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One Doctor Asks: Why Are We Arguing About Measles Vaccines In 2015?

By Dr. Rebecca Weintraub
Guest Contributor

This week, as I juggled work, family and shoveling, I prepared a lecture on promoting equity in health delivery. My first slide is a picture of the Ebola virus, and as of this morning, my last slide is a map of the ongoing measles outbreak. That’s because this week, we’ve heard a clear public health message from both President Obama and Surgeon General Vivek Murthy: Vaccines are safe and effective.

Why is this message being repeated in 2015?

As a mother and physician, I am dismayed that all Americans are not practicing this guidance based on evidence from 40 years ago. Vaccines are safe and effective. There is no link between vaccines and autism.

In 1757, Dr. Francis Home proved the infectious nature of measles and detected the virus in blood. The highly contagious virus spreads via droplets and replicates within the newly infected person for 14 days. The symptoms include high fever, red eyes, runny nose and cough. A few days after the onset of these symptoms, “Koplick’s” spots—bluish markings on the inside of the cheek—appear. Then, a rash starts at the head and travels to the feet. The infected person is contagious for four days before and after the onset of the rash. We test suspected cases for antibodies against the virus. After confirmation, the treatment is supportive, including rehydration, nutritional support, medicines to reduce fever, antibiotics for superimposed infections, and Vitamin A supplementation. Once the measles infection has taken hold, there is no cure.

We’ve made tremendous strides in the discovery and development of new vaccines. In 2000, the Centers for Disease Control and Prevention declared the measles virus eliminated. But now, there are over 100 confirmed cases of measles across 14 states. Our most vulnerable populations are at risk of contracting an entirely preventable disease. This is not only an issue of choice, but an issue of health equity and our role as global citizens.

So now we can, and must, eradicate measles… again. We can learn from Mississippi and West Virginia, which have been at the forefront of new vaccination efforts. Continue reading

Why The Current, Post-Eradication Measles Outbreak Is So Infuriating

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

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

That certain parents refuse to get their kids vaccinated isn’t new. But suddenly, it’s news. And it’s troubling. I’m a big supporter of “crunchy” parenting, but not when it puts other people’s children (and mine) at risk. The current measles outbreak has infuriated many parents and medical professionals who, fuming, wonder why we are arguing about a virus that was already eliminated here in the U.S. 15 years ago.

So, here’s one such parental rant on the topic by Alicair Peltonen, an administrative assistant at the Harvard School of Public Health and a journalism student at the Harvard Extension School.

By Alicair Peltonen
Guest Contributor

When I was in elementary school, one of my favorite books was called “The Value of Believing In Yourself,” by Spencer Johnson, MD. It was part of a children’s book series meant to teach lessons through the life stories of historical figures. The Value of Believing In Yourself was about Louis Pasteur and his quest to develop the rabies vaccine.

That book still stands as my most cherished source for the science of immunity. Even with a bachelor’s degree in biology, a career spent working in scientific and medical research and a current job in the immunology department of a prestigious graduate school, I still picture all viruses as scruffy black blobs with scary pink faces and foaming fangs. And vaccines are the steadfast soldiers in uniform with huge mustaches and bayonets that are sent in to get the bad guys. How on earth could anyone be more scared of the soldiers than the black blobs?

I have kids. I know all about fear. Those first days with my oldest daughter were magic, but it was a dark magic. It came with visions of this tiny creature I was now in charge of falling off my lap as I breast-fed or rolling face-first into a crib bumper. I imagined a hundred ways she could be injured or worse — and I imagined all the ways it would be my fault.

I went straight to my local Isis Maternity (a wonderful organization that no longer exists) and signed up for new mommy classes. Those classes were an education for me, not in what to do as a new parent, but what not to do. All the women I sat criss-cross applesauce with were lovely, caring, engaged moms who were genuinely searching for the best way to rear happy, healthy child. And every single one of them was irrationally afraid of one thing. And those “things” were all different. Continue reading

Frostbite, Hypothermia And Other Fun Facts To Remember On Blizzard Day

It’s going to be a long, long day. If you’re like us, you’ve already cooked some kind of elaborate breakfast, chosen the morning movie lineup, and set up the “Let’s Dance” Wii. And it’s not even 8 a.m.

When you’re ready to venture outside and “play,” remember it’s freezing, with ferocious winds. No doubt you’re familiar with this kind of extreme weather, but there are a few health tips worth repeating. Here’s the Boston Public Health Commission with a cute video reminder:

CDC: Risks Loom As Many Women Of Child-Bearing Age Are Prescribed Painkillers

Source: CDC

Source: CDC

The U.S. Centers For Disease Control and Prevention reports that many women of child-bearing age (notably, women on Medicaid) are taking opioid pain medications and that these drugs taken during pregnancy can increase the risk of birth defects.

According to the agency’s latest Morbidity and Mortality Weekly Report:

During 2008–2012, more than one fourth of privately insured and more than one third of Medicaid enrolled reproductive-aged women (15–44 years) filled a prescription for an opioid from an outpatient pharmacy each year. Prescription rates were consistently higher among Medicaid-enrolled compared with privately insured women.

The most frequently prescribed opioids, says the CDC, were hydrocodone, codeine and oxycodone.

The report details why early exposure is particularly risky:

“The development of birth defects often results from exposures during the first few weeks of pregnancy, which is a critical period for organ formation. Given that many pregnancies are not recognized until well after the first few weeks and half of all U.S. pregnancies are unplanned, all women who might become pregnant are at risk.”

Continue reading

White Coats For Black Lives: Toward Racial Equality In Health Care

Kaitlyn Veto/flickr

Kaitlyn Veto/flickr

Acknowledging the public health impact of racism and deep disparities in the quality and accessibility of medical care for patients of color, a national organization, White Coats for Black Lives, says it’s launching a new effort today, in celebration of Martin Luther King, Jr.

Dorothy Charles, one of the group’s organizers and a first year medical student at the University of Pennsylvania’s Perelman School of Medicine, offers some context in an email:

Racism profoundly impacts people of color: the black-white mortality gap in 2002, for example, accounted for 83,570 excess deaths. As future physicians, we are responsible for addressing the perpetuation of racism by medical institutions and seek policy change to eliminate disparities in outcomes.

Here’s a statement from the White Coats for Black Lives National Steering Committee:

Upon matriculating in medical school, students recite the Hippocratic Oath, declaring their commitment to promoting the health and well-being of their communities. On December 10, 2014, students from over 80 medical schools across the United States acted in the spirit of that oath as we participated in a “die in” to protest racism and police brutality. In our action, we called attention to grim facts about the public health consequences of racism, acknowledged the complicity of the medical profession in sustaining racial inequality, and challenged a system of medical care that denies necessary treatment to patients unable to pay for it, disproportionately patients of color.

Today, in celebration of the legacy of Dr. Martin Luther King Jr., we announce the founding of a national medical student organization, White Coats for Black Lives. This organization brings together medical students from across the country to pursue three primary goals:


1. To eliminate racism as a public health hazard

Racism has a devastating impact on the health and well-being of people of color. Tremendous disparities in housing, education, and job opportunities cut short the average Black life by four years. Physicians, physician organizations, and medical institutions must therefore publicly recognize and fight against the significant adverse effects of racism on public health. We additionally advocate for increased funding and promotion of research on the health effects of racism.

2. To end racial discrimination in medical care

We recognize that insurance status serves in our healthcare system as a “colorblind” means of racial discrimination. While it is illegal to turn patients away from a hospital or practice because of their race, patients across the country are frequently denied care because they have public insurance or lack health insurance. We support the creation of a single payer national health insurance system that would give all Americans equal access to the healthcare they need. Such a system would create a payment structure that reflects the fact that “Black lives matter.” Moreover, ample evidence suggests that patients of color receive inferior care even when they are able to see a doctor or nurse; we therefore advocate for the allocation of funding for research on unconscious bias and racism in the delivery of medical care. Continue reading

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