El Niño and climate change—contributing factors in the dispersal of Zika virus in the Americas? In their letter, Isaac I Bogoch and colleagues (Jan 23, p 335) 1 anticipated the international spread of Zika virus from Brazil through air traffic. Permissive climatic conditions for Aedes mosquitoes might have contributed to the explosive spread of Zika virus in Brazil. In fact, the 2015 El Niño caused exceptional climatic conditions in northeastern South America during winter and spring in the southern hemisphere. According to the US National Oceanic and Atmospheric Administration,2 the temperatures over north and eastern South America were “record warmest”, accompanied by a severe drought, throughout the second half of 2015. These extreme conditions might also be a manifestation of climate change that have contributed to the rapid dispersal of the Zika virus. A striking overlap emerges when regions with extreme climatic conditions in one month are juxtaposed to the geographic distribution of Zika virus in the subsequent month (appendix). 3–5 Temperature is known to have a role in adult vector survival, viral replication, and infective periods. Elevated temperatures (within a temperature envelope) can expand the geographic vector range, decrease the extrinsic incubation period of the pathogen, and increase the female mosquito biting rate.6 Although precipitation provides essential habitat for larvae during the aquatic stages of the Aedes lifecycle, drought can indirectly expand the vector’s range. In several locations (including northeastern Brazil), the risk of range expansion of Aedes aegypti is correlated with an increase in water storage in household containers during a persistent regional drought.7 Thus, the unique climatic conditions created www.thelancet.com Vol 387 February 20, 2016
during this severe El Niño event should be considered contributing factors in the dispersal of Zika virus in the Americas and should also be considered as the virus continues to spread. We declare no competing interests.
*Shlomit Paz, Jan C Semenza [email protected] Department of Geography and Environmental Studies, University of Haifa, Mt Carmel, Haifa, 3498838, Israel (SP); and Stockholm Environmental Institute, Stockholm, Sweden (JCS) 1
2
3
4
5
6
7
Bogoch II, Brady OJ, Kraemer MU, et al. Anticipating the international spread of Zika virus from Brazil. Lancet 2016; 387: 335–36. National Oceanic and Atmospheric Administration. Global analysis—annual 2015. https://www.ncdc.noaa.gov/sotc/ global/201513 (accessed Jan 25, 2016). US National Oceanic and Atmospheric Administration (NOAA), National Centers for Environmental Information. A Land-Ocean temperature percentiles in September 2015. http://www.ncdc.noaa.gov/sotc/service/ global/map-percentile-mntp/201509.gif (accessed Jan 25, 2016). US National Oceanic and Atmospheric Administration (NOAA), National Centers for Environmental Information. Land only precipitation anomalies of September 2015, with respect to a 1961–1990 base period. http://www.ncdc.noaa.gov/sotc/service/global/ map-prcp/201509.gif (accessed Jan 25, 2016). European Center for Disease Prevention and Control (ECDC). Epidemiological update: Outbreaks of Zika virus and complications potentially linked to the Zika virus infection. Figure 1. States with laboratory-confirmed cases Zika virus disease, Brazil, 2015, as of 23 November 2015. Last update: 18 Dec 2015. http://ecdc.europa.eu/en/press/news/_ layouts/forms/News_DispForm. aspx?ID=1342&List=8db7286c-fe2d-476c9133-18ff4cb1b568&Source=http%3A%2F%2 Fecdc%2Eeuropa%2Eeu%2Fen%2Fhealthtopic s%2Fzika_virus_infection%2Fpages%2Findex %2Easpx (accessed Jan 31, 2016). Morin CW, Comrie AC, Ernst K. Climate and dengue transmission: evidence and implications. Environ Health Perspect 2013; 121: 1264–72. Pontes RJ, Freeman J, Oliveira-Lima JW, Hodgson JC, Spielman A. Vector densities that potentiate dengue outbreaks in a Brazilian city. Am J Trop Med Hyg 2000; 62: 378–83.
Do not forget the orphan children of Syria As Syria’s humanitarian plight begins its sixth year in March, 2016, nearly 1 million children have been estimated to have become orphans after losing their parents. 1 Many orphan children are living in Syria,
but many more children have fled the country, and are psychologically affected by their situation in addition to other injuries they might have. To make matters worse, many orphan children in the bordering refugee countries have been sent out to work, mostly in unsafe types of child labour, to help in surviving.2 The orphan children of Syria are at high risk of developing mental health disorders due to traumatic experiences, adjustment difficulties, and loss. 3 Findings of epidemiological studies suggest that displaced and war-affected populations have high rates of mental disorders, especially post-traumatic stress disorder and major depressive disorder.4 Psychiatric morbidity does not simply resolve with relocation to a stable living environment.4 In view of these serious considerations, mental health interventions on all levels are necessary to reduce the morbidity and mortality associated with mental illness in this special, high-risk population. The Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergency Settings 5 is an excellent resource that helps guide humanitarian actors in addressing the mental health needs during a humanitarian crisis. This approach includes the provision of basic services, security, family or community support, and both nonspecialised and specialised mental health services. The cooperation of international agencies, medical relief associations, and humanitarian organisations will be necessary. Many of the agencies working in the region already have existing mental health programmes, so the development of an inter-agency mental health committee is a practical, vital step to address the mental health needs of orphan children and other high-risk populations. The first step of such a committee would be to complete needs assessments and determine the
Sinclair Stammers/Science Photo Library
Correspondence
Published Online February 1, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)00256-7
See Online for appendix
See Editorial page 717 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
745
Correspondence
available resources of its members. Systems and networks can then be planned and developed to allow for the coordination of efforts to achieve the best possible service and resource delivery. The establishment of a telepsychiatry clinic in northern Syria by a team of Canadian doctors providing psychiatric care through the internet to Syrian patients is an example of this successful approach.6 Inter-agency collaboration, planning, and robust methodology has made a difference. The time is now. The world has an ethical obligation not to leave these innocent children behind. We declare no competing interests.
*Humam Saltaji, Saleem Al-Nuaimi [email protected] Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 1C9, Canada (HS); Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada (SA-N); and The Union of Syrian Medical Relief Organizations in Canada (UOSSM-Canada), Edmonton, AB, Canada (SA-N) 1
2
3 For the Istanbul Protocol see http://www.ohchr.org/ Documents/Publications/ training8Rev1en.pdf
4
5
6
746
Fagge N. “They beat their father, poured petrol over him and set him alight. He screamed at them to run away but the soldiers made them watch”: the terrifying plight of the orphans of the Syrian civil war. Mail Online Sept 14, 2015. http://www.dailymail.co.uk/ news/article-3233620/They-beat-fatherpoured-petrol-set-alight-screamed-run-awaysoldiers-watch-terrifying-plight-orphansSyrian-civil-war.html#ixzz3tNSUBaW9 (accessed Jan 1, 2016). The Guardian. Syrian refugee children in Lebanon forced to seek work—in pictures. The Guardian June 12, 2014. http://www. theguardian.com/global-development/2014/ jun/12/-sp-syrian-refugee-children-inlebanon-forced-to-seek-work-in-pictures (accessed Jan 1, 2016). International Medical Corps. Ongoing war creates invisible mental health crisis for Syrian people. March 16, 2015. https:// internationalmedicalcorps.org/pressrelease/2015_03_16-syria-mental-healthreport-release (accessed Jan 1, 2016). Steel Z, Silove D, Phan T, Bauman A. Longterm effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study. Lancet 2002; 360: 1056–62. Inter-Agency Standing Committee. IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: InterAgency Standing Committee, 2007. CBC News. Edmonton doctor helps Syrians in online psychiatric sessions. CBC News July 7, 2014. http://www.cbc.ca/news/canada/ edmonton/edmonton-doctor-helps-syrians-inonline-psychiatric-sessions-1.2698236 (accessed Jan 25, 2016).
Assessment of sequelae of torture for refugees in host countries Millions of refugees trying to escape destabilised countries are often described in the public as a threat or at least a challenge for integration, which distracts attention from the reasons why these populations leave their homes and occupations in the first place. Help in host countries focuses mainly on primary medical, psychosocial, and economic crisis interventions. However, a big, yet largely neglected, problem in the region is the exposure of many refugees from Syria, Iraq, and Afghanistan not only to war experiences but also to torture. Already before these wars, torture was a common practice in some police stations, prisons, and other places of detention of present and past regimes.1,2 Amnesty International and other international human rights organisations have reported severe acts of mistreatment in the present situation, and helpers have reported injuries caused allegedly by police or other representatives of authorities in transit countries.3,4 Besides the obvious and immediate needs addressed by refugee-care interventions in host countries, the early recognition, documentation, and investigation of torture and degrading treatment is demanded and guided by international standards, especially by the Istanbul Protocol. 5 The Istanbul Protocol is an interdisciplinary medicolegal standard supported by the UN and international health-care umbrella organisations, including the World Medical Association and the World Psychiatric Association, that guides the examination and interviews of alleged torture survivors to be sensitive to both trauma and culture. Documentation with the Istanbul Protocol serves several important purposes. First,
asylum procedures need to address sequelae of torture as evidence and respect trauma-related distress, but impairment in concentration and memory during interviews due to factors such as post-traumatic spectrum disorders should also be taken into account.6 Second, justice in national or international courts, international monitoring, and interventions against human rights abuse requires solid evidence that usually is not readily available in countries with civil war or widespread repression. Finally, adequate early recognition, support, protection, and treatment of survivors of torture and similar atrocities does provide relief but these are also some of the first indispensable steps for successful recovery and, where feasible, integration. Documentation based on the Istanbul Protocol should receive special attention in host countries involved in the present special situation. We declare no competing interests.
*Thomas Wenzel, Siroos Mirzaei, Manfred Nowak [email protected] Medical University, 1090 Vienna, Austria (TW); Wilhelminenspital, Vienna, Austria (SM); Hemayat, Vienna, Austria (SM); Boltzmann Institute for Human Rights, Vienna, Austria (MN); and University of Vienna, Vienna, Austria (MN) 1
2
3
4
5
6
Al-Saffar S. Integrating rehabilition of torture victims into the public health of Iraq. Torture 2007; 17: 156–68. Moisander PA, Edston E. Torture and its sequel—a comparison between victims from six countries. Forensic Sci Int 2003; 137: 133–40. Amnesty International. Syria: harrowing torture, summary killings in secret ISIS detention centres. Dec 19, 2013. https://www. amnesty.org/en/latest/news/2013/12/syriaharrowing-torture-summary-killings-secretisis-detention-centres/ (accessed Jan 21, 2016). Amnesty International. Balkans: refugees and migrants beaten by police, left in legal limbo and failed by EU. July 7, 2015. https://www. amnesty.org/en/latest/news/2015/07/ balkans-refugees-and-migrants-beaten-bypolice/ (accessed Jan 21, 2016). den Otter JJ, Smit Y, dela Cruz LB, Ozkalipci O, Oral R. Documentation of torture and cruel, inhuman or degrading treatment of children: a review of existing guidelines and tools. Forensic Sci Int 2013; 224: 27–32. Wenzel T. Torture. Curr Opin Psychiatry 2007; 20: 491–96.
www.thelancet.com Vol 387 February 20, 2016
during this severe El Niño event should be considered contributing factors in the dispersal of Zika virus in the Americas and should also be considered as the virus continues to spread. We declare no competing interests.
*Shlomit Paz, Jan C Semenza [email protected] Department of Geography and Environmental Studies, University of Haifa, Mt Carmel, Haifa, 3498838, Israel (SP); and Stockholm Environmental Institute, Stockholm, Sweden (JCS) 1
2
3
4
5
6
7
Bogoch II, Brady OJ, Kraemer MU, et al. Anticipating the international spread of Zika virus from Brazil. Lancet 2016; 387: 335–36. National Oceanic and Atmospheric Administration. Global analysis—annual 2015. https://www.ncdc.noaa.gov/sotc/ global/201513 (accessed Jan 25, 2016). US National Oceanic and Atmospheric Administration (NOAA), National Centers for Environmental Information. A Land-Ocean temperature percentiles in September 2015. http://www.ncdc.noaa.gov/sotc/service/ global/map-percentile-mntp/201509.gif (accessed Jan 25, 2016). US National Oceanic and Atmospheric Administration (NOAA), National Centers for Environmental Information. Land only precipitation anomalies of September 2015, with respect to a 1961–1990 base period. http://www.ncdc.noaa.gov/sotc/service/global/ map-prcp/201509.gif (accessed Jan 25, 2016). European Center for Disease Prevention and Control (ECDC). Epidemiological update: Outbreaks of Zika virus and complications potentially linked to the Zika virus infection. Figure 1. States with laboratory-confirmed cases Zika virus disease, Brazil, 2015, as of 23 November 2015. Last update: 18 Dec 2015. http://ecdc.europa.eu/en/press/news/_ layouts/forms/News_DispForm. aspx?ID=1342&List=8db7286c-fe2d-476c9133-18ff4cb1b568&Source=http%3A%2F%2 Fecdc%2Eeuropa%2Eeu%2Fen%2Fhealthtopic s%2Fzika_virus_infection%2Fpages%2Findex %2Easpx (accessed Jan 31, 2016). Morin CW, Comrie AC, Ernst K. Climate and dengue transmission: evidence and implications. Environ Health Perspect 2013; 121: 1264–72. Pontes RJ, Freeman J, Oliveira-Lima JW, Hodgson JC, Spielman A. Vector densities that potentiate dengue outbreaks in a Brazilian city. Am J Trop Med Hyg 2000; 62: 378–83.
Do not forget the orphan children of Syria As Syria’s humanitarian plight begins its sixth year in March, 2016, nearly 1 million children have been estimated to have become orphans after losing their parents. 1 Many orphan children are living in Syria,
but many more children have fled the country, and are psychologically affected by their situation in addition to other injuries they might have. To make matters worse, many orphan children in the bordering refugee countries have been sent out to work, mostly in unsafe types of child labour, to help in surviving.2 The orphan children of Syria are at high risk of developing mental health disorders due to traumatic experiences, adjustment difficulties, and loss. 3 Findings of epidemiological studies suggest that displaced and war-affected populations have high rates of mental disorders, especially post-traumatic stress disorder and major depressive disorder.4 Psychiatric morbidity does not simply resolve with relocation to a stable living environment.4 In view of these serious considerations, mental health interventions on all levels are necessary to reduce the morbidity and mortality associated with mental illness in this special, high-risk population. The Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergency Settings 5 is an excellent resource that helps guide humanitarian actors in addressing the mental health needs during a humanitarian crisis. This approach includes the provision of basic services, security, family or community support, and both nonspecialised and specialised mental health services. The cooperation of international agencies, medical relief associations, and humanitarian organisations will be necessary. Many of the agencies working in the region already have existing mental health programmes, so the development of an inter-agency mental health committee is a practical, vital step to address the mental health needs of orphan children and other high-risk populations. The first step of such a committee would be to complete needs assessments and determine the
Sinclair Stammers/Science Photo Library
Correspondence
Published Online February 1, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)00256-7
See Online for appendix
See Editorial page 717 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
745
Correspondence
available resources of its members. Systems and networks can then be planned and developed to allow for the coordination of efforts to achieve the best possible service and resource delivery. The establishment of a telepsychiatry clinic in northern Syria by a team of Canadian doctors providing psychiatric care through the internet to Syrian patients is an example of this successful approach.6 Inter-agency collaboration, planning, and robust methodology has made a difference. The time is now. The world has an ethical obligation not to leave these innocent children behind. We declare no competing interests.
*Humam Saltaji, Saleem Al-Nuaimi [email protected] Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 1C9, Canada (HS); Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada (SA-N); and The Union of Syrian Medical Relief Organizations in Canada (UOSSM-Canada), Edmonton, AB, Canada (SA-N) 1
2
3 For the Istanbul Protocol see http://www.ohchr.org/ Documents/Publications/ training8Rev1en.pdf
4
5
6
746
Fagge N. “They beat their father, poured petrol over him and set him alight. He screamed at them to run away but the soldiers made them watch”: the terrifying plight of the orphans of the Syrian civil war. Mail Online Sept 14, 2015. http://www.dailymail.co.uk/ news/article-3233620/They-beat-fatherpoured-petrol-set-alight-screamed-run-awaysoldiers-watch-terrifying-plight-orphansSyrian-civil-war.html#ixzz3tNSUBaW9 (accessed Jan 1, 2016). The Guardian. Syrian refugee children in Lebanon forced to seek work—in pictures. The Guardian June 12, 2014. http://www. theguardian.com/global-development/2014/ jun/12/-sp-syrian-refugee-children-inlebanon-forced-to-seek-work-in-pictures (accessed Jan 1, 2016). International Medical Corps. Ongoing war creates invisible mental health crisis for Syrian people. March 16, 2015. https:// internationalmedicalcorps.org/pressrelease/2015_03_16-syria-mental-healthreport-release (accessed Jan 1, 2016). Steel Z, Silove D, Phan T, Bauman A. Longterm effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study. Lancet 2002; 360: 1056–62. Inter-Agency Standing Committee. IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: InterAgency Standing Committee, 2007. CBC News. Edmonton doctor helps Syrians in online psychiatric sessions. CBC News July 7, 2014. http://www.cbc.ca/news/canada/ edmonton/edmonton-doctor-helps-syrians-inonline-psychiatric-sessions-1.2698236 (accessed Jan 25, 2016).
Assessment of sequelae of torture for refugees in host countries Millions of refugees trying to escape destabilised countries are often described in the public as a threat or at least a challenge for integration, which distracts attention from the reasons why these populations leave their homes and occupations in the first place. Help in host countries focuses mainly on primary medical, psychosocial, and economic crisis interventions. However, a big, yet largely neglected, problem in the region is the exposure of many refugees from Syria, Iraq, and Afghanistan not only to war experiences but also to torture. Already before these wars, torture was a common practice in some police stations, prisons, and other places of detention of present and past regimes.1,2 Amnesty International and other international human rights organisations have reported severe acts of mistreatment in the present situation, and helpers have reported injuries caused allegedly by police or other representatives of authorities in transit countries.3,4 Besides the obvious and immediate needs addressed by refugee-care interventions in host countries, the early recognition, documentation, and investigation of torture and degrading treatment is demanded and guided by international standards, especially by the Istanbul Protocol. 5 The Istanbul Protocol is an interdisciplinary medicolegal standard supported by the UN and international health-care umbrella organisations, including the World Medical Association and the World Psychiatric Association, that guides the examination and interviews of alleged torture survivors to be sensitive to both trauma and culture. Documentation with the Istanbul Protocol serves several important purposes. First,
asylum procedures need to address sequelae of torture as evidence and respect trauma-related distress, but impairment in concentration and memory during interviews due to factors such as post-traumatic spectrum disorders should also be taken into account.6 Second, justice in national or international courts, international monitoring, and interventions against human rights abuse requires solid evidence that usually is not readily available in countries with civil war or widespread repression. Finally, adequate early recognition, support, protection, and treatment of survivors of torture and similar atrocities does provide relief but these are also some of the first indispensable steps for successful recovery and, where feasible, integration. Documentation based on the Istanbul Protocol should receive special attention in host countries involved in the present special situation. We declare no competing interests.
*Thomas Wenzel, Siroos Mirzaei, Manfred Nowak [email protected] Medical University, 1090 Vienna, Austria (TW); Wilhelminenspital, Vienna, Austria (SM); Hemayat, Vienna, Austria (SM); Boltzmann Institute for Human Rights, Vienna, Austria (MN); and University of Vienna, Vienna, Austria (MN) 1
2
3
4
5
6
Al-Saffar S. Integrating rehabilition of torture victims into the public health of Iraq. Torture 2007; 17: 156–68. Moisander PA, Edston E. Torture and its sequel—a comparison between victims from six countries. Forensic Sci Int 2003; 137: 133–40. Amnesty International. Syria: harrowing torture, summary killings in secret ISIS detention centres. Dec 19, 2013. https://www. amnesty.org/en/latest/news/2013/12/syriaharrowing-torture-summary-killings-secretisis-detention-centres/ (accessed Jan 21, 2016). Amnesty International. Balkans: refugees and migrants beaten by police, left in legal limbo and failed by EU. July 7, 2015. https://www. amnesty.org/en/latest/news/2015/07/ balkans-refugees-and-migrants-beaten-bypolice/ (accessed Jan 21, 2016). den Otter JJ, Smit Y, dela Cruz LB, Ozkalipci O, Oral R. Documentation of torture and cruel, inhuman or degrading treatment of children: a review of existing guidelines and tools. Forensic Sci Int 2013; 224: 27–32. Wenzel T. Torture. Curr Opin Psychiatry 2007; 20: 491–96.
www.thelancet.com Vol 387 February 20, 2016
