Monday, August 31, 2009

Wakefield on Dateline?

Anyone catch Andrew Wakefield on Dateline this weekend? If you find the video on the web let me know where -- I would like to see it.

Wakefield is the doctor who first seriously posed a connection between autism and MMR. There has been lots of controversy surrounding his work in both the scientific and popular literature.

Monday, August 24, 2009

H1N1 in Birds

Interesting report out of Chile of a flock of turkeys infected with influenza A (H1N1) 2009. According to the ProMED report, more than 20,000 birds were infected.

Influenza viruses mutate regularly (this is described as antigenic shift or drift, depending on the extent of the mutation). This is why we get flu shots annually -- the shot you had last year may not cover the strain circulating this year. Viruses evolve. This is survival of the fittest at its most basic. One way that influenza viruses evolve is through the comingling of two strains within one host. So say a person is infected with a seasonal strain of influenza at the same time they are infected with the pandemic strain. The two viruses then have the opportunity to swap genes and create a new strain (please note that is a horribly simplistic explanation of the process).

One area of concern with viruses is their ability to jump species. This creates more opportunities for the virus to evolve.

Many species have their own influenza viruses. Dogs, for example, get a variety of flu strains which do not affect humans. Birds too. You may have heard about avian flu. A current strain is an H5N1 which has been circulating for a few years now. This H5N1 virus is highly pathogenic in birds -- this means it is highly lethal to them. It has also demonstrated the ability to infect humans, although on a relatively limited basis. It is highly pathogenic to humans as well. This virus has been the drive behind recent pandemic planning programs. We all assumed that the next pandemic would come from this strain, and the infectious disease community has been eyeing it closely. Human to human transmission of H5N1 has not happened on a widespread basis -- that virus does not appear to have the capability for rapid human to human spread.

H1N1 does though.

The rate of H1N1 spread has been unprecedented. It is now in most all corners of the globe. So what happens when a bird infected with H5N1 is coinfected with H1N1? Highly pathogenetic meets highly transmissible. I'm not liking the sound of that.

Thursday, August 20, 2009

Ethics of Mandatory H1N1 Vaccination

For weeks I have been spouting that the H1N1 vaccine would not be made mandatory. All I have read coming from CDC said so, and I believed it. My apologies. I regret to note that New York will be requiring healthcare workers to have both the seasonal vaccine and the H1N1 vaccine. .

They argue this is a patient safety issue. And I do agree with that argument. Last winter, I investigated a pediatric influenza-related death of a child who contracted influenza while hospitalized with something else. Of course I could not say whether the child caught it from a healthcare worker or visitor. Nonetheless, I am an advocate of vaccinating healthcare workers for flu. I am fully on board with the seasonal vaccine.

I am NOT an advocate of forcible vaccinations, however.

I read somewhere recently (sorry that I cannot recall the source) that the essence of bioethics is the answer to the question, does this harm anyone? On the one hand, we could argue that an unvaccinated healthcare worker has the potential to harm patients. Certainly in cases of fragile or at-risk patients this is a concern. You might recall an early post about a pulmonologist with H1N1. The flip side is that one could harm the healthcare worker with the vaccine. While the science is good, we are pushing out a new vaccine. Some healthcare workers will be clearly contraindicated, such as with an egg allergy. The news article referenced above does not talk about exemptions, but surely there are medical exemptions. Some healthcare workers will have religious objections. Some will simply be afraid to take a new, under-studied vaccine.

Massachusetts has deputized additional healthcare workers to give H1N1 vaccinations. I love that word in this context. Perhaps they will be issuing guns and badges as well? They could meander over to New York and help enforce the vaccine mandate.

A colleague today accused me of being anti-vaccine. This is not the case at all. I am a big proponent of vaccines. Vaccines have spared uncountable deaths and suffering. Rather, I am advocating for safety and science. I don't want to be sucked into the vortex of pandemic panic. I have been there, it is not a pleasant place to be.

Tuesday, August 18, 2009

Scientists and Mystics

Today at the health food store, picking up some organic sour cream and strawberries for an Indian dessert, I picked up one of those free health publications. On the cover, a blurb spotlighting their feature article, an interview with some man I had never heard of, billed as "scientist and mystic." That alone was worth the read. How does one become both a scientist and mystic? By definition, a scientist views the world objectively, rationally. What is objective, what is rational, about the mystic?

I am all for "alternative" medicine. My medicine cabinet contains zinc, echinacia, myrrh, and a variety of Dr Bach's flower remedies. Also, Tylenol, Alieve, and Ambien. I have a variety of medicinal plants growing in the backyard. I think though that publications such as the one I picked up today, give the whole genre an aire of the ridiculous. There was nothing objective or rational about the articles. Rather, it was, as a good friend of mine would say, "a lot of hoo ha."

In other news, there is a scramble to sign up health care providers to receive H1N1 vaccine. I hope that we will have some science in that realm soon. Because right now it is rather mystical.

Saturday, August 15, 2009

Condoms and Prostitutes

Maslow came up with great theory for explaining human behavior. Good to keep in mind when you are doing public health.

I interviewed an incarcerated woman with a host of sexually-transmitted aliments. Part of my job was to educate her how not to become reinfected with the ones that were treatable. Or to catch worse. Here's the trouble though -- she's a prostitute. A prostitute addicted to heroin.

When looking at human behavior and social change, you must first meet people where they are at. She was no Julia Roberts Pretty Woman. This hooker was an unfortunate looking woman. Older than most of her peers. Quite large and round (not your typical heroin physique) but had substantial scaring -- tracks and sores -- on her arms. The prostitute and I had different agendas. I was asking her to use condoms, she was working the streets for drug money. She could get $50 if she had sex bareback (without a condom), or $20 with a condom. So if she needs $100 in a night, she can have sex with 2 guys and hope for the best, or she can protect herself but have to screw 5 guys. Which would you choose?

This is where Maslow comes in handy. The prostitute's need for drugs and food is more important to her than her need to protect herself from invisible germs (add in there that it is difficult to find free condoms in the area where she works -- she would have to buy them, further cutting into her profits). Rather than focusing on condoms, she needs drug treatment and the means for an income other than her current profession. If those to needs are not addressed, all the safe sex education in the world is not going to make much of an impact.

Monday, August 10, 2009

Healthcare Reform

The buzz around the office is all about healthcare reform. Despite working for a government agency, most of my coworkers oppose government-run healthcare. Perhaps it is because they work for the government they feel this way.

The physicians worry their pay would be cut. Others worry about long wait lines, delayed urgent care, and high taxes.

I do not have a solution. But I am glad that healthcare reform is at least being considered. Here is a true story:

Not long ago, a man came into the clinic on a Monday morning with a hurt elbow. Friday evening, he had been doing some work around his house and had fallen from a ladder. He heard the crack when he landed on his arm. He howled in pain, drawing his wife out to find him. She insisted he go to the emergency room.

This man did not have insurance. He was employed full-time as a construction worker. He worked for a small company that is not required by law to provide its employees with health insurance.

In America, if you go to an emergency room and do not have insurance, the hospital is required by law to ensure that your condition is stabilized. After a three hour wait, the man was finally seen. They took x-rays of his arm and discovered he had broken off a piece of his elbow joint. They put his arm in a sling, wrote him a prescription for some pain meds, told him he needed to find an orthopedic surgeon (they provided him a list of names), and sent him on his way. Had he had insurance, they likely would have called the surgeon in and his surgery would have happened that, or the next, day. But he didn’t, and this wasn’t a life-threatening condition.

By Monday, the bit of bone which had broken off had wedged its way into the joint. He could no longer straighten his arm.

He was seen by a nurse practitioner in the clinic. There was nothing the NP could do – the man needed an orthopedist. He was referred to the clinic social worker. She spend the next few days calling every orthopedic surgeon in the area to see if anyone would do the surgery either for free or for a reduced price, or even with a payment plan (for the surgery is thousands of dollars). None would. No insurance, no surgery.

The small company that did not have to provide health insurance was also exempt from having to provide sick leave. The man, who could not do construction with a busted arm, was fired.

The last I heard, there was no surgery. The man’s arm healed (more or less) with total loss of mobility in the elbow. The social worker helped him get on social security disability since he could no longer work. Prior to the injury, this man was a contributing member to the economy. Now he receives government benefits.

You can’t tell me we don’t need healthcare reform.

Saturday, August 8, 2009

H1N1 Kills Nurse

California recently reported an H1N1 death in a nurse. This is the first health care worker to die from the illness in the state.

She was coinfected with MRSA. MRSA is frequently associated with influenza deaths. We see this a lot in the pedaitric deaths. The patient is infected with influenza and then develops MRSA pneumonia. They go downhill scary fast, and those who succumb often die within a day.

While the MRSA infection was disturbing, so is the fact that this was a previously healthy woman. She was a triathlete.

There has been a lot of attention to underlying conditions and H1N1 deaths. In framing deaths in terms of underlying conditions, we reduce some of our own fears -- oh, well, that man had COPD, or that woman was pregnant, and I am neither of those, do I do not need to worry. It is a useful coping mechanism. But we need to be careful not to create a myth of H1N1, a myth that only those with underlying conditions are vulnerable, and then forget to protect ourselves.

Tuesday, August 4, 2009

Where's the Voice of Reason?

There is a flurry of activity surrounding H1N1 vaccine. Where is the voice of reason in all this? As scientists, we should not be driven by social or political whims, nor by the driving force of capitalism. Rather we should take a close look at the evidence. In this case, the data show that overall this disease is mild. Several higher risk groups have emerged. Pregnant women are a big concern, but when you look at the raw numbers, the low N size worries me. True, percentage-wise pregnant women in the US are proportionally impacted, but isn’t the total number of deaths 13? Low N sizes skew statistical analysis. Especially if you are comparing that number to the total number of pregnant women.

There is an established process and procedure for testing new vaccines, established to minimize adverse events. Everything I read suggests that this vaccine is being produced with new processes and may possibly include ingredients previously not in US flu vaccine. I read an article yesterday where a researched noted that it better be shown to be safe in rats before she would have it put in her arm. I am in agreement.

Meanwhile the companies who make the vaccine stand to make (and already have for that matter) millions of dollars. Doctors may be able to cash in too.

Hopefully, everything will run smoothly, the vaccine with be a good one, and a lot of people will be protected. But we can’t forget the previous swine flu vaccine fiasco. Or how the early pertussis vaccines injured some children. Or the early rotovirus vaccine which caused some children’s intestines to slough off.

Vaccines have prevented an enormous amount of suffering and death, and I whole heartedly support vaccination programs. But as public health officials, we cannot stand behind all vaccines just for the fact that they are vaccines. That is just as ignorant as opposing all vaccines just because they are vaccines.