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.

Global public health development goals: Paul Farmer on who lives and who dies.

Global public health development goals: Paul Farmer on who lives and who dies..

Economics should never have sought to divorce itself from the other social sciences and can advance only in conjunction with them. -Thomas Picketty

A day late for World Health Day. I hope my prof won’t mind if I share an article from this week’s readings. It’s going to be a task to disentangle the social injustice from the ethics of access from the rageifying post-colonialist cut-and-run, then weave in a thread of third world problems here in the US, but hey I’ll do my best to analyze coherently.

I can’t tell if the article is unwieldy or if it’s just my feelings on the subject. Either way a worthwhile read.

Cancer: The Emperor of All Maladies and My Cancer: The Wrecker of All Normalcy

Video: Cancer: The Emperor of All Maladies Trailer | Watch Cancer: The Emperor of All Maladies Online | PBS Video.

You’re all watching this, right? You’ve already watched it?

Good. I need to re-watch a time or two more before I give you my bullet points, but wow.

Hot off the press for my policy class about being a patient and looking at treatment options and statistics. No good choices yet.

The Fear & The Data

I’m the kind of patient who wants to, no insists, on knowing the numbers. When I was diagnosed with melanoma a little bit more than a year ago the sentence after “the tumor is malignant” was me asking “how deep.” I already had the tumor staging chart in front of me. That’s not true. It was dark, I was outside, and I had that thing memorized. My tumor was staged 2B, my stats are 60% survival at 5 years. I absolutely consent to a wide tumor excision and sentinel node excision. I am unable to undergo the recommended course of immunotherapy (12 month course) for adjuvant treatment that would have got me an additional 7% survival, due to my comorbid Lupus. I look for second and third and fourth opinions, and find a reputable oncologist with specific experience in my sub-type of melanoma who recommends adjuvant cutaneous radiation. The doc, my radiation oncologist, and I pull the best studies we can and make a good argument for radiation therapy in reducing recurrence of melanoma at the site (and more than 80% of melanomas of my subtype reoccur at the site) by 12-15%. SOLD! For $6,000 out-of-pocket, 6 weeks of my life, and 2 months of healing third degree burns and radiation toxicity. Steep. But fear is a powerful motivator. And fear of abandoning your young child? I mean I don’t have to tell you.

Would I have done the radiation for 5% reduced recurrence? I am aware that radiation can cause late malignancies. But REGRET. I could never forgive myself a lost chance to raise my child. Despite my lack of faith in integrity of studies in general, my non-surprise at aberrant results, and my belief that as a young person I may have more bounce back in me, I cling to the numbers with fear and with hope. Some people see themselves as the exception. I can’t help but see myself as the rule.

CDC Recommends Antiviral Drugs For At-Risk Patients : NPR

CDC Recommends Antiviral Drugs For At-Risk Patients : NPR.

The flu is awful this year. I’m in the bathroom washing my child’s hands all Lady Macbeth the second he gets home from school. In this interview Tom Freiden, Director of the CDC, explains plainly why the flu is so bad right now and why people who have gotten the flu shot are still getting sick. He also talks about antiviral use in flu patients.

I’m concerned for public health and the future success of flu shot campaigns. The strain that is infecting people despite vaccination was chosen for the vaccine, but between it’s selection and the beginning of our flu season it mutated. ARGH. This wasn’t a failure on the part of the CDC but it will lose them good faith in a year where we already had our eyes set to roll at their very next press release. So now add to the giant list of reasons people won’t get their flu shot “they messed it up last year.” Which is bad for community immunity.

Below, data for health districts reporting in VA (two weeks old). The red is the sub-type of flu the vaccine does not cover.

flu data
http://www.vdh.virginia.gov/Epidemiology/flu/WklyPhysReport.pdf

Knowledge cures ignorance so here is the back story of the flu vaccine and why this year was a one-off to convince you to please get your flu shot next year, too:

How are the viruses selected to make flu vaccine?

The influenza (flu) viruses selected for inclusion in the seasonal flu vaccines are updated each year based on which influenza virus strains are circulating, how they are spreading, and how well current vaccine strains protect against newly identified strains. Currently, 141 national influenza centers in 111 countries conduct year-round surveillance for influenza and study influenza disease trends. These laboratories also send influenza viruses to the five World Health Organization (WHO) Collaborating Centers for Reference and Research on Influenza located in Atlanta, Georgia, USA (Centers for Disease Control and Prevention, CDC); London, United Kingdom (National Institute for Medical Research); Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory); Tokyo, Japan (National Institute for Infectious Diseases); and Beijing, China (National Institute for Viral Disease Control and Prevention) for additional analyses.

The influenza viruses in the seasonal flu vaccine are selected each year based on surveillance-based forecasts about what viruses are most likely to cause illness in the coming season. WHO recommends specific vaccine viruses for inclusion in influenza vaccines, but then each individual country makes their own decision for which strains should be included in influenza vaccines licensed in their country. In the United States, the U.S. Food and Drug Administration (FDA) determines which vaccine viruses will be used in U.S.—licensed vaccines.

FDA Proposes Easing Lifetime Ban On Blood Donations By Gay Men | Kaiser Health News

image

FDA Proposes Easing Lifetime Ban On Blood Donations By Gay Men | Kaiser Health News.

Let’s look at some facts and data, shall we? Then I’ve got questions.

Statement from the FDA.
From Red Cross:

redcross blood safety

redcross blood safety 2

What it means: Blood is tested for antibodies to HIV 1&2 as part of the battery of tests performed to ensure donated blood is safe for use. However it may take several weeks to months after infection for HIV antibodies to present in the serum (if you contracted it last night, it may not be apparent until 3 months from now).

From CDC:
cdc hiv transmission rts

What it means: The population of concern are people who have been exposed to HIV but have not yet developed screen-able antibodies–new infections. So we look at the most recent transmission data from the CDC and note that men having sex with men are 2.5 times as likely to have a new infection as the second largest category, heterosexual contact.

My questions: How is the one year waiting period scientifically justified? One year would allow time for antibodies to appear, of course. But there is risk of undetectable infection in blood of people engaging in heterosexual contact, too. Even it it’s 2.5 times less than MSM is that risk not deserving of the one year abstinence period? And then where would be be in terms of blood supply? What is the risk benefit analysis here? I don’t yet get how this is a decision based in evidence on the part of the FDA. To me, it’s a little don’t-ask-don’t-tell-y. And by that I mean homophobic and embarrassing.

Also, I would like to know that data on the risk of transmission of HIV and the Heps when anitgen/antibody complexes are undetectable in the serum. And the number of people per year who contract HIV or Hep B or C from blood transfusions. Add that lit search to the pile.

Why the cops don’t get called for campus sexual assaults.

How does it make sense that universities are responsible for adjudicating sexual assaults on campus? Well, Title IX and US Supreme Court rulings dating back to the 1970s. Read the article, it explains the why and makes clear just how short UVA and others are coming up in complying with the mandate. Ugh.

via No, We Can’t Just Leave College Sexual Assault to the Police – Alexandra Brodsky and Elizabeth Deutsch – POLITICO Magazine.

What Alexander helped to establish, then, is that campus rape is not just a crime but also an impediment to a continued education—and to subsequent success in the workplace and public life. That means that Title IX’s protections are necessary for an individual student’s learning opportunities and for gender equality throughout American life. If sexual violence goes unaddressed at universities, women will face unconscionable obstacles to education, professional success and full citizenship.

 

Now everyone feels bad about the pies.

(Image from CDC)

Happy day after Thanksgiving. Now that we’re all in regret mode, diabetes! This is a slow-motion public health train wreck, amiright? And it’s another marker of race disparity in health… but I’ll save that for another day.

Diagnostic for diabetesHemoglobin A1C>=6.5 OR 8 hour fasting plasma glucose of >= 126 mg/dl OR oral glucose tolerance test of >= 200 mg/dl OR random plasma glucose of >=200 mg/dl.

Super user-friendly.

So diabetes is a clear medical diagnosis to make, but telling someone with a fasting blood sugar of 120 that they do not have diabetes is the wrong message. You either have HIV or you don’t. Diabetes is a disease on a continuum. Even with moderately high sugars the vessels of the fingers and toes and heart are getting damaged. The delicate vasculature of kidneys and eyes is getting all junked up, and pancreas… oh poor pancreas you will never be the same.

So it would make sense to do some intensive nutrition education for people that fall into that pre-diabetic category, you know, maybe keep them from become full-blown diabetic? As it stands, Medicare does not reimburse (pay for) nutrition consults until you have the official diagnosis of diabetes. So we are giving nutrition education to people in the hospital after they have had their toes amputated, between debridements of wounds that won’t heal, and in dialysis while they wait for a kidney transplant. These are miserable, life-limiting procedures. All of which are way pricier than some front-end nutrition education. And the cost of diabetes has increased 41% over the past 5 years.

My mom falls into the pre-diabetes category. I write little lists and send texts and talk to her on the phone about how she is managing a blood sugar that is next door neighbors with diabetes. Based on my very limited knowledge of nutrition (nursing schools could really fortify this part of our education), here are some of tips I’ve given her: First, 5 a day, lots of fiber, and minimal processed foods. Look for added sugar in all all foods, especially processed. If a product is labeled low or non fat, you can assume that they replaced that fat with sugar. Check the label. Also, exercise helps your cells metabolize sugar, bringing down your blood sugar. Even if you don’t lose pounds. What else can I do? I’m genuinely asking.

Think globally, outrage locally.

One of the volunteers at our tiny county’s only food bank/emergency assistance provider/shelter is always wearing a t-shirt that says IF YOU AREN’T OUTRAGED YOU AREN’T PAYING ATTENTION. He’s one of the gentlest guys I know–a middle aged black man living in rural poverty who relies on the food bank and is its most faithful volunteer. I used to give his son a lot of (unsanctioned by my employer) rides back when I was working in our nearby town. Also soft-spoken and kind. And tall and broad and one of those kids whose stupid luck ends him up in the wrong place sometimes. I worry.

But that t-shirt, oh man it makes me like that guy.

So here’s something I wasn’t paying attention to before one of my nursing colleges (Michael Swanberg, a member of ACT UP, certified nurse midwife, and enchanting human being) brought it to light. This data is pulled from the Thomas Jefferson Health District’s community health assessment, 2012. Page 54. The image quality is terrible but the dark blue is TJHD black infant mortality, teal is TJHD white infant mortality.

infant mortality image

An examination of infant mortality stratified by race demonstrates the same phenomenon in Virginia and TJHD as in the nation — African-American babies die more frequently than white babies. In 2007-2011, the rolling average IMR in TJHD was 4.5 infant deaths per 1,000 live births among white infants, lower than the Virginia (5.4) and U.S. rates; it was 17.3 among African-American infants, which was higher than the Virginia (13.8) and the U.S. rates (Figure 109).

Check my math but that means that African-American neonates in our health district are nearly four times more likely to die than their white counterparts. Brand new no-jackass-on-earth-can-say-their-deaths-were-deserved babies. Are you feeling the outrage? The black neighborhoods in Charlottesville are literally in the shadow of the towers of an academic health center. Tell me how this can be.

Whooping cough outbreak at Grand Traverse Academy nearly doubles to 161 probable cases

Image NIAID

Whooping cough outbreak at Grand Traverse Academy nearly doubles to 161 probable cases | MLive.com.

Herd immunity/community immunity: when enough people are immune to a disease, that disease will not spread through the population. As a result those who are not or cannot be vaccinated (pregnant women, infants, immunocompromised) are protected from the disease as well.

Infants are eligible to receive their first pertussis immunizations at 2 months. Pertussis/whooping cough in the first three months of life is frequently severe and often fatal. Pertussis is a respiratory disease that in early stages has the same symptoms of a cold. Babies are most likely to get the disease from a parent or a sibling. (American Academy of Pediatrics)

I’m not going to ruin my night by getting on the soap box because it’s Saturday and ACA open enrollment is not a total disaster so far and I was just destroying at Jeopardy, but y’all are picking up what I’m putting down, right?

Between Two Lives – Features – Fall 2014 – Johns Hopkins Public Health Magazine

via Between Two Lives – Features – Fall 2014 – Johns Hopkins Public Health Magazine.

Does fleeing family violence and the nation with the world’s highest murder rate qualify Wilter as a refugee?

Though it’s been bobbing in and out of the news cycle, there is still a Central American migrant crisis. I got into the weeds on immigration policy, then deleted it all because jeez it may be the one thing more complicated than health policy. For reference: UNHCR definition of refugee, US Citizen and Immigration Services definition of refugee.

But this current event is germane to public health. By not having a comprehensive policy in place we are unable to mobilize resources to address the health and safety needs of a large group of immigrants, mostly children. The humane thing to do would be to accept and give the best care we can possible to these refugees. At bare minimum, to protect our native population we should ensure screening for infectious diseases (TB, measles, mumps, rubella, Hep A-C, pertussis), treatment, and vaccinations.

If you have the time and the inclination to have your heart broken, watch the film Sin Nombre. It was done more than five years ago and is of course fiction, but by all accounts captures the migrant journey well. What keeps me up at night is thinking of what home must be like if this voyage is the better option.