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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

Report: Fewer Infections Overall At Mass. Hospitals (But Problems Remain)

(UCI Irvine/flickr)

(UCI Irvine/flickr)

For the most part, patients are contracting fewer infections inside Massachusetts hospitals — but some problem spots remain, according to numbers from the state’s Department of Public Health.

WBUR’s Martha Bebinger reports:

It’s almost impossible to compare the quality of specific hospital procedures, but you can make a few hospital system comparisons.

For instance, the latest data show lower rates for three types of hospital infections — central line and surgical site infections for hysterectomies and colon operations. On the other hand, rates for urinary tract infections from catheters have increased.

Still, required reporting is spurring change, says Patricia Noga, VP for Clinical Affairs of the Massachusetts Hospital Association.

“When there is reporting and particularly when there is public reporting, people stand up and take notice of it,” Noga says. “Sometimes more than they would otherwise.”

Here are some specifics from the state Center for Health Information and Analysis:

•Central line-associated blood stream infections in Massachusetts have declined by 47%. In Massachusetts’ Intensive Care Units and neonatal ICUs, [such infections] declined by 57% and 49%, respectively.

•Surgical site infections related to abdominal hysterectomy declined by 23% in Massachusetts hospitals. While 8% of reporting hospitals had an observed to expected ratio greater (worse) than the national ratio, overall Massachusetts’ improvement is on track with positive national trends.

•Surgical site infections related to colon surgery declined by 19%. Massachusetts’ ratio of observed to expected infections is in line with the nation’s.

•Catheter-associated urinary tract infections have increased by 45% in the Commonwealth. In Massachusetts ICUs, [these types of infections] have increased by 64%. Among reporting hospitals, 15% had an observed to expected ratio greater (worse) than the nation’s. Massachusetts significantly lags national performance on this measure.

Continue reading

Poor Get Poorer But Babies Get Healthier, Thanks To Help For Moms

Patricia Wornum,right, is a 'home visitor' with Healthy Families. Every two weeks she check in with Keisha Harrison and her daughter, Cassidy, in their Dorchester home. (Gabrielle Emanuel/WBUR)

Patricia Wornum,right, is a ‘home visitor’ with Healthy Families. Every two weeks she check in with Keisha Harrison and her daughter, Cassidy, in their Dorchester home. (Gabrielle Emanuel/WBUR)

In elephant-print pajamas, 21-month-old Cassidy nuzzles her head into her mother’s lap and then pops up, grabs a ballpoint pen, and starts scribbling. Her squiggles decorate an important piece of paper; it contains a checklist of all the things her mother does for Cassidy, from getting her shots to daily reading aloud.

Cassidy and her mother, Keisha Harrison, are in their Dorchester living room with Patricia Wornum, a “home visitor” with Healthy Families Massachusetts. On the couch, Wornum glances at the decorated checklist and, in her perpetually upbeat manner, asks: “Any papers back from housing?”

Harrison shakes her head. She hasn’t heard anything about her various applications for subsidized public housing. She and Cassidy are staying with her mom — at age 20, she has aged out of a teen shelter — so Harrison is worried they’ve lost their spot on the housing waiting list. Wornum immediately makes a plan to figure out what’s going on. “You got this!” she says.

Wornum and over a hundred other home visitors in Massachusetts are trying to combat a known phenomenon: If you are born to a poor mother, that overwhelmingly raises the chances that you will grow up to be poor. The odds are stacked against you in several ways: Poverty can mean stress and anxiety, poor nutrition and environmental toxins, higher risks of obesity and heart disease. An entire issue of the journal Science on “The Science of Inequality” this month rounded up some of that bad news.

But it also shared what Janet Currie, an economics professor at Princeton, calls a “bright spot” — though inequality has been rising, the health of newborns born into the poorest families has been improving.  TWEET The conclusion: Public policies can make a difference and improve a child’s chance of success. The “Science” article she co-authored looks at which policies are most effective, and found many that work, from early education to family planning services. Home visiting programs like Wornum’s appear to work particularly well.

“You often just hear about how things are getting worse,” Currie says. “The unfortunate consequence of that is that people are left with the impression that nothing works. We wanted to point out that there are programs that work, that they do make a difference.”

What The Statistics Say

Keisha Harrison was in high school when she found out she was pregnant. She remembers it as a clarifying moment.

“Before I was pregnant I really didn’t think I was going to graduate,” says Harrison. “And then once I got pregnant, I just kicked everything into high gear.” Continue reading

Tick Season: Scary New Stats And Five Smart Tips (Spray Your Shoes)

A tiny nymphal deer tick among poppy seeds. Can you spot it? (TickEncounter Resource Center/ Brian Mullen)

A tiny nymphal (the most dangerous stage) deer tick on a poppy seed bagel. Can you spot it? (TickEncounter Resource Center/ Brian Mullen)

Fine. I’m a nag. I tell you the same thing over and over for your own good. But only once a year, and now is the time: Caution. Especially if you live in the Northeast, Midwest or mid-Atlantic. Watch out for the deer ticks that carry Lyme and other diseases.

This is the worst season, when the voracious adolescent “nymphal” ticks come out in force, plotting (I may be projecting a bit here) to creep under your clothes and drink your blood and give you their germs, knowing you’re unlikely to notice a dark speck the size of a poppy seed — check out the photo above — until it’s too late.

A bit of added incentive this year to take preventive measures: scary new statistics and some smart new tips. We cannot know whether this will be a particularly heavy tick year, but Dr. Catherine Brown, of the Massachusetts Department of Public Health, told WBUR, “We haven’t seen any weather in the last couple of years that is particularly bad for ticks, and so my suspicion is that there’s quite a few of them out there.”

That’s a suspicion already borne out by copious anecdotes along the lines of “I pulled a dozen of them off my dog this weekend on Cape Cod.” And tick spottings appear to be up around the country.

The scary new statistics come from the CDC: Last summer, it adjusted upward its estimate of Lyme disease prevalence by a factor of 10, to about 300,000 American cases a year. Most are easily resolved with prompt antibiotic treatment but some — an estimated 10 to 20 percent — are not, and once you’ve heard a few of the lingering Lyme horror stories, you resolve to do all you can to protect yourself and your loved ones.

‘May has definitely proven itself to be the tickiest month all across America.’
– Dr. Tom Mather

So what to do? The CDC offers its tips here, and I spoke with Dr. Tom Mather, director of the University of Rhode Island’s Center for Vector-Borne Disease and its TickEncounter Resource Center, a rich repository of evidence-based tick knowledge. He offered five fresh tips, and some new findings on how humidity affects the tick population:

1. Spray your shoes with repellent containing Permethrin. Dr. Mather: “Treating your shoes is a good idea because the nymphal-stage deer ticks are in leaf litter, and so as your shoes move through the leaf litter, that’s where those ticks take hold. They’re not going to to fall out of trees, they’re not going to fly and bite you or anything like that. They’re going to latch onto your shoes and crawl up, and they can crawl up pretty fast. And they’re going to crawl up generally inside your clothes.”

2. Pants. “And so the next place that you want to create a barrier would be your lower clothes, like pants legs. You should be treating the inside as well as the outside, or buy commercially treated clothes that are treated both inside and outside.”

3. The dryer: “Just strip your clothes off as soon as you come inside and throw them in the dryer for 10 minutes on high heat and that will pretty much desiccate any ticks you might carry in.”

4. But you can’t put your dog in the dryer: “So you want to make sure that your dog has effective quick kill product on it like Advantix II. Seresto collars are also very good.” Continue reading

CDC: Record-Breaking Year For Measles Due To Travel, Non-Vaccinated Residents

Back of female with measles/ Wellcome Library, London. Wellcome Images/flickr

Back of female with measles/ Wellcome Library, London. Wellcome Images/flickr

Measles, one of the most contagious diseases in the world, was officially eliminated from the U.S. in the year 2000.

Nevertheless, we’re in the midst of a record-breaking year for measles in this country, according to a new report from the Centers for Disease Control and Prevention, with 288 confirmed cases so far.

There are two main reasons for the spike, said Anne Schuchat, M.D. (RADM, USPHS) assistant surgeon general, United States Public Health Service and director of the CDC’s National Center for Immunization and Respiratory Diseases, speaking at a telebriefing for reporters today.

First, she said, travelers are importing measles into the U.S. from other parts of the world, including Europe, Asia, Africa and the Pacific, notably the Philippines, which has been experiencing a large measles outbreak. In addition, Schuchat said, the imported measles is spreading within communities of non-vaccinated people.

CDC: It's a record-breaking year for measles

CDC: It’s a record-breaking year for measles

From the agency’s weekly Morbidity and Mortality Report:

Most of the 288 measles cases reported this year have been in persons who were unvaccinated (69%) or who had an unknown vaccination status (20%); 30 (10%) were in persons who were vaccinated. Among the 195 U.S. residents who had measles and were unvaccinated, 165 (85%) declined vaccination because of religious, philosophical, or personal objections, 11 (6%) were missed opportunities for vaccination, and 10 (5%) were too young to receive vaccination.

When asked if the non-vaccinated U.S. residents who contracted measles had declined shots due to widely discredited information linking autism to the MMR vaccine, Schuchat said no, public health officials don’t believe that to be true.

Her bottom line message was clear, however: “This year we are breaking records for measles,” Schuchat said. “And it’s a wake up call. Measles may be forgotten but it’s not gone.” Continue reading