Category Archives: Heart Disease

First double hand transplant involving a child declared a success

After almost 11 hours of surgery involving four teams of doctors, Zion Harvey had earned his place in medical history. The eight-year-old had become the first child in the world to receive two new hands in a procedure that seemed to herald a revolution in transplant medicine.

Two years on, the sports-mad boy from Baltimore, Maryland, is enjoying the freedom and independence his new hands have given him. In the first medical journal report of Zion’s pioneering treatment, published on Wednesday, the experts involved declare the operation a success and say other children could benefit from the knowledge gained.

Zion had to rely on others after he had his hands and feet amputated aged two when he contracted sepsis. For six years he used a combination of his residual limbs and specialist equipment to dress, wash himself and eat – until the double transplant changed his life.

“At 18 months [after the transplant], the child had exceeded his previous adaptive abilities. As of 18 months after transplantation surgery he is able to write and feed, toilet and dress himself more independently and efficiently than he could do before transplantation,” writes the team from the Children’s hospital of Philadelphia in the Lancet Child and Adolescent Health.

Organ transplantation is risky in that a recipient’s body may reject the new body part, while the drug regime involved carries a series of health risks. Two years on from the surgery he had in July 2015, Zion, now 10, is coping well with both.

Zion playing baseball

Zion playing baseball. Photograph: The Lancet/PA

“Cases like this demonstrate how new developments and innovation in science and transplantation have the potential to make enormous differences to the quality of life of patients,” said Lorna Marson, the president of the British Transplantation Society, which represents specialists working in the field across the NHS.

“Transplantation is a constantly evolving sector and it is heartening to hear the positive outcomes of groundbreaking transplants such as this one.”

More than 100 people worldwide have had a hand or arm transplant since the first adult received a new hand in 1998, closely followed by the first replacement of both hands in 2000. Many countries now conduct such transplants on small numbers of carefully selected patients.

In May 2000, a baby girl in Malaysia who was born with a severe congenital deformity became the first child to receive a new hand and arm, transplanted from her identical twin sister who died at birth.

Hand transplant graphic

In an update last year on his progress in the year since his surgery, Zion said: “The only thing that’s different is instead of no hands, I have two hands. I’m still the same kid everybody knew without hands.”

Referring to his new hands, he added: “Here’s the piece of my life that was missing. Now it’s here, my life is complete.”

Within eight months of the operation Zion was using scissors and crayons and after a year he was able to swing a baseball bat with both hands – once throwing the opening pitch at a Baltimore Orioles game.

Dr Scott Levin, team leader for Zion’s 10-hour surgery, has praised his young patient’s bravery. “I’ve never seen Zion cry. I’ve never seen him not want to do his therapy. He’s just such a remarkable human being, let alone child or adult. He has such courage and determination and gives us all inspiration,” he said.

But the last two years have been mentally and physically hard for Zion. He has had huge amounts of physiotherapy and occupational therapy to help him adjust, as well as counselling to aid his psychological recovery.

Zion after the transplant surgery in 2015

Zion after the transplant surgery in 2015. Photograph: Clem Murray/Rex Shutterstock

The doctors write: “Since his surgery he has undergone eight rejections of the hands, including serious episodes during the fourth and seventh months of his transplant. All of these were reversed with immunosuppression drugs without impacting the function of the child’s hands.”

He is still taking four different immunosuppressant drugs to maximise the chances of his body continuing to tolerate the pair of new hands, though doctors hope to reduce the dose.

“While functional outcomes are positive and the boy is benefitting from his transplant, this surgery has been very demanding for this child and his family,” said Dr Sandra Amaral, a member of the team at the Philadelphia hospital.

However, in an accompanying comment article, Dr Marco Lanzetta, an Italian expert in hand transplant surgery, doubts that many children could tolerate a similar procedure and highlights the risks from lifelong use of immunosuppressants. Zion’s case was exceptional as he was already on the drugs, after receiving a kidney from his mother, Pattie Ray.

Prosthetic hands and limbs, adds Lanzetta, have now developed so much that they, rather than transplant surgery, are more likely to prove the future for patients like Zion.

What is being done to tackle the NHS workforce crisis?

Concerns about the health and social care workforce are at an all-time high due, in part, to the impact of austerity, Brexit and the lessons learned from the Mid Staffordshire hospital scandal.

There has been a 96% drop in the number of EU nurses registering to work in the UK. Nursing and Midwifery Council (NMC) figures published in June showed a marked decline from a high of 1,304 in July 2016, to 344 in September, and then just 46 EU nurse registrants in April 2017.

Any indication that the UK is becoming a less attractive place to work is naturally a cause for alarm, especially as social care and health services will continue to depend on workers from outside the UK in the short to medium term. Actions by the government to reassure European Economic Area citizens and by the regulator to improve its processes are welcome, although much still needs to be done.

One example is the Cavendish Coalition, a group of 35 health and social care organisations that came together in the wake of the referendum result to address the workforce implications of Brexit.

A number of organisations are also working together to respond to the concerns of the workforce and to keep more of them working within the NHS and social care. While much attention has focused on the impact of seven years of pay restraint, other areas need to be addressed, including funding of postgraduate education, access to affordable accommodation, the poorer experience of BME colleagues, greater flexibility, and better use of technology.

Retaining talented staff is therefore crucial in the immediate term, but we must look at what we need to do to attract people to the healthcare sector in the longer term. NHS Employers’ own work in this area is stepping up, with a briefing document launched at its annual workforce summit, held in Liverpool in June, covering ways to bring in, and then consequently keep, local talent over the longer term.

There are plenty of instances of good practice from employers taking steps in this area, which we highlight.

South Tees hospitals NHS foundation trust works with Jobcentre Plus to offer a 12-week pre-employment scheme, which provides certain mental health service users with opportunities to get back into work through structured learning and vocational experience.

Meanwhile, Chelsea and Westminster hospital NHS foundation trust and Imperial College London medical school offer a scheme called MedEx summer school, which provides four-day work experience to year 12 students. It’s aimed specifically at students from underprivileged backgrounds who show talent for and interest in medicine.

Public Health England (PHE) uses the Project Search initiative, with a programme supporting young people with learning disabilities or who are on the autistic spectrum through a 10-month rotating work experience scheme, alongside specially tailored coaching and on-the-job training.

NHS Employers itself also has a number of programmes designed to help employers look differently at attracting and retaining a talented and diverse workforce, including practical support and information on apprenticeships, support to engage with young people via its ThinkFuture campaign, and briefings to encourage and support practices such as improving access to employment for people with mental illness.

The greater part of our workforce is sourced from the UK, and there is more we can and will do in that area. We need, however, to combine our focus on increasing domestic efforts with ensuring that the country develops a post-Brexit immigration system that won’t be detrimental to health and care.

There are many challenges facing the NHS, and more broadly, health and social care, regarding the availability of our workforce. We will continue to challenge the government to support better supply and retention, but we must also challenge ourselves to improve access to employment and to retain the people we already have through better quality workplaces and work.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

If you’re looking for a healthcare job or need to recruit staff, visit Guardian Jobs.

Suicide Act breaches human right to dignity, high court told

The 1961 Suicide Act breaches human rights protecting dignity and personal autonomy and should be declared illegal, the high court has been told.

At the opening of a week-long courtroom challenge aimed at legalising assisted dying, Richard Gordon QC said risk cannot be entirely removed from making difficult medical decisions at the end of patients’ lives.

Gordon represents Noel Conway, 67, a retired lecturer suffering from motor neurone disease, a terminal degenerative illness. He has been diagnosed as having less than 12 months to live.

Conway, who wants medical help to end his life in the UK, is too unwell to attend the hearing in court nine of the Royal Courts of Justice in London. He is expected to participate by videolink on Wednesday.

The court has been told that section two of the act, which criminalises any attempt to encourage or assist another person in killing themselves, is incompatible with article 8 of the European convention on human rights, which guarantees a right to respect for private life.

Gordon said those over 18, diagnosed with a terminal illness and given less than six months to live, who have made a voluntary, clear and settled decision to die and have the ability to undertake a final act, should be allowed medical assistance to carry out their wishes in the UK.

Currently, those wishing to end their lives in a more dignified and less painful way say they have to travel to the Dignitas clinic in Switzerland. Conway and his supporters say the UK ban forces them to make that choice far earlier than should be the case.

“The aim of the challenge is to ensure autonomy for everyone in this group,” Gordon said. “Maybe there will be some risks [to weak and vulnerable people], but risks are already present in the law.”

The legal challenge, he told the court, was not about morality, but the law being incompatible with human rights.

Speaking ahead of the hearing, Lady Meacher, the chair of Dignity in Dying, said: “About 80% of the population support a change in the law to make assisted suicide legal. People feel passionate about this issue and MPs need to understand that.”

In 2015, the House of Commons rejected a private member’s bill to introduce assisted dying. It was talked out before MPs had an opportunity to debate the bill in detail.

Linda Deverell, a patron of Dignity in Dying, which supports Conway’s challenge, said before the hearing that a system requiring the approval of at least two doctors and a judge for assisted dying would provide sufficient legal safeguards.

“A law like that is very tight and it’s been working perfectly well in the US state of Oregon for the past 20 years,” she said.

Deverell’s husband had terminal cancer and travelled to Belgium to end his life. “It was absolutely his choice,” she said. “He had to go earlier than if he could make the choice here.

“Not everyone can do it. People talk about ending their lives, but when it comes to it and saying ‘This is the moment’, not all are comfortable with their own mortality.

“My husband would have had a few more weeks [if assisted dying had been legal in the UK]. He always had a very bad reaction to morphine. The last few weeks when the cancer was in his liver and lungs were very painful.”

The hearing continues.

The man who may have secretly fathered 200 children

Twenty five years ago, when she was 35, Esther-Louise Heij made two decisions that would shape the rest of her life. The first decision went entirely to plan: it gave her the children she longed for. But the second decision would play out in a bizarre twist she could never have imagined, and would plunge her family into a sea of heartache that continues to this day.

Both decisions were brave to make a quarter of a century ago, and are testament to Heij’s judgment as well as her tenacity. First, she decided that although she was single, and had recently ended a 12-year relationship, she would forge ahead with her plans to become a mother by opting for IVF with donor sperm.

Second, and no less unusual at the time, she would make sure that her children would be able to trace their genetic father.

“Back then, the accepted wisdom was that donor children didn’t need to know,” she says. “But I felt it was their right to know. Where we come from, who our parents are – these things are important in anyone’s life, and I wanted them for my children.”

She heard about a clinic near Rotterdam whose director sounded forward-thinking, went along for a consultation, and was impressed.

“The doctor seemed very good at what he did,” she says. “He was a pioneer in his attitudes. He talked me through what it would be like to raise children on my own; he seemed very serious and professional.”

And he was supportive, too, of her hope that any children she had would be able to know their father. “He assured me that would be possible. He was an important doctor in a white coat. I trusted him; it never crossed my mind that I couldn’t.”

The doctor, Jan Karbaat, told Heij that he would find a donor whose physical attributes fitted into her family. “He asked me for pictures of my relatives, so he could find a good match. And he said he would make sure the donor was a man who would be open to being traced later.”

The Heij family.

The Heij family. Photograph: Joanna Moorhead

Heij and her children live in the southernmost tip of the Netherlands: their village, she tells me proudly, is on the only mountain in the country. “You won’t see scenery anywhere else in Holland like this,” she says, as we drive up the hill towards their house. Its hilltop position is fitting, because there have been many peaks and troughs to navigate for the Heij family.

During a long relationship with a partner, the one that lasted 12 years, she was pregnant twice; both times it ended in a stillbirth. Once she got the go-ahead for IVF from Karbaat, there would be nine unsuccessful attempts before she got a positive result. A daughter, Lotte, now 23, was born in 1994. Almost two years later, in 1995, Heij gave birth to a second child, Yonathan; Karbaat assured her the sperm was from the same donor.

Being a single mother of two was tough; but it was also the life she had wanted, and Heij has no complaints. The family moved around, supported by her work as a physiotherapist: living first in a village on an island in the north of Holland, then on an island in Norway.

She tried to be as open as possible with the children about their roots. “I told them: ‘A man gave his seed and that’s how you were born: if you want to know who he is you will get the chance to do that one day.’”

There were many children in the neighbourhood who didn’t live with both parents; but people asked questions that weren’t always easy to deal with, particularly for Yonathan. “They would say, ‘Where is your father?’ I made up a story about him being a man called Peter from Rotterdam, who was the captain of a ship, which explained why he was never around.”

One of the things that brought them back to Holland was Yonathan’s academic prowess: he was bright, and teachers at the small school in Norway felt they couldn’t challenge him sufficiently. Back in Holland, though, he flourished; Lotte, too.

When Lotte reached 16, she turned out not to have a burning desire to contact their father. Two years later, Yonathan took a different view. “For a boy to grow up without a father figure is a big thing; a father is important, especially for a boy. I wanted to know who he was: there were things I wanted to ask him. And I wanted to find out whether certain ways I behaved were connected with him – things that made me seem different from my mother and my sister, like that I’m much more laid back than they are.”

In 2011, Yonathan and his mother approached the organisations that should have been able to get the information she needed from Karbaat’s clinic. The news that came back was worrying: the files were in disarray, records had not been properly kept, and it was going to be difficult to find out who their donor was. What had originally seemed like an easy quest was going to be a much tougher haul; but they pressed on, making phone calls and filling in forms and requesting information.

Yonathan and Lotte speak to journalists prior to a court decision last month.

Yonathan and Lotte speak to journalists prior to a court decision last month. Photograph: Remko de Waal/EPA

At the same time, though, they became aware of growing suspicions about Karbaat’s clinic. “Rumours were rife,” says Yonathan. There were stories starting to circulate that the sperm donors had been fellow doctors, medical students; but the biggest upset of all were rumours that Jan Karbaat himself had provided much of the sperm that had impregnated his patients.

“We were in shock – it was a feeling of total disbelief. Karbaat was a doctor, and to use his own sperm to get women pregnant would have been totally prohibited. It was difficult to process the enormity of what this meant. But right away I thought: ‘This man could be my father.’ I was scouring pictures of him, looking for physical similarities.”

Yonathan was thrown into emotional turmoil. He had previously written to Karbaat asking for information about his father, and the letters had been returned unopened. “I thought, is that how little he cares? He seemed so cold, so arrogant. And this man could be my father – it was all very hard to come to terms with.”

Then a documentary about the clinic, shown on Dutch TV, raised the disturbing possibility that as many as 200 children could have been fathered by the same sperm donor.

“Yonathan was watching the television, saying: ‘These could be our brothers and sisters,’” says Heij. “A lot of them were very intelligent, just like him; and we were looking at them thinking: ‘Do they look like Yonathan and Lotte?’”

The family was thrown into a quandary, and found themselves at the centre of a very public controversy: eventually, both children gave DNA samples to find out whether they were related to any of the others conceived at the clinic who were now seeking answers.

Groups of individuals were found who were related to each other, but there seemed to be no sibling match for Yonathan and Lotte. “It was disappointing,” says Yonathan. “I hoped I would find at least some siblings. But I still wanted to know who my father was. Some people were saying: ‘If your father was Karbaat, maybe it would be better not to know.’ After all, he’s turned out to be an unscrupulous man. But I said no, I still want to know – however bad he was, he must have had some good qualities. It was like part of my identity was missing. I knew I needed to find out the truth.”

Over the past 18 months, a group of families whose children were born via IVF at Karbaat’s clinic have started legal proceedings to allow them to do DNA tests using cells from Karbaat.

Karbaat opposed the move, but he died, aged 89, in April this year. Police seized personal objects from his home, including his toothbrush, and a ruling on whether the DNA taken can be released to the families is expected shortly. In the meantime, though, the Heij family’s own DNA tests have proved Yonathan and Lotte are definitely full siblings, and that their father is most likely to come from central Europe.

The Heij family.

The Heij family. Photograph: Courtesy Esther-Louise Heij

The situation is changing all the time, says Yonathan: one of Karbaat’s acknowledged children has now been DNA-tested, and the results of that test suggest it’s less likely the Heij children are Karbaat’s, though by no means certain.

“Everything is up in the air now. I’m conscious that I may get a phone call tomorrow telling me who my father was, or I might have to wait 20 years,” he says. “It feels like waiting to find out whether you’ve won the lottery, but knowing you probably will.”

Indeed, according to Laura Bosch, of Defence for Children in Leiden – the legal organisation representing the Heijes and other families – that is precisely the point: technological advances, she says, have made ethical issues concerning paternity identification redundant.

“The existence of large DNA databases mean it’s getting easier and easier to trace a donor parent – it’s no longer feasible for anyone to say donors have the right to anonymity. I would argue that in any case the child’s right to information should prevail, and takes precedence over the donor’s right to anonymity, but the landscape is shifting.”

The health minister of the Netherlands, Edith Schippers, has asked men who donated sperm pre-2005, when the right to anonymity was lifted, to do “a second good deed” and come forward to make it easier for their children to trace them.

The emotional turmoil has taken its toll on 58-year-old Heij, who seems tired, and is tearful discussing all she’s been up against. But when it comes to Karbaat, she finds it impossible to condemn him out of hand. “He made me a mother,” she says simply. “He gave me these wonderful children. But he was also arrogant and narcissistic. He seems to have thought he was better than other donors, that he was doing women a favour to get them pregnant using his sperm.”

For Yonathan, meanwhile, the saga has led to what might seem a surprising decision. “I’ve decided to become a sperm donor myself,” he says.

As he explains it, it makes perfect sense. “I know that any children born as a result will be able to find me in the future. And I feel I will be able to help them, I will understand their situation in a way some donors can’t, because I’ve been through everything they’re going through. I will be able to relate.”

On Karbaat, his feelings are mixed. “He was a clever man but it’s dangerous to allow someone to work with no brakes; he had a lot of power, and a big ego. He wasn’t honest with my mother or with other patients – he didn’t tell the whole truth. I feel he had good intentions but his methods were wrong – he didn’t do things the way they should have been done, and some of the things he should never have done at all.”

Woman who fears daughter faces FGM gets deportation reprieve

Theresa May has intervened to halt the deportation of a woman who claimed that her three-year-old daughter would face female genital mutilation if they returned to Nigeria.

The decision to refuse Lola Ilesanmi’s application to remain in the UK has been withdrawn and the prime minister has ordered Brandon Lewis, the immigration minister, to personally oversee a review of her case.

Ilesanmi, 29, alleged that she was beaten, forced to have an abortion and had her face “smashed with an iPad” by her estranged husband because of her refusal to subject their daughter to FGM. He has denied the allegations.

May wrote a letter to Ilesanmi’s MP, Hannah Bardell of the Scottish National party, stating that she regarded FGM as “abhorrent” and that Amber Rudd, the home secretary, had heard her account.

In her letter, the prime minister said: “FGM is a crime, it is child abuse and will not be accepted in this country. This government will not tolerate a practice that can cause extreme and lifelong physical and psychological suffering to women and girls.

“I made my commitment to end this practice clear during my time as home secretary … This government takes the issue of FGM very seriously and remains committed to ending FGM within a generation.”

Ilesanmi, who worked as a business analyst with RBS for four years in Livingston, Scotland, had a joint visa with her husband. He is believed to have told Home Office officials that they were estranged after she and her daughter fled the marital home. The Home Office subsequently refused Ilesanmi leave to stay in the UK.

Bardell appealed for May to intervene at prime minister’s questions in the House of Commons earlier this month.

Hannah Bardell, left, with Nicola Sturgeon

Hannah Bardell, left, with Nicola Sturgeon. Photograph: Jeff J Mitchell/Getty Images

The MP said she was very glad about May’s intervention and added: “Lola needs leave to remain to restart her life in Livingston … Leave to remain is not yet guaranteed and is vital for the safety of Lola and her young family.”

Ilesamni has previously said that she wants to rebuild her life in Scotland, her home for the past six years. “I am not here for benefits, I am not here to seek help from the government,” she told the BBC. “I am an educated woman I just want to continue to empower myself so that I can continue to contribute to society, to contribute to the community.

“All I ask is just to get my life back together and to not allow this man to win because that would be the height of abuse.”

A report released last week disclosed that more than 9,000 attendances to NHS services in England in 2016 involved the identification or treatment of FGM. The data, covering the period from April 2016 to March 2017, includes figures from NHS trusts and GP practices.

The findings show that there were 9,179 attendances in the past year in which FGM was identified or treatment was given or a woman with FGM had given birth to a baby girl. In total, 5,391 attendances were recorded in the system for the first time, including 114 cases involving girls under the age of 16.

‘Cholera is everywhere’: Yemen epidemic spiralling out of control

Ali Muhammad’s entire family are sick. In the months since his home district of Abs in northern Yemen was hit by a cholera outbreak, he has lost both parents and all six of his children have fallen ill.

“Cholera is everywhere,” he said, according to a testimony provided by Médecins Sans Frontières, who are caring for his eldest daughter at a cholera treatment centre in Abs. “The water is contaminated and I don’t drink it. We have tanks, but we don’t get water regularly. The situation cannot be worse.”

As the area grapples with both the cholera epidemic, which began to spread in April, and the impact of the country’s civil war, the life of the qat harvester has become harder and harder. “Everybody is sick and in rough shape, and their poor financial condition does not enable them to move from one health centre to another.

“My father got sick and although we hospitalised him, he passed away. My mother died as well. And I am just like many others.”

The Abs district was the scene of a deadly airstrike by the Saudi-led coalition last August that demolished a hospital supported by MSF, killing 19 people, including one of the aid agency’s staff members, and injuring 24.

Less than a year later, as the ongoing conflict hits an stalemate, creating the largest humanitarian crisis in the world, the MSF cholera treatment centre in Abs town alone is receiving more than 460 patients daily, which is more than anywhere else in the country.

A girl drinks water from a well that is allegedly contaminated with cholera.

A girl drinks water from a well that is allegedly contaminated with cholera. Photograph: Hani Mohammed/AP

The International Committee of the Red Cross warned on Monday that the cholera epidemic in Yemen was spiralling out of control, reaching a milestone of over 300,000 suspected cases. More than 1,600 people have died. Children account for nearly half of all suspected cholera cases in the country, according to the UN’s children agency.

Sana’a-based Taha Yaseen, from the Mwatana Organisation for Human Rights, said obstacles that stand in the way of controlling and containing cholera today in Yemen, include but are not limited to the ongoing war.

“During [the war] almost all health facilities and healthcare services reached a point of thorough collapse and thus are unable to respond to the increasing need to address fatal diseases and civilian victims. Many hospitals [have] shut down and many others were hit either by air or ground strikes, occupied by militias or used as military barracks,” he told the Guardian.

“Most [people] cannot afford even the transportation from their countryside areas or displacements communities to the nearest medical centres to treat them for cholera,” he added.

MSF’s Roger Gutiérrez, who has just returned from a seven-month service in Abs, said the wards in the hospital there, the only public hospital in the area, “are bursting at the seams … what’s happening in Abs sums up the current state of Yemen.”

The district hosts more internally displaced people than anywhere else in the country but most health facilities are not functioning; there is a lack of staff and medical supplies are running short.

“When a plane flies overhead, many patients and staff feel that fear, that vulnerability. For seconds everything stops,” he said, according to a testimony provided by MSF. “You see mothers disconnecting their children’s feeding tubes so they can run out of the hospital’s nutrition ward.”

Ayed Ali, a Yemeni caretaker based in al-Sharq district of Hajjah governorate, said most people in the area drink from exposed wells and tanks, “no matter the water is clean or not”. “There are no salaries and no services,” he said, according to MSF. “Even public hospitals are down. There are no drugs. If you have money, you get treatment. Otherwise, you’ll die.”

The conflict in Yemen is between Houthi rebels controlling the capital Sana’a, who are allied with former president Ali Abdullah Saleh, who led the country from 1990 to 2012, and forces loyal to the ousted president, Abd-Rabbu Mansour Hadi. Since March 2015, Saudi Arabia has led a US-backed military intervention in Yemen, aimed at reinstating Hadi, who lives in exile in the Saudi capital, Riyadh, and countering advances of Iran-backed Houthis.

Yemen expert Adam Baron, speaking to the Guardian, said “the key thing to remember is that while combat deaths continue to get more attention, it is the indirect results of the conflict – things like the cholera outbreak, the hunger crisis and the rise of deaths from preventable disease – that remain the largest killers.”

While Houthis have taken some significant losses this year, Baron said the conflict has largely seen a continued stalemate on most key fronts. “By and large, the war in Yemen continues to flare,” he said. “Airstrikes and shelling continue as civilians continue to get caught in the crossfire. But even as the conflict proves to be the catalyst for the collapse of Yemen’s already weakened healthcare system, the country continues to get little attention. The worry is that this won’t change until it’s far too late.”

According to the World Health Organization, suspected cholera cases have been reported in 95.6% of Yemen governorates. Apart from Hajjah, the other three affected areas are Amanat al-Asimah, al-Hudaydah and Amran. Only 45% of health facilities in Yemen remain with limited functionality, the UN has said.

4 Unexpected Ways Summer Heat Is Throwing Your Body Out of Whack  

Summer is finally in full swing—which means cute sandals and sunglasses, beach vacations, and ridiculously scorching weather. If you’re feeling the heat, literally (does it really need to be 85 degrees before nine in the morning, seriously?) you’re not alone.

Hot temperatures can mess with your body in all sorts of sneaky ways, and we don’t just mean the threat of a sunburn or sweating through your outfit on the way to work. Here are four common ways hot, humid weather takes a toll on your health, plus how you can beat heat’s effect on your system.

RELATED: 20 Ways to Stop Allergies

You’re sniffling and sneezing

Flowers bloom in the summer—and so do plants and grasses that produce pollen, says Kim Knowlton, MD, an assistant clinical professor at Columbia University’s Mailman School of Public Health. In response to the warm weather, pollen production goes up, and the presence of pollen in the air can leave even people with mild allergies sneezing, sniffling, and rubbing their itchy eyes through Labor Day.

To reduce these allergy symptoms, pay attention to the daily pollen count and try to stay indoors as much as possible on high-count days. If you can’t give up your outdoor run or yoga class, try to time it (as well as other outside activities) toward the end of the day, when pollen counts go down. And keep windows shut in your house to keep allergens from turning you into a sneezy mess in your own home.

You toss and turn all night

Too hot to sleep—but the air conditioning in your room is making you shiver? Summer makes it tough to find that happy medium. Most people sleep best when the temperature is at 65 to 66 degrees; as the temperature goes up, sleep quality tends to go down, says Chris Winter, MD, neurologist and sleep medicine specialist at Charlottesville Neurology and Sleep Medicine in Virginia. 

The right temperature could also help you stay asleep through the night and score better sleep quality. So if you find yourself waking up fatigued and fuzzy-brained, try adjusting the thermostat. Dr. Winter says many of his patients have reported resting much better when they lower their bedroom temperature, even if they hadn’t noticed sleep problems. Don’t feel guilty for using so much electricity—cranking up the AC to a healthy level is good for you.

Your heart pounds way more than normal 

You do a hard-charging cardio workout three times a week, but your heart rate is suddenly spiking on your walk to work in the morning. What gives? Jonathan Newman MD, MPH, cardiologist at NYU Langone Medical Center in New York City, says higher temps have both direct and indirect effects on your heart.

For starters, if you live in an urban area, you may notice smog or haze fogging up summer skies. Air quality tends to get worse at higher temperatures, and that air pollution itself can take a toll on the heart and vascular system, Dr. Newman says.

Plus, at the most basic physical level, “your heart is working overtime” in the summer, says Kim Knowlton, MD, an assistant clinical professor at Columbia University’s Mailman School of Public Health. “Your heart beats faster in order to pump overly warm blood from your body’s core out to the skin’s surface,” says Dr. Knowlton, which helps cool you down.

Since your faster heartbeat is all part of your body’s way of keeping you cool, there’s not much you can do to prevent it. Taking normal precautions in the heat—drinking lots of water, not exerting yourself too much—are always good ideas. And of course, ”eating a heart-healthy diet, controlling your blood pressure, controlling your cholesterol, and increasing physical activity,” Dr. Newman says, will keep your ticker in good shape so it can handle 90-degree days.

RELATED: Everything You Must Know About Mosquitoes This Summer

You’re racking up lots of mosquito bites

When the weather is warm, you want to spend as much time in the great outdoors as possible. But while you’re embracing nature, dining al fresco, or just enjoying a backyard barbecue, mosquitoes are making you their buffet.

Unfortunately, summer is prime time for mosquitoes. Their prey (in other words, us) are outside more, and the little vampires also mature faster when the sun is out strong. That means skeeters live fast and die young, so the time between the day one hatches and the day it becomes a disease-transmitting adult is shorter. With mosquitoes taking less time to reach this stage, diseases (such as Zika and the West Nile Virus) can spread more quickly, says Aileen Marty, MD, an infectious disease specialist in Washington, D.C. 

What can you do to protect yourself? When you’re hanging outside, skip your signature scent in favor of bug spray, says Debra Jaliman, MD, New York City-based dermatologist and author of Skin Rules. She recommends Ultrathon Insect Repellent. ”It’s creamy and it says on your skin longer,” says Dr. Jaliman. It also has DEET, one of the few ingredients that have been shown to be truly effective in warding off mosquitoes.

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And what you heard as a kid is right—don’t scratch! As itchy as these bites are, scratching them can create an open wound, making you susceptible to infections, especially since there’s plenty of bacteria hiding under your nails, says Dr. Jaliman. 

If you just can’t keep your hands off your bites, Dr. Jaliman has a few suggestions. ”Use ice cubes to stop the itching; over-the-counter hydrocortisone cream or aloe vera gel will also diminish the itch and reduce swelling,” she adds.