Why It’s Still Worth Getting a Flu Shot – The New York Times

If I wrote the book on public health I would insist on a subtitle. Here’s how it would read:

Public Health: IT’S NOT ABOUT YOU

I’m punting to the expertise of Aaron Carroll and his timely Upshot article this week. I myself, a yearly getter of the flu shot, have the flu. AND I WOULD GET THAT FLU SHOT AGAIN. Because, of course, it is not about me. And sure the flu I have is possibly less virulent than it could have been and I haven’t needed to tap the resources of any health care facility so my only cost has been reduced personal productivity (I’ve met writing deadlines but my apartment is disgusting and hair is dry shampoo). But even assuming that my flu shot did nothing to make my personal experience of flu season better, I’d still get one.

First, a statistical concept used to evaluate the efficacy of an intervention or treatment: N.N.T. or number needed to treat. Surgery is the easiest example to cite to explain it. In an appendectomy, N.N.T. is always 1. One surgery, 1 removed appendix. Unless something really weird is going on.

If everyone that got the flu shot was guaranteed to not contract the flu, then flu shot N.N.T. would be 1. One shot equals one protected patient. But the flu shot was never planned as a N.N.T.=1 type of disease prevention. The flu is too wily, too quick to mutate. Flu shots are here to reduce the disease burden in our overall population. Less infections mean less contagion, lower overall cases mean demand on public health resources is manageable, people that do get sick have better access to the care they need, and ultimately less morbidity and mortality (illness and death) result.

According to Dr. Carroll’s article, this year the flu shot’s N.N.T. is 77. For every 77 people that get the flu shot, 1 will avoid what would have been an flu infection. Considering the cost of the flu vaccine (literally zero dollars if you have any sort of insurance which legally ethically and morally you should but that is another conversation) is five minutes at CVS plus mild soreness for a day…I like to imagine my group of 77 responsible flu shot getting citizens saved a baby this flu season. Maybe that 2 week old baby I saw at the thrift store last month and wanted to scream “FOR ALL THAT IS GOOD AND HOLY GET THAT CHILD OUT OF THIS HUMAN VIRUS SOUP.”

So there’s the lesson for the day. But read The Upshot, Dr. Carroll tells it in true doctor-professor speak, and continues to explain the important role of cost/benefit in the vaccine:

Let’s say that this year’s flu vaccine is even worse than we think. Maybe the absolute risk reduction will be as low as 1 percentage point, making the N.N.T. 100. That’s still not that bad. Even at an N.N.T. of 100, for every 100 people who get a flu shot, one fewer will get the flu. That’s a pretty low N.N.T. compared with many other treatments that health experts recommend every day.

There is a movie review in this blog.

Print journalism has been so good these past months that felt like years. Remember back in 2012, that gleeful feeling you got when you read Pete Wells’ review of the Guy Fieri superfund site in Times Square? Well, I just re-read it and it is a mere amuse bouche for the righteousness served daily by journalists at the Washington Post, New York Times, and smaller dailies in Detroit, Cincinnati, so on. Oh, lord, ProPublica’s piping hot Pulitzer-prize winning online investigative journalism. Just as you might “a plate of pale, unsalted squid rings next to a dish of sweet mayonnaise with a distant rumor of spice,” choke down this justice!

All of this is to say that print journalism is being the kind of excellent that one can only imagine was motivated by a prior laziness, a willful misinterpretation of equal coverage, a cowardice so big it created a universe of language to explain a phenomenon where one word would do (lie); all contributing to the rise of the a leader that in brief, is frickin’ dangerous.

SO! What I mean to say is now is the time to hug your journalist. And, if you like me think human lives are fascinating and the people that spend theirs writing about others even more cause they are themselves fascinating in super intelligent, hard to get along with, quirky beyond all reason ways, please watch the documentary Obit.

Somewhere buried in the documentary the writers address the “isn’t it sad to write about dead people all day” question. I couldn’t agree more with the answer, which is: not at all. They get to write about a life that, likely if it makes The New York Times, is full and brilliant, meaningful, left a legacy, and often lasted a long time.

I feel the same way about taking care of people at end-of-life. Is it sad? Not usually. Not really. No.

I regret even starting with the Guy Fieri stuff. I’ve lost my appetite.

 

 

 

 

 

 

American guns and public health and hope.

America is not a hostage to itself in the battle over how to handle guns. We are able to change. The evening after another massacre, the word weary for being trotted out month over month, I’ll make an appeal.

With the will, we can get better.

Our current president dismissed the Surgeon General Vivek Murthy, the first in the position to declare gun violence a public health issue. Like HIV/AIDS in the 1980s and tobacco in the 1960s, the Surgeon General can be the first political officer to acknowledge a public health disaster. This should not be a controversial position…I’ll quote from Healthcare Triage, which has a very worthwhile primer on gun death stats:

guns hctraige

There is evidence to show that a gun-loving nation can be made less violent. You may know the history of our fellow former colony (and the only place where you can make a grittier western than home) Australia, and it’s remarkable policy-driven turn around addressing gun violence. Through compulsory buy-backs, stricter regulations, and cutting off the flow of new guns among other measures, the country responded to a harrowing mass shooting with sweeping policy change that turned their gun violence trajectory upside down. Sure, they are more than ten times smaller than the US. But in most all measures they are our closest comparator. There is no reason that their success could not be seeded here.

No reason not counting money and gun makers and, most important, political will. All of this is just to say we’re selling ourselves short with thoughts and prayers and other things offered in the face of hopelessness. We can get better.

 

 

 

 

Puerto Rico nearing becoming a public health catastrophe | Miami Herald

Every time you hear about Americans in Puerto Rico with no water, no fuel to boil water, no way to get rid of waste water…think water-borne infectious disease. This will be an epic disaster. One that was entirely predictable.

Public health officials should be shoulder to shoulder with the military, staged for response. I’ve searched the CDC and looked at the reporting coming out of the island in the many days since the storm, and I see no trace of action.

I pray they are not waiting for a call.

Below, from the Miami Herald, is an appeal from the Dean of Florida International University’s College of Social Work and Public Health, Tomas R. Guilarte, describing what the chaos looks like to a public health expert:

In the days since Hurricane Maria ravaged Puerto Rico, conditions on the island continue to deteriorate and become a humanitarian and public health catastrophe that could rival the damage caused by Hurricane Katrina in New Orleans.

The fact that the power grid failed creates many obvious problems and some that are not so evident. When the sewer system stops working, wastewater—aka human feces and urine—and seaborne bacteria contaminate the water supply.

This leads to bacterial infections — such as cholera, dysentery, E. coli and typhoid — that can be disastrous. The typical treatments, like tetanus shots or powerful antibiotics, are not readily available on the island, where medical supplies are quickly running out.

Source: Puerto Rico nearing becoming a public health catastrophe | Miami Herald

Public overdoses and my friend is a lifesaving superhero at a all-day-breakfast restaurant.

What were you up to at 3AM? Oh, just looking for an article about the increase in public overdoses of opioids and what that says about the power of addiction, the danger of the fentanyl-laced drug, and the will of people to, despite their dire state, be saved.

I couldn’t find the specific article, but I promise it exists and this is not an academic publication so sue me. The NYT article below about availability of Narcan as a health and safety measure like CPR training and AEDs in public places is good, too. I’m for it because I’m for life saving.

I’m going to tell someone else’s story; I’ve asked permission. This happened recently. Of the six of you who read this five probably know her. To know her is to love her, get ready to love this too, especially if you’re nursey and can do that thing we do where we care about people to a degree that we dedicate our lives to them but at our core lies a daaaark and morbid sense of humor.

So our friend is a recent PhD in nursing. A person who commiserated with me in when I was walking in the valley of clinical care is scary gross by saying “I knew it wasn’t for me the first time I emptied a peritoneal dialysis bag.” She’s an empath to the nth degree. Terrifically gifted in the field of psychology. Destined to be great to innumerable patients and, if there is justice, the wider field of psych/nursing/medicine. She is however not into emergency or critical care.

She’s in a medium sized city in the south, enjoying her favorite breakfast-all-day chain restaurant with her man, just having given their orders to their waiter who looks exactly like you would expect a breakfast-all-day chain restaurant waiter to look. The youngish ones. In the kitchen there is a commotion being made. Staff is peeling away from the dining room, forming a crowd. SOMEBODY DO SOMETHING is hollered. Our friend, the gifted psych nurse, is getting a look from her man (also a doctor of not medicine).

IS ANYONE HERE A DOCTOR?

Shit.

She’s getting the go get ‘em tiger from her fella. She rises, whispers to the backs of the crowd “I’m a nurse.”

SHE’S A NURSE” Hollers her dude with the authoritative bass of a public lecturer. The sea of people parts.

It’s their waiter, passed out on the floor of the breakfast-all-day restaurant kitchen. She is hella smart, so clinical person or not she can handle an OD. She activates that emergency response system (call 911, damn it), asks for an AED (there is none–what?!), checks that carotid pulse for not more than ten seconds (absent), and starts high quality chest compressions times thirty at a rate of not less than one hundred per minute with two rescue breaths between cycles.

Woman saved a life, people. SHE SAVED A LIFE.

EMS comes in narcannons blazing and brings the victim back. Poof. Death-be-gone.

Sigh. So that is our girl. My girl. My nurse friend and mentor. It feels good to know someone this gangster.

In summation: the opioid crisis is real, everyone must learn CPR, Narcan should be in first aid kits, and let’s address institutional cycle of poverty creating helplessness and hopelessness in economically depressed areas such as the stripped-bare resource colonies of the southeast leading to physical manifestations of what might be at the root existential disability and the introduction of opioids.

Virginia Gov: Health Commissioner gives standing orders for residents to receive opioid reversal drug

Virginia responds to opioid crisis with standing orders written by State Health Commissioner Dr. Marissa J. Levine allowing residents to obtain opioid reversal drug naloxone from pharmacies. Has anyone seen a set of standing orders used in this way during a public health crisis? I’m thinking bold moves. Which is what I wholeheartedly support.

Governor McAuliffe:
“The overdose rates in Virginia have led me to agree with Dr. Levine that we are indeed experiencing a public health emergency. This declaration helps us respond in a nimble way to a rapidly changing threat, while the Naloxone standing order from Dr. Levine broadens our ability to get life-saving medication into Virginians’ hands.”

Source: Governor – Newsroom

BUT WHAT ABOUT

From Medline:
You will probably be unable to treat yourself if you experience an opiate overdose. You should make sure that your family members, caregivers, or the people who spend time with you know how to tell if you are experiencing an overdose, how to use naloxone injection, and what to do until emergency medical help arrives.

Who will do the educating? Public health campaign to instruct people on what a opioid habit looks like so they know to be prepared with the reversal drug? Pharmacists to educate on how/when to use it? What’s the plan, where’s the funding, how are we going to implement, and in what way will we measure success.

Also, check out: http://vaaware.com/treatment-recovery/

 

Zika Virus Update from Dr. Fauci

DEET. Use it liberally.

You might have noticed that one of my favorite humans in health care is Dr. Fauci, Director of NIAID. Link below is his review of Zika up to now. It is solid and made for laypeople. He’s of the older school (patriarchal but not exclusive to male MDs) where doctors were bosses, not patient partners. This almost out-of-fashion kind of doctoring is reassuring in an emergency when the doc wears his title as a moral obligation to get the right answers and fix it fix it fix it. The perfect amount of condescension so you feel confident that he’s one of the smartest people on the planet and you’re lucky he’s working for you.

I find the mass of information put out by CDC hard to wade through. This press conference covers brief history, current state of the science, vaccines in development, funding issues.

Fauci at the National Press Club

And I enjoy the image of Dr. Fauci in his DC backyard knocking standing water off of plant leaves.

Many Well-Known Hospitals Fail To Score 5 Stars In Medicare’s New Ratings | Kaiser Health News

Of the 102 hospitals that received a five-star rating, few are among the elite generally praised for great care. Major academic health centers did not shine. Is the star rating an unfair measure?

Source: Many Well-Known Hospitals Fail To Score 5 Stars In Medicare’s New Ratings | Kaiser Health News

My hospital scored four stars, and we are no Cleveland Clinic. We do work hard. But we don’t take the sickest patients (we transfer to other facilities when our capabilities aren’t sufficient to care for a patient). High acuity patients can be incredibly complex and often therapies that are indicated in less complicated patients are not a wise choice for the critically ill. So, we can’t use our VTE prophylaxis bundle and must assume the risk of blood clots as smaller harm than intracranial hemorrhage. Their hospital stays can be many times longer than the average, increasing the chances for acquiring HAIs (hospital acquired infections) and pressure ulcers. Transferring to a higher-acuity major center, data-wise, is a sending a negative result across town by ambulance to another hospital’s spreadsheet.

Low-scoring large academic health centers treating our sickest patients would point out that they also treat our poorest patients. Socio-economic/demographic factors of course have influence on re-admission rates. This is one of seven measures, but has a weighted score of 22% in calculating the star rating. SO, much like schools in areas where kids are poor and hungry and the teachers spend a great deal of time figuring out how to keep them fed so they can stay awake long enough to learn an equation–making the idea of imposing the standardized testing of No Child Left Behind on that classroom and thinking it is an appropriate way to compare that school to the one in the next county where the average household income is $100,000/year and the PTA meetings are standing room only…well we know how that ended. Our large public hospitals are caring for patients with heart failure who can not read the discharge instructions, do not have access to transportation to get them to the follow up care that they don’t have the health insurance to pay for and can’t take the prescription drugs that they don’t have covered (in non-Medicaid expansion states). Maybe they also don’t have a grocery store in their neighborhood with a selection of food will keep their sodium intake at the strict low level needed to keep them from returning in a few weeks with an acute exacerbation. If that patient is 40% of your population, you have a challenge in front of you.

Good news is these low scores are really lighting a fire under hospital management. Even though right now it feels like the building is burning down a little. It is the hospital CEO’s prerogative to incorporate community building into his financial agenda (Star ratings aren’t tied to reimbursement, but they are composed of Medicare quality indicators that do affect how much the hospital gets from the Medicare-insured patients).

But the data. Where did this data came from and how just or unjust is it? My preliminary ruling is this is a treasure trove of information openly available to the public and I love that; but the population a hospital serves does have bearing on the score a hospital pulls. That doesn’t excuse the hospital from being rated. It points to where funding and research and pilot programs should be in place to address community health indicators, cause hospital walls are permeable.

If you want to go deep on the data, I encourage it! Go here. If you don’t feel like 40-odd pages of methodology and another government website, here are the two bits I found most helpful as points of reference for what was measured and how:

This chart (source):

star ratings chart

and this quote (same source):

For example, in April 2015, OP-21 (Median Time to Pain Management for Fractures) had a national average performance of 55.6 minutes with a standard deviation of 17.75 minutes. In contrast, VTE-6 (Incidence of Potentially Preventable Blood Clots) had a national average of 7.23% with a standard deviation of 9.10%. After standardization and redirection, both measures had a mean score of 0 and standard deviation of 1; both were reversed so that a higher standardized score indicates better quality.

I’m just going to leave a few more links here.
https://www.medicare.gov/hospitalcompare/About/What-Is-HOS.html — Much more on quality measures.
https://data.medicare.gov/Hospital-Compare/Hospital-General-Information/xubh-q36u –The you-need-four-computer-screens-to-read spreadsheet with all the hospitals’ star ratings! SLICK!

Some of the information wants to be free

CDC queries= my mood boards.

SO lots of facts and figures this week. The gun deaths data used by every pundit, editorial author, and Facebook meme maker (well maybe not) in this country can be found in our national database of mortality statistics compiled by the CDC and available for anyone with internet access to search. I did a therapeutic amount of searching this morning. This is a great tool and resource and one of the public health biggies with open access. It’s government data and PubMed abstracts for me until I decide to drop out of life and get that sweet academic journal access that comes with being a Ph.D candidate. Pffft. Right though: http://wonder.cdc.gov/

Mortality and morbidity statistics are tracked by ICD medical billing codes. Because if there’s two things you can count on it’s death and your survivors being billed for your death.

The design is not good but what were you expecting? That’s how you know it’s authentic. I could spend all week in this.

CDC databases

Narrow your search. Slightly less easy that learning how to properly use MeSH search terminology.

CDC table layout

Results for all codes under “firearm” reporting data from the entire United States in the year 2014. But go have a look for yourself, too. Compare it to cancer. Compare it to car accidents. Dare to look at medical error, too. It’s in your hands. We need help.

CDC databases results

Guns and public health

Firearm deaths are driven principally by availability of firearms. While frequently after these events we link them to mental illness, the evidence is very clear that this is a negligible part of the problem. People with mental illness are much more likely to be victims than perpetrators of firearm violence.

–Sandra Galea, Dean at the School of Public Health at Boston University

Scientific American: Gun researchers say Orlando is a public health emergency