Ebola
The Ebola virus causes an acute, serious illness which is often fatal if untreated. Ebola virus disease (EVD) first appeared in 1976 in 2 simultaneous outbreaks, one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name.
The current outbreak in west Africa, (first cases notified in March 2014), is the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 1976. There have been more cases and deaths in this outbreak than all others combined with 15,145 people believed to have been infected, resulting in 5420 deaths (see this month’s cover story for a more detailed timeline).
To date, there have been no confirmed cases in Canada and four in the United States.
Enterovirus D-68
Enterovirus- D68 (EV-D68) is a previously rare enterovirus that can cause mild to severe illness. The virus is spread person-to-person through contact with the respiratory secretions of infected persons.
EV-D68 was first identified in 1962. It has occurred infrequently since that time, although from 2008-2010, the Centers for Disease Control and Prevention reported on six clusters of EV-D68 in the Philippines, Japan, the Netherlands, and three US states (Georgia, Pennsylvania and Arizona). The clusters appeared to be concentrated in the fall. Four of the six outbreaks only reported infected children, one outbreak reported only infected adults and one outbreak involved both adults and children. Patients in these clusters often had new onset or worsening wheezing. Hospitalizations and admissions to intensive care units were noted and three individuals died.
In August 2014, several children’s hospitals in the US reported increases in children hospitalized with severe respiratory illness. EV-D68 was identified in many of these children; notably, 70 per cent of the children had a history of asthma or wheezing.
Since then, over 500 cases in 43 US states and the District of Columbia have been confirmed to have respiratory illness caused by EV-D68. Although not nationally notifiable, cases of EV-D68 were also identified in five Canadian provinces (BC, Alberta, Saskatchewan, Manitoba, and Ontario). More case reports are anticipated as diagnostic testing for EV-D68, which requires sequencing of the virus, is completed on suspect cases.
On September 26, 2014, the US CDC issued a Health Advisory to clinicians reporting a cluster of polio-like illness in nine children (aged 1-18 years) in Colorado. Of the eight tested specimens, six were positive for entero/rhinoviruses, of which four were confirmed as EV-D68, with two typing results pending at the time of report. As part of this advisory, the US CDC requested further information on patients ≤21 years of age presenting with acute onset of focal limb weakness occurring on or after August 1, 2014, and an MRI showing spinal cord lesion largely restricted to grey matter. Since then, clusters of polio-like illness have been cited in some provinces including BC, Ontario and Alberta although information about whether these may have been associated with EV-D68 was still pending.
Right-to-die: Assisted suicide
Following the death of Dr. Donald Low in September 2013, and his post-humus video pleading with Canadians to rethink their views on assisted suicide, end-of-life care was brought out of the shadows .
More recently, Gillian Bennett took her own life to avoid the indignities that come with dementia. She believed it was her right to choose how she would live and die. Not wanting to spend her final years as ‘a vegetable in a hospital unable to handle her own affairs or make decisions regarding her care’ she chose to die on her own terms. Following her death, her thoughts were posted on a website she created: deadatnoon.com to ignite a conversation about death and difficult end-of-life issues.
Currently, assisted suicide in banned in Canada. In June, Quebec joined several US States when it passed the Act Respecting End of Life Care, bypassing the Criminal Code by incorporating medically assisted death into provincial health care legislation. The new law is expected to come into force by the end of 2015 and allows people with a terminal illness that is causing unbearable suffering to ask a physician to administer a lethal dose of medication.
Assisted suicide is an emotionally divisive issue and evokes strong emotions from both sides. It is a debate that has been ongoing for many years, and is likely to continue for many more. With terminally ill patients like Dr. Low, Gillian Bennett and Brittany Maynard (a US woman who chose to end her life before her suffering from brain cancer became unbearable) going public, people are starting to talk about death. Dying with Diginity, a national, member-based charity committed to helping people achieve quality in dying recently commissioned the most comprehensive Canadian survey ever undertaken on the public’s perception of dying with dignity.
According to the survey, most Canadians generally agree with the concept of assisted dying, regardless of how it is specifically defined. Nine in ten (91%) agree that a person should not be forced to endure drawn-out suffering, and a similar proportion (91%) agree that palliative care is not enough. Regarding the statement “A doctor should be able to help someone end their life if the person is a competent adult who is terminally ill, suffering unbearably and repeatedly asks for assistance to die”, 84 per cent agree, while 16 per cent disagree.
In August 2014, Doctors at CMA’s annual meeting voted overwhelmingly for an advisory resolution giving them the right to choose to participate in assisted dying.
In October, the Supreme Court of Canada began hearing an appeal brought by the B.C. Civil Liberties Association that would grant terminally ill Canadians the right to assisted suicide. The Association, along with two British Columbia families, is arguing that the current law violates the rights of terminally ill Canadians. It is expected to take months for the court to render a decision.
‘Choosing Wisely Canada’ Campaign
On April 2nd, nine national medical organizations released lists of 40 tests, treatments and procedures that patients do not need in all circumstances. The lists have been developed to spur dialogue between doctors and their patients and to ensure delivery of high-quality medical care.
The lists are based on definitive evidence that these specific interventions provide no benefit to patients. They are the foundation of Choosing Wisely Canada, a campaign launched to help physicians and patients engage in conversations to make smart and effective choices to ensure high-quality care.
Clear and straightforward materials have been created for both physicians and patients to support decisions on what procedure is required or necessary, and what is not. For example, Choosing Wisely Canada would not recommend the ordering of diagnostic imaging for lower-back pain of less than six weeks duration unless there are red flags.
“Choosing Wisely Canada is about changing the culture that more is always better when it comes to medical tests and procedures,’’ explains Dr. Wendy Levinson, founder of Choosing Wisely Canada, and a faculty member at the University of Toronto. “The goal of this is about providing good care with the right patient getting the right test and treatment and avoiding unnecessary tests and procedures.”
The Canadian Medical Association (CMA) is a lead partner in the campaign, which is focusing on linking best available medical evidence to both physicians and their patients.
“The Choosing Wisely Canada lists and materials being developed are not only a valuable conversation starter, but also a way for patients to get good, useful and trustworthy information,” says Dr. Chris Simpson, CMA President. “Choosing Wisely Canada will empower both physicians and their patients to be true partners in care.”
To date, more than 30 Canadian medical specialty societies are at various stages of engagement in the campaign. All provincial and territorial medical associations have endorsed the campaign. Choosing Wisely Canada is modelled after the successful Choosing Wisely ® campaign in the United States, launched by the American Board of Internal Medicine’s, ABIM Foundation.
For more information and to access campaign material visit www.choosingwiselycanada.org
Medicinal marijuana
On April 1st 2014 new regulations for medical marijuana were to come into effect across Canada that would effectively prohibit people from growing their own marijuana at home and force them to buy their cannabis from new large-scale commercial operations. However, a Federal Court ruling on March 21 changed the legal landscape, at least temporarily, and users licensed for personal production as of Sept. 30, 2013, will be able to keep growing their pot at home pending a future trial.
Under the new Marijuana for Medical Purposes Regulations, doctors will in effect become gatekeepers, determining who can gain access to pot legally. It’s a position most doctors are reluctant to take on.
The Canadian Medical Association’s position is that there is insufficient scientific evidence available to support the use of marijuana for clinical purposes. It also believes there is insufficient evidence on clinical risks and benefits, including the proper dosage of marijuana to be used and on the potential interactions between this drug and other medications. The CMA will continue to urge that Health Canada support development of rigorous research on the effects, both positive and adverse, that the use of marijuana for medical purposes will have.
A trial is expected by March 2015.
Canada needs a national senior care strategy
Nearly all Baby Boom Canadians aged 45 years and over (95 per cent) identify the need for a panCanadian seniors care strategy, according to the Canadian Medical Association’s (CMA) 2014 National Report Card on health issues. Not only are 81 per cent of these Canadians concerned with the quality of health care they can expect in their future, 78 per cent are worried about their ability to access quality home and long-term care in their retirement years, the Ipsos Reid poll found.
Nine out of 10 respondents (91 per cent) agreed a national seniors care strategy would improve the overall health care system. Elderly patients could be cared for at home or in long-term care facilities, alleviating chronic hospital bed shortages that are pushing up wait times for everything from emergency treatment to hip transplants.
Furthermore, this type of infrastructure planning would lend itself to a better use of health care dollars. One day of care for a patient in a hospital remains high at $1, 000. By contrast, one day spent in a long-term care facility costs about $130 and home care $55. The CMA estimates at least $2.3 billion a year could be used in a more effective way in the health care system.
New CMA president Dr. Christopher Simpson, a cardiologist at Kingston General Hospital says gridlocked hospitals around Canada are struggling to make room for incoming arrivals because so many older patients have no other place to go. “Hospitals are increasingly invoking what is known in the medical world as “Code Gridlock” when a hospital reaches or exceeds capacity,” he adds.
Dr. Simpson said Canada needs a national seniors strategy involving all levels of government to develop investment in long-term care infrastructure and home care and community support programs. “As a society, we need to step up investment in long-term care and invest much more in services for home and community care.”
Code Gridlock is fast becoming the new normal in Canadian hospitals as medical staffs are resorting to putting patients in “windowless nooks, crannies and broom closets —anywhere we can squeeze in a stretcher or a bed,” he adds. Dr. Simpson said his own hospital is currently on its 25th consecutive day of gridlock.
“To those outside the medical world, the two words probably won’t be heard over the white noise of a busy hospital. But to everybody else in the building they work like a dog whistle — start freeing up beds immediately. All physicians, nurses and other health care professionals are urged to do whatever they can to expedite discharges. We are warehousing them. We do the best we can. But it’s not anywhere near good enough.”
The ALS Ice Bucket Challenge
In August 2014, a global viral phenomenon was created raising $16.2 million dollars in Canada, through the support of over 260,000 Canadians. This phenomenon is called the ALS Ice Bucket Challenge.
The roots of the ALS Ice Bucket Challenge can be tracked to the Frates Family in Boston. Out of love and a deep need to help their friend, Pete Frates, his colleagues and family came up with a brilliant, simple idea – take ice, water, a bucket, dump and call out social networks and challenge them to do the same or donate to an ALS charity.
The impact of the challenge has transformed the history of ALS. A devastating neurodegenerative disease that currently has no treatment or cure, ALS stands for amyotrophic lateral sclerosis. It is a where the “living wires” which connect a person’s brain to their muscles degenerate, leading to a loss of mobility and eventual paralysis, changes or complete loss of speech and eventually the ability to breathe. Approximately 2,500-3,000 Canadians are living with ALS and it is estimated 1,000 Canadians will die because of ALS and 1,000 will be newly diagnosed each year. The average lifespan is two to five years.
A disease that as of a few months ago was fairly unknown to Canadians is now at the forefront of the global consciousness. ALS is no longer an unknown disease. The awareness translated into action, with hundreds of thousands donating to help change the reality of this disease to being treatable, not terminal.
On November 19, 2014, the ALS Societies across Canada announced the impact this challenge has had on the ALS community and the disease. In total, $10 million from the funds generously given through the ALS Ice bucket challenge will go to ALS research and $6 million to programs to deliver critical support to Canadians living with ALS. And it didn’t stop there. Because of Canadians support, ALS Societies across Canada were able to match 1:1 the research investment through a partnership with Brain Canada, totally $20 million going towards ALS research in Canada.
“We are incredibly grateful for all of the support and awareness for ALS in the last four months as a result of the ALS Ice Bucket Challenge,” says Tammy Moore, CEO, ALS Canada. “We know donors and our community will be pleased that we have demonstrated strong stewardship of the gift we have received, and that, with the matching research funds from Brain Canada the total impact of the ALS Ice Bucket Challenge is $20 million. We want to thank all of our donors and assure you that we understand how important this is to people and their families living with ALS.”
In August of 2014 the world came together to make it a better place and made history towards ALS.