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Why You Really Need A Flu Shot (Even Though The Vaccine Isn’t Great)

(WFIU Public Radio/Flickr)

(WFIU Public Radio/Flickr)

By Richard Knox

This flu season is shaping up to be a bad one. And this year’s vaccine doesn’t work very well against the most common flu virus going around. So should you even bother getting a flu shot?

Yes. Putting it a different way: My wife, my daughters and I will. And the evidence says you’d be somewhere between slightly foolish and dangerously blasé if you don’t — depending on your personal risk factors.

I know there are naysayers — the Internet is full of them. “I recommend that my patients of all ages not take these incessantly promoted immunizations, primarily because of their lack of effectiveness,” writes blogger Dr. John McDougall. He says he’s not one of those across-the-board vaccine deniers but just doesn’t think flu vaccines (of any given year) are worth taking.

To understand why I think he’s wrong — even this year, when vaccine effectiveness is expected to be even lower than usual — you need to know something about the situation we’re all in.

Several viruses circulate during any given flu season. And flu viruses are always changing — sometimes not so much from year to year; sometimes in a bunch of little ways (a phenomenon called genetic “drift”); and sometimes in a big, sudden way, called a “shift,” which touches off pandemics.

Drifts Or Shifts?

Public health researchers constantly monitor flu virus mutations. But even the smartest flu dudes can’t know in advance when they’ll happen, or whether mutations will be drifts or shifts.

This year, one of the flu viruses outwitted them. Or, since viruses can’t have intentions, it’s better to say that random genetic drift in that viral strain, called H3N2, happened in late March. That’s a bad time in the annual cycle of vaccine production.

Just a few weeks earlier, leading flu specialists gathered at the World Health Organization in Geneva and decided that this season’s vaccine (for the Northern Hemisphere) should contain the same viruses as last year’s — two type-A viruses (an H1N1 that caused the pandemic of 2009 and has stuck around since, and an H3N2 that first appeared in Texas two years ago) and two type-B flu viruses.

Late-Breaking Mutant

Making each year’s flu vaccine is a complicated business that waits on no virus. The recipe has to be decided in February to get the chosen viruses growing in hundreds of millions of special chicken eggs, the first step in vaccine production. Continue reading

Viewpoint: Consider Tough Penalties To Boost Disabled Patients’ Access To Care

We already know that patients with disabilities face major obstacles when trying to access basic medical care. Now, a team of researchers are proposing some novel strategies to help fix the system, including withholding payments to health care organizations and making accreditation contingent on compliance with disability law.

The researchers, Dr. Tara Lagu and colleagues at Baystate Medical Center, Tufts University School of Medicine, and a Massachusetts not-for-profit organization, the Disability Law Center, suggest that this is the first time these types of strategies have been proposed.

“The goal of this paper was to start the conversation,” says Dr. Lagu via email.

Dr. Tara Lagu, M.D., MPH (Courtesy)

Dr. Tara Lagu, M.D., MPH (Courtesy)

Lagu’s groundbreaking earlier study on access to care for people with disabilities found that even in the current high-tech health care environment, many elements of routine medical care — like getting a patient on to an exam table — remain elusive.

The latest article, published in JAMA Internal Medicine, describes the range of barriers, including:

“…physical barriers to entering health care establishments, lack of accessible equipment, lack of a safe method for transferring the patient to an examination table, and the lack of policies that facilitate access.The barriers persist despite 2 federal laws (the Americans With Disabilities Act [ADA] of 1990 and Section 504 of the Rehabilitation Act of 1973) that explicitly state that health care settings must be accessible to patients with disabilities.

And here, Lagu offers some possible solutions:

As our study last year reported, patients with disabilities face real difficulties when they try to access health care. This suggested that our current strategy for enforcement, lawsuits, have fallen short. In part, this is because patients don’t want to bring lawsuits against doctors with whom they have an existing relationship and because lawsuits are extremely unpopular with physicians. More importantly, lawsuits have failed to initiate system-wide change: it is not clear that, in recent years, there have substantial improvements in access to care for patients with disabilities.

For these reasons, we believe that novel strategies are needed. As we considered what such strategies might look like, we considered other mechanisms of enforcement that have been successful at motivating change in health care settings, and we came to four possibilities: withholding payment, making accreditation contingent on compliance, regulation, and lawsuits at the state or national level aimed at initiating large-scale policy change. Continue reading

New Pro-Circumcision Guidelines: Cutting Comments, Adolescent Choice

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

Just days after the U.S. Centers for Disease Control and Prevention issued draft recommendations on male circumcision asserting that the health benefits outweigh the risks, more than 300 comments (and counting) have been posted on the agency’s website.

Surprise: The feedback overall reflects anger over mounting institutional support for what some call a “barbaric, outdated practice.” (The public comment period on the agency’s proposed recommendations ends on Jan. 16.)

Here are a few random comments:

When I was a little girl and discovered my little brothers had been cut, I was horrified for them and grateful I wasn’t born a boy.

The only benefit of infant circumcision is the fatter wallet of the circumciser. Wake up people! Condoms prevent sexually transmitted diseases, not circumcision. Males deserve the same protection from genital cuttings that females do. Shame on the CDC for condoning such a barbaric, outdated practice that nearly every other industrialized nation has refused to adopt!

Routine infant circumcision is morally wrong because it is non-essential cosmetic surgery performed on the body of a human being not yet old enough to give informed consent….

Your agenda clearly shows your primary purposes is for health insurance to pay for male genital mutilation. Please don’t continue to make the U.S. the continued laughing stock of the international medical community.

You get the picture.

The CDC stopped short of actually telling parents they must circumcise their baby boys; instead the agency offered guidelines — including a new recommendation that un-circumcised adolescent boys discuss the risks and benefits with their doctors — and laid out the latest research. Male circumcision, according to an AP report, can:

•Cut a man’s risk of getting HIV from an infected female partner by 50 to 60 percent.

•Reduce their risk of genital herpes and certain strains of human papillomavirus by 30 percent or more.

•Lower the risk of urinary tract infections during infancy, and cancer of the penis in adulthood.

Studies have not shown that circumcision will reduce an HIV-infected man’s chances of spreading the AIDS virus to women. And research has not found circumcision to be a help in stopping spread of HIV during gay sex.

The guidelines say circumcision is safer for newborns and infants than for older males, noting the complication rate rises from 0.5 percent in newborns to 9 percent in children ages 1 to 9, according to the CDC. Minor bleeding and pain are the most common problems, experts say.

CDC officials are recommending doctors tell parents of baby boys of the benefits and risks of circumcision…

These are the first federal guidelines on circumcision, a brief medical procedure that involves cutting away the foreskin around the tip of the penis. Germs can grow underneath the foreskin, and CDC officials say the procedure can lower a male’s risk of sexually-transmitted diseases, penile cancer and even urinary tract infections.

I asked circumcision expert Marvin Wang, co-director of the newborn nurseries at Massachusetts General Hospital (and someone who has performed thousands of circumcisions), about the new CDC draft recommendation, and he offered this thoughtful analysis:

First a little history:

For decades, the American Academy of Pediatrics (AAP) (which produces the majority of research-based policy for U.S. pediatric care) has led a relatively neutral stance on male neonatal circumcision, as the literature has shown that there is a relatively small health benefit by performing circumcision (there is huge debate on how one interprets the numbers on this, but overall, that conclusion is true). However, a game changer that tilted the balance towards claiming health benefits came in 2005-2007, when three separate World Health Organization clinical trials were performed in Africa demonstrating that circumcision among adult men in Sub-Saharan African settings reduced the acquisition of HIV by 50%.

With that, the AAP changed its recommendations in 2012 to reflect these studies. Their statement basically said that, yes, we know that there are health benefits now – enough to encourage parents to strongly consider circumcision for the newborn. However, the decision still lays with the parents, balanced by their beliefs (which may be influenced by religious, social or familial reasons). There are other tenets to the statement, but let’s just focus on this one topic, as this is most relevant to the recent CDC statement.

In light of the infectious disease issues involved, the medical community had been told that the CDC would make their recommendations regarding circumcision at about the same time as the AAP’s release. So, with this week’s statement, you are basically seeing a reaffirmation of the 2012 AAP statement. We don’t really see anything new. The health benefits touted in the CDC report have all been discussed before in the literature.

The only potentially new issue here is a topic that the 2012 AAP statement neglected: The idea of encouraging un-circumcised adolescents to discuss the option with their physician. Continue reading

Fat Stigma Fading? Fewer See Obesity As Problem Of Bad Personal Choices, Survey Says

Are public perceptions and stereotypes around obesity beginning to shift?

Maybe.

New research presented this week in Boston suggests that the general public and health care providers are starting to view obesity more as a “community problem of shared risks” as opposed to a personal problem stemming from “bad choices.”

These findings were presented as part of The Obesity Society’s Annual Meeting.

Americans’ view on fat has been evolving for some time, spurred by a robust “fat acceptance movement” and a decision last year by the American Medical Association to officially recognize obesity as a disease.  Also, a wave of media and advocacy revolving around healthier eating and lifestyles, from Michelle Obama’s Let’s Move campaign to the film Fed Up, has focused the national attention on the nitty gritty of food and weight.

The Obesity Society

The Obesity Society

The latest research shows that bias against fat people may also be evolving.

Here’s more from the Obesity Society news release:

…For adults in the United States, perception has moved away from seeing obesity as a personal problem resulting from bad choices. Healthcare professionals were already less likely than the public to view obesity as a personal problem of bad choices.

“Despite the high prevalence of obesity in the U.S. and worldwide, weight bias and stigma continue to complicate clinical and policy approaches to obesity treatment,” said study author Ted Kyle, RPh, MBA, of ConscienHealth in Pittsburgh, PA. “The goal of our study was to measure any shifts that might affect or result from public policy changes.” Continue reading

Expert Opinion: Travel Bans And Quarantines For Ebola Could Backfire

New York Gov. Andrew Cuomo speaks during a news conference at Bellevue Hospital to discuss Craig Spencer, a Doctors Without Borders physician who tested positive for the Ebola virus last week in New York City. Along with New Jersey Gov. Chris Christie, Cuomo announced a mandatory Ebola quarantine for health workers returning from treating patients in West Africa. (John Minchillo/AP)

New York Gov. Andrew Cuomo speaks during a news conference at Bellevue Hospital to discuss Craig Spencer, a Doctors Without Borders physician who tested positive for the Ebola virus last week in New York City. Along with New Jersey Gov. Chris Christie, Cuomo announced a mandatory Ebola quarantine for health workers returning from treating patients in West Africa. (John Minchillo/AP)

By Richard Knox

The United States has entered a new phase in its response to Ebola. Call it “officially sanctioned panic.”

Governors from both parties — N.J. Gov. Chris Christie and N.Y. Gov. Andrew Cuomo — declared over the weekend that even symptom-free health care volunteers coming home from Ebola duty in West Africa will be considered infected (and infectious) until they prove otherwise — by not falling ill for three weeks after their return.

Three out of four Americans want to seal the nation’s borders against travelers from Ebola-affected countries in West Africa. Republican members of Congress are demanding it.

But experts say mandatory quarantine of health workers and travel bans are unnecessary and could cripple the global fight against Ebola.

“The only way to buy an insurance policy is to defeat the disease in West Africa.”
– Prof. Alessandro Vespignani

Against this backdrop, I had a long conversation this past weekend with Prof. Alessandro Vespignani. He’s a Northeastern University expert on how humans behave in the face of disease threats. The main takeaways: The key to defeating the outbreak is to get health care workers to West Africa and back, so to the extent a travel ban or quarantines impede that flow, they will be dangerously counter-productive. And travel is so hard to control fully that bans do little to stem the spread of disease anyway.

Vespignani is spending a lot of time these days consulting with the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention and the World Health Organization on how the Ebola situation could evolve over the coming months.

He’s thinking some ominous thoughts, which he says reflect the views of U.S. and international health officials that he talks to. But the scenarios they worry about are very different from those that preoccupy many politicians and voters. Politicians worry more about the small, containable immediate threat to Americans of occasional imported cases than the longer-term and potentially catastrophic Ebola scenario that could affect the whole world — in other words, an Ebola pandemic.

Here’s an edited version of our conversation:

RK: Your group published a paper the other day in the journal Eurosurveillance that would seem counter-intuitive to many Americans. You say that imposing a ban on travelers from Ebola-affected countries won’t do much to prevent importation of the virus to the United States. Why is that?

Vespignani: People think if you have a travel ban everybody from those countries will be kept out. It’s not like that.

It’s important to know that we don’t have direct flights from West Africa. So a travel ban has to be coordinated internationally. There are a lot of people with two passports (whose country of origin can’t be easily tracked). People would try to circumvent the travel ban, and they wouldn’t be trackable — that’s one of the most dangerous things.

You can stop 95 percent of travelers from a country, but it’s very difficult to do 100 percent. And even a 90 or 95 percent travel ban is going to delay the arrival of Ebola (in the U.S.) by only about two months. It’s only buying time.

Already there is almost an 80 percent reduction in travel to the U.S. from that region, so we have already bought some time — about four to five weeks.

So what’s the practical effect of that delay? How much would a travel ban reduce Americans’ risk? Continue reading

E-Cigarette Debate: 7,000 Flavors Of Addiction, But What Health Risks?

I’m not young or edgy enough to hang out with anyone who smokes e-cigarettes, but I’ve been vaguely aware that they’re a big and growing thing, and the focus of a big and growing controversy. To wit: Do they end up a net positive, because they help people quit the classic “cancer sticks,” or a net negative, because they act as “gateway” cigarettes just when we’ve finally beaten our smoking rates down?

Answer: We don’t know yet. That’s my takeaway from a major multimedia project on electronic cigarettes on Boston University’s new research website. But it’s such an important question that it’s even a source of debate between prominent researchers on campus — though both strongly concur that more research is needed. From “Behind The Vapor:”

At Boston University, Avrum Spira, a pulmonary care physician and School of Medicine associate professor of pathology and laboratory medicine and bioinformatics who studies genomics and lung cancer, was one of the first scientists to receive funding from the FDA to investigate the health effects of e-cigarettes. “In theor y—- and how they’re marketed — e-cigarettes are a safer product because they don’t have tobacco, which has known carcinogens,” Spira says. “The question is: does safer mean safe?”

(From the Boston University video)

(From the Boston University video)

Across BU’s Medical Campus from Spira, Michael Siegel, a physician and professor of community health sciences at the School of Public Health, has emerged as perhaps the country’s most high-profile public health advocate for e-cigarettes. Siegel, who is not currently researching e-cigarettes, says he believes that the device could potentially help large numbers of smokers quit, or drastically decrease, a habit that is the leading cause of preventable deaths in the US. He points out that despite all the existing smoking cessation products on the market, only a small fraction of cigarette smokers manage to quit. Only 4 to 7 percent break the habit without some nicotine replacement or medication, according to the American Cancer Society. At the same time, Siegel says, more research is needed on the health effects of e-cigarettes as well as their effectiveness in helping people quit smoking.

Check out the full project here, including the video above, “7,000 Flavors of Addiction.” And while you’re on the new website, a couple of other particularly grabby features: The Secret’s In The Spit (the gluten-saliva link — who knew?) and The Secret Life of Neutrinos.

Opinion: Why America’s Ebola Fears Are Dangerously Misplaced

Cpl. Zachary Wicker demonstrated the use of a germ-protective gear in Fort Bliss, Texas on Tuesday. (Juan Carlos Llorca/AP)

Cpl. Zachary Wicker demonstrated the use of a germ-protective gear in Fort Bliss, Texas on Tuesday. (Juan Carlos Llorca/AP)

By Richard Knox

At the memorial service last weekend for the only person to have died of Ebola on American soil, the Liberian clergyman who eulogized his countryman Thomas Eric Duncan posed a question we all should be thinking hard about right now.

“Where did Ebola come from to destroy people — to set behind people who were already behind?” Methodist Bishop Arthur F. Kulah wondered.

Here’s the reality: Until the world (and especially the United States of America) refocus on the “people who were already behind” in this battle of virus-versus-humanity, no one can rest easy.

Ebola is an animal virus that has sporadically caused local human outbreaks in Africa for at least 38 years. But now it has crossed into people who live in densely populated African nations with barely functioning health systems and daily jet connections to the rest of the planet.

“It’s like you’re in your room and the house is on fire, and your approach is to put wet towels under the door.”
– World Bank chief Jim Yong Kim

This is entirely predictable, as scientists who watch emerging diseases have long known. They just didn’t know which virus would be the next to terrorize the world. (SARS and HIV showed how it can happen, remember?)

Those of us who, like me, report on global public health have a sense of inevitability as we watch the Ebola crisis unfold. We always knew it would mostly affect, as Bishop Kulah so aptly puts it, “people who were already behind.”

And we knew the people least affected by this scourge — privileged denizens of wealthier countries — would overreact out of misplaced fear for themselves, rather than a reasoned and compassionate understanding about what needs to be done.

So we see the freaked-out, wall-to-wall, feedback-loop media coverage we’re experiencing now. Schools closing down in Ohio for completely unnecessary disinfection. Recriminations against hapless health workers who suddenly find themselves dealing with an exotic new threat. Continue reading

What The Boston Marathon Response Can Teach Us About Ebola: 5 Lessons

By Leonard Marcus, Ph.D, Barry Dorn, M.D., Richard Serino and Eric J. McNulty, M.A.

The massive and growing Ebola outbreak in West Africa is tragic both in the suffering and deaths among the affected population and in the difficulty of mounting a sufficient response. The number of cases is rising exponentially. We have had the first death in the U.S., the first case of someone contracting the disease in this country and the first case of transmission in Europe. Over the weekend, a man who had recently traveled to Liberia was taken to Beth Israel Deaconess Medical Center to be evaluated for possible Ebola.

Fear and anxiety are rising.

This has the potential to be the defining public health crisis of the 21st century. Boston has stepped up by sending doctors and other health care professionals with extensive experience and expertise. There is, however, something more that Boston has to share: the leadership lessons from the Boston Marathon bombing response.

(Ebola in Guinea/European Commission HG ECHO/flickr)

(Ebola in Guinea/European Commission HG ECHO/flickr)

After the Marathon, we saw federal, state and local agencies, as well as organizations in the private and non-profit sectors, came together as an integrated enterprise that can serve as a model for the Ebola response. While the two events are quite different, the principles for leadership effectiveness are actually similar.

There are five key interrelated lessons from Boston that can be useful as the world confronts Ebola:

Build A United Effort

An effective Ebola response requires linking and leveraging many organizations into a collaborative, cooperative enterprise, much like we saw in Boston after the bombing. Continue reading

Crowdsourcing Food Poisoning; Yelping About Your Vomit

From the informatics experts at Children’s Hospital Boston who created Health Map to track local and global disease outbreaks comes another novel proposal: tracking food-borne illness through Yelp. Here’s their pitch to use social media for public health,  published on Vector, the hospital’s blog:

You just had a great meal at a restaurant. So you grab your phone and fire off a glowing review on Yelp.

Yelp Inc. /flickr

Yelp Inc. /flickr

Consider the opposite scenario: You just had a horrible meal at a restaurant. So you grab your phone and fire off a scathing review on Yelp.Now here’s one more: You had a great meal at a restaurant but woke up vomiting the next morning. Do you grab your phone and fire off a complaint on Yelp that your dinner made you sick… A report in Preventive Medicine, authored by John Brownstein, PhD, Elaine Nsoesie, PhD and Sheryl Kluberg, MSc, judges Yelp’s usefulness as a food poisoning surveillance tool. Their efforts are part of a growing trend among public health researchers of trying to supplement traditional foodborne illness reporting with what we, the people, say on social media. It’s estimated that some 48 million Americans get food poisoning every year, but that number is likely far off the mark. “Foodborne illness is under-reported, under-documented and hard to get at,” says Brownstein, who co-founded the HealthMap epidemic tracking tool and who also has a data grant from Twitter focused on foodborne illness. Continue reading

Leading Pediatrician: Sick Time Is Health Issue; Will Doctors Step Up?

(Mary MacTavish/Compfight)

(Mary MacTavish/Compfight)

Call me Sherlock Holmes, but when a ballot measure has “sick” in its title, I get a sneaking suspicion that it may involve an issue of health.

As in Question 4 on the Massachusetts ballots this November, which the secretary of state titles “Earned Sick Time For Employees” and summarizes as a proposed law that “would entitle employees in Massachusetts to earn and use sick time according to certain conditions.”

It would guarantee up to 40 hours of paid sick time if you work for a large employer and up to 40 hours unpaid if you work for a small employer. (More details here.)

This referendum — and measures like it in other states and at the federal level — tend to be portrayed as labor issues, pitting employers against employees. But Dr. Mark Schuster, Chief of General Pediatrics at Boston Children’s Hospital and Professor of Pediatrics at Harvard Medical School, argues that sick days are a health issue — and no one knows that better than doctors.

In the New England Journal of Medicine, he and Dr. Paul Chung of UCLA discuss the risks inherent in an economy where about 40 percent of employees get no paid sick leave, and many cannot even take unpaid sick days without risking their jobs.

They begin with the big-picture public health problem of the 2009 H1N1 flu pandemic, when health authorities were begging sick people to stay home and some workers were responding that they simply couldn’t.

And then there are the human difficulties that play out every day:

Consider a mother who knows both how to assess her son’s asthma symptoms and when he needs to see a clinician. If his medicine doesn’t seem to be working on a weekend or at night, they go straight to the clinic, he receives treatment, and they avoid a hospital admission. But when the boy has an asthma attack on a weekday morning, his mother sends him to school, fearing that missing work will mean losing her job. Three times in 18 months, when she waits until after work to bring him to the clinic, his asthma worsens, and he ends up hospitalized. Each time, what should have been three hours in the clinic becomes three days in the hospital.

Or consider a young girl with a fever and flulike symptoms who is given Tylenol and sent to school by her father because he can’t miss work. Two days later, the girl develops the rash characteristic of fifth disease on her cheeks. Her whole class has been exposed, and because the teacher is pregnant, her fetus is at risk.

About half of American workers get no paid sick days that they can use to care for family members, they note. And they end with a call to action directed at other health care professionals: “At the intersection between health and work, the health care community needs to provide a voice for patients and their families.”

Will it, though? Continue reading