Thursday, July 30, 2009

Mass Sociogenic Illness

Yesterday a classic example of mass sociogenic illness occurred at a bank building in Fort Worth.

Initial reports indicated some sort of poisoning. Hundreds of workers spilled outside the building due to fumes. The fire department was soon on the scene with hazmat crews. Rapid assessments of local hospitals were made – How many beds did they have available for a possible mass casualty event? Early reports indicated that a carbon monoxide monitor was going off, and it was believed that dozens of people had been injured. More than one hundred workers were triaged at the scene for symptoms. Around thirty patients were transported to area hospitals for evaluation with chest pains and shortness of breath. When they arrived, the emergency rooms did not know the cause of the illness – hazmat teams still had not identified the source of the fumes.

Mass sociogenic illness is an interesting phenomenon. The power of suggesting in a group setting makes people develop symptoms consistent with illness. At the time, people truly believe they are ill, but in reality, it is all in their mind. That is exactly what happened in Fort Worth.

Apparently, this all began when two employees complained to a supervisor that they felt dizzy after a third employee sprayed on some perfume. According to media reports, their supervisor made an announcement throughout the building over the PA system that anyone else feeling dizzy from the fumes should exit the building.

Imagine this: You are sitting at your desk. An announcement comes over the speakers – there are fumes in the air and if you feel sick you should exit the building. What fumes? you wonder. You’re cubical mate gets up, says the fumes are giving her a headache. You notice others in your area leaving. Your heart starts to beat faster, have I been exposed to something? You stand up and look around. A woman is crying, she says she has chest pains. You decide you should go outside too, who knows what is in the air? On the way you realize you feel dizzy as well.

But you aren’t. At least not from any fumes. It is a psychosomatic reaction to the events around you. It is fear-induced.

Hazmat crews showed up and set up air monitoring units. Of course they could not detect anything because there was nothing in the air to detect.

There are multiple reports of this sort of behavior in the literature, and they are a source of interest to many sociologists who study collective behavior. Mass sociogenic illness can be a major social problem, particularly in an age of heightened anxiety over terrorism. Consider the cost of yesterday’s event, the large number of first responders involved, from the fire department, hospitals, and the public health department, not to mention the cost to the business of the day’s disruption. Not to mention the personal cost of having succumbed to one’s fears, the embarrassment (how would you like to be that poor supervisor?).

Wednesday, July 29, 2009

H1N1 and Pregnancy

Pregnancy can be scary enough as it is, but here's one more thing to worry about: Pregnancy is emerging as a critical risk factor for H1N1 complication and death. In a recent study, investigators found that of the 45 H1N1 deaths reported between 4/15/09 and 6/16/09, 13 percent were previously healthy pregnant women. Pregnant woman were four times more likely to be hospitalized due to H1N1 infection.

Seasonal flu disproportionately affects pregnant women also. While it is not completely clear why, there are a few theories. First, during the later stages of pregnancy, the growing fetus compresses the diaphragm, giving the mother overall lowered lung capacity. Second, the mother’s immune system changes, compensating for the growing body inside her. This change may lower her ability to fight the influenza virus.

Pregnant women will likely be a target group for H1N1 vaccination, although safety of the vaccine in pregnancy has yet to be determined. In terms of the season flu vaccine, safety has been demonstrated and pregnant women are encouraged to be vaccinated. Likewise, household members are encouraged to get the seasonal shot so that they will not give the flu to the new baby.

A health educator colleague of mine is pregnant. She has done a lot of educational work on flu prevention, while worried about her own safety. She has expressed concerns about the risks and benefits of taking the H1N1 vaccine. Fortunately for her, her baby will be here before the vaccine is released, so the point is moot. But clearly if we are promoting this vaccine to this population, evidence of vaccine safety must be a priority. Is there time to establish that if the vaccine is due out in a few months?

I know I am sounding like a broken record here but more and more I find myself on the fence over the whole issue.

Monday, July 27, 2009

H1N1 Vaccine Production

Talk in the flu pandemic world is all about vaccine, and manufacturers are rushing to production.
With the sprint to get the vaccine in the public, there is also a sprint through various safety protocols. In the world of public health, it is difficult to discuss production of a swine flu vaccine without reference to the 1976 fiasco. With that vaccine, about 1 in 100,000 people developed some sort of neurological problems and 25 people died. Safety this time around is obviously of concern. I read this morning that CDC has constructed a large net for monitoring vaccine safety, which will keep us all even busier this flu season.

I have seen rumor on the internet that the government plans to force the public to take the vaccine. There is no truth in this (at least in the US). No one will be forced to have the vaccine.

There is also a lot of discussion about why we are pushing this so hard. I’ve considered that myself. Signs still indicate that the disease is relatively mild. Risk groups have emerged, and I think it is most important to ensure that they are protected, just as I would want to protect people at risk from any preventable disease. My understanding is that in the US, the government is picking up the tab for the vaccine and vaccination supplies. I assume then that the vaccine will be free. Free vaccine means more likelihood that people will get it. So more doses are produced. Some vaccine manufacture is going to be in for whirlwind profits. I am not one to propagate conspiracy theories, but I worry that corporate greed is driving this bus (and now all the public health folks are invited to argue that point).

I’m very curious to see how many people show up for the jab. Personally, I will not be at the front of the line. While I am not overly concerned, I do want to ensure that it is safe, and unfortunately that takes time.

Tuesday, July 21, 2009

Explaining Drug Overdose to a Five Year Old

On the way to swimming lessons, my five year old started asking questions about her heart. "What if it beeps too fast?" she asks me.

"Your heart is fine," I say. I fiddle with the CD player.

"Do you know that guy who died?"

I think about this for a moment. "Do you mean Michael Jackson?" I ask. She had mentioned him the night before.

"Yes. How old was he when he died?"

For some reason she is obsessed with Jackson's death. Which I find difficult to comprehend. We do not have a TV, so she has not seen any of the hoopla. Best I can figure, she's heard talk of it on NPR.

"He was fifty," I say.

"He had a heart attack," she tells me.

"Not exactly." How terrifying for a five year old. To think that one's heart could just stop. "He had something called a drug overdose."

She considers this.

I have only heard snippets of the Jackson story. It is not my cup of tea. I'm sure he was a talented performer, but I was not one of his legions of fans. Rather, I have been a bit surprised by the hypocrisy of those banking on his death. The artists who've suddenly released tribute albums, the journalists who are singing Jackson's praise, the tiny rhinestone glove pins for sale at the grocery store check-out counter. Seems like a lot of people are making a buck off of this.

I want to explain this in a way that she will understand. A way that will not scare her. I don't want her afraid of doctors or medicine, but I want her to know what happened so she doesn't have to worry that it will happen to her. Explain in limited doses, so to speak.

"You know how you are only allowed to take one vitamin?" I ask her. "If you take two vitamins, that could make you sick, right?"

She nods. We had that talk after she started taking extra iron.

"Well, Michael Jackson took ten vitamins."

"Ten!"

"Yes, ten. And that's why he had a heart attack. He had a drug overdose."

"Oh. That was not very smart."

"No. It wasn't."

Wednesday, July 15, 2009

Human Rabies Survivor

There is some great footage on You Tube of a girl who survived rabies. Fair warning -- parts of the videos are quite graphic, but it is excellent. Well worth your time.

Rabies has been thought to be 100% fatal, however there are isolated reports of survival. The health care providers involved in this case are to be commended, as are the researchers who are working towards cures. Rabies is a violent, painful death. Typically, its victims are tied to a bed, left in darkness for the disease to overcome them. Insanity is spliced with terrifying moments of lucidity.

Rabies immune globulin and vaccine are very expensive, and the treatment is not pleasant (although quite preferable to contracting the disease). I myself have undergone rabies post-exposure prophylaxis after a dog bite. The vaccine made me feel quite ill. There has also been a shortage of vaccine, which has led to changes in the regimen (unfortunately those changes came after my incident and I had more shots).

Monday, July 13, 2009

Obesity and H1N1 Deaths

Obesity has emerged as a risk factor for death from H1N1. I had heard some early reports of this, but is seems to be on the increase. Are you obese? Yes, if your BMI is > 30. Find out here.

In studies on obese H1N1 patients , researchers found many developed blood clots in the lungs. Interestingly, this has not previously been a finding in seasonal influenza deaths. Nor has obesity in itself been a risk factor for flu complications. In one H1N1 death study, of 10 obese patients who died from the disease, 9 were male.

Yet another reason to get on the treadmill.

Saturday, July 11, 2009

A Disease You Don't Want To Get

If you want to get people in my office to jump, say the words Meningococcal Meningitis. Meningococcal meningitis is bad, bad, bad.

First, a little background. A lot of people freak when they hear the word meningitis. We spend a lot of time calming people down when someone they know if diagnosed with meningitis. Meningitis is simply an inflammation of the meninges, a protective layer that goes around the spinal cord and brain. The most common symptom is headache, and a lot of unexplained severe headaches are diagnosed as meningitis. Lots of things can cause meningitis. Viruses. Bacteria. I once investigated a case where a guy had meningitis due to mold growing in his cerebral-spinal fluid (not good). Fungus can cause it. Sometimes the docs aren't able to isolate the cause, and they call it aseptic. To decipher the cause of the meningitis, a spinal tap is taken. The CSF is typically then run through a variety of bacterial panels -- bacterial generally being the most deadly. If that comes up negative, or if the doc strongly suspects another cause, it can be tested for viruses or other bugs. West Nile can cause viral meningitis. The most common menigitis we see is caused by enterovirus, we see that a lot in little kids, especially in the summer.

For most cases of meningitis, there is no public health response. This is confusing for some people who have heard about people getting shots after exposure to meningitis. Meningococcal meningitis is another story though. Meningococcal meningitis can be really, really bad.

So here is a case that I worked not long ago. Identifying details have been changed out of respect to the patient.

It is a Friday afternoon (because all bad things happen on Friday afternoons -- more so if it is a holiday weekend, but this wasn't). I get a call from one of the hospitals. They have a patient with a presumptive positive (this is a preliminary and not confirmatory -- it later was confirmed) meningococcal test in the CSF. The patient came in to the ER complaining of high fever, headache, and stiff neck.

An interruption -- when we say stiff neck, we don't mean sore. We mean STIFF. Like, it hurts to touch your chin to your chest and/or you can't hardly move your neck at all.

He also had a petiacial rash. The rash is a bad sign. If you have all these things, you need to get to the ER FAST. These are the patients who are healthy in the morning and dead in the evening.

So. The patient had been infused with a ton of antibiotics and moved to the ICU, where he was on a ventilator. His wife was in the ICU with him. The doctors at the hospital had already started the wife on cipro as a precautionary measure, and healthcare workers who had had close contact with him had also taken a dose.

Meningococcal meningitis is spread through saliva. Actually, a fair percentage of people are carriers. They carry it in their nasal passages. It's transient -- so it's not like they will always be carriers. But they don't get sick.

Why? That I can't tell you. Why does one person carry the bacteria with no illness whatsoever, and another die from it? That is the hard question I am always asked.

When someone is diagnosed with meningococcal meningitis, our job here in public health is to identify others who may have been exposed within the 2 weeks before the person showed symptoms, so that we can get them on preventive meds. All household members and sexual contacts are given antibiotics. Then we look for anyone else who may have kissed the person, shared a cigarette, drank after the person, shared other food, maybe that person coughed in their face? Any way that someone could have come in contact with that person's spit. For babies, we will medicate the whole daycare class, we're not taking any chances there. We've found some interesting ones: a girl who had attended a sex party with at least 30 other people, a tuba player who had shared his new mouthpiece with other members of the band, a developmentally disabled woman who liked to spit at people. It takes a lot of interviews to find these people, I can assure you.

In this case, it was only his wife. Of course, I could not talk to the patient. Sometimes other people will come out of the woodwork, lovers and whatnot, but none in this case. I did speak with his work place -- no one could come up with any exposures there, but I had to do a lot of education (including giving a lunch-time presentation to the frightened employees with a Q&A session).

The patient developed multi-system organ failure and we located the death forms. And we all felt really bad for him. And for his wife.

But then. That guy was a fighter. He fought and fought. And every day we called the hospital to check on him to find he was still alive. And after a while, we put the death forms away. He was going to make it.

After two months in the hospital, he was discharged to a long-term care hospital. The doctor who told me about this was very excited. All the folks at the hospital who cared for him were. They saved him! Even they didn't think he would make it.

I requested a copy of his chart for the record. At discharge, he was off the vent but required oxygen. His kidneys were fried -- he would be on dialysis from now on. One leg was amputated due to necrosis. He had necrotic tissue on his face and arms, and was under the treatment of a burn specialist. Three fingers on one hand had been amputated. He was fed through a GI tube.

Two days later, he was in the ER of another hospital. He had spiked a fever -- he had a bloodstream infection, likely from his wounds. They admitted him. He stayed another two months in this hospital. He lost the other leg, and one of his arms (the one with this missing fingers). He was on high doses of anti-depressants. He had significant scaring on his face, to the point of being virtually unrecognizable. He was again discharged to a long-term care facility.

There is a vaccine against meningococcal meningitis. It is recommended for people in group settings, especially college students (all that spit-swapping, something's bound to be transmitted).

Wednesday, July 8, 2009

No More Health Education

This morning on the way to work, NPR reported that high school students in Texas will no longer be required to take a health class.

It is interesting to me how we rank academic knowledge. Math and the hard sciences on top, followed by social sciences, with arts and humanities at the bottom. Professors who teach engineering and medicine make significantly more money than English professors. Some subjects are fluffy and others serious.

This is ridiculous.

I know a health educator who does an STD program in the local high schools (during health class). Because the schools receive federal funds, they are barred from discussing safer sex. No mention of condoms, birth control pills, etc. The health educator basically gives a horrorshow of photos and gory details of STDs. Abstain children, or your privates could look like THIS!! Some of the teachers get around the restriction by allowing some time at the end of the presentation for one-on-one questions with the educator. Here are the types of questions and comments she hears:

-- If I have anal sex, I am still a virgin, right?
-- I heard if you brush your teeth right after oral sex it kills any germs you might have picked up
-- If you have sex standing up you can't get pregnant
-- Don't only gay people get HIV? (I swear, people still think this)
-- If you have sex in the shower you can't get pregnant

Meanwhile, we have a blossoming cohort of teen parents. They are not even allowed to talk about safer sex in the teen parenting class. All of the kids in that class are either expecting or already parents. Some of them have multiple children. The health educator said in that class they over-use euphemisms for everything: "If you are going out this weekend, remember to bring sunscreen! And if you find yourself in the sun, wear sunscreen!" They mixed metaphors often and while the kids seemed to get it, the educator got confused. She also hoped none of them were rubbing sunscreen on their genitalia with the belief that it would prevent pregnancy...

But I digress.

Why cut health class? When we examine the totality of knowledge that children should have when they graduate from high school, don't we want them to know something about being healthy? About nutrition, substance abuse (remember most of them will be off to college with easy access to substances), stress reduction? How is this less important than some of the other topics they learn? Personally, I would rather my kids know about health than how to dissect a frog. 

Saturday, July 4, 2009

Raising Awareness

I read this blog recently, about Raising Awareness. This is how we combat problems in America, we raise awareness. It's meant to be funny, but I keep coming back to it. That IS how we combat problems in America. Hence the magnetic yellow ribbons for your car (raising awareness about US soldiers) and pink Kitchenaid mixers (which will raise your awareness of breast cancer, somehow...). There is a whole industry of pink products for breast cancer, some of which are pretty snazzy. And red ones for HIV. But how does that red $50 t-shirt really DO anything about HIV? Tonight, will the wearer get drunk in a bar, pick up a cute girl, and, as he removes the shirt, think, hey, this red shirt reminds me, I need to put on a condom? I'm not sure. Perhaps one could argue the 50 cents the company donates to research for each product they sell helps, but it seems to me that if that's what you're after, it would be better to give the researchers the whole fifty bucks. 

A friend of mine went on vacation in San Diego last week. He commented on the intrusive number of warning signs. He noted that every bridge, even ones not that high off the ground, has suicide hotline information. As he described the plethora of warnings about how everything hurts your health, I though, it is no wonder we have so much anxiety. 

A few months ago, we cut off our cable. That's right, no TV for us (we do make exception for Netflix movies). And honestly, I think my overall anxiety level has decreased. I still listen to Morning Edition on the way to work every day -- I figure they will report on anything I really need to know. That, or I will hear about it at work or from friends. I have no TV and I still know that John and Kate are having some major problems, so I figure being TV-less is not leaving me too far out of the loop. 

On the other hand, I think it was Marshall McLuhan (certainly his predecessors) who argued that we are so bombarded by messages that we tune them out. 

All this takes me back to public health messaging. I can't even tell you how many pamphlets we have in our building. And posters. Booklets. Coloring books. All with different messages. Smoking kills. A glass of red wine per day may be good for you, but no more than that, you lush. Maintain a healthy weight (eat 5 fruits and vegetables every day). Wear mosquito repellent, sunscreen, a condom, a helmet, and your seat belt. Don't drink and drive and for gods sake cook your food to the appropriate temperature (and don't eat raw eggs).  

And yet. Despite all the messaging, I just cooked brownies. I ate a spoonful of batter and then licked the bowl clean. It was fabulous. I, who am bombarded with the messages daily, I, who have investigated a child with salmonella in his knee joint and a girl with shigella in her eye (it blinded her permanently), I still eat raw eggs on a pretty regular basis.

It makes me wonder how effective Raising Awareness is.