereas only two mutations on average were seen in the laboratory exposed pairs. All daptomycin-nonsusceptible strains had a mutation in a phospholipid biosynthesis gene. This included mutations in the previously described mprF gene, but also in other phospholipid biosynthesis genes, including cardiolipin synthase (cls2) and CDP-diacylglycerol-glycerol-3-phosphate 3-phosphatidyltransferase (pgsA). EM and lipid membrane composition analyses on two clinical pairs showed that the daptomycin-nonsusceptible strains had a thicker cell wall and an increase in membrane lysyl-phosphatidylglycerol. Conclusion: Point mutations in genes coding for membrane phospholipids are associated with the development of reduced susceptibility to daptomycin in S. aureus. Mutations in cls2 and pgsA appear to be new genetic mechanisms affecting daptomycin susceptibility in S. aureus

The Intersection of Law, Religion, and Infectious Disease on the Handling and Disposition of Human Remains

The 2014 West Africa Ebola crisis highlights the pressing need for effective laws and procedures governing the handling and disposition of infectious human remains. Existing frameworks, both domestically and internationally, are inconsistent and underdeveloped in ways that jeopardize public health and disregard decedents’ wishes concerning post-mortem disposition, trample on survivors’ quasi-property rights, and conflict with religious beliefs regarding care of the body. These issues become critically important when death results from a highly contagious deadly disease. For example, persons who die of Ebola have very high levels of the Ebola virus on their skin and on any leaked bodily fluids. Thus, when family members come in contact with the body, they can contaminate themselves and others. The World Health Organization noted that certain religious rites in the post-mortem handling of Ebola patients, such as washing, shrouding, and praying over the deceased, directly contributed to a significant number of new Ebola infections in the 2014 outbreak. In addition to its preparation and handling, the final disposition of the body also presents significant concerns. Although cremation may be viewed as an ideal scientific solution for final disposition of Ebola victims, it may violate moral values, cultural practices, and many religious beliefs, and meet significant resistance. When Liberian President Sirleaf decreed that Ebola victims had to be cremated, many in the community viewed the mandate as contrary to religious tenets and, instead, performed secret burials that led to even more infections. Without thoughtful and culturally sensitive laws and procedures in place, governments may, in times of crises, dictate particular methods of handling and disposing of highly contagious human remains that may not be as effective as needed and may unnecessarily infringe upon deeply held religious beliefs. The lack of an effective legal framework should be of serious concern to policymakers in all countries, including the United States. We propose the need for such a framework and provide guidance for decision makers confronting these issues. We suggest that any legal framework educate communities to understand the public health issues and empower them to address these issues in ways that respect religious beliefs. Moreover, in order to be truly effective, we also recommend that any solutions be inherently interdisciplinary and combine legal, medical, moral, humanitarian, and religious elements.https://ecollections.law.fiu.edu/faculty_books/1139/thumbnail.jp

Monkeypox 2022 Identify-Isolate-Inform: A 3I Tool for frontline clinicians for a zoonosis with escalating human community transmission.

Monkeypox 2022, a zoonotic virus similar to smallpox, presented as a rapidly escalating human outbreak with community transmission outside endemic regions of Africa. In just over one month of detection, confirmed cases escalated to over 3300, with reports of patients in at least 43 non-African nations. Mechanisms of transmission in animals and the reservoir host remain uncertain; spread from humans to wild or domestic animals risks the creation of new endemic zones. While initial cases were reported in men who have sex with men (MSM), monkeypox is not considered a sexually transmitted infection. Anyone with close contact with an infected person, aerosolized infectious material (e.g., from shaken bedsheets), or contact with fomites or infected animals is at risk. In humans, monkeypox typically presents with a non-specific prodromal phase followed by a classic rash with an incubation period of 5-21 days (usually 6-13 days). The prodrome may be subclinical, and the monkeypox virus may be transmissible from person-to-person before observed symptom onset. Most clinicians are unfamiliar with monkeypox. Information is rapidly evolving, producing an urgent need for immediate access to clear, concise, fact-based, and actionable information for frontline healthcare workers in prehospital, emergency departments/hospitals, and acute care/sexual transmitted infection clinics. This paper provides a novel Identify-Isolate-Inform (3I) Tool for the early detection and management of patients under investigation for monkeypox 2022. Patients are identified as potentially exposed or infected after an initial assessment of risk factors and signs/symptoms. Management of exposed patients includes consideration of quarantine and post-exposure prophylaxis with a smallpox vaccine. For infectious patients, providers must immediately don personal protective equipment and isolate patients. Healthcare workers must report suspected and confirmed cases in humans or animals to public health authorities. This innovative 3I Tool will assist emergency, primary care, and prehospital clinicians in effectively managing persons with suspected or confirmed monkeypox

Monkeypox 2022: A Primer and Identify-Isolate-Inform (3I) Tool for Emergency Medical Services Professionals.

Monkeypox 2022 exhibits unprecedented human-to-human transmission and presents with different clinical features than those observed in prior outbreaks. Previously endemic only to West and Central Africa, the monkeypox virus spread rapidly world-wide following confirmation of a case in the United Kingdom on May 7, 2022 of an individual that had traveled to Nigeria. Detection of cases with no travel history confirms on-going community spread. Emergency Medical Services (EMS) professionals will likely encounter patients suspected or confirmed to have monkeypox, previously a rare disease and therefore unfamiliar to most clinicians. Consequently, it is critical for EMS medical directors to immediately implement policies and procedures for EMS teams - including emergency medical dispatchers - to identify potential monkeypox cases. These must include direction on actions EMS professionals should take to protect themselves and others from virus transmission. Monkeypox 2022 may manifest more subtly than it has historically. Presentations include a subclinical prodrome and less dramatic skin lesions - potentially limited to genital or anal body regions - which can be easily confused with dermatologic manifestations of common sexually transmitted infections (STIs). While most readily spread by close contact with infectious skin lesions on a patient, it is also transmissible from fomites, such as bed sheets. Additionally, droplet transmission can occur, and the virus can be spread by aerosolization under certain conditions. The long incubation period could have profound negative consequences on EMS staffing if clinicians are exposed to monkeypox. This report summarizes crucial information needed for EMS professionals to understand and manage the monkeypox 2022 outbreak. It presents an innovative Identify-Isolate-Inform (3I) Tool for use by EMS policymakers, educators, and clinicians on the frontlines who may encounter monkeypox patients. Patients are identified as potentially exposed or infected after an initial assessment of risk factors with associated signs and symptoms. Prehospital workers must immediately don personal protective equipment (PPE) and isolate infectious patients. Also, EMS professionals must report exposures to their agency infection control officer and alert health authorities for non-transported patients. Prehospital professionals play a crucial role in emerging and re-emerging infectious disease mitigation. The monkeypox 2022 3I Tool includes knowledge essential for all clinicians, plus specific information to guide critical actions in the prehospital environment

Systematic review of registered trials of Hydroxychloroquine prophylaxis for COVID-19 health-care workers at the first third of 2020

In the absence of a vaccine the medical and scientific community is looking intensely at utilizing a pre or post exposure drug that could decrease viremia. The search for a medication that could reduce risk of serious disease, and ideally of any manifestation of disease from SARS-CoV2, and of asymptomatic shedding of SARS-CoV2 is of urgent interest. Repurposing existing pharmaceuticals is among the approaches to achieve these ends. We performed a systematic review of all interventional studies registered in ClinicalTrials.gov with a focus on one repurposed drug, Hydroxychloroquine (HCQ). The detailed analysis of these studies, some of them already recruiting, provide an overall picture of HCQ use as a COVID-19 prophylaxis around the world. Among the included studies, all but three were randomized and parallel and most of them (74%, 23/31) were double-blinded to quadruple-blinded studies. We found a great diversity in dosing and nearly all the possible scientifically reasonable regimens are under evaluation. This diversity offers benefits as well as challenges. Importantly, the final analysis of these trials should be done through an extensive reading of the results in regard to the clinical design, it will be crucial to carefully read and evaluate the results of each study in regards to the clinical design rather than quickly glancing a 140 characters-based social media message announcing the failure or success of a drug against a disease