The Epidemiologist

Welcome to My World

2010-04-12T14:12:00.000-05:00

Transcript of a voice message left on my phone earlier:

Hi. Ummm…. I am not sure if this is the right person to talk to but I was
transferred over to you by a guy I talked to at environmental health? Yes, well,
my name Jeanie and I am calling to report that we found some Hornets from Hell
in our backyard and I think you should alert the emergency rooms in the area
they should watch for people with stings. If you just Google that, Hornets from
Hell, you can see what I mean. They are these new, killer hornets that are
normally found in Japan? But we have them here. My husband said you can come
over and try to catch one and that will prove they are in America. Please call
me back, I’m at….

I never know exactly what to do with these calls. I feel bad for the woman, I could tell by her voice she was upset, but what am I supposed to do about this? And gee, thanks environmental health, for transferring her to me.

I googled it and found this.

I did not alert the emergency rooms.

I also did not go to her house to catch one of her hellacious hornets.

MRI

2010-04-09T13:09:00.007-05:00

Having an MRI is an unpleasant experience. This is what people told me before I had mine:
1. The machine makes noise.
2. You have to lie real still.
3. It's a pleasant time out of your day. I fell asleep.

Here's the reality:
1. The machine makes a deafining symphony of grating mechanical shrieks that despite the earplugs will still bother your ears the next day.
2. You have to lie perfectly still for like 45 mintues or you have to start the whole thing over again. Because of this your nose will itch like a swarm of pregnant mosquitoes had a recent blood feast and you will shiver uncontrolably due to the crazy fan they have going on you (that's right, no one mentioned the fan).
3. Number three is an out and out lie unless there were heavy sedatives involved. I'm just sayin.

After all that, I got a disk of cool pictures. Like this one.

Pain, Pain, Go Away....

2010-04-06T13:50:00.002-05:00

Yes, I realize it has been a crazy long time since I've posted anything. Sorry about that. I have been battling the sage of Unexplained Facial Pain (is it or is it not Bell's Palsy, MS, or a brain tumor? Stay tuned for MRI results!). I have contemplated blogging about it, but I get so tired of even thinking about it that it has been tough to write about. Maybe I will one day.

Until then, enjoy this fabulous rendition of a pain chart. I have been going to the chiropractor too many times to count and each time I go I have to circle my pain on a scale like this (well, not like this, just 1 to 10 without the awesome drawings). Mine has ranged from This Is Distressing to I Am Actively Being Mauled By A Bear. Hilarious.

The Pink Virus

2010-01-05T09:14:00.002-06:00

A number of risk factors make one person more likely to develop breast cancer than another person. Being female, for instance, is a biggie. Age. Family history. Use of artificial hormones. Obesity. Some people will have few or none of the risk factors and still contract the disease, although their chances of getting it are lower. Some people will have many of the risk factors and never develop the disease.

Cancer results when a mutated gene proliferates. But what causes that mutation to occur in the first place? I have written before about viruses that are known to cause cancers. If we knew that some breast cancers were caused by a virus, there would be the potential for vaccine development and anti-viral treatments.

Dr Kathleen Ruddy, founder and president of the Breast Health and Healing Foundation, was kind enough to give me a copy of her book, The Pink Virus: Does a Virus Cause Breast Cancer in Women? An intriguing tome, which I highly recommend for people interested in this topic. Ruddy provides a primer on viruses and cancer before discussing specific research into a breast cancer virus, in accessible language with practical examples. The book is well-tuned for both a professional and lay audience.

Dr Ruddy has been a breast cancer surgeon for 15+ years. She notes that in her field the emphasis has been on breast cancer treatment and cure, with little attention to the primary cause of the disease. In fact, she writes that less than 2% of the funding for breast cancer research goes to work on breast cancer’s cause. Is breast cancer preventable? A person could work to reduce some risk factors, but not all. And what of the people without risk factors? Something else must be at work.

The research is compelling, and disturbing, for the line of thinking begins in the 1930s, yet this research is absent from most textbooks on breast cancer. Ruddy notes that in the 1930s, a researcher discovered that baby mice, when fed milk from a mouse with breast cancer, would also develop breast cancer. He called this the “milk-agent.” The milk-agent was later found to be a virus, mouse mammary tumor virus (MMTV). In the late 1960s, another researcher discovered particles similar to MMTV in human breast milk, particles indicative of a related virus. The following decade, more researchers discovered positive reactions to MMTV in cancerous breast tissue but not in benign breast tissue. In the 1980s, researchers found women with breast cancer were more likely than women without breast cancer to have evidence of MMTV in their blood. In 1988, researchers found that 97% of the breast cancer patients studied showed evidence of a retrovirus, further implicating MMTV. In 1996, researchers hypothesized that a significant number of human breast cancers were associated with viral sequences similar to MMTV, which may in fact be a human mammary tumor virus (HMTV). In 2000, researchers noted breast cancer incidence was positively correlated with mus comesticus (house mice).

Ruddy provides an extensive reference list for anyone interested in reading the scientific literature.

More than 1.3 million women will be diagnosed with breast cancer this year. Nearly half a million women will die from breast cancer this year. The line of research into a HMTV is compelling, and should be supported.

Thormahlen Family Fundraiser

2009-12-25T19:17:00.001-06:00

A very old friend of mine, Peter Thormahlen, was shot in a convenience store robbery while buying juice for his toddler. He suffered spinal and other internal injuries. He had just started a new job, which he has since lost, along with it, all his health insurance. If you are feeling generous, please contribute below. Every penny goes to his care. Thank you.

2009-12-25T19:16:00.001-06:00

On Running

2009-12-23T13:05:00.002-06:00

I have started up a second blog (which doesn't make much sense since I don't post regularly on this one) about my attempt to run a 5k. Forgive the URL -- it is very difficult to find an original one on Blogspot.

Follow the Money

2009-12-11T08:46:00.004-06:00

Interesting article in The Atlantic about a recent study which questions the use of tamiflu for influenza treatment. Some of my public health colleagues are quite angry about it -- they worry that people who need tamiflu will now not take it. They suggested that we use the staff of The Atlantic as a placebo group in a study testing the drug. Personally, I think The Atlantic handled the topic well. The research does raise questions about the usefulness of the drug. I know a lot of physicians who don't like to use it (especially in children) because it can cause vomiting, which in turn can lead to dehydration, which in turn can lead to hospitalization. Speaking for myself, I began taking the drug within 12 hours of onset of influenza. I felt fine the first day, but the next morning I vomited for two hours and I stopped taking it. There have been reports out of Japan of neurological side effects in children.

This post is not to bash tamiflu, nor is it to discourage people from taking the drug who need it. I would rather step away from the efficacy of the drug itself and offer the question which I have blogged on in the past -- is government policy being driven by science or by politics? Big pharma made millions (billions?) off tamiflu. Big pharma made millions (billions?) off pandemic H1N1 vaccine.

Stay Home When You Are Sick -- You Too Doc

2009-12-08T09:49:00.002-06:00

I had a disturbing conversation with a colleague over breakfast this morning. She is a physician in a clinic for underserved populations. She is the only physician in that clinic, but she has a nurse practitioner who works with her. Between the two of them, they have more open charts than is advisable, but they are the only low-income clinic in their area and do the best they can to see all the folks who need care. This morning the NP called in sick. This throws a wrench in the clinic scheduling, as the NP was already overbooked with appointments all day. The doctor will now have to work her butt off to see all the patients herself. This means long waits, even less time per patient, and a very long day for her.

She explained to me that the NP felt really guilty for taking off. The NP came down with fever and chills yesterday, but worked through it. This morning, the NP could hardly get out of bed she was so sick.

“But that is what sick time is for. She will still get paid. If she is that sick, she needs to take off. Filling her slot is an administration issue. You administrator should have a back up plan,” I said. Because I am an epidemiologist, I don’t want the sick NP coming to work. I preach it all the time: Stay home when you are sick.

This was not the response the doctor was looking for. “Doctors work sick all the time. That’s what we do. We push through it,” she said. “If we don’t that’s 30, 40 people who are sick because they couldn’t see us.”

“But as a patient, I don’t want the doctor who sees me to be sick,” I said.

She looked at me like I was crazy.

“That’s nothing. You should see what they do in hospitals. It’s even worse in hospitals. No one ever calls in sick; that is unheard of. I’ve seen surgeons slap on a mask and work through it. It’s just what we do,” she said, as if this were a point of pride.

Now it was my turn to give the crazy look. “I’m sorry, but I don’t want someone cutting me open when they are sick. Send the sick one home. I want someone who is alert and paying full attention.”

Doctors should be role models for healthy behavior. They should not be operating with snot dripping into their surgical masks. This should not be a badge of honor. I understand there is a healthcare worker shortage in this country. Rather than pushing docs to work when they are sick, we should be looking for ways to increase the number of healthcare providers.

Another colleague told me about a program she worked in many years ago at a university teaching hospital. The hospital had a severe shortage of nurses. The school created a program where mothers on welfare could get an LVN on their campus for free, provided they would work in the hospital for at least one year after graduation. Tuition was free, room and board were free. Free remedial classes were offered to those who needed them. Daycare was provided. A short-term investment proved a long-term boon – the families were able to get off welfare and became tax payers. The mothers had a good source of income. A career, with benefits. The hospital had plenty of nurses. The program worked so well that they created a LVN to BA RN program for nurses who wanted to pursue it.

I have heard the psychologists say that we teach people how to treat us. If the doctor is willing to work through an illness, she has taught the administration that there is no need for a back up plan. I suppose the back up plan will be the hiring of a new doctor when that one keels over dead? A sick doctor is not fully present in their patient’s care. They run the risk of making mistakes, and we all know about the high numbers of injury and deaths due to plain old mistakes. They also run the risk of infecting their patients with whatever ailment they are carrying, and an ailment that may make the healthcare worker uncomfortable could be deadly to his ICU patient.

In the end, I think I made my friend mad.

What Causes Breast Cancer?

2009-12-02T13:10:00.005-06:00

What causes breast cancer? We know there are factors which raise or lower a woman's risk of developing the disease, but what is the mechanism that causes the cancer in the first place. I recently met a woman, Dr Kathleen Ruddy, who has a viable hypothesis. Dr Ruddy is head of the Breast Health and Healing Foundation. When I met her, she invited me to spend some time on the Foundation's website. Which I did. And I have to say, it kind of pissed me off.

Dr Ruddy is interested in exploring the possible connection between breast cancer and mouse mammary tumor virus. She has written about book about it, The Pink Virus, which she was kind enough to send to me and I will be reviewing here in a few weeks.

I have long suspected there might be a virus at work in breast cancer. I have to present at a meeting this afternoon on viruses and cancer. Most of us know about human papiloma virus and cervical cancer thanks to the advertisements for the HPV vaccine (it can also cause anal and penile cancers). Hepatitis B and Hepatitis C viruses can cause liver cancer. I heard recently about a possibly connection between Xenotropic Murine Leukemia Virus-Related Virus and prostate cancer (and a possible connection between XMLV and chronic fatigue syndrome, which I blogged on in a previous post). Did you know that there are links between Epstein-Barr Virus (the virus that causes mono) and Burkitt’s Lymphoma, Hodgkin’s Lymphoma, B Lymphoproliferative Disease, and Nasopharyngeal Carcinoma? There are other viruses which have been linked to other cancers as well.

So why does the Foundation's web site irk me? Because if they are correct, if there is a link, why isn't there more research being done on this topic? If the cause is viral, there is potential to make vaccine. If the cause is viral, there is a potential to entangle the epidemiology and find different means of prevention. If it is viral, new treatment options may be available.

When I was a child, it was common knowledge that stress caused ulcers. This notion was so prevalent, I remember seeing the theme interwoven into TV shows. A character could clutch his stomach, and talk about his ulcer, and we, the viewers would accept this as a signal that he (because at that time it was always a he) was under too much stress. The antidote was to drink milk. And reduce stress. Of course now we know that many stomach ulcers are caused by a bacterial infection, H pylori, and can be treated with antibiotics.

It will be interesting to see what the research into cancer and viruses continues to discover.

H1N1, Tamiflu, and Pregnancy

2009-11-09T14:03:00.005-06:00

I wrote a long, thoughtful, and, let's face it, wonderful post all about H1N1 and pregnancy. And then somehow I managed to delete it before it was posted. It happens to everyone, but that doesn't make it less annoying.

The gist of the post was concern over following up on the use of Tamiflu during pregnancy. Due to a number of factors, pregnant women should be concerned about flu. Women are much more likely to suffer complications and risk death due to flu during pregnancy, and Tamiflu may be a life-saving drug. Conversely, Tamiflu is a Category C drug in pregnancy. To be classified a Category C drug, the drug must either be untested in pregnant women or have had concerning animal studies. In the case of Tamiflu, some research has demonstrated skeletal anomalies in fetal mice. How does this translate to humans? Perhaps it doesn't. Oftentimes those studies use ridiculously high dosages. Mice physiology clearly differs from human. And the timing of the medicine is likely to make a difference, with the higher risk during the first trimester as opposed to later in the pregnancy.

This brings up the ethical concern of a woman's right to chose her treatment. If a woman refuses treatment could she be charged with fetal endangerment? Or if she did accept treatment and had a negative outcome, could she (or her health care provider) be charged with the same thing?

There is an urgent need to follow up with women who have taken Tamiflu during their pregnancies to establish the safety of the drug. I would not want to see a woman decline what might be a life-saving intervention for fear of injuring her fetus -- I have already heard of women who have made this choice and I have heard of OBs who refuse to write the prescription for pregnant women. We must ensure that the science keeps up with the H1N1 outbreak, at least as much as possible.

The Great Flu Shot Chase

2009-11-03T09:57:00.001-06:00

I meant to post this when I first heard it on NPR -- an excellent commentary on the problems with the recommendation to get seasonal flu shots combined with the lack of access to the vaccine.

Infected with H1N1

2009-11-03T09:06:00.002-06:00

I have spent the last 13 days getting to know our friend H1N1 personally. While I have said many times this is a mild to moderate illness, I managed to have the moderate bout. More than once I thought I would end up investigating myself as a hospitalized case. Fortunately that did not happen, but I did end up with three separate trips to the doctor.

The morning after a sudden onset (7pm on a Thursday night, scratchy throat and a fever of 101.3 – it was so sudden I remember), I began a course of Tamiflu. And that day, despite fatigue and chills, I felt like I would have a quick recovery. The following morning, with the start of the second day’s dosage, I threw up for three hours. This is one of the side effects of Tamiflu. We often see children hospitalized due to dehydration with the flu, occasionally brought on by the side effects of the drug. I stopped taking it, knowing full well the potential for breeding drug-resistant virus. At that point though the cure was making me sicker than the illness, and frankly I am a poor patient when it comes to drug compliance anyway.

In the end I wished I had stuck with the Tamiflu. By the following day my throat was so raw I thought perhaps this was a misdiagnosis and I actually had strep. I went to the doctor. No strep, just lots of post-nasal drainage. So much post-nasal drainage that I could not sleep. I felt I was drowning on all the draining, and could not lie down. I created an awkward pallet of pillows on the sofa and tried my best to sleep sitting up (no, I don’t own a recliner, and yes, I know that would have helped). The fever came and went. I choked on snot. I threw up a lot. I was generally miserable. I ended up back at the doctor again and got some high powered decongestant. Only then everything was so dry I coughed for the dryness of it. I took a lot of antibiotics to ward off early signs of pneumonia, and steroids which always make me feel like air is seeping through my chest walls – easier to breathe but unpleasant. I also took multivitimins, tried a grape seed extract nasal spray (pretty much worthless), and drank a terrible tasting cold tea which helped quite a bit. All in all it was a terrible experience which I do not recommend.

Sick

2009-10-30T14:27:00.002-05:00

Sorry for the lack of new postings. So much in the news and lots of commentary I'd like to give, but I'm afraid I have been sick with the H1N1 for the last week and a half. Miserable. Will try to post all about it next week.

Chronic Fatigue Syndrome Virus

2009-10-09T09:20:00.002-05:00

Researchers have identified a virus thought to be the cause of chronic fatigue syndrome. This virus, called XMRV -- xenotropic murine leukemia virus-related virus -- was identified in a significant number of patients with CFS. It is a retrovirus. Similar to HIV, this virus replicates via RNA. This suggests that antiretrovirual drugs used for HIV may help patients with CFS. They is also some research with suggests that XMRV may be responsible for prostate cancer as well.

I wonder how many other cancers are associated with viruses. And there is need for work on the epidemiology of XMRV. How is it transmitted? How can we prevent transmission?

We have long suspected CFS was caused by a virus. There has been some suggestion that it was a rickettsial infection (similar to Lyme disease). In fact, I see many patients with CFS diagnosed with Lyme, although the fit with that diagnosis often seems tenuous. What an exciting discovery.

Military Mandatory H1N1 Vaccine

2009-10-08T09:04:00.003-05:00

While it is no surprise that the military would mandate pandemic H1N1 vaccine, this article is interesting. The military vaccination program will really be a big experiment in safety. With such large numbers of personnel receiving vaccine (millions), it should be clear relatively quickly if there are any immediate safety concerns.

In the words of one commander (quoted in the article referenced above):"Because I can compel people to get the shots, larger numbers will have the vaccine... They will, as a percentage of the population, be vaccinated more rapidly than many of us. So we may see some objective results, good or not, of the vaccinations."

Here's hoping they are all good. (There are people out there who argue that 'Gulf War Syndrome' is a result of the anthrax vaccine, although the science behind that argument is grossly lacking).

In related news, my health department received the first shipment of vaccine -- a very small allotment of H1N1 flumist. The doses were given to local hospitals and offered to public health clinical staff (those with direct patient care). We expect the vaccine to slowly trickle in.

Meanwhile, numbers of people infected continue to climb. I am curious to see when we will reach the peak in the epidemic curve. Before long we will have herd immunity; it remains to be seen how much of that will be from natural immunity (having had the disease) or artificial (vaccination).

Tamiflu in the River

2009-10-05T09:29:00.006-05:00

Intriguing thread on ProMED about Tamiflu contamination of rivers in Japan. Apparently, when we take Tamiflu, we pee out the active form of the drug. Our Tamiflu-pee then travels through the sewage system and eventually ends up back in the environment.

This process has been found with a number of drugs. Several studies of the river which flows into the lake where my drinking water comes from have found high levels of antidepressants and birth control in the water. So we have mellow fish who don't reproduce (That's a joke of course, but the medicine is there and it gets in the fish).

Drugs in the water can have an effect the wildlife and one wonders (suspects) if we end up drinking them again. In the case of Tamiflu, there is a potential for waterfowl to consume the water and breed resistance. The studies that have been done so far suggest that the Tamiflu will survive through the water treatment process. There is a potential for all of us to drink the water and breed resistance.

While the CDC continues to stress limited use of Tamiflu, patients often demand the drug, and some healthcare providers continue to use it liberally. In recent weeks, a child with no underlying health conditions died in area and the media covered it judiciously. The child was taken to the doctor and had rapid results positive for influenza A. The child did not meet the recommendations for receiving Tamiflu and was not prescribed the drug. A few days later the child died. A sad, tragic story, to be sure. And speaking as a parent and not a public health official, if my child were diagnosed with influenza, after hearing that story I would be afraid. You never know which patient will be the one that goes horribly wrong. Many, many parents have called me, terrified because their kid has flu but their doc won't give them Tamiflu. In 99% of those cases, their child will be fine. But there's that 1% chance. That risk that your child will be the one on the news next time.

Obesity

2009-10-02T09:08:00.001-05:00

A friend of mine had gastric bypass surgery several months ago. Prior to the surgery, she was, to use the clinical term, morbidly obese. She tried all the usual weight-loss routes – special diets, pills, programs – without success. She was diagnosed with type II diabetes, hypertension, and a host of other ailments (including suffering a fractured tibia – her leg couldn’t support her weight).

Since the surgery, she has lost more than 100 pounds. Her diabetes and hypertension have resolved, and aside from the loss of much of her hair, she feels great.

She used to be very self conscious. Despite the push for eduction on obesity, 99.99% of people who are obese know they are fat (especially if they are women). She tried very hard never to be seen eating in front of others, because she was afraid that they judged her with every bite she put in her mouth. When she did go out to eat, she said that she planned the excursion in detail prior to leaving the house. She always ensured that wherever she went has tables and no booths – because she knew she could not fit into a booth and wanted to avoid the embarrassment of having to explain should a host attempt to seat her in one.

For the first time in her life, she bought a pair of jeans last week. They never fit her right before.

For the first time in her life, she rode carnival rides this weekend. She was too big to ride them before.

I never realized all the small things she worried about that I took for granted.

She feels so much better, and is much happier overall with her life.

I feel like I should wind this up with some powerful insight into weight and health, but really I just wanted her to know I am proud of her.

Info Gathering is a Skill

2009-09-28T12:52:00.003-05:00

I have two MPH student interns. This morning they were shocked to learn that my investigator has an MS, not an MPH. An MS in counseling psychology with no formal education in public health.

To be an epi investigator, you have to be able to talk to people. Crunching numbers is all fine and well, but you have to collect the data to begin with. My investigator has a background in crisis counseling. Perfect for this job. Because most people we are in contact with are in crisis. They have just found out they have a strange illness they may never have heard of, and the health department is calling them, asking questions. All most people know of this is what they've seen on TV, which we know is not always accurate. Having a background in crisis counseling helps my investigator calm the person down, provide some education, and get the information needed for the investigation.

In much public health work, we rely on people to give us information, willingly. It is all voluntary. People can (and do) hang up on us, or not even answer the phone. To do this job, you need to be skilled in social interaction. I am not that great on the phone with patients, which is why I have someone to do that for me. I am, however, pretty good at talking with docs, nurses, school administrators, mosquito control folks, sanitarians, etc.

A while back I had an intern who thought she was good with people. What she did, rather, was suck up to people. "Oh, Dr G, that is sooooo interesting!" "I'm sooooo impressed with people who have their PhDs!" I couldn't stand her. We both knew it was bullshit, so why bother?

I'm talking about being real with people. Don't treat them like they should give you the info you want just because you're you. And don't try to schmmoze people -- they see right through it.

This is a skill that most of the MPH students I interact with don't seem to have. I would say it is just a lack of working experience on their part, but I know these skills can be taught. I learned more about how to gather data from my qualitative methods courses in grad school than I ever did in the quantitative courses. The MPH programs I have worked with are so quantitative oriented, that they are missing that qualitative skill set.

Texas Hosptial Overflow Has Patients in Tents

2009-09-23T13:25:00.004-05:00

A children's hospital in Austin has set up tents to deal with the mass numbers of kids coming to the ER. Most are mildly to moderately sick with the pandemic H1N1.

So far today I have received 5 reports of H1N1 hospitalizations. Prior to this, since April I only had 14. Glancing through the reports, the illnesses do not appear to be terribly serious. None of these 5 were in ICU or in need of ventilation. One was admitted for severe dehydration. Two were asthma exacerbation. One was a pregnant woman. The other one had significant underlying health conditions.

Surveillance shows an incredible amount of influenza-like illness in my area. I take the numbers with a grain of salt, though. Awareness is very high -- let's face it, it's tough to get away from "swine flu" messages right now. Combine that with fear. I suspect (and have in some cases been told) that school nurses are being very cautious with sick kids and reporting them as ILI when they might not have in the past. I also think that due to the hoopla people are more likely to seek health care now that usually. While demand has increased in some of the ERs, the overall level of hospital admission with serious illness is low. To me, the real signal to the severity of this pandemic will be severe illness and death.

Think of the common cold. How many of us get the common cold? I catch one or two cold viruses without fail each winter. Get myself a nasty sinus infection. I typically do not go to the doctor. But if I had reason to believe a particular cold might be something to get alarmed about, I might seek medical attention even though I did not need it. That would be a fear-driven response rather than a needs-based one.

Every time we have a highly publicized outbreak, many more people seek medical attention than would normally. Plus, when there is a highly publicized outbreak, docs are more likely to test for it. Some patients will demand the test even when the doc doesn't really have a medical reason for doing so. I heard about an ER fight this summer where a patient screamed for the test even though they didn't meet the lab criteria for testing, and there was no diagnostic reason for doing so. The poor ER doc ended up collecting a specimen which the lab promptly discarded. During the last peanut butter outbreak, people called me wanting to "get tested" because they felt sick to their stomachs. In our litigious society, many of these want to get in on the eventual class-action lawsuit. Still others like the novelty of saying they had the "peanut butter salmonella" or whatever else is going around.

Someone told me the other day that his kid has "The H." We all decided that sounded cooler than H1N1.

I am not advocating complacency, but rather reasoned caution. I'll keep an eye on severity (heck, H1N1 is all I ever do any more). We'll all wash our hands, because, let's face it, it will stop lots of germs from infecting our bodies. We'll all cough in our sleeves and we'll all stay home when we are sick. And the vast majority of us will be just fine. I wonder if one day this will all be looked upon as the 2009 Y2K, with senate hearings on the vast amounts of money being spent on pandemic control.

The Flu Queen

2009-09-17T07:45:00.006-05:00

Yesterday I gave a presentation to a grassroots community coalition about flu. Today I am presenting at a hospital. This afternoon I am presenting to a group of school nurses. I spend all day, every day, dealing with flu. A colleague has dubbed me the Flu Queen and my investigator the Flu Princess and promises to have us both sparkly tiaras soon.

The good news on the flu front is that data from the pandemic H1N1 vaccine are starting to spill out. The New England Journal of Medicine had several articles on trails. In terms of safety, the reports are mild side effects, the kind expected when you give any shot -- sore arm, in some cases fever. There was also reports of headache. Nothing alarming. No sentinel events. The FDA has approved the vaccine both in shot and nasal spray. Lots and lots of doctors will be giving the shot, so it looks like most people will just be able to go to their primary care physician to get it, or to a pharmacy or doc-in-the-box. If they can't get it there, they can get it from their health department.

In other news, a case of cysticercosis was reported the other day. A guy was in a bar fight, ended up in the ER. They did a CAT scan of his head due to the injuries, and lo and behold, there were worms in his brain. Nothing delusional about them. That's a bad Friday night out.

H1N1 Conspiracies

2009-09-14T12:20:00.004-05:00

This weekend someone sent me a link to this video. It is the wackiest H1N1 conspiracy theory I have heard yet. I looked up the claim that Oklahoma is mandating the vaccine -- they aren't. And while health departments across the nation are receiving and exorbitant amount of money to administer H1N1 vaccine, there are no plans of blockades, checkpoints, or non-removable metal bracelets. At least not that I am aware of. And considering that if such plans were in place, I would be one of the government workers administering them, I am fairly confident that we can all calm down.

I think that some people truly want the worst-case scenario, The Postman, Dies The Fire, Y2K, post-apocalyptic scenario to happen. The survivalist fantasy is exciting. The copy repair man who becomes a military leader after the power goes out, the librarian who becomes a hero. That notion that we could be more in the right circumstances, if only we weren't caught in the tedium of day to day lives, working to pay off the mortgage, car loans, and credit cards. Let's erase everything and start over.

I'm afraid H1N1 isn't it.

Delusions of Parasitosis

2009-09-11T15:15:00.003-05:00

Imagine, for a moment, that you have a crawling sensation on your arm. You scratch at the itch, and it seems to go away. A short time later it returns, and you find yourself scratching at it again. You examine your arm for the cause and find what look like small insect bites.
The next day, your arm is itching again. This time you cannot find relief, and your back begins itching as well. The itch distracts you throughout your day, and towards the end of the evening you ask a friend to look at your back. She says it is a bit red, but otherwise she doesn’t see anything. That night as you try to sleep, you feel something crawling across your skin. You turn on the light, but find nothing.

In the morning you find that you have scratched so much that whelps have scabbed over. Bits of white debris are on the spot where your arm itches. When you examine the debris closely, you see that it looks like tiny insects. You realize with a touch of horror that you are infested with some sort of bug. You place the carcasses into a small plastic container and make an appointment with your doctor.

You explain the situation to your doctor. He sees you scratching, sees the discomfort you are in. He examines you, and examines the bugs in the container. Unbelievably he tells you there is nothing wrong with you. “Those are not bugs at all,” he says. “It is bits of your skin.” He claims it is all in your mind.

Delusional Parasitosis (DP), also known as Ekbom’s Syndrome, was first described in the medical literature in the 1800s. Patients complained of parasitic infestation, however, no physical evidence of that infestation could be found. The infestation was, in fact, all in their minds. A delusion. A hallucination.

Patients with DP most often describe that insects are crawling, biting, and/or burrowing in their skin, although there have been reports of delusional intestinal parasitosis and DP of the oral cavity. In their delusion, many patients will actually “see” the parasite, and can describe, and even draw, the insect in great detail. Many will bring their physicians containers of matter they say is from the bugs. This behavior is so common that it is known as the “matchbox sign,” i.e. debris is carried to the doctor in a matchbox. Upon evaluation, however, the matter is often small bits of human skin or hair, or other fibers.

To rid themselves of the insects, patients will often impart in elaborate purification rituals, which often lead to self-mutilation. They may apply pesticides or disinfectants to the skin, and will often scratch themselves to bleeding. They may cut into the skin in an attempt to remove the parasites. One study describes a patient who tried to remove the parasites using a blowtorch. Changes in the skin, such as excoriation or lichenification, are typically observable, particularly on the scalp, face, and hands. Occasionally the condition leads to suicide.

Two variants of DP are described in the literature. Primary DP occurs in the absence of any underlying disorder. There is nothing wrong with the patient -- aside from the delusion. DP may also be secondary to other conditions, including schizophrenia, depression, and dementia, as well as other physical disorders, such as diabetes mellitus, renal insufficiency, hepatitis, vitaminB12 deficiency, multiple sclerosis, or leprosy. DP may also be induced via use of drugs, for example amantadine, anticholinergic agents, levodopa, and occasionally by some antibiotics, as well as recreational drugs, such as crystal methamphetamine and amphetamines. DP is so common among cocaine users that it is referred to as “cocaine bugs” by cocaine users.

Most DP patients share the following characteristics: (1) They are likely to exhibit slightly paranoid or obsessive-compulsive behaviors, (2) have difficulty expressing anger or hurt feelings, (3) have difficulties forming close relationships, and have limited social networks, (4) they may be predisposed to skin conditions which cause varied sensation responses, (5) they are likely to live in impoverished conditions, and (6) they may have underlying sexual impulses or thoughts which them deem to be “filthy” or “unclean.” Overall however, their mental status is stable.

Onset of DP has been reported following traumatic events (such as death of a loved one), after flooding of one’s home, travel, injury, and after contact with persons with an actual insect infestation (i.e., lice, scabies); however, DP does not necessarily include a recognizable precursory event.

DP takes a significant toll on the patient’s life. Patients will express significant concern about infecting others, and will take steps they feel will prevent this from occurring. Shared delusions, known as folie á deux or folie á famille, have been reported. Some studies suggest this phenomenon occurs in as many as 25% of DP cases. In this case, one or more household members of the DP patient reports infestation. Typically, the initial patient is the mother – who is often a dominating family force. They will often consult a number of different healthcare providers of many different specialties, as well as pest control professionals and entomologists. Ultimately, much time, money, and effort are expended in an attempt to get rid of the bugs. Frustration will mount, and feed into a perception that no one wants to help them. Despite the quest for assistance, however, DP patients generally refuse psychiatric intervention. The suggestion that the problem is one of the mind reinforces the aforementioned feelings of abandonment by the medical community.

A key issue in terms of treatment is the general refusal of DP patients to seek psychiatric help. The delusion is real to them – they truly believe they are infested with parasites – therefore to refer them for psychiatric evaluation is to further reinforce their belief that the healthcare practitioner does not care about their suffering.

The incidence of delusional parasitosis is difficult to determine due to lack of reporting and the variety of health care practitioners consulted. One study estimated seven in 10,000 psychiatric admissions were related to DP. A 2007 study of dermatologists found that 85% of the doctors in the study had observed patients at some point in their practice with DP.

In cases associated with substance abuse, patients are more likely to be young adults of marginalized socio-economic status. In contrast, DP patients without history of substance abuse are more likely to be over age 50. DP seems to affect older women at a higher rate than older men. A 1978 study of 57 DP patients described a mean age of onset at 64 years of age and a predilection for women (74%). Other characteristics included a history of mental retardation, folie á deux, underlying chronic disorder (such as dementia and diabetes) and additional underlying psychiatric disorders. Two of the patients in this study reported history of suicide attempt.

A 1983 survey of dermatologists also found that women were more likely to exhibit DP, particularly when over age 50. This survey also noted underlying chronic conditions such as diabetes and hepatitis, as well as psychological disorders, including depression and schizophrenia. A similar survey of dermatologists in 1986 found older women more likely to present with DP. This was supported yet again in a 1990 study in which 82% of the patients were women.

Seasonality has been described in the literature. One researcher conducted a long-term survey of telephone consultations of persons suspected of having DP with the Mississippi health department and cooperative extension offices. Over an eight year period, he found DP to be more prevalent during the late summer and early fall. Interestingly, most of the calls I have taken like this occur in the spring. The weather warms up and the DP cases increase.

It is important to rule out actual insect infestation or allergens before beginning other treatments, as well as to explore co-morbidities or behaviors (i.e. drug abuse) which may be causing the delusion (as in secondary DP). While a physical cause for the patient’s symptoms may not be found upon examination, the suffering of DP patients is intense, real, and clearly visible. Interviewing techniques that include empathy and relationship-building are repeatedly emphasized in the literature.

It has been suggested that many health care professionals who treat DP patients may not have the specific expertise to effectively manage the patient’s psychological needs, and dermatological training that covers psychodermatoses may be beneficial. For dermatologists and others who encounter DP patients in their offices, it is helpful to have an established relationship with a psychiatrist for referrals of patients willing to see one. In some instances, it may be possible for the psychiatrist to evaluate the patient in the dermatologist’s office. A liaison that can smoothly transition the patient between dermatological care and psychiatric care can also be beneficial.

Due to the negative side effects of neuroleptic DP treatments, health professionals may find it useful to determine which patients could develop insight into their condition over time. There is some discussion in the literature of patients presenting with “shakable” as opposed to “fixed” (true delusion) beliefs about the parasites. This is an important distinction in terms of treatment. Studies have demonstrated that some DP patients hold shakable beliefs, and will agree that they perhaps are not infested when presented with ample evidence to the contrary. For these patients, talk therapy, as well as treatment of any underlying disorder, is indicated. The therapist should empathize with the patient’s condition and accept that the patient truly is in distress; however, to agree that the patient is actually infested only furthers the delusion.
Material brought by the patient (the matchbox sign) should be examined. The therapist should explain what the specimen actually is (fibers, bits of skin, etc). The therapist should review the negative laboratory studies with the patient and explain their meaning, and remind the patient that no medical professional has been able to validate their claim. Patients with shakable beliefs, may, when confronted with enough evidence, accept that they are not infested. Some patients will continue with their delusion regardless of evidence presented.

DP is a condition which a variety of healthcare workers, public health professionals, veterinarians, and etymologists may encounter in their practice. The condition has significant impact on the lives of those who suffer from it. When confronted with a DP patient, a compassionate response is indicated. One should empathize with the patient without feeding in to the delusion, and demonstrate scientifically (when feasible) that there is no rational basis for their claim. Preexisting relationships with mental health providers may facilitate getting patients proper treatment and alleviating much suffering.

Kids in School, Spreading Flu

2009-09-09T12:30:00.003-05:00

I never intended for this to become an influenza blog, yet it does seem to be trending in that direction, doesn't it? I suspected flu levels would increase when school started back up, but Boy Howdy. I wasn't quite prepared for the onslaught.

The question should not be who has flu, but rather who doesn't have it. A school in my city almost closed because so many kids were out sick yesterday. This wasn't a disease control issue, but rather a financial one -- 26% of the kids were absent.

I have a pretty intensive surveillance system for influenza-like illness in the schools. Levels right now mimic those that I typically see at the beginning of seasonal epidemics.

The hopeful news is that this may burn through the population, peak, and level out to usual flu activity. My prediction is that we see an early peak in the next month or two, followed by a peak in seasonal flu in February, and then in subsequent years H1N1 just becomes another strain in the usual circulation, we call swine the new seasonal and we are done with it. I hope I'm right on that one. I feel like H1N1 has taken over my life. It's all I do at work anymore. And I think my spouse may have it.

Wakefield on Dateline?

2009-08-31T14:19:00.002-05:00

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.

H1N1 in Birds

2009-08-24T12:02:00.002-05:00

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.

Ethics of Mandatory H1N1 Vaccination

2009-08-20T18:13:00.002-05:00

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.

Scientists and Mystics

2009-08-18T19:12:00.004-05:00

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.

Condoms and Prostitutes

2009-08-15T15:24:00.005-05:00

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.

Healthcare Reform

2009-08-10T13:09:00.003-05:00

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.

H1N1 Kills Nurse

2009-08-08T21:01:00.005-05:00

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.

Where's the Voice of Reason?

2009-08-04T13:12:00.004-05:00

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.

Mass Sociogenic Illness

2009-07-30T12:54:00.003-05:00

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?).

H1N1 and Pregnancy

2009-07-29T12:08:00.004-05:00

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.

H1N1 Vaccine Production

2009-07-27T12:15:00.004-05:00

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.

Explaining Drug Overdose to a Five Year Old

2009-07-21T13:57:00.004-05:00

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."

Human Rabies Survivor

2009-07-15T15:42:00.002-05:00

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.

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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).

Obesity and H1N1 Deaths

2009-07-13T10:34:00.005-05:00

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.

A Disease You Don't Want To Get

2009-07-11T15:46:00.003-05:00

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).

No More Health Education

2009-07-08T15:32:00.005-05:00

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.

Raising Awareness

2009-07-04T13:49:00.004-05:00

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.

Novel H1N1 Kills the Economy

2009-06-30T12:57:00.003-05:00

I don't know how things are where you live, but in my neck of the woods, the economic crisis has not been kind. The neighbors across the street are moving out today -- another foreclosure. The local news is filled with reports of more lay-offs, including scores of government and school district employees.

Economically -- bad timing for a global flu pandemic.

On a basic local level, we have already spent tens of thousands of dollars on supplies, transportation of specimens, and employee overtime. But researchers at Oxford Economics estimate dire consequences for the global economy. That's right. Dire. Not that I am over-reacting... What does that look like? Increased unemployment, decreased consumer spending, possible deflation, long-term consequences -- ultimately increasing the length of the recession (depression?).

Irradiated Cat Food

2009-06-30T07:39:00.001-05:00

This was just too interesting not to comment on. In a Promed report, there was discussion about how investigators in Australia determined that irradiation of dry cat food was leading to fatal neurological damage in some cats. For some reason, only female cats who became pregnant while on a diet of the irradiated food were affected -- male cats and the kittens did not develop symptoms. Dogs were not affected. Irradiation is apparently performed on imported foods. They also irradiate some human foods (although this is qualified with a note that it is at much lower levels than the pet food).

A couple of weeks ago, I spoke with a USDA inspector who was involved with the E coli outbreaks in produce from California. He said he believes all produce should be irradiated. Anyone else concerned about this? I'm not a cat, but I'm not terribly excited about eating irradiated foods.

Not My Cookie Dough

2009-06-24T07:42:00.002-05:00

Frozen chocolate chip cookie dough has been recalled due to possible contamination with E coli O157:H7. This is a really nasty bug that can lead to kidney failure and, in some cases, death. Investigators performed a case control study. Basically, what you do is interview all the sick people, find out every food they ate in the last two weeks. Then you interview a well person, usually someone else in the home, and find out everything they ate in the last two weeks. This is tough -- a lot of people don't remember everything they ate. Sometimes you have to ask about foods normally eaten. For example, I don't ever eat fried liver, so I know I haven't eaten it in the last two weeks. So that would be a 'no' on the questionnaire. I do eat raw spinach, and while I can't remember for sure if I ate it in the last two weeks, there is a good possibility, so it should be marked 'yes.' In the case control study, frozen cookie dough emerged as the most likely culprit. Statistically, people who were sick were significantly more likely to have consumed it than people who were not sick.

The big question in my mind is how the heck did the E coli end up in raw cookie dough? E coli primarily comes from contaminated cattle, although other animals can be infected. When you hear about produce outbreaks, in all likelihood the field was contaminated somehow, like through water runoff or wild animal activity. How did it end up in the dough? I heard a news report which suggested that meat products are also processed at the cookie dough plant, but it still seams odd to me.

In one of the salmonella in commercial food outbreaks investigators found that birds roosting in the rafters of the processing facility were defecating down into the works of the machinery. How disgusting is that?

If you still have any of the recalled dough, throw it away. While cooking it would kill the bacteria, there is a very high likelihood for cross-contamination of your hands and kitchen. Which means you would get sick any way. You might be able to see if you can get your money back from the store where you purchased it.

Pandemic Severity Index

2009-06-19T14:05:00.005-05:00

Since the "stages" of pandemic do not appear to be terribly useful in describing novel H1N1, CDC has created a Pandemic Severity Index. It mirrors the hurricane severity index, with a Category 1 being mild, like seasonal flu, versus Category 5 as the most severe. Disease control activities are then based on the severity of the illness, although I would think you would still be concerned with the stage -- ie the levels of transmission within the area -- in conjunction.

I just returned from a table top exercise on what I suppose would be a Category 4 or 5 pandemic. Bad case scenario, where lots of people die, the grocery stores run out of food, people have heart attacks on the street because the hospitals are too full to accept them, etc. One of the big worries the responders expressed was about how the public will react next time -- "See there they go again, the government over-reacting!" and then ignoring prudent advice.

One of the big problems is that for the last few years (decades?) we have lived in a culture of fear. Fear is the primary motivation for people. Scare the crap out of people to get them to do things. Check your breasts monthly so you don't die of breast cancer. Put your kids in car seats so they don't die in car wrecks. Everything is dangerous. Nothing is safe. Parents won't let their kids play outside because of a fear that they might be abducted.

Not long ago I had a conversation with a friend about the use of fear as a tool to control people in religion, and how there has been a shift away from that. As a kid, I was scared to death that I would burn in a lake of fire. Terrified, terrorized really, of going to hell (why yes, I was a Catholic. What do you ask?). A lot of churches (Western, Christian) have gotten away from that message, and now promote spirituality and having a relationship with God for the sake of the relationship, rather than blindly following church doctrine out of fear of hell. It seems to me that this is something we should consider moving towards as a society -- acting because something is the right thing to do, rationally, rather than being driven by fear and anxiety. I am not sure how to accomplish that, but it makes sense to me.

Influenza Pandemic

2009-06-15T13:00:00.003-05:00

I've been meaning to post for a few days now, but vacation activities and yet another viral illness (GI through the family) interfered. So here you go:

The World Health Organization has declared that we are now in an influenza pandemic. Pandemic alert phase 6.

It is sort of anti-climactic, isn't it?

Pandemic is a scary sounding word. The truth is, all it means is that person-to-person transmission is happening in several regions of the world. We've been in an HIV pandemic for quite a few years now and the majority of Americans are not too worked up about that.

Interestingly, there is some evidence that this bug has been around longer than we first thought.

There are still lots of reported problems with testing for novel H1N1. The rapid flu tests seem to be hit or miss, and the PCR testing seems to be running at about 90% accuracy, according to Promed. On the plus side, some of the commercial labs are now offering the test, which should take some of the pressure off of the LRNs.

Last week, Egypt reported cases of novel H1N1. This is concerning because they have cocirculating influenza H5N1 -- otherwise known as the avian flu we've all been worried about. Of course they are not the only country to have both, but they have had a lot of H5N1 human cases of late.

An epidemiologist friend of mine told me that she investigated a household in which one family member tested positive for novel H1N1 and another family member tested positive for seasonal influenza. That's a family to watch -- it is situations like that which allow for gene swapping and breeding of new bugs.

Common Cold

2009-05-28T12:35:00.003-05:00

I have spent the last few days fighting with what is probably a rhinovirus. Common cold. Frankly, I needed some rest, but sheesh, what misery. I have become a leaky incubus of viral plague. It is hard to stay positive when you are drowning in your own fluids.

In the meantime, here is a tool for differentiating between regular flu and swine flu: http://doihaveswineflu.org/.

Swine Flu Death -- Underlying Medical Conditions?

2009-05-19T13:12:00.004-05:00

Check out this video. It is an interview Larry King did with the husband of one of the first people to die of swine flu in the US. This is not the first media report I have seen about this woman. Aside from the lawsuit issue, what is key here is the issue of "underlying medical conditions." Most media reports I have seen used this turn of phrase -- She died because of an "underlying medical condition." So what are we supposed to take from that? Oh, well, she would have died anyway? We don't have to worry about ourselves, because obviously she was at risk because of an "underlying medical condition"?

Here's her "underlying medical condition." She was pregnant. An emergency Cesarean section was performed in order to save her baby.

Lyme Disease

2009-05-18T13:36:00.003-05:00

There's a very sad story on MSNBC about a woman with Lyme disease. In the late stages of the disease, she finally killed herself to get away from its misery.

From a medical standpoint, one of the problems with Lyme is the difficulty of diagnosis. The positive cases that are reported to me (Lyme is a reportable condition) generally place onset at a year or more ago. Sometimes many years ago. Unfortunately, they have missed the window of opportunity in which treatment is most effective. For many patients, the diagnosis was not considered until late in the illness. I had a doc tell me recently that we don't have Lyme disease in this part of the country. Well, A) that's not true, and even if it were, B) people do travel outside of this area.

When doing a case history, I have found that most people with Lyme disease do not remember ever having a tick attachment. Some do. Some clearly had the bull's eye rash. But a lot of them didn't.

Sometimes laboratories will report positive results which the physician will contest. It's a false positive, the doc will say, even though all the markers are there. Certainly that is a possibility, but these scare me, because the patient will not receive treatment.

It is important to review your lab work with your doctor. Ask to see it, and ask what it means. Laboratories flag values that are out of normal so the doctor can easily see it. If you see a flag, ask about it. If your doctor says it is a false positive, ask why she or he thinks that, and ask to be retested.

Swine Flu and Sick Time

2009-05-15T10:40:00.001-05:00

CDC backed off school closures and everyone decided swine flu (or novel H1N1, whatever) was not any big deal. Here’s a problem with that. A little kid was reported to me with a positive rapid influenza A screen. A specimen was forwarded to the reference lab for further testing. I talked to the kid’s mom. She was concerned because she had just started feeling bad – and she is a pulmonologist. Who spends more of her time in a hospital intensive care unit. I told her per the CDC guidelines to stay home for 7 days, longer if she is still sick. She had me speak with the hospital administrator about this – yes, she really should stay out of your ICU, I said. The investigation was done, entered into our database, and filed.

Today we received confirmation that the child did have swine flu. I called the mom to let her know. Mom is still sick – she’s been running a temp of 102 for days and days. Oh, and she’s been working too. Instead of staying out of work at least 7 days, she stayed out 2. Her reasoning was that she does not get sick time and she was off unpaid. Then she tells me that one of her patients – with lung cancer – spiked a fever. Could he have swine flu? Hmmmm. YES DOC HE COULD. Why don’t ya go ahead and do a flu screen, then send a swab in for further testing? Please. Sheesh.

How utterly irresponsible. I informed the hospital infection control practitioner so he could follow up on exposed patients. He was not pleased (to put things mildly).

Having an infectious disease is a nuisance. It is an inconvenience. But please, let’s all take some personal responsibility. If you are infectious, you should not be around other people. And if you are an employer, be humane to your employees and provide sick time.

Off-Line

2009-05-11T10:27:00.003-05:00

The blog has been down for a few days. It unexpectedly received a lot of media attention. That should be a blogger's dream, but I feared I might experience work-site related repercussions. Thank you kindly to those who wished to do interviews with me, but I am unable to do that at this time. Thank you for your understanding.

Back peddling?

2009-05-11T09:29:00.004-05:00

CDC's back peddling on school closures sent a message to the public: "We over-reacted. So sorry. Nothing to see here folks, move along." But the crazy thing is, the virologist and epidemiologists don't seem to be in agreement.

Data coming out of Mexico on fatalities is showing people in their 30s with the highest case fatality rate. That is disturbing. In Norway, they grew a new variant of the H1N1 swine flu. The southern hemisphere goes into regular flu season soon, which means co-circulating viruses. And no one has said what will happen with H1N1 swine flu hits areas like Egypt who are reporting new cases of Avian influenza (human and bird) almost daily.

I don't mean to be Chicken Little here, but come on people. Let's not count our eggs before they've hatched. It will take time -- like it or not -- to truly understand how this thing will unfold. For now, in the US, it is mild. Thank goodness for that. But I think it is a mistake to totally let our guard down. There is too much evidence in the scientific community to support that.

This is a marathon, not a sprint. Now go wash your hands.

The Swine Flu Continues

2009-05-01T07:22:00.003-05:00

A public health disaster is not like a tornado or a hurricane. They don’t just hit and leave you with a bunch of debris to clean up. They are insidious. Sneaky bastards.

This is my analogy of where we are today. I am standing on the beach, with scores of other public health workers standing along side of me. In the distance, off in the ocean, we see a hurricane. At least, we think we see a hurricane. It is hazy, and we are not 100% sure about what we are seeing. Nonetheless, we are all blowing as hard as we can, hoping to turn the hurricane back out into the ocean, where is will fizzle into nothingness.

More schools have closed. It is a tremendous burden on those who make that decision.

Many schools have cancelled extracurricular events for the time being. Several mothers left messages on my phone yesterday demanding to know why I would cancel prom and who was going to compensate them for the $800 they spent on their daughter’s dress.

First off, I didn’t cancel prom. I recommended people consider cancelling large gatherings. The school did not cancel prom. They rescheduled it. Second off, I would rather have your daughter not go to prom and be alive than go to prom and be dead in a week. Is it that dire? I don’t know, but I am not going to take that risk with your child.

It is so hard to work so many hours and then be criticized at every turn for over-reacting. Maybe we are. Honestly, I hope we are. I would love nothing more than for this to turn out to be nothing.

Remember Katrina? Remember how everyone criticized the government for not doing enough? Remember all the complaints, the fears, the people dying on the roofs of their houses? We learned a few lessons from that. One was don’t hesitate.

Friends of mine worked 50 hours straight on the ground in New Orleans. Their thanks was a big slap in the face for not doing enough.

Please know that the underlying philosophy, the guiding principal here is that WE DON’T WANT YOU TO DIE. That is why we do what we do.

School Closure and Swine Flu

2009-04-28T07:13:00.003-05:00

One of the big lessons learned often cited from historians of the 1918 influenza pandemic is that communities who practiced social distancing had significantly less mortality than those who did not. A problematic lesson to emulate in places like New York City. But here in the land of desert and suburban sprawl it is a possibility. The media is reporting that school districts in Texas have closed schools due to this flu (which the pork industry is lobbying to change from swine flu to North American flu as they are already taking a financial hit from lowered pork sales).

School closure is a double edged sword. On the one hand, you have the potential (although there is little evidence based research to back this up) to quell flu activity in your community. On the other hand, with kids out of school you run the risk of losing a significant proportion of your workforce as they go home to care for the kids. Not a problem in some industries, but it is a problem when we talk about healthcare workers. Especially if the case count continues to creep up. So should we close the schools? The advice from CDC is yes when you have one confirmed case or one epi linked case. I have heard some health authorities who say that is too conservative -- the time to act is now, get ahead of the thing -- and others who think it is too liberal, a gross over reaction.

I caught a CNN reporter yesterday (it is now a permanent fixture in our emergency ops center) discussing the "scary, deadly virus." Um, CNN guy, that is not helpful. Fear mongering only makes this worse. A commentator from Mexico City on NPR stated that 20 million of his neighbors were infected -- with fear. Fear is what prompted the literally hundreds of calls my staff fielded today. A bit of fear is a good thing. Too much is paralyzing.

Should we panic? No. We should be cautious. We should all have enough food and supplies in our homes to minimize trips out in public. We should avoid crowds. And wash our hands a lot. And certainly if we are sick, we should take some personal responsibility and stay home.
The cases in the US reported so far have been relatively mild. I am hopeful that trend will continue. I would like nothing more than for this to fizzle out in a y2k bust and let us have egg on our faces for over reacting. I would much prefer that to the nightmare scenarios in our disaster drills. However it goes, to all the workers battling this disaster, take care of yourselves too. God bless, and God speed.

Swine Flu Day

2009-04-27T14:44:00.003-05:00

This has been my day. The phone rang constantly, to the point that I had to set it to go immediately to voicemail. As I checked my voicemail, more messages rolled in. Most of the calls were from physicians. Guidance from the state health department told them to contact their local health department for additional information. Unfortunately, we do not have the answers yet either. My health department has very limited lab capacity, yet all these providers want testing for swine flu.

Many of them are seeing positive influenza A in their offices. I have been trying to get their specimens to the LRN for additional testing. So far we have no confirmed cases, but I suspect it is only a matter of time.

I am also getting calls from the schools -- should they close or not? And city leaders -- what should they do? I advised EMS to mask up when on runs with febrile patients.

Are we all going to die???

The problem here is lack of information. Please be patient with us -- we are doing our best to give good advice, but the known is so limited at the moment. And it changes literally minute to minute.

Swine Flu Continues

2009-04-27T13:19:00.002-05:00

There has been much activity surrounding swine flu. Since I got to work at 6:30 this morning it has been constant phone calls and emails. It is a bit overwhelming. At least 10 doctors have called me saying they have positive flu A cases and they want further testing for swine flu. I am trying to get that arranged. Normal flu A season had come to an end, so all these cropping up are not good news. That being said there is not a flurry of activity with the hospitals, good news there. Hopefully this bug will continue to be a mild illness. I will try to post more this evening.

In the meantime, while I do not recommend anyone freak out, this is a good time to ensure that you have a 2 week supply of food for your family -- just in case it is advised that you stay home. It would also be prudent to stay away from crowds of people. And please, wash your hands.

Swine Flu Concern

2009-04-24T08:54:00.003-05:00

There is a large swine flu outbreak in Mexico. I copied the text of a news article for you:

Mexico shuts schools over deadly influenza epidemic
Article from: Agence France-Presse

April 24, 2009 07:46pm
MEXICAN authorities have closed all schools in the capital and central Mexico as the WHO announced hundreds of human cases of swine flu in the country, including 57 suspected deaths.The outbreak has killed at least 20 people in the past month, Health Minister Jose Angel Cordova said in announcing the school closures. "This afternoon the epidemic was confirmed by Canadian and US labs to be a new influenza virus," Mr Cordova said in a televised statement in which he urged people to avoid large crowds, shaking hands, kissing people as a greeting, or using the subway. The Government has gathered 600,000 vacines to help protect health care workers dealing with the outbreaks, the health minister said. The World Health Organisation said there are 800 suspected swine flu cases in Mexico and seven cases reported in the southwestern United States. It was not immediately clear whether Mexican authorities had identified the outbreak as that of swine flu, as labelled by the WHO. Since March 18, 13 people have died in Mexico City, four in the central state of San Luis Potosi, two in Baja California in the northwest and one in the southern state of Oaxaca, Mr Cordova said.

Swine Flu

2009-04-22T13:56:00.002-05:00

In an MMWR Dispatch this week, CDC reported cases of Swine Influenza A in a couple of children in Southern California. It doesn’t seem like the two kids had interaction with each other, nor did they have contact with pigs. The question then is, where did these kids get swine flu? It suggests there is some person-to-person transmission occurring. The report asks for surveillance from this California healthcare providers along with surveillance of people who work with swine or who were in contact with the sick kids. The report notes that one of the sick kids travelled to Texas earlier this month, so there are some investigations and enhanced surveillance happening there too. One wonders how the kid got to Texas – Vehicle? Airplane? -- and if there were other exposures en route.

Swine flu is an issue because most of the population probably does not have any antibodies. There has been a lot of concern among public health officials in the last couple of years about influenza pandemics. Of specific concern is the influenza A H5N1 virus. However, there is just as much chance of a pandemic from another strain, such as this one. According to the report, “This particular genetic combination of swine influenze segments has not been recognized previously among swine or human isolates in the United States, or elsewhere based on analyses of influenza genomic sequences available on GenBank.”

Pandemic is a scary sounding word. It doesn’t necessarily mean death, destruction, and the end of life on earth as we know it (despite often being portrayed that way). From the report it appears that the kids had mild illness, and both have recovered. The fact that it was swine flu was picked up through enhanced influenza surveillance and might not have been caught otherwise.

Dead Cows

2009-04-13T10:58:00.001-05:00

I got a call this morning from a woman concerned about some dead cattle. She lives out in the country, and at her fence line, several cattle on her neighbor’s property are dead. She said that she called the Sherriff’s office and an animal control guy came out and took pictures. She called them today to find out what they were going to do about it and animal control told her they couldn’t do anything because the cattle are on private property.

Now I know there is more to this story than she knows, because I have worked with those guys and they wouldn’t just take pictures and be done with it. That being said, there is something funny about living in the West. It has to do with jurisdiction. Out here in the West, people guard their freedom and independence with a vengeance. Government authority is pretty limited – especially in the unincorporated areas. If you live in an unincorporated area, jurisdiction falls to the County. But the County has much, much less authority than City government. So when the animal control folks say they can’t do anything about the dead cattle, it may be true. If they have contacted the owner and the owner refuses to let them on the property, they will need to get a search warrant. Which means they have to establish probable cause. That is likely the reason for the photographs – to get a sense of how the animals died. Did they starve to death? Then they could argue for animal cruelty and get a warrant that way. Was it a natural cause? They will need to convince a judge to write the warrant though, which is another tricky step.

Meanwhile, this woman is terrified it is anthrax.

Sixth Graders are Goofy. And They Are Having Sex.

2009-04-09T11:26:00.005-05:00

A group of researchers out of the University of Texas School of Public Health recently published results of a recent study on the sexual behavior of middle school students. They looked at the rates of kids engaging in various sorts of intercourse (vaginal, anal, oral), and here's what they found: By age 12, 12% of students have had vaginal sex, 7.9% have had oral sex, 6.5 have had anal sex, and 4% have engaged in all three.

By age 12???

Meanwhile, schools are supposed to teach abstinence only, and not allowed to discuss safe sex.

If you start having sex at 12, how many partners have you had by the time you're in your mid-20s? How many opportunities to contract an STD? If you are having sex at 12, how likely is it that you really understand the implications of catching an STD? I'm thinking you don't.

The study goes on to note that a third of these kids aren't using condoms, and -- seriously -- a quarter of them have had 4 or more partners.

I understand reluctance around the issue of providing sex education to kids. I don't want to give anyone tacit approval either. But, come on. Isn't part of our responsibility as parents, as educators, as adults, to make sure that our children are safe?? Clearly these children are engaging in unsafe activities. And the adults are preaching Just Say No and withholding life-saving information.

My department gives a HIV/AIDS prevention program targeted at IV drug users in the county jail. On a recent visit over there, I had a 19 year old girl ask me questions about her recent chlamydia diagnosis. "I just don't understand how I caught this," she told me. "I've only been with 17 guys."

I kid you not.

Ok, it is easy to poke fun at that, but she was serious, she truly did not understand STD transmission. The thing is, a lot of other young people don't know either. I've had high school kids tell me that you can do it anally and still be a virgin. They didn't know anal sex was riskier than vaginal.

It's time to rethink this whole abstinence only stance and provide real sexual education to our children.

Vaccines

2009-04-06T13:03:00.001-05:00

How about another measles outbreak? This one took place in Washington state. Eight kids in one household all got sick. They did not visit the pediatrician because of the rash, but rather due to complications of measles infection. Two developed pneumonia and one thrombocytopenia.

Nineteen cases altogether were associated with the outbreak. Of these, 16 were school-aged. All of these were unvaccinated due to philosophical exemption. Eleven of the children were homeschooled and 5 attended a faith-based private school.

The cases were linked to a large religious event held in a neighboring city. Four of the cases attended this event. Unfortunately, a month past before public health learned of the first cases which left lots of room for transmission. They believe the outbreak was stated by a Japanese national who also attended the event. She developed a rash while at the conference, and her brother had been clinically diagnosed with measles prior to her arrival to the US. She had received an MMR due to the exposure to her brother. There is not definitive evidence of this connection, however.

I feel compelled to out my stance on philosophical vaccine objections. As a public health worker and infectious disease epidemiologist, I should be hard core pro-vaccine. I am not. I understand parental concern over vaccines and I disagree with my colleagues who seek to demonize vaccine objectors. The scientists say one thing, the parents whose children have been inured by vaccines say another. How do you decide what is best for your child?

Vaccine preventable diseases can be devastating. In his autobiography, Benjamin Franklin wrote: “In 1736 I lost one of my sons, a fine boy of 4 years old, by the smallpox… I long regretted bitterly and I still regret that I had not given it to him by inoculation; this I mention for the sake of parents, who omit that operation on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that therefore the safer should be chosen.” The dilemma for parents today is that we are much more likely to be confronted with examples of vaccine injury than illness and/or death from vaccine preventable diseases. As such it is rational for parents to avoid the injury.

Nonetheless, at present, science does not validate the levels of anxiety about vaccines.

This is Public Health

2009-04-06T11:22:00.001-05:00

Happy National Public Health Week! Check out a great video on public health here. And give a big shout out to all the public health professionals who work to keep all of us safe.

Measles Outbreak in a Hosptial

2009-04-03T14:04:00.003-05:00

The National Immunization Conference was well worth the trip to Dallas, despite the hellacious downtown traffic and exorbitant parking fees. One of the more interesting sessions was on the recent US measles outbreaks. Preeta Kutty gave a talk on the outbreak in Arizona.

A little measles background. Prior to the introduction of measles vaccine in the US, between three and four million people were infected annually. Of these, about 48,000 required hospitalization, and 450ish died. Now we see less than 100 cases per year, and almost all of those are epidemiologically linked to imported cases. Looking at the genetic sequencing of the measles isolates, we can further discern that the virus was imported by linking it back to known endemic strains. Presently, measles is not endemic in the US – thanks to the vaccine. Despite all this, MMR uptake has been declining recently due to the concerns over a hypothesized MMR-autism link, leaving pockets of vulnerable populations. When an imported case is introduced into one of these pockets, we have seen several generations of transmission. I have lots to write about MMR and autism (another hot topic at the conference), but that will be in a different post.

Worldwide, measles continues to be a significant cause of morbidity and mortality. The World Health Organization reports that in 2007, there were 197,000 deaths from the disease. There continues to be a global initiative to eliminate measles from the earth; however, one wonders how much progress will be lost due to safety concerns over the vaccine.

At any rate. Last year, a traveler from Switzerland brought measles to Arizona. The patient made multiple visits to an emergency room before proper diagnosis – she was at first sent home with a “viral syndrome.” During those visits, she was never masked (measles spreads most commonly through coughing). Because measles was not recognized at first, the patient was not placed under isolation. Fourteen people altogether were infected. Six of them caught measles nosocomially – that is, from being in the hospital with the index case. Another case caught it in a pediatrician’s office. Interestingly, the hospital did not have record of immunity among the health care workers. They ended up requiring proof of vaccine or positive titer checks. This resulted in a delay in vaccination of susceptible health care workers. Four hundred people were vaccinated at the hospital. In total, estimates are that 4269 patients, 1872 healthcare workers, and 410 others were exposed to measles.

Lessons learned here? First off, if you are in charge at a healthcare facility – any healthcare facility – make sure you know the immune status of your employees (all of them). They should either provide proof of vaccination or positive titers. Some facilities forgo the proof option altogether any have them show positive titers. A tedious and expensive process to be sure, but better than ended up in a blog as the hospital with the nosocomial measles outbreak. Ok, that was mean. I really feel for their infection control and occupational health folks. I know they had to have had a rough time with all this.

Next, we need to continue educating our healthcare workers about the signs and symptoms of measles. In their defense, measles is hard to detect in the prodromal period, especially in the absence of Koplik’s spots. All the worse when you would have no reason whatsoever to suspect measles. Still, lots and lots of healthcare workers have never seen an actual case of measles (frankly, I haven’t), or a lot of other vaccine-preventable diseases.

The final lesson here is to ensure that cases are isolated and that public health is contacted upon suspicion, not conformation. Time between suspicion and conformation can be several days depending on your lab resources. If you wait for conformation to start implementing control measures, you have the potential to end up with a lot of cases.

National Immunization Conference

2009-03-31T17:42:00.002-05:00

This week I am in Dallas for the National Immunization Conference. And I must say it is very good! I promise to post on some of the sessions I attended.

As an aside, why must all events held in Texas be somehow cowboy themed?

We Want To Talk To You

2009-03-17T13:52:00.002-05:00

Sometimes when we call people to investigative communicable disease reports, they get angry with us. They want to know how we got their info when it is supposed to be private. HIPPA does protect the privacy of your health records; however, it contains a stipulation which allows public health access to your information in regards to a public health investigation. One guy recently yelled at my investigator about invading his privacy. This was a guy with salmonella. He said, “Why are you bothering me? You people need to be doing something about the peanut butter!!”

Yes. He’s right. We do need to be doing something about the peanut butter. And we are. The thing is, how do you think we found out the peanut butter was a problem? We figured out through patient interviews. When we call and interview someone with salmonella, we ask them to name all of the foods they ate in the few days before onset of their symptoms. We find out every restaurant, and as much as possible about what else they ate, what exactly it was, and where it came from. That way we can identify patterns. If we have ten cases of salmonella reported to our health department within a short time span, and they all said they ate at the IHOP, we are going to go over to the IHOP and see if there is a problem. If CDC identifies a national outbreak through their lab surveillance system, then multiple jurisdictions get together on a conference call and compare notes to figure out what the likely culprit was. Once we’ve pegged down a possibility, we will conduct a case-control study to further confirm that’s what it is. Meanwhile, CDC alerts the FDA so they can start product tracing. All of this – ALL OF IT – is dependent on sick patients telling us what they ate.

Personal health information is private. But not at the expense of the public’s health. More about the balance between private and public interests later.

Don't Eat It If You See Human Blood

2009-03-13T10:47:00.003-05:00

A good one today... A doctor's office called wanting advice on how to handle a blood-borne exposure. They had a patient visit them who claimed that she had gone out for a burger at lunchtime and was concerned about possible disease exposure. After she bit into the burger, she realized that there was "something on it that looked and tasted like human blood." She claimed to have spit it out and did not finish the burger.

"Is she sure it wasn't ketchup?"

"We asked her that too. Nope. She says it was blood."

"Did she tell the manager?"

"We didn't ask. Do we need to test her for blood-borne pathogens?"

We get calls about blood-borne exposures on occasion. These typically come from EMS, fire fighters, police officers. In the course of duty they get splashed with blood. Sometimes in their eyes or mouth. Or both. Generally speaking, the risk of contracting HIV or hepatitis B or C this way is pretty unlikely, but anything is possible. In those cases we recommend baseline testing. If possible, we would like to test the person who belonged to the blood but we are not always able to. If we feel the exposure was particularly risky, we will consult with the patient's doctor about post-exposure prophylaxis. Baseline testing is done, with a follow-up test at 6 months. Sometimes they will follow-up at 3 months also, but it really takes until 6 to be sure. This may not prevent anything, but at least gives them records to file for worker's comp.

There is a huge fear factor for a lot of people when it comes to human blood.

Back to our hamburger woman. While I am skeptical about the story, it wouldn't hurt to do baseline testing. My investigator brought up a good point: Perhaps the burger is just a cover story. Perhaps the woman shot up with a friend the night before and thinks she caught something.

I have a tendency to assume people are telling the truth. In this job, you find out pretty quickly that sometimes people lie.

Either way, if your burger has something that looks like human blood on it, send it back to the kitchen.

Recession and Infectious Disease?

2009-03-10T13:05:00.005-05:00

MSNBC published a story yesterday about the potential rise in infectious diseases as a result of the economic downturn. They site leishmaniasis, Chagas, dengue, and other bug-borne illnesses as likely candidates for re/emergence in the US. Pro-MED mail sent out a report of a woman in Washington who inadvertently gave herself and her children botulism from improperly canned green beans. The editors of that report also hypothesized that we may see more of this as people turn to home canning to save money. This is not to imply that home canning is necessarily dangerous, but it is important to know what you are doing.

Meanwhile public health funding continues to decline.

Microbes and Genetics

2009-03-10T09:42:00.008-05:00

This morning on the way in to the office, I caught a story on NPR about the role of genetics in susceptibility to infectious diseases.

What factors in the host make the host more susceptible to particular germs than others? This question is often asked of me. I once investigated an elementary school outbreak of coxsackie virus. The school nurse called me: She had more than 100 vomiting kids. Could I help? I grabbed an intern (new on the job), and called the sanitarian to meet me out there. Upon arrival, we were confronted with a hallway lined with little kids puking in trash cans.

Here's the thing about a bunch of kids puking: It is really, really difficult to figure out who is actually sick and who is sick because of the sight/smell/sound of everyone else throwing up. The school nurses call it WGA. They have "what's going around." We focused on those who first succumbed.

They were mostly first graders. The little epidemiologists had already determined this was all a result of the hot dogs they had eaten in the cafeteria the day before. I remember school cafeteria hot dogs. I get why they were pegged. Nonetheless, the intern and I set about conducting our own interviews. We tried to focus on the teachers. Who among them were sick? What did they eat? Was it different from the well teachers? We interviewed some of the kids too. Next time you talk to a first grader, ask her what she ate for lunch the day before. Recall bias is a challenge! Despite the children's insistence that the hot dogs were the problem, statistically in our case control study we did not find that to be the case. No particular food stuck out as the likely culprit.

This outbreak appeared to be point-source -- in other words, they were probably all infected at the same time by the same source. All of the children and teachers who got sick did so within a couple of hours of each other. Interestingly, once they all recovered there were not any more cases.

The sanitarians had better luck. They identified a cafeteria worker who had been sick for a few days before all this, and came to work with active diarrhea. Was she our index case? Schools are required to save a tray of all the foods served for at least a week just in case something like this happens. We took the tray and sent it to the lab. The lab found a high coliform count (in other words, fecal contamination).

In the end we hypothesized that the sick cafeteria worker had contaminated hands (wash your hands people!!) and spread her germs all over the cafeteria. It didn't matter what the kids ate; the contamination was probably not contained to one food item.

Of all the kids, only one went to the doctor, so despite the puking drama, the kids were not that sick. But the one kid who went to the doctor actually went to the emergency room. He was diagnosed with viral myocarditis, an infection of his heart, as a result of coxsackie virus.

We don't know for sure that the other children has coxsackie virus. The samples that were taken were unfortunately tested for bacterial infections only and all came back negative. But outbreaks like this are certainly not unheard of. But if the outbreak was due to coxsackie, why is it that some of the children experienced mild gastrointestinal symptoms, but this one child was hospitalized because the virus entered his heart? Perhaps the answer is that some people are genetically more susceptible to certain infectious diseases than others.

Welcome to the Epidemiologist!

2009-03-10T07:32:00.001-05:00

"You have such crazy stories. You should write them down."

I can't tell you how many times colleagues have told me this.

I am the Chief Epidemiologist of a large public health department. My jurisdiction encompasses a population of about three-quarters of a million people -- larger than some states. I oversee infectious disease investigations, disaster epi, and occasionally am involved in some chronic disease surveillance.

So this is my blog, my collection of stories about the life of a disease detective. Hope you enjoy.