Government approach to filling top national lab job worries scientists

Though most people are in the dark about it, the top job at Canada's National Microbiology Laboratory is vacant. And some of the few who know are deeply concerned about the effort afoot to fill it.

While the laboratory's website still lists him as scientific director, Dr. Frank Plummer quietly ended his nearly 14-year tenure as head of the Winnipeg lab at the end of March. In equally low-key fashion, the federal government posted his position on a government jobs website, giving would-be candidates scant time to submit applications.

Some scientists and public health leaders around the country who are aware of the events are worried about the way the search for Plummer's replacement is unfolding, seeing troubling signs in the job posting itself and the way the government has advertised the position.

Dr. Francis Plummer ended his 14-year tenure as head of the National Microbiology Laboratory in March. Plummer is one of the world's top HIV researchers, and in 2005 he was awarded a Grand Challenges Grant for $8.3 million from the Bill and Melinda Gates Foundation to continue his work. (The Canadian Press)

"To me all the indications are that they're not serious about finding outstanding people," says Dr. Henry Friesen, one of the scientific leaders who is concerned about what will happen to the Winnipeg lab in the post-Plummer era.

The short time frame, the lack of attention drawn to the opening, and the salary scale listed — starting at $132,600 — suggest to Friesen and others that the federal government may not be looking for a top-notch scientist to replace Plummer.

Some fear there may be more interest in selecting a bureaucrat than a scientist.

'Minimalist exposure to science'

In fact, while the posting says bilingualism is imperative, it does not explicitly state that candidates must be experienced scientists. Likewise, applicants do not appear to be required to have published scientific papers — the coin of the realm in the world of science.

Instead, it calls for experience managing the delivery of health-related programs, providing strategic scientific advice and representing an organization nationally and internationally.

The posting does not even demand a doctorate, though it says one would be a benefit. The educational requirement lists either a medical degree or "a degree from a recognized university in a health-related field." Technically that could be a bachelors or a masters level degree, notes Friesen, a former director of the Medical Research Council of Canada and a 1977 winner of a Gairdner award — known as the baby Nobels — for his discovery of the hormone prolactin.

"They're certainly offering a great deal of flexibility to allow whoever chooses to choose individuals with what I would regard as potentially a minimalist exposure to science at any depth," he says.

Dr. Bonnie Henry, interim executive medical director at the British Columbia Centre for Disease Control, shares the concern. "It sounds like you could be a physician or a bureaucrat," she says of the posting.

Despite the fact that the government has known for a while that Plummer's tenure would be up this spring, the job was only posted on the jobs.gc.ca site on April 23, three weeks after his term expired. The posting closes three weeks later, on May 14.

Dr. Henry Friesen was presented with a promotion within the Order of Canada in 2003. Friesen won a Gairdner Award, commonly called the 'baby Nobels,' for his discovery of the hormone prolactin. (Jonathan Hayward/The Canadian Press)

People familiar with the way executive head-hunting works say four weeks is generally a standard posting length. And at least one noted that the fact the posting coincides with the end of the academic year may make it tough for candidates to meet that deadline.

"They have to post it," says an executive search consultant who works extensively in the academic and scientific research field and who asked not to be named.

"But one of the ways to make sure that the good people aren't interested is to post it in a kind of obscure place, with the timelines and stuff that has anybody who is serious and who could seriously be a good candidate saying 'Uh, who wants that anymore?"'

Friesen agrees a search like this cannot be done quickly. "Good people by and large aren't looking for jobs. You've got to go out and hunt them, find them. And all of that takes time."

Another prominent scientist aware of the situation, Dr. Arnold Naimark, suggests the tight timeline might rule out the possibility that key Canadian scientific talent working abroad could be lured home for the job.

And he's not sure that's what the federal government is looking for. "It's not clear to me to what extent they see this job as requiring a scientist leader or established senior scientist in the broader community."

An international reputation

When the national laboratory was relocated to Winnipeg from Ottawa in the late 1990s, an external search committee was set up to find a scientific director with credentials befitting the state-of-the-art facility. Naimark, a former University of Manitoba president who is now director of the centre for advancement of medicine at the university, was a consultant to the search committee.

He and others say the goal at the time was to find a scientist with an international reputation, one who would put the new lab on the map and draw top-tier scientists to Winnipeg. The committee identified Winnipeg native Plummer — a world renown HIV researcher — as that candidate.

Plummer was (and remains) on the faculty of the University of Manitoba, but he had spent most of his career up until then at the university's research project in Nairobi, Kenya. There he identified the role heterosexual sex played in fuelling Africa's AIDS epidemic and that some women — female prostitutes — who were repeatedly exposed to HIV did not become infected.

He agreed to take the lab director job on a secondment from the University of Manitoba, an arrangement worked out so that he could continue his research — which he has done. In 2005 Plummer was awarded a Grand Challenges grant for $8.3 million from the Bill and Melinda Gates Foundation for his HIV research. Over the course of his career he has published more than 360 scientific papers and was recently awarded both the Prix Galien and a Killam Prize.

But at a point Plummer was told the secondment arrangement could not be continued. Plummer, who has had health problems over the past year or so, decided it was time to take on another role. He declined to be interviewed about the search for his successor.

'They're certainly offering a great deal of flexibility to allow whoever chooses to choose individuals with what I would regard as potentially a minimalist exposure to science at any depth.'- Dr. Henry Friesen, University of Manitoba professor emeritus

The press office of the Public Health Agency of Canada said Tuesday that Plummer is now senior adviser to the Agency's deputy head — another key public health job in the federal government that is currently vacant. The previous chief public health officer of Canada, Dr. David Butler Jones, stepped down last year after suffering a stroke in May 2012.

According to the website of Ottawa-based executive search firm Renaud Foster, the search for Butler-Jones' replacement is still underway.

Until Plummer's successor is named the laboratory's executive director, Steve Guercio, has assumed responsibility for day-to-day operations, Sylwia Krzyszton, an agency spokesperson, said via email. Dr. Rainer Engelhardt, an assistant deputy minister for infectious disease prevention and control, has taken on the role of chief science officer, another hat Plummer wore.

Big shoes to fill

Friesen says the fact that Butler-Jones's job hasn't yet been filled might also deter some potential candidates from seeking the scientific director's job, noting some people might be unwilling to take a job when they didn't know who their boss would be.

The salary could also be a serious deterrent to top-flight candidates, who could earn considerably more in many provincial governments.

The posting suggests the successful candidate would be assigned one of two federal job classifications, depending on whether she or he is a medical doctor.

A doctor would be classified as an MOF-05, which has a salary range of $195,599 to $231,924. But if the selected candidate isn't a physician, he or she would be an EX-03 — which is not a high level position in the bureaucracy — and be paid somewhere between $132,600 and $155,900. Medical microbiologists working for Public Health Ontario earn more than double the salary at the top end of the EX-03 scale.

"At that level it would not be competitive in trying to recruit an internationally recognized scientist in this area," says Naimark. "And it certainly wouldn't entice people to move."

But Dr. Alan Bernstein, former head of the Canadian Institutes of Health Research and current president of the Canadian Institute for Advanced Research, suggests people should reserve judgment, wait to see who is selected "and give that individual a chance to fill Frank's big shoes."

Bernstein, who had not been aware Plummer's term had expired, says the national lab flourished under Plummer, who he called a terrific leader.

Asked what is needed in Plummer's replacement, Bernstein says: "The easiest thing for me to say is 'Someone like Frank.' ... Someone who's respected for their research credentials, on the one hand, (and) who has a public health bent."

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Camels a likely source of human outbreak of Mideast respiratory syndrome

Camels have been implicated in a Middle Eastern respiratory syndrome known as MERS, a viral infection that has caused outbreaks in humans in that part of the world, a new study suggests.

As of April 23, 345 laboratory-confirmed cases, including 107 deaths, have been linked to the coronavirus and reported to public health authorities worldwide, according to the European Centre for Disease Prevention and Control.

More than 60 cases, or about a quarter of the global total since MERS was identified, have been reported in the past month, the American Society for Microbiology says.

Now scientists have grown the virus from nasal swabs of two dromedaries in Saudi Arabia, genetically sequenced it and found it was an "indistinguishable" match to MERS coronavirus found in humans — an indication that the virus in the animals is capable of infecting humans.

"Together with data indicating widespread dromedary infection in the Kingdom of Saudi Arabia, these findings support the plausibility of a role for dromedaries in human infection," Thomas Briese, associate director of the Center for Infection and Immunity at Columbia University in New York and his co-authors concluded in Tuesday's online issue of the journal mBio, published by the American Society for Microbiology.

The finding strengthens the argument that the camels are a reservoir for the virus, Briese said.

"We have evidence going back as far as the early 1990s that this virus has been in camels. Human cases didn't start till 2012. So one very important question is what happened that caused this virus to cause severe disease in humans, noticeable disease in humans for the first time in 2012?" said Dr. Allison McGeer, an infectious disease specialist at Toronto's Mount Sinai Hospital who has helped investigate the new virus in Saudi Arabia as part of a World Health Organization-led team.

Veterinarian Dr. Ehab Al-Shabori in Riyadh said everything is normal among camels.

"If it were risky or there were any problems, we would have received an alert or brochures," Al-Shabori said in Arabic to Reuters. "We would have witnessed cases infected with coronavirus. But there is nothing."

If the infections were coming directly from the camels, you would expect disease in the people who work more closely with camels, but that's not what scientists are seeing, McGeer said.

"So you can speculate about a number of different explanations for why it's true, but we clearly need to understand what's happening and how it's happening."

The majority of cases now in Saudi Arabia are not linked to camels, but are associated with person-to-person transmission in hospitals, McGeer said. "Continuing transmission in hospitals is a concern. It's just not possible to tell from the data we have what's driving that."

Seventy-two of the 345 cases have been health-care workers, the European CDC said.

As for the recent spike in cases, several theories have been proposed, including a potential seasonal explanation. Like cows, camels give birth in the spring. Viral nucleic acid has been detected more in juvenile dromedary camels, the study's authors said.

"The theory is that camels are being born, there's more infection in baby camels and so the risk is higher. That's a great theory. It just might not be true," McGeer said.

As a precaution, health authorities such as the Public Health Agency of Canada are advising people to avoid contact with direct and indirect contact with camels, including unpasteurized camel milk.

The World Health Organization says there's no need for travel restrictions. It's recommended that all countries enhance surveillance to detect any cases of severe respiratory illness quickly and test them.

"We're much better off not having a travel ban but making sure that all of us in Canada are ready for the first case, able to deal with it and going to manage it properly," McGeer said.

A team of eight WHO staff members are currently in Saudi Arabia working with the health ministry and other partners to get a better understanding of the virus and to look at recent outbreaks in health-care facilities in Jeddah, spokesman Tarik Jasarevic said in an email. They are also trying to determine what's the best public health advice to give people.

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1 in 5 Canadians struggle with chronic pain

If you don't already suffer from chronic pain, there's a high likelihood that some day you will or, at the very least, that you'll learn about it through the experience of a close friend or family member.

Dr. Pat Morley-Forster, a professor of anesthesiology and the director of the Chronic Pain Program at Western University in London, Ont., says that, overall, about one in five Canadians suffer from some kind of chronic pain.

"Whether it be chronic headache, chronic back pain, or pain after a surgical procedure," she explained. 

Morley-Forster says chronic pain is loosely defined as pain that lasts longer than three months — the usual time needed for injuries or wounds to heal.

It is a problem that can be caused by a combination of physical, psychological, social and occupational factors, and it can be disabling. And, looking at incidences of chronic pain occurring in different age groups, it appears the problem only concentrates with time.

"The number goes up with the aging population, so it could go up to one in three or one in four, for a population that's 65 and over," Morley-Forster said.

Chronic pain has been a major problem for many seniors for years, dramatically impacting their quality of life.

According to data gathered by Statistics Canada data in two surveys in 1996/1997 and 2005, roughly 27 per cent of seniors living at home and up to 38 per cent of those living in health-care institutions have chronic pain, and reporting rates were higher for women than for men.

The 1996/1997 National Population Health Survey found that chronic pain interfered with the activities seniors could perform, with 64 per cent of those experiencing chronic pain while living in institutions reporting that it interfered with most of their activities. In households, 54 per cent of those living with chronic pain reported that it interfered with most of the activities they did.

Ada Glutstein has been living with chronic pain for over 10 years. She leads a support group in Vancouver to help others who are also struggling with the problem. (Elaine Chau )

One such sufferer is Ada Glutstein, a 71 year old who has lived with chronic pain for over 10 years.

'Everything became very difficult, and I had to start thinking about how I was going to position my body to do different things.'- Ada Glutstein, chronic pain sufferer

She used to be a teacher in Vancouver, but had to retire early because her condition made everyday tasks extremely difficult.

"I just found I couldn't walk very well," she said. "[I] couldn't put the dishes in the dishwasher, or bend over to take them out."

"Everything became very difficult, and I had to start thinking about how I was going to position my body to do different things," she explained. "I [once] was the kind of person who ran up and down stairs, and did everything quickly. I became somebody who walked with a cane."

Morley-Forster says Canadian doctors have difficulty treating patients with chronic pain because of a lack of national standards and because doctors tend to look at chronic pain as a secondary problem.

The situation is changing though, because more and more experts and institutions are beginning to define chronic pain as a disease.

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'World is headed for a post-antibiotic era' without urgent action, WHO warns

David Livermore, director of antibiotic resistance monitoring at Britain's Health Protection Agency, holds a plate coated with the antibiotic-resistant bacteria called Klebsiella, a common intestinal bacteria behind hospital-acquired infections, such as pneumonia and bloodstream infections.

Bacteria resistant to antibiotics have now spread to every part of the world and might lead to a future where minor infections could kill, according to a report published Wednesday by the World Health Organization.
 
In its first global survey of the resistance problem, WHO said it found very high rates of drug-resistant E. coli bacteria, which causes problems including meningitis and infections of the skin, blood and the kidneys. The agency noted there are many countries where treatment for the bug is useless in more than half of patients.

WHO's report also found worrying rates of resistance in other bacteria, including common causes of pneumonia and gonorrhea.
 
Unless there is urgent action, "the world is headed for a post-antibiotic era in which common infections and minor injuries which have been treatable for decades can once again kill," Dr. Keiji Fukuda, one of the agency's assistant director-generals, warned in a release.
 
WHO acknowledged it couldn't assess the validity of the data provided by countries and that many had no information on antibiotic resistance available.
 
Health experts have long warned about the dangers of drug resistance, particularly in diseases such as tuberculosis, malaria and flu. In a report by Britain's Chief Medical Officer last year, Dr. Sally Davies described resistance as a "ticking time bomb" and said it was as big a threat as terrorism.
 
In 1928, Alexander Fleming's discovery of penicillin revolutionized medicine by giving doctors the first effective treatment for a wide variety of infections. Despite the introduction of numerous other antibiotics since then, there have been no new classes of the drugs discovered for more than 30 years.
 
"We see horrendous rates of antibiotic resistance wherever we look …including children admitted to nutritional centres in Niger and people in our surgical and trauma units in Syria," said Dr. Jennifer Cohn, a medical director at Doctors Without Borders, in a statement. She said countries needed to improve their monitoring of antibiotic resistance. "Otherwise, our actions are just a shot in the dark."

WHO said people should use antibiotics only when prescribed by a doctor, that they should complete the full prescription and never share antibiotics with others or use leftover prescriptions.

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Why was John Silva's chronic pain undiagnosed for so long?

CBC reporter Susana da Silva launches a special series on chronic pain this week with her personal account of her father's struggle. Watch for more stories in the days ahead.

As a reporter, I'm used to telling other people's stories. But now I'm telling my own — or more specifically, my late father's.

Joao (John) Silva was 76 years old, a proud Portuguese-Canadian and former construction worker. I watched his terrible struggle with pain before his difficult death three months ago.

'With so many tools at our disposal, why is it so hard to manage pain in our modern medical system?'  

The way he died raised so many questions about our medical system's handling of pain, that it compelled me to investigate the issue. With so many tools at our disposal, why is it so hard to manage pain in our modern medical system?

In my father's case, his ordeal began with a mystery illness, a strange pain, that started a few years ago.

He underwent laparoscopic surgery in October of 2010 to have a benign polyp removed. A couple of small incisions were made in his belly, including one near his navel.

He brushed off the mild, infrequent discomfort that followed as a simple upset stomach, and it would go away.

In February of 2013, his health deteriorated rapidly. He came down with pneumonia, and he coughed and coughed. The mild, intermittent abdominal discomfort he'd had a hard time describing became a daily, unrelenting presence.

A man who had worked out at a gym three hours a day, three days a week, was now essentially homebound, barely able to move from his chair. The burning and sensitivity he felt in his belly meant that even the waistband on his pants caused him great pain.

So began a year's worth of tests and visits to doctors to try to figure out what was wrong.

Understandably, when there's discomfort in the abdomen, doctors must rule out all kinds of serious problems such as cancer. So the tests began. My father underwent a slew of them: a colonoscopy (his second in just over a year), a lung biopsy (his second in less than a year), two gastroscopies, two ultrasounds, three chest X-rays, four CT scans of different kinds and a variety of other tests. We also revisited the laparoscopic surgeon, who said he didn't know what could be wrong.

Each time we asked what could be wrong, there was no clear answer. Theories were floated: It could be gastritis, or lymphocytic gastritis, or a bacterial overgrowth in the small intestine or an intolerance to dairy or gluten — the list went on and on.

But no matter what medication was taken or which diet tried, nothing helped. My dad was wasting away. He lost his appetite, 25 pounds and all the conditioning he had worked so hard to achieve at the gym.

In November of 2013, our gastroenterologist said he had no idea what was going on, and that he had no solutions to offer.

We took a desperate step. We flew my father to the Mayo Clinic in Minnesota.

It quickly became apparent that they too didn't know what was going on but, in one doctor's report posted online after one of our appointments, there was a brief mention of neuropathic pain.

I began doing my own research, only to discover a series of medical journal articles on neuropathic pain and its relationship to chronic abdominal wall pain. There, in black and white in front of me, were the exact descriptions of all of his symptoms, along with discussions of how the diagnosis is often missed.

I was stunned.

The journals even described a test for neuropathic pain that was developed more than 85 years ago, in 1928: find a patient's sorest point, then ask the patient to do a curl up. If the pain is still present when you press on the sore spot and the patient is curled up, it indicates that the problem is likely on the outside of the abdominal wall, as the tightened abdominal muscles would protect any internal problems.

I tested him myself in the hotel room, over and over again. Sure enough, the pattern of pain seemed to indicate a problem on the abdominal wall itself, and not within.

We then went to the Mayo Clinic's pain clinic. Doctors there conducted the same test and came to the same conclusion I had. They injected lidocaine, a numbing agent, into the sorest point and after a couple of days my father finally had some relief.

We returned home, and looked at getting him into a pain clinic here in B.C., only to learn there were wait times of six to 12 months.

'I was left with many questions about chronic pain and how it is managed in Canada.'  

It was too long. My father's health was still spiralling downward. In desperation, we made an appointment at a private pain clinic.

Two days before his scheduled appointment, my father was admitted to hospital. A previous lung condition had flared up. It came out of the blue, because we'd been regularly checking to make sure it was not the cause of the pain. All appeared to be fine, at least on the surface, until it roared back.

I believe it was helped along by his chronic, weakened state.

After four days of pleading with hospital staff, we finally got access to a pain specialist. The specialist floored us with what he said "of course" — that my father had a neuropathic pain problem. "It's not rocket science," he said, and he suggested some treatments. But it all came too late.

My father's lungs got worse. He couldn't breathe. Three weeks later, he passed away.

Upon reflecting on what happened, all that I had learned and all the medical journals I had read, I was left with many questions about chronic pain and how it is managed in Canada.

So I started to do what I do everyday, and I began talking with the people who might have some answers. Many times what the experts and the experienced said led simply to more questions about the level of chronic pain care both in B.C., and across the country. 

I soon discovered I wasn't alone in my concern. There are new initiatives underway right now to try to improve chronic pain care, but many experts say they are still large gaps in the system.

My father fell into one.

His unrelieved pain, and our battle to find his help, has left lasting emotional pain for those who loved him, and as yet unanswered questions about why he, and so many others, have to suffer.

Watch for more stories on chronic pain by CBC reporter Susana da Silva in the days ahead.

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Largest measles outbreak in 30 years ends in Fraser Valley

The largest outbreak of measles in decades was officially declared over Monday with a vast reduction in the number of transmissions and new cases, says Fraser Health's chief medical health officer.

Over a four-week period earlier this spring, the Fraser Health region had over 400 cases of measles with some patients requiring hospitalization.

Dr. Paul Van Buynder, the chief medical health officer, says the outbreak is now over with few new cases being reported.

"The size of, and speed at, which this outbreak spread resulted in more cases of measles than the province has seen in the past 15 years, and was the largest outbreak in almost 30 years," says Dr. Van Buynder.

The outbreak initially began after dozens of cases were reported at a Christian School in Chilliwack with a low vaccination rate. That school was temporarily closed.

Health authorities say the low vaccination rates within that small population led to the measles spreading to the broader population.

Officials are urging residents to keep up with immunization and vaccinations to protect themselves against preventable illnesses.

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ACL knee injuries in young athletes can be reduced with training

A knee tear injury is on the rise among children and teens, particularly girls, who play sports, say pediatricians who recommend extra training before hitting the soccer field, gymnastics studio or basketball court.

Injuries to the anterior cruciate ligament, or ACL, in athletes age 18 and younger have increased over the last 20 years.  A report in Monday's issue of the journal Pediatrics offers information for parents, young athletes and clinicians on preventing, diagnosing and treating the injury before and after puberty.

Aliya Mustafina of Russia gets assistance after suffering from an injury at the vault during the women's individual all-around gymnastics final in 2011. Mustafina had surgery for an ACL injury, (Gero Breloer/Associated Press)

The ACL is one of four major ligaments that hold the bones of the knee together. The ligaments also work to stabilize the knee during movement. It can tear when athletes quickly change direction, land from a jump incorrectly, or slow down or stop suddenly.

ACL injury rates increase sharply during puberty, especially for girls, who have higher rates than boys when playing similar sports.

"After puberty, girls have a 'machine motor mismatch,'" study author Timothy Hewett of the Council on Sports Medicine and Fitness said, in a release. "In contrast, boys get even more powerful relative to their body size after their growth spurt. The good news is that we've shown that with neuromuscular training, we can boost the power of girls' neuromuscular engine, and reduce their risk of ACL injuries."

Neuromuscular training programs work to strengthen muscles in the lower extremities, improve core stability and show athletes how to avoid jumping and landing improperly.

A few other factors are thought to be behind the increasing ACL injury rates, including the growing number of kids and teens participating in organized sports, more intense training at younger ages and greater rate of diagnosis thanks to increased awareness and advanced imaging.

Female athletes between 15 and 20 years old accounted for the largest number of ACL injuries.

At the high school level in the U.S., girl's soccer has the most ACL injuries, followed by boy's football, girl's basketball, girl's gymnastics, and lacrosse for both.

At the college level, U.S. data suggested ACL injury rates were highest in men's spring football and women's gymnastics.

The study's authors called the treatment of ACL in young athletes "challenging and controversial," but that the tear is not a surgical emergency.

Ideally, surgical treatment would be postponed until the athlete's skeletal structure is fully mature. Now, less invasive surgical techniques can be used and ACL surgery is about 90 per cent successful in restoring knee stability and patient satisfaction, they said.

Regardless of treatment, athletes with ACL tears are up to 10 times more likely to develop early-onset degenerative knee osteoarthritis that can lead to chronic pain and disability.

The authors suggested that pediatricians and orthopedic surgeons direct patients at highest risk of ACL injuries, such as adolescent female athletes or those with a family history, to resources such as the pediatric academy's Council on Sports Medicine and Fitness.

It's estimated that at least 70 per cent of ACL injuries are noncontact in nature.

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Housing before treatment a better plan for homeless: study

A study lauding the effectiveness of the "housing first" model for addressing homelessness couldn't have come at a better time.

Research out of McMaster University shows that by putting the importance of a bed ahead of treatment for addictions or mental health issues, it is not only more effective, but cheaper, too.

This month, federal dollars assigned to curb homelessness in Hamilton switched over to a model that allocates 65 cents of every dollar to the housing first model, which focuses on finding permanent housing rather than shelter maintenance for the street populations.

One housing first Hamilton program being used right now  goes even further, and may be the next step in evolving strategies against homelessness.

Julia Woodhall-Melnik, the author of a year-long study out of McMaster and the Centre for Research on Inner City Health at St. Michael's Hospital in Toronto, said the "graduation" model offered by Wesley Urban Ministries in Hamilton is providing the last, important step to the housing model.

Once stable housing is found, participants are put into a "maintenance" mode that checks in on their graduates who have found housing, provides support in case of slip ups, and fosters a recreational network that is providing to have harm-reduction qualities.

And for participants, it's all at their own pace.

"They're able to dictate the level of support that they want," said Woodhall-Melnik.

"We're allowing for people to be housed, irregardless of the other concerns that they have going on in their lives and it's showing they are able to fare well, they are able to be stable, and we are able to save money. So it's kind of a win-win."

At Wesley, the Transition to Home (T2H) program not only helps find participants a home, but also helps them apply for subsidies, 30 per cent of which is tapped for rent. Funds from the city and Wesley top up the rent.

What is different about the Hamilton program, says Woodhall-Melnik, is the extra recreational activities. The Homeless Baseball League – which was named so by the players – is one example of programming out of Wesley that is providing a much needed link for participants who have recently found housing, and are being weaned off the shelter system.

Other programs include cooking classes, movie and bowling nights, said Woodhall-Melnik.

"In our research, we found that onsite addictions supports and access to recreational therapy assisted participants in rebuilding stability in their lives," writes the report. "For example, in offering therapeutic recreation activities, the T2H program was able to assist participants with harm reduction and forming new social connections with other program participants."

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Ebola survivors, though few in numbers, face isolating stigma

The doctor has beaten the odds and survived Ebola, but he still has one more problem: The stigma carried by the deadly disease.

Even though he is completely healthy, people are afraid to come near him or to have anything to do with him.

For example, the man was supposed to give an interview on Guinean radio to describe his triumphant tale. But the station would not allow him into the studio.

"We'd prefer he speak by phone from downstairs," the station's director told a representative of Doctors Without Borders, while the survivor waited outside in a car. "I can't take the risk of letting him enter our studio."

The Ebola outbreak in West Africa has claimed more than 145 lives so far. More than 240 people, mostly in Guinea, are suspected of having caught the illness, which causes horrific suffering, including bursting blood vessels and bleeding from ears and other orifices. There is no vaccine, no treatment and the disease is almost always fatal.

The virus is transmitted by direct contact with the blood, body fluids and tissues of infected persons. (Centres for Disease Control and Prevention)

But a handful of the infected do survive. About 30 patients have survived in Guinea so far, according to Doctors Without Borders. Liberia has not recorded any cases of survival.

Unfortunately for the lucky few, the stigma lingers long after the virus has been purged from their bodies.

'This disease is worse than the fever'

"Thanks be to God, I am cured. But now I have a new disease: the stigmatization that I am a victim of," said the Guinean doctor, who spoke to The Associated Press but refused to give his name for fear of further problems the publicity would cause him and his family. "This disease (the stigma) is worse than the fever."

Several other people who survived the disease refused to tell their stories when contacted by the AP, either directly or through Doctors Without Borders.

Sam Taylor, the Doctors Without Borders spokesman who had taken the doctor to the radio station, confirmed that the man had been infected and survived.

The doctor believes he caught Ebola while caring for a friend and colleague who died in Conakry, Guinea's capital. At the time, he said, he did not know that his friend had Ebola.

Shortly after his friend's death, the doctor got a headache and came down with an intractable fever. And then the vomiting and diarrhea began.

Doctors collect samples of the Ebola virus at the Centre for Disease Control in Uganda during an outbreak there in 2012. (Edward Echwalu/Reuters)

"I should have died," the doctor said, but he responded to care, which includes intensive hydration, and unlike most other Ebola patients, he lived.

Surviving Ebola is a matter of staying alive long enough to have the chance to develop enough antibodies to fight off the virus, said David Heymann, a professor of infectious disease epidemiology at the London School of Hygiene & Tropical Medicine.

That's because it's typically the symptoms of Ebola — severe fever, hemorrhaging, dehydration, respiratory problems — that kills a patient.

Even though he has been cleared of Ebola, the doctor says that people avoid him.

"Now, everywhere in my neighbourhood, all the looks bore into me like I'm the plague," he said. People leave places when he shows up. No one will shake his hand or eat with him. His own brothers are accusing him of putting their family in danger.

Recalls the early days of HIV epidemic

Stigma often accompanies the spread of deadly, poorly understood diseases, said Meredith Stakem, a health and nutrition adviser for Catholic Relief Services in West Africa, noting that the terrified reaction to Ebola recalls the early days of the HIV epidemic.

Ebola may incite an even more severe reaction because health workers responding to it wear head-to-toe protective gear that look like space suits, Stakem noted.

In this outbreak, the homes of some of the infected in Liberia have been attacked and Doctors Without Borders briefly abandoned a clinic in Guinea that was targeted.

The families of those who die from Ebola face similar problems.

Aziz Soumah, who lives in a suburb of the Guinean capital of Conakry, said his family was forced to move after his brother died, apparently from Ebola.

"I went to pray at the mosque. As soon as I entered, all the worshippers left the mosque," recounted Soumah, a 30-year-old engineer. "I was alone. No one around me."

International health organizations are doing extensive community outreach to explain how the disease is transmitted — only through direct contact with the bodily fluids of symptomatic people — and to explain that those cured are no longer contagious.

The most powerful tool to combat stigma is the way health care workers treat a discharged patient, said Corinne Benazech, the representative in Guinea for Doctors Without Borders in Guinea.

"The patient never leaves alone," she said of when Ebola survivors leave their isolation wards, and health care workers individually shake hands with the survivor.

Discharged patients receive a certificate from the minister of health that states they are no longer contagious, said Tom Fletcher, an infectious disease physician with the World Health Organization who is working in Guinea. However, the virus may linger in a male patient's semen, so men are given a three-month supply of condoms, he added.

The Guinean doctor was treated for about a week before he was declared cured. Fletcher said that's typical for the miraculous few: "These people should be celebrated, really, as opposed to stigmatized."

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Testicular, breast cancer social media campaigns get edgier

The shock value of naughty cancer awareness campaigns on social media do create buzz, but whether they work in the long run is less clear, a marketing expert says.

Recent campaigns include one with the hash tag #C--kInASock, where the first word is fully spelled out. The campaigns show men wearing nothing but long socks below the belt, buffed men promoting breast self exams, selfies of women with no makeup promoting women's cancer awareness and research, and a female model touching herself and demonstrating how to look for early signs of testicular cancer on a bag of fake testicles.

"I can hear some extreme male groups saying, well you know, isn't it exploitative?" said Alan Middleton, a professor of marketing at York University in Toronto. "The answer is yes it is. But like everything, does it do it successfully in the cause?"

Creating broader awareness in an age of social and digital media has value for disease charities aiming to engage people beyond those directly involved, such as patients and their loved ones, Middleton said.

Last year, the Canadian Cancer Society launched Nutiquette: a dude's guide to checking his nuts. The social media campaign encouraged people to share the awareness video with young men — testicular cancer is the most common cancer in men aged 15 to 29.

In the YouTube video for the Canadian Cancer Society's Nutiquette campaign, a man with a guitar sings the steps men should follow to check for testicular cancer. (Canadian Cancer Society)

In the YouTube video, a man with a guitar sings the steps men should follow to check for testicular cancer as Pop-Up Video-style tips appear in bubbles.

"Telling the story, our main message was you have to check yourself regularly and know what's normal for you. The humour element, we had to go a little outside of that, so it's where do you check it, when do you check it, what's appropriate?" said Andrew Kinnear, vice president of digital strategy at Environics Communications, which developed the video.

Market research suggested that young men didn't want to be preached to or read a brochure. Using humour helped to ensure that people would watch all the way to the end to get the full message, Kinnear said.  

"What they told us was don't preach to us, make it engaging, make it funny, be a little edgy and different and that's what we're going to share and going to really appeal to us," said Mathew Sepkowski, director of marketing for the Canadian Cancer Society.

Sepkowski said he's aware of more graphic testicular cancer awareness campaigns than Nutiquette that are pushing the boundaries.

"Some have been more shocking than others. Some I think take it a little bit too far, but I think that the fact that they're getting [the message] out there and creating more awareness overall is positive."

So how far will the trend go? Will good taste prevail?

"You can shock people into awareness, but over time, will it deliver what you want, which is people giving you money, better research going into the problem and more volunteers?" Middleton said.

Middleton expects to see more "experiments" from major health charities until the sexualization bandwagon becomes tiring.

"We're past the age of hearts and flowers," he said.

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If today's an average day, 3 Canadians will die on the job

Today is the National Day of Mourning to remember workers injured, killed or afflicted with an occupational illness while on the job. And if it turns out to be an average day for workplace safety in Canada, three workers will die.

In 2012, the most recent year for official statistics, there were 977 workplace-related fatalities in Canada, according to the Association of Workers' Compensation Boards of Canada. But those numbers only cover workplaces where workers can receive provincial compensation benefits.

"Hundreds more die from under-reported illnesses and occupational diseases that go unrecognized in the compensation systems," says the Canadian Labour Congress, which first established the National Day of Mourning exactly 30 years ago this year.

The AWCBC statistics show that the official number of 2012 fatalities was very close to the average of 972 for the years 2000-2012.

Construction industries accounted for 22 per cent of fatalities, with manufacturing was in second place with 19 per cent.

Health and social service industries accounted for the highest number of injuries on the job, according to the AWCBC. That's 17 per cent of the 245,365 workplace injuries in Canada in 2012.

Manufacturing was second  and construction third on the injuries graph.

The number of work-related injuries has fallen dramatically since the late 1980s, according to federal government and AWCBC statistics. In both 1986 and 1987, there were almost 50 work-related injuries per 1,000 employed workers in Canada, according to federal government calculations. By 2010 that number had fallen to about 15 per 1,000.

The AWCBC numbers, which only cover workplaces under the workers' compensation systems, suggest that ratio likely continued to drop in 2011 and 2012.

The labour movement attributes much of that drop to improving health and safety standards in the workplace.

Nevertheless, an average of 672 workers were injured every day on the job in Canada in 2012, as counted by the AWCBC.

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PTSD in military, emergency crews focus of 48-stop tour

Cpl. Jamie MacWhirter has been through the nightmares and angry outbursts of post-traumatic stress disorder, and he has a message for those struggling alone.

"If you believe you have a problem, if your wife or spouse has said anything to you, it doesn't hurt to go and talk to somebody."

MacWhirter chronicled his 2006 deployment in Kandahar and subsequent troubles with PTSD in his memoir, A Soldier's Tale: A Newfoundland Soldier in Afghanistan.

He's now working on another book about his long journey back to better mental health.

On May 5, MacWhirter will speak in St. John's to help launch a cross-Canada tour aimed at raising awareness about how soldiers, emergency workers, police, correctional officers and others are affected by PTSD.

Jamie MacWhirter published a memoir last year on his experiences in Kandahar and his subsequent troubles upon coming home. (Paul Daly/Canadian Press)

The Heroes Are Human tour organized by the Tema Conter Memorial Trust in Toronto will include stops in 48 cities and towns. Two-hour community meetings will be free of charge for anyone wanting to learn more about how to cope with a still highly stigmatized condition.

MacWhirter said it has been especially hard to learn of recent suicides involving soldiers and veterans of the Afghanistan mission.

"People are afraid to come forward and admit that they need help," he said in an interview. "Most soldiers, they're taught to hide the pain. They're taught to soldier on and continue work.

"It's hard to change your thought pattern and say, 'I need help."'

Offering support and healing

MacWhirter, 38, said he has heard stories of soldiers whose military careers have stalled after admitting to such problems. But his own experience has been one of support and, over time, healing.

He first sought help through the military almost eight years ago when his symptoms began to escalate.

"I tried to deal with it myself. But my wife, God love her, she pretty much told me: 'You need help."'

MacWhirter said finding a counsellor in St. John's who could help him put in perspective and let go of the most rattling memories of his time overseas has made the difference. He expects to finish his mental health treatment in June.

MacWhirter said he'll likely deal with PTSD symptoms for the rest of his life but that he now understands what triggers to avoid and how to calm himself.

"I believe now I'm ready to carry on with my life and carry on my career."

Former paramedic drawn to issue

It's a message of hope that Vince Savoia, founder and executive director of the Tema Conter Memorial Trust, wants to take across the country.

Savoia's own battle with PTSD began as a 27-year-old paramedic in 1988 when he was called to a grisly murder scene in Toronto. Tema Conter, a 25-year-old woman, had been bound, raped, beaten and stabbed to death.

Savoia, now 52, said he felt profound sadness, guilt and other symptoms that would not be properly diagnosed as PTSD until almost 12 years later.

'What most PTSD sufferers want is to go back prior to that trauma and be normal again. That's really almost impossible to do because that traumatic event has happened and it has changed you to some degree'- Vince Savoia

He quit emergency services in 1992 and was a financial planner for 18 years. He now works full-time for the trust founded in Tema Conter's memory.

"I think PTSD as a whole within our community is really, really misunderstood. It's what we call the invisible injury.

"What most PTSD sufferers want is to go back prior to that trauma and be normal again," he said. "That's really almost impossible to do because that traumatic event has happened and it has changed you to some degree."

Savoia said the key is to know there is help available and that it's okay to seek it.

Provincial governments should increase access to mental health services, he said.

Wait lists for psychologists are often months long, and appointments costing at least $150 an hour are too much for many people, he added.

MacWhirter and Savoia agree that non-judgmental guidance to find a focus or program that eases PTSD symptoms is crucial.

For Savoia, starting the trust in honour of the woman he could not help was a God-send, he said.

"It allowed me to take all that negative energy that I had and apply it to something that I perceive to be very positive."

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E-cigarette ban for minors proposed in U.S.

The U.S. Food and Drug Administration proposed rules on Thursday that would ban the sale of e-cigarettes to anyone under 18, but would not restrict flavoured products, online sales or advertising, which public health advocates say attract children.

The long-awaited proposal would subject the $2 billion US e-cigarette industry to federal regulation for the first time.

FDA commissioner Margaret Hamburg said at a briefing that the proposal represented the first "foundational" step towards broader restrictions if scientific evidence shows they are needed to protect public health.

Critics of e-cigarette advertising say it risks introducing a new generation of young people to conventional cigarettes when little is known about the long-term health impact of the products. And they lamented the fact that limits were not included in the proposed rule.

"It's very disappointing because they don't do anything to rein in the wild-west marketing that is targeting kids," said Stanton Glantz, a professor at the Center of Tobacco Control Research and Education at the University of California San Francisco. "They should not have been so timid."

Eric Scheman demonstrates an e-cigarette at Vape store in Chicago on Wednesday. The U.S. government wants to ban sales of electronic cigarettes to minors and require approval for new products and health warning labels. (Nam Y. Huh/Associated Press)

Hamburg said the current proposal "lays the foundation for many more actions and activities."

Vince Willmore, a spokesman for the Campaign for Tobacco Free Kids, said the proposal "by no means does everything we think needs to be done, but it starts the process. What is critical now is that they finalize this rule and then move quickly to fill the gaps."

Likewise in Canada, the Non-Smokers' Rights Association called the proposed U.S. moves a step in the right direction. 

"Right now, we have e-cigarettes being advertised and promoted in all the same ways that tobacco products were and that is one of the main risks we think to promoting e-cigarette use, nicotine addiction and possibly even cigarette addiction amongst youth is the re-normalization of smoking-type behaviours," said Melodie Tilson, director of policy for the Non-Smokers' Rights Association in Ottawa.

Ban on free samples proposed

A law passed in 2009 gave the FDA authority to regulate cigarettes, smokeless tobacco and roll-your-own tobacco and stipulated the agency could extend its jurisdiction to other nicotine products after issuing a rule to that effect. E-cigarettes use battery-powered cartridges to produce a nicotine-laced inhalable vapour.

'By not addressing the youth-directed marketing it means it won't be addressed for a very long time.'- Stanton Glantz

In the short term, the rule would prohibit companies from distributing free e-cigarette samples, forbid vending machine sales except in adult-only venues and prohibit sales to minors. Companies would be required to warn that nicotine is addictive, but no other health warnings would be required. The addiction warning would have to be added no later than two years after the rule is set. The companies would not be allowed to make health claims in any advertising.

The proposal is subject to a public-comment period of 75 days. Willmore said the FDA should aim to establish the rule within a year.

Some are skeptical that restrictions on marketing or flavors will come any time soon.

"The reality of these things is that every step takes years," said Glantz. "By not addressing the youth-directed marketing it means it won't be addressed for a very long time."

Evolving 'vaping' industry

Some e-cigarette companies that sell primarily through convenience stores were surprised at the lack of restrictions on online sales, since it can be difficult to verify a customer's age over the internet.

"The internet thing is very surprising to me," said Miguel Martin, president of Logic Technology, one of the biggest e-cigarette manufacturers. "It reduces the visibility of the sales of the products and the type of products that the government has awareness of."

The rules would require companies to submit new and existing products to the FDA for approval. They would have two years to submit applications from the time the rule goes into effect. Companies may continue selling their products and introducing new products pending the FDA's review.

In the meantime, they would be required to register with the FDA and list the ingredients in their products. They would not be required to adhere immediately to specific product or quality control standards. That could come later, Hamburg said.

Canadian regulations

E-cigarettes and other "vaping" devices generate roughly $2 billion a year in the United States, and some industry analysts expect their sales to outpace the $85-billion conventional-cigarette industry within a decade.

Advocates of e-cigarettes claim they are a safer alternative to conventional cigarettes, since they do not produce lung-destroying tar. But there is little data about their long-term safety.

Health Canada said in an email that it is monitoring the actions of other regulators and "considering all options for appropriate oversight of these products."

"Health Canada reminds Canadians that e-cigarettes with nicotine or e-cigarettes with a health claim are not authorized for sale in Canada," a spokeswoman said in an email.

"To date, there is not sufficient evidence that the potential benefits of e-cigarettes in helping Canadians to quit smoking outweigh the potential risks. A company would have to provide evidence of safety, quality and effectiveness in order to have its product authorized. Without this scientific evidence, Health Canada continues to advise Canadians, especially youth, against the use of these products."

The Nova Scotia government said it is looking for guidance from Health Canada before the province introduces legislation in the fall. Nova Scotia Health Minister Leo Glavine is concerned about what may be in the "juice" of e-cigarettes. 

"These are showing up in schools because they're not illegal," said Glavine. "So our legislation will bring e-cigarettes under the Smoking and Public Places Act and so that will be restrictive and also in terms of if there's approval in Canada for sales, they would not, of course, be able to be sold to minors."

Daniel David, a spokesman for the Electronic Cigarette Trade Association, said the FDA proposals should be adopted in Canada to make it clear to vendors that there are regulations to follow.

The FDA's proposal leaves many questions unanswered about how new products would be regulated over the long run. One key question relates to how products are approved.

Under current law, new tobacco products can be approved if they are "substantially equivalent" to a product that was on the market before Feb. 15, 2007. It is unclear whether any e-cigarettes were on sale before then, to be used as a benchmark.

Mitch Zeller, head of the FDA's tobacco division, said at a briefing that the agency would be seeking more information during the public-comment period on whether the "substantial equivalence" pathway is even valid for e-cigarettes.

If it is not, e-cigarette companies would have to use a different process, which would require them to prove their products are appropriate for public health, a higher hurdle to clear.

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Organ donor rule change may presume consent in Nova Scotia

Health Minister Leo Glavine says the province is considering changes to organ donation rules. (CBC)

Nova Scotia is considering changing organ donation rules so people are presumed organ and tissue donors unless they choose to opt out of the donor list.

Right now, only people who have consented before they die are considered eligible donors.

Doctors and nurses may ask grieving families for permission to harvest a loved one's organs but that does not happen often.

Health Minister Leo Glavine thinks Nova Scotians may be ready for a system of "presumed consent."

"I think Nova Scotians are very thoughtful about this and I believe there's a good indication that Nova Scotians may in fact be prepared to go in this direction," he said.

Glavine said he wants to hear from Nova Scotians on the issue and will soon launch a formal consultation, although the idea is still in the planning stages and there are no definite timelines.

April is organ donation month.

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Measles cases hit record levels in U.S.; vaccinations encouraged

Measles can be infectious for four days before visible onset and for four days after, public health officials say. (U.S. Centers for Disease Control and Prevention)

Measles cases are at their highest level in the U.S. for this point in the year since 1996, so public health officials are urging parents to vaccinate their children and are reminding health-care providers how to recognize the illness.

The U.S. Centers for Disease Control and Prevention said Thursday that 129 cases have been reported in 13 states since mid-April, mainly in California and New York City.

As of Wednesday, B.C.'s outbreak in eastern regions of the Fraser Valley has 416 confirmed cases of measles. Since fewer new cases and transmissions are occurring, the health authority hopes to declare the most intense period of the outbreak over soon, a spokeswoman said.

The Public Health Agency of Canada says cases have also been reported this year in Alberta, Saskatchewan, Manitoba and Ontario.

"This is the most measles cases reported in the first four months of the year since 1996," Dr. Anne Schuchat, the U.S. assistant surgeon general and director of the U.S. National Center for Immunization and Respiratory Diseases, told reporters.

"Measles has gotten off to an early and active start this year."

Half of the imported cases, or 17, were among returning American travellers or visitors from the Phillippines, where a recent measles epidemic has caused at least 20,000 illnesses.

Shuchat stressed that borders can't stop measles but vaccinations can.

The success of measles vaccination campaigns over decades means many younger doctors have never seen a case and some older ones could use a refresher on diagnosing it quickly and nipping its spread.

Among the 58 cases reported from California, at least 11 were infected in doctor's offices, hospitals or other health-care settings, according to a report released Thursday by CDC. New York City health officials say two of their 26 cases were infected in medical facilities.

To that end, a new commentary in the Annals of Internal Medicine offers doctors advice on how to isolate suspected measles patients.

"As more parents decline to vaccinate their children, measles incidence is increasing — a fact that alarms me both as a hospital epidemiologist and as a parent of a vulnerable infant too young to receive the measles vaccine," wrote Dr. Julia Shaklee Sammons, an infectious disease specialist at the Children's Hospital of Philadelphia.

"For suspected cases of measles, early reporting and rapid control efforts are vital to prevent spread in health-care facilities. Providers should encourage patients and their parents to call before coming into medical offices or emergency departments so that appropriate precautions can be taken."

If measles is suspected, precautions include isolating the patient in a room with special ventilation to keep the air from circulating around the building, having the patient put on surgical wear and donning surgical masks or respirators for health-care workers.   
 
The measles virus spreads easily through the air and in closed rooms. Infected droplets can linger for up to two hours after the sick person leaves.

Measles causes a fever, runny nose, cough and a rash all over the body.

Unless physicians see a measles rash consistently, they may not be able to distinguish it from other rashes, said Dr. Mel Krajden, head of virology at the B.C. Centre for Disease Control. Krajden called vaccination key to containing measles.

Death occurs in one to three per 1,000 reported cases and is most common in young children or people who are immunocompromised, Sammons said.

The vaccine itself is not perfect.

"Today's measles outbreaks are too often the result of people opting out. Most of the people or 84 per cent of the U.S. cases that are reported to have measles this year so far were not vaccinated or didn't know their vaccination status. Of the unvaccinated U.S. residents, 68 per cent had what we call personal belief exemptions," Shuchat said.

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MERS virus hasn't changed, not reason for surge in Saudi cases

A German coronavirus expert says the virus responsible for the MERS infection appears not to have changed.

Dr. Christian Drosten says based on what his laboratory has seen so far, this month's surge in MERS cases cannot be explained by mutations in the virus.

Drosten's lab at the University of Bonn has been looking at genetic sequences of RNA drawn from samples from 30 recent cases from Jeddah, Saudi Arabia, where the largest increase in cases has occurred.

In an email, Drosten says the lab has sequenced three nearly full genomes and they see no signs of significant changes that could account for the increase in cases.

Earlier work on the samples showed no major changes in any of sequences, though at that point only a small part of the genome of each had been sequenced.

Drosten says the increase in cases may be due to infection control problems in hospitals where the virus has spread as well as milder cases coming forward as the public has become more aware of and concerned about MERS.

This is the first analysis of MERS viruses from cases that have occurred in 2014 and fills an important information gap.

The number of new cases has spiked sharply this month, leaving experts worried about the possibility that the virus might have become more transmissible among people.

There have been as many cases reported so far this month as in the 24 previous months combined. The earliest known cases of MERS occurred in April 2012.

On Saturday, Saudi Arabia reported an additional 10 cases and two deaths, bringing their total to date to 323 cases, 94 of which have been fatal.

Most of the April cases have been reported by Saudi Arabia, but there has also been several dozen cases in the United Arab Emirates.

In total, affected countries have reported just over 400 cases to date.

On Saturday authorities in Egypt said they had diagnosed their first MERS case, in a man who had recently been in Riyadh, Saudi Arabia.

People infected with MERS have recently travelled from Saudi Arabia and UAE to Malaysia, the Philippines, Jordan and Greece. To date there is no evidence any of those people spread the infection to others in those countries. The Malaysian man, who was a religious tourist to Mecca, died from his infection.

In a risk assessment issued Thursday, the World Health Organization warned more exported cases are "very likely" to occur in travellers, religious pilgrims and foreign nationals who work in affected Middle Eastern countries. It urged countries to be on the lookout for MERS cases.

Mounting evidence suggests that camels are the source of the virus, but it is not yet known how people are contracting it.

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E-cigarette ban for minors proposed in U.S.

The U.S. Food and Drug Administration proposed rules on Thursday that would ban the sale of e-cigarettes to anyone under 18, but would not restrict flavoured products, online sales or advertising, which public health advocates say attract children.

The long-awaited proposal would subject the $2 billion US e-cigarette industry to federal regulation for the first time.

FDA commissioner Margaret Hamburg said at a briefing that the proposal represented the first "foundational" step towards broader restrictions if scientific evidence shows they are needed to protect public health.

Critics of e-cigarette advertising say it risks introducing a new generation of young people to conventional cigarettes when little is known about the long-term health impact of the products. And they lamented the fact that limits were not included in the proposed rule.

"It's very disappointing because they don't do anything to rein in the wild-west marketing that is targeting kids," said Stanton Glantz, a professor at the Center of Tobacco Control Research and Education at the University of California San Francisco. "They should not have been so timid."

Eric Scheman demonstrates an e-cigarette at Vape store in Chicago on Wednesday. The U.S. government wants to ban sales of electronic cigarettes to minors and require approval for new products and health warning labels. (Nam Y. Huh/Associated Press)

Hamburg said the current proposal "lays the foundation for many more actions and activities."

Vince Willmore, a spokesman for the Campaign for Tobacco Free Kids, said the proposal "by no means does everything we think needs to be done, but it starts the process. What is critical now is that they finalize this rule and then move quickly to fill the gaps."

Likewise in Canada, the Non-Smokers' Rights Association called the proposed U.S. moves a step in the right direction. 

"Right now, we have e-cigarettes being advertised and promoted in all the same ways that tobacco products were and that is one of the main risks we think to promoting e-cigarette use, nicotine addiction and possibly even cigarette addiction amongst youth is the re-normalization of smoking-type behaviours," said Melodie Tilson, director of policy for the Non-Smokers' Rights Association in Ottawa.

Ban on free samples proposed

A law passed in 2009 gave the FDA authority to regulate cigarettes, smokeless tobacco and roll-your-own tobacco and stipulated the agency could extend its jurisdiction to other nicotine products after issuing a rule to that effect. E-cigarettes use battery-powered cartridges to produce a nicotine-laced inhalable vapour.

'By not addressing the youth-directed marketing it means it won't be addressed for a very long time.'- Stanton Glantz

In the short term, the rule would prohibit companies from distributing free e-cigarette samples, forbid vending machine sales except in adult-only venues and prohibit sales to minors. Companies would be required to warn that nicotine is addictive, but no other health warnings would be required. The addiction warning would have to be added no later than two years after the rule is set. The companies would not be allowed to make health claims in any advertising.

The proposal is subject to a public-comment period of 75 days. Willmore said the FDA should aim to establish the rule within a year.

Some are skeptical that restrictions on marketing or flavors will come any time soon.

"The reality of these things is that every step takes years," said Glantz. "By not addressing the youth-directed marketing it means it won't be addressed for a very long time."

Evolving 'vaping' industry

Some e-cigarette companies that sell primarily through convenience stores were surprised at the lack of restrictions on online sales, since it can be difficult to verify a customer's age over the internet.

"The internet thing is very surprising to me," said Miguel Martin, president of Logic Technology, one of the biggest e-cigarette manufacturers. "It reduces the visibility of the sales of the products and the type of products that the government has awareness of."

The rules would require companies to submit new and existing products to the FDA for approval. They would have two years to submit applications from the time the rule goes into effect. Companies may continue selling their products and introducing new products pending the FDA's review.

In the meantime, they would be required to register with the FDA and list the ingredients in their products. They would not be required to adhere immediately to specific product or quality control standards. That could come later, Hamburg said.

Canadian regulations

E-cigarettes and other "vaping" devices generate roughly $2 billion a year in the United States, and some industry analysts expect their sales to outpace the $85-billion conventional-cigarette industry within a decade.

Advocates of e-cigarettes claim they are a safer alternative to conventional cigarettes, since they do not produce lung-destroying tar. But there is little data about their long-term safety.

Health Canada said in an email that it is monitoring the actions of other regulators and "considering all options for appropriate oversight of these products."

"Health Canada reminds Canadians that e-cigarettes with nicotine or e-cigarettes with a health claim are not authorized for sale in Canada," a spokeswoman said in an email.

"To date, there is not sufficient evidence that the potential benefits of e-cigarettes in helping Canadians to quit smoking outweigh the potential risks. A company would have to provide evidence of safety, quality and effectiveness in order to have its product authorized. Without this scientific evidence, Health Canada continues to advise Canadians, especially youth, against the use of these products."

The Nova Scotia government said it is looking for guidance from Health Canada before the province introduces legislation in the fall. Nova Scotia Health Minister Leo Glavine is concerned about what may be in the "juice" of e-cigarettes. 

"These are showing up in schools because they're not illegal," said Glavine. "So our legislation will bring e-cigarettes under the Smoking and Public Places Act and so that will be restrictive and also in terms of if there's approval in Canada for sales, they would not, of course, be able to be sold to minors."

Daniel David, a spokesman for the Electronic Cigarette Trade Association, said the FDA proposals should be adopted in Canada to make it clear to vendors that there are regulations to follow.

The FDA's proposal leaves many questions unanswered about how new products would be regulated over the long run. One key question relates to how products are approved.

Under current law, new tobacco products can be approved if they are "substantially equivalent" to a product that was on the market before Feb. 15, 2007. It is unclear whether any e-cigarettes were on sale before then, to be used as a benchmark.

Mitch Zeller, head of the FDA's tobacco division, said at a briefing that the agency would be seeking more information during the public-comment period on whether the "substantial equivalence" pathway is even valid for e-cigarettes.

If it is not, e-cigarette companies would have to use a different process, which would require them to prove their products are appropriate for public health, a higher hurdle to clear.

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Organ donor rule change may presume consent in Nova Scotia

Health Minister Leo Glavine says the province is considering changes to organ donation rules. (CBC)

Nova Scotia is considering changing organ donation rules so people are presumed organ and tissue donors unless they choose to opt out of the donor list.

Right now, only people who have consented before they die are considered eligible donors.

Doctors and nurses may ask grieving families for permission to harvest a loved one's organs but that does not happen often.

Health Minister Leo Glavine thinks Nova Scotians may be ready for a system of "presumed consent."

"I think Nova Scotians are very thoughtful about this and I believe there's a good indication that Nova Scotians may in fact be prepared to go in this direction," he said.

Glavine said he wants to hear from Nova Scotians on the issue and will soon launch a formal consultation, although the idea is still in the planning stages and there are no definite timelines.

April is organ donation month.

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Measles cases hit record levels in U.S.; vaccinations encouraged

Measles can be infectious for four days before visible onset and for four days after, public health officials say. (U.S. Centers for Disease Control and Prevention)

Measles cases are at their highest level in the U.S. for this point in the year since 1996, so public health officials are urging parents to vaccinate their children and are reminding health-care providers how to recognize the illness.

The U.S. Centers for Disease Control and Prevention said Thursday that 129 cases have been reported in 13 states since mid-April, mainly in California and New York City.

As of Wednesday, B.C.'s outbreak in eastern regions of the Fraser Valley has 416 confirmed cases of measles. Since fewer new cases and transmissions are occurring, the health authority hopes to declare the most intense period of the outbreak over soon, a spokeswoman said.

The Public Health Agency of Canada says cases have also been reported this year in Alberta, Saskatchewan, Manitoba and Ontario.

"This is the most measles cases reported in the first four months of the year since 1996," Dr. Anne Schuchat, the U.S. assistant surgeon general and director of the U.S. National Center for Immunization and Respiratory Diseases, told reporters.

"Measles has gotten off to an early and active start this year."

Half of the imported cases, or 17, were among returning American travellers or visitors from the Phillippines, where a recent measles epidemic has caused at least 20,000 illnesses.

Shuchat stressed that borders can't stop measles but vaccinations can.

The success of measles vaccination campaigns over decades means many younger doctors have never seen a case and some older ones could use a refresher on diagnosing it quickly and nipping its spread.

Among the 58 cases reported from California, at least 11 were infected in doctor's offices, hospitals or other health-care settings, according to a report released Thursday by CDC. New York City health officials say two of their 26 cases were infected in medical facilities.

To that end, a new commentary in the Annals of Internal Medicine offers doctors advice on how to isolate suspected measles patients.

"As more parents decline to vaccinate their children, measles incidence is increasing — a fact that alarms me both as a hospital epidemiologist and as a parent of a vulnerable infant too young to receive the measles vaccine," wrote Dr. Julia Shaklee Sammons, an infectious disease specialist at the Children's Hospital of Philadelphia.

"For suspected cases of measles, early reporting and rapid control efforts are vital to prevent spread in health-care facilities. Providers should encourage patients and their parents to call before coming into medical offices or emergency departments so that appropriate precautions can be taken."

If measles is suspected, precautions include isolating the patient in a room with special ventilation to keep the air from circulating around the building, having the patient put on surgical wear and donning surgical masks or respirators for health-care workers.   
 
The measles virus spreads easily through the air and in closed rooms. Infected droplets can linger for up to two hours after the sick person leaves.

Measles causes a fever, runny nose, cough and a rash all over the body.

Unless physicians see a measles rash consistently, they may not be able to distinguish it from other rashes, said Dr. Mel Krajden, head of virology at the B.C. Centre for Disease Control. Krajden called vaccination key to containing measles.

Death occurs in one to three per 1,000 reported cases and is most common in young children or people who are immunocompromised, Sammons said.

The vaccine itself is not perfect.

"Today's measles outbreaks are too often the result of people opting out. Most of the people or 84 per cent of the U.S. cases that are reported to have measles this year so far were not vaccinated or didn't know their vaccination status. Of the unvaccinated U.S. residents, 68 per cent had what we call personal belief exemptions," Shuchat said.

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1st MERS case detected in Egypt

92 people have died from the SARS-like virus in Saudi Arabia since September 2012

Thomson Reuters Posted: Apr 26, 2014 10:37 AM ET Last Updated: Apr 26, 2014 10:37 AM ET

Egypt's state news agency says authorities have detected the first case of a SARS-like virus in the country.

MENA says a 27-year-old civil engineer was diagnosed Saturday after returning from Saudi Arabia, where the Middle East respiratory syndrome, or MERS, has been centred. It says the man was quarantined upon his arrival at Cairo airport Friday and transported to a nearby hospital.

Saudi Arabia's Health Ministry said late Friday that five more people in the kingdom have died from MERS.

The ministry says 92 people have died and 313 have contracted the virus in Saudi since September 2012. MERS can cause symptoms such as fever, breathing problems, pneumonia and kidney failure.

King Abdullah fired his health minister Monday as officials struggle to alleviate public concerns amid a spike in infections.

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Organ donor rule change may presume consent in Nova Scotia

Health Minister Leo Glavine says the province is considering changes to organ donation rules. (CBC)

Nova Scotia is considering changing organ donation rules so people are presumed organ and tissue donors unless they choose to opt out of the donor list.

Right now, only people who have consented before they die are considered eligible donors.

Doctors and nurses may ask grieving families for permission to harvest a loved one's organs but that does not happen often.

Health Minister Leo Glavine thinks Nova Scotians may be ready for a system of "presumed consent."

"I think Nova Scotians are very thoughtful about this and I believe there's a good indication that Nova Scotians may in fact be prepared to go in this direction," he said.

Glavine said he wants to hear from Nova Scotians on the issue and will soon launch a formal consultation, although the idea is still in the planning stages and there are no definite timelines.

April is organ donation month.

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Measles cases hit record levels in U.S.; vaccinations encouraged

Measles can be infectious for four days before visible onset and for four days after, public health officials say. (U.S. Centers for Disease Control and Prevention)

Measles cases are at their highest level in the U.S. for this point in the year since 1996, so public health officials are urging parents to vaccinate their children and are reminding health-care providers how to recognize the illness.

The U.S. Centers for Disease Control and Prevention said Thursday that 129 cases have been reported in 13 states since mid-April, mainly in California and New York City.

As of Wednesday, B.C.'s outbreak in eastern regions of the Fraser Valley has 416 confirmed cases of measles. Since fewer new cases and transmissions are occurring, the health authority hopes to declare the most intense period of the outbreak over soon, a spokeswoman said.

The Public Health Agency of Canada says cases have also been reported this year in Alberta, Saskatchewan, Manitoba and Ontario.

"This is the most measles cases reported in the first four months of the year since 1996," Dr. Anne Schuchat, the U.S. assistant surgeon general and director of the U.S. National Center for Immunization and Respiratory Diseases, told reporters.

"Measles has gotten off to an early and active start this year."

Half of the imported cases, or 17, were among returning American travellers or visitors from the Phillippines, where a recent measles epidemic has caused at least 20,000 illnesses.

Shuchat stressed that borders can't stop measles but vaccinations can.

The success of measles vaccination campaigns over decades means many younger doctors have never seen a case and some older ones could use a refresher on diagnosing it quickly and nipping its spread.

Among the 58 cases reported from California, at least 11 were infected in doctor's offices, hospitals or other health-care settings, according to a report released Thursday by CDC. New York City health officials say two of their 26 cases were infected in medical facilities.

To that end, a new journal commentary offers doctors advice on how to isolate suspected measles patients.

"As more parents decline to vaccinate their children, measles incidence is increasing — a fact that alarms me both as a hospital epidemiologist and as a parent of a vulnerable infant too young to receive the measles vaccine," wrote Dr. Julia Shaklee Sammons, an infectious disease specialist at the Children's Hospital of Philadelphia.

"For suspected cases of measles, early reporting and rapid control efforts are vital to prevent spread in health-care facilities. Providers should encourage patients and their parents to call before coming into medical offices or emergency departments so that appropriate precautions can be taken."

If measles is suspected, precautions include isolating the patient in a room with special ventilation to keep the air from circulating around the building, having the patient put on surgical wear and donning surgical masks or respirators for health-care workers.   
 
The measles virus spreads easily through the air and in closed rooms. Infected droplets can linger for up to two hours after the sick person leaves.
 
Measles causes a fever, runny nose, cough and a rash all over the body.

Unless physicians see a measles rash consistently, they may not be able to distinguish it from other rashes, said Dr. Mel Krajden, head of virology at the B.C. Centre for Disease Control. Krajden called vaccination key to containing measles.

Death occurs in one to three per 1,000 reported cases and is most common in young children or people who are immunocompromised, Sammons said.

The vaccine itself is not perfect.

"Today's measles outbreaks are too often the result of people opting out. Most of the people or 84 per cent of the U.S. cases that are reported to have measles this year so far were not vaccinated or didn't know their vaccination status. Of the unvaccinated U.S. residents, 68 per cent had what we call personal belief exemptions," Shuchat said.

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E-cigarette ban for minors proposed in U.S.

The U.S. Food and Drug Administration proposed rules on Thursday that would ban the sale of e-cigarettes to anyone under 18, but would not restrict flavoured products, online sales or advertising, which public health advocates say attract children.

The long-awaited proposal would subject the $2 billion US e-cigarette industry to federal regulation for the first time.

FDA commissioner Margaret Hamburg said at a briefing that the proposal represented the first "foundational" step towards broader restrictions if scientific evidence shows they are needed to protect public health.

Critics of e-cigarette advertising say it risks introducing a new generation of young people to conventional cigarettes when little is known about the long-term health impact of the products. And they lamented the fact that limits were not included in the proposed rule.

"It's very disappointing because they don't do anything to rein in the wild-west marketing that is targeting kids," said Stanton Glantz, a professor at the Center of Tobacco Control Research and Education at the University of California San Francisco. "They should not have been so timid."

Eric Scheman demonstrates an e-cigarette at Vape store in Chicago on Wednesday. The U.S. government wants to ban sales of electronic cigarettes to minors and require approval for new products and health warning labels. (Nam Y. Huh/Associated Press)

Hamburg said the current proposal "lays the foundation for many more actions and activities."

Vince Willmore, a spokesman for the Campaign for Tobacco Free Kids, said the proposal "by no means does everything we think needs to be done, but it starts the process. What is critical now is that they finalize this rule and then move quickly to fill the gaps."

Likewise in Canada, the Non-Smokers' Rights Association called the proposed U.S. moves a step in the right direction. 

"Right now, we have e-cigarettes being advertised and promoted in all the same ways that tobacco products were and that is one of the main risks we think to promoting e-cigarette use, nicotine addiction and possibly even cigarette addiction amongst youth is the re-normalization of smoking-type behaviours," said Melodie Tilson, director of policy for the Non-Smokers' Rights Association in Ottawa.

Ban on free samples proposed

A law passed in 2009 gave the FDA authority to regulate cigarettes, smokeless tobacco and roll-your-own tobacco and stipulated the agency could extend its jurisdiction to other nicotine products after issuing a rule to that effect. E-cigarettes use battery-powered cartridges to produce a nicotine-laced inhalable vapour.

'By not addressing the youth-directed marketing it means it won't be addressed for a very long time.'- Stanton Glantz

In the short term, the rule would prohibit companies from distributing free e-cigarette samples, forbid vending machine sales except in adult-only venues and prohibit sales to minors. Companies would be required to warn that nicotine is addictive, but no other health warnings would be required. The addiction warning would have to be added no later than two years after the rule is set. The companies would not be allowed to make health claims in any advertising.

The proposal is subject to a public-comment period of 75 days. Willmore said the FDA should aim to establish the rule within a year.

Some are skeptical that restrictions on marketing or flavors will come any time soon.

"The reality of these things is that every step takes years," said Glantz. "By not addressing the youth-directed marketing it means it won't be addressed for a very long time."

Evolving 'vaping' industry

Some e-cigarette companies that sell primarily through convenience stores were surprised at the lack of restrictions on online sales, since it can be difficult to verify a customer's age over the internet.

"The internet thing is very surprising to me," said Miguel Martin, president of Logic Technology, one of the biggest e-cigarette manufacturers. "It reduces the visibility of the sales of the products and the type of products that the government has awareness of."

The rules would require companies to submit new and existing products to the FDA for approval. They would have two years to submit applications from the time the rule goes into effect. Companies may continue selling their products and introducing new products pending the FDA's review.

In the meantime, they would be required to register with the FDA and list the ingredients in their products. They would not be required to adhere immediately to specific product or quality control standards. That could come later, Hamburg said.

Canadian regulations

E-cigarettes and other "vaping" devices generate roughly $2 billion a year in the United States, and some industry analysts expect their sales to outpace the $85-billion conventional-cigarette industry within a decade.

Advocates of e-cigarettes claim they are a safer alternative to conventional cigarettes, since they do not produce lung-destroying tar. But there is little data about their long-term safety.

Health Canada said in an email that it is monitoring the actions of other regulators and "considering all options for appropriate oversight of these products."

"Health Canada reminds Canadians that e-cigarettes with nicotine or e-cigarettes with a health claim are not authorized for sale in Canada," a spokeswoman said in an email.

"To date, there is not sufficient evidence that the potential benefits of e-cigarettes in helping Canadians to quit smoking outweigh the potential risks. A company would have to provide evidence of safety, quality and effectiveness in order to have its product authorized. Without this scientific evidence, Health Canada continues to advise Canadians, especially youth, against the use of these products."

The Nova Scotia government said it is looking for guidance from Health Canada before the province introduces legislation in the fall. Nova Scotia Health Minister Leo Glavine is concerned about what may be in the "juice" of e-cigarettes. 

"These are showing up in schools because they're not illegal," said Glavine. "So our legislation will bring e-cigarettes under the Smoking and Public Places Act and so that will be restrictive and also in terms of if there's approval in Canada for sales, they would not, of course, be able to be sold to minors."

Daniel David, a spokesman for the Electronic Cigarette Trade Association, said the FDA proposals should be adopted in Canada to make it clear to vendors that there are regulations to follow.

The FDA's proposal leaves many questions unanswered about how new products would be regulated over the long run. One key question relates to how products are approved.

Under current law, new tobacco products can be approved if they are "substantially equivalent" to a product that was on the market before Feb. 15, 2007. It is unclear whether any e-cigarettes were on sale before then, to be used as a benchmark.

Mitch Zeller, head of the FDA's tobacco division, said at a briefing that the agency would be seeking more information during the public-comment period on whether the "substantial equivalence" pathway is even valid for e-cigarettes.

If it is not, e-cigarette companies would have to use a different process, which would require them to prove their products are appropriate for public health, a higher hurdle to clear.

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MERS spread by travellers 'very likely,' WHO warns

Countries should be on the lookout for cases of MERS in people returning from Middle Eastern countries affected by the virus, the World Health Organization says in an updated risk assessment of the new coronavirus.

The number of known infections has skyrocketed in recent days, with Saudi Arabia alone reporting 48 cases on Wednesday and Thursday. In the 20 months since the world became aware a new coronavirus was infecting people, there has not been a single month where the total cases from all affected countries was as high as that two-day tally.

Saudi photographers wear masks during a soccer match in Riyadh on Tuesday. A spokesman for the World Health Organisation in Geneva told Reuters Friday it was "concerned" about the rising MERS numbers in Saudi Arabia. (Fayez Nureldine/AFP/Getty)

In the past two weeks alone cases were exported to Greece, Malaysia, Jordan and the Philippines, the global health agency said, warning that the virus may pop up in various parts of the globe carried by people who have been to countries like Saudi Arabia and the United Arab Emirates.

"It is very likely that cases will continue to be exported to other countries, through tourists, travellers, guest workers or pilgrims, who might have acquired the infection following an exposure to the animal or environmental source, or to other cases, in a hospital for instance," Thursday's risk assessment said.

The WHO noted that diagnosing cases rapidly may be a challenge because some have mild or atypical symptoms. The man detected in Greece, for instance, did not initially appear to have a respiratory infection. He had a protracted fever and diarrhea, but doctors were suspicious because he had travelled to Greece from Saudi Arabia. The man developed pneumonia while in hospital.

The risk assessment suggested that given the potential to initially miss MERS cases, health-care workers should apply infection control precautions consistently with all patients, all the time, regardless of their diagnosis.

The document said the WHO continues to recommend against border screening as a method of trying to detect incoming cases. As well, it recommends that governments not apply travel or trade restrictions against countries that are sources of MERS infections.

A senior official of the Public Health Agency of Canada said federal authorities are in regular communications with provincial and territorial counterparts about the situation and the possibility of imported cases of MERS or avian influenza in travellers.

Canada watching for cases in travellers

Dr. Theresa Tam said since last September more than 3,000 people have been screened in Canada, but to date no cases of MERS have been found.

"The bottom line is that we've been ramped up for quite some time, not just on this bug but to deal with any emerging viruses," said Tam, who is the head of the Public Health Agency's health security infrastructure branch.

"Like Greece or France or Italy, it's possible to get a traveller for sure. And so the system is designed to try to pick that up."

France, Italy, Germany and Britain have also diagnosed MERS cases in people who travelled to the Middle East or flew from there to Europe for treatment. Those importations happened in 2012 and 2013.

The number of MERS cases has soared this month, fuelled in part by outbreaks in health-care settings in Jeddah, Saudi Arabia, and Abu Dhabi, United Arab Emirates.

The WHO has confirmed 254 cases, but at this point its tally lags far behind the numbers reported by affected countries. The combined case count announced by countries has reached about 385 cases since the first known infections. The death toll to date is over 100.

More than 45 per cent of all MERS cases that have ever been diagnosed have been recorded this month. That enormous spike in cases is raising concerns about the virus, with experts wondering if it has changed to become more easily transmitted from person to person.

Person-to-person spread

The WHO says three-quarters of the recent cases appear to be ones where the transmission was person to person, not from an animal or environmental source to a person.

In two cases, person-to-person-to-person spread has been suspected, the risk assessment said.

There have been no recent reports of scientists analyzing MERS viruses to see if they have changed. But on Thursday, German coronavirus expert Dr. Christian Drosten confirmed that he recently received a shipment of samples from Saudi Arabia and his laboratory has begun to sequence the material.

"Currently the sequences don't tell a lot. They look all the same," said Drosten, who is the head of virology at the University of Bonn.

He cautioned that the work has just begun, and only a small portion of the viruses have been sequenced, but said that what he has seen so far looks 100 per cent identical to viruses from earlier in the outbreak.

The WHO risk assessment said it appears that there is slightly more human-to-human spread than there has been in the past. But whether that is because the virus had become more transmissible or is due to a combination of outbreaks in hospitals and more aggressive searching for cases can't be determined at this point.

The global health agency suggested that people who are likely at high risk of becoming seriously sick if they contract the virus should take precautions when visiting farms, barn areas or markets where camels are present.

Camels have been heavily implicated in the MERS story, though it is still not clear how people are catching the virus from the animals.

The WHO said people at high risk should think about avoiding camels, and refraining from drinking raw camel milk or food that may have been contaminated with animal secretions until it has been properly washed, peeled or cooked.

People considered to be at high risk of becoming seriously ill with MERS include those with diabetes, chronic lung disease, kidney failure or who are immunocompromised.

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