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.

Why out-of-control costs matter

Complexity. From how you get insurance (THREE MORE DAYS FOR MARKETPLACE PLANS) to who the emergency department treats to the non-communicating EMRs that create a chorus of fax tones ringing out across this great nation of over-paying under-served… well it ends like this: envelopes.

Cramming up your mailbox. Every medical service, every brick and mortar facility, every radiologist in his/her darkened bedroom reading films in memory foam slippers, is going to send to a separate bill. And this is why you still have a checkbook. Because even within the same organization, let’s say a fictional system called ANOVA that I visit for one scan, get 3 bills (physicians group, facility, and radiologist), then I go again in 3 months for the exact same thing. None of my six account numbers will be the same. Cram that in your electronic bill pay.

Here, loves, are my preventative health costs since October. Cancer screenings, with no expensive imaging like CT/MRI. Just doc visits, PAP pathology, and a radiology bill for who knows what that is? $12? I’m leaving out my $400 surprise colposcopy. But, VACCINE PLUG: get your son/daughter an HPV vaccine and the his girl/she may never know the surprise cervical pinch of colposcopy. It is a terrible thing to surprise a woman with. (I was too old, to not a virgin at 26 when vaccines became available).

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Don’t feel bad for me. Maybe set me up one of those gofundmesoIcanaffordfollowupcancersurveillanceandhaveayearlypapsinceI’msexuallyactive. Not a big draw on that?

Alright then. Just pay attention as policy, which people seem to be more averse to than illness itself, is being made. Taxes (for a few) may be losing their place on that short list of inevitability, but mortality my loves, endures.

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

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/

 

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.

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.

A complete novice refutes the statements of a qualified professional

Why I oppose payment reform- Alan Weil, Health Affairs Blog

Interesting article but I’ve got counterpoints ’cause I’m a student with more opinions than I have a right to and am cocksure enough to comment on statements made by the editor-in-chief of Health Affairs.

Summaries of his points are in bold. Please read his article regarding opposing payment reform in health care to get his full and well considered arguments.

The current workforce is unprepared for a model that doesn’t reward for filling beds, doing tests:

  • There are tremendous rewards for innovation in the field of health care right now! These folks have seen the model they came up in become more and more of a frustration to them and their patients. Everywhere I look, from floor staff to executives, the feeling is very get on the train folks, we’re heading to the future. Alternately: retire, find a different gig, or learn to cope with the new requirements. People are learning to become successful and you better believe that new leaders are prepared for these challenges.

Any money saved will move its way to the top (health systems, hospitals) and workers on the front lines won’t see any benefit:

  • Maybe. Based on the ones I’ve spoken to I don’t think dietitians, social workers, and community health workers are expecting a huge raise. But many hospitals are dramatically understaffed in these positions to the point that they are unable to perform the core competencies of their roles. As these workers bring forward evidence showing the financial benefit to hospitals of having, say, a full time dietitian to improve nutrition and reduce pressure ulcer rates, hospitals will have a financial reason to staff these professionals.

There is no current evidence to suggest that payment reform will achieve the goals we need it to achieve, and there is some evidence to the contrary.

  • Okay, your evidence is good here, but early days! There is evidence showing smaller programs put into place are already saving money such as reduced re-admissions with heart failure transitional care (article unfortunately not open access, DOI: 10.1097/JCN.0b013e31827db560).

The original rationale offered for payment reform doesn’t match the current objectives.

  • I think it does match that original rationale (to pay for quality rather than quantity of care). Health systems do not have an incentive to stop a practice for which they are getting reimbursed. We know patient falls are bad thing for a patient, but more days in the hospital to recover from your now necessary hip surgery is money in the hospital’s pocket. Why would you spend money reducing falls to stop yourself from making money? When hospitals are told they won’t be getting paid for the consequences of that fall innovations in care happen and adverse event rates go down. Of course we need metrics to quantify success and failure, and because these rule changes are rolled out in a way that intends to give health systems time to introduce new measures without sinking the rusty old tub. And certainly hospitals with higher acuity patients are getting the shaft, hence even more complex models to try to even the playing field.
Payment reform poses a risk for the growing understanding of the importance of patient-centered care (What is an appropriate value formula when patients differ in their goals for recovery).
  • The value formula is simple: “Patient, are you satisfied that you have reached your stated goal of x?” If your 95 year old patient states his goal is successfully completing the Marine Corps Marathon pain-free then you’ve got to use your negotiating skills to get him back on this planet. The point is to set patient centered appropriate goals before undertaking invasive or potentially harmful interventions.

Poetry from the AIDS Epidemic, another for World AIDS Day

Excerpt of “Atlantis” by Mark Doty
About his partner with AIDS

 6. NEW DOG
Jimi and Tony
can’t keep Dino,
their cocker spaniel;
Tony’s too sick,
the daily walks
more pressure
than pleasure,
one more obligation
that can’t be met.
And though we already
have a dog, Wally
wants to adopt,
wants something small
and golden to sleep
next to him and
lick his face.
He’s paralyzed now
from the waist down,
whatever’s ruining him
moving upward, and
we don’t know
how much longer
he’ll be able to pet
a dog. How many men
want another attachment,
just as they’re
leaving the world?
Wally sits up nights
and says, I’d like   
some lizards, a talking bird,
some fish. A little rat.
So after I drive
to Jimi and Tony’s
in the Village and they
meet me at the door and say,
We can’t go through with it,

we can’t give up our dog,
I drive to the shelter
—just to look—and there
is Beau: bounding and
practically boundless,
one brass concatenation
of tongue and tail,
unmediated energy,
too big, wild,
perfect. He not only
licks Wally’s face
but bathes every
irreplaceable inch
of his head, and though
Wally can no longer
feed himself he can lift
his hand, and bring it
to rest on the rough gilt
flanks when they are,
for a moment, still.
I have never seen a touch
so deliberate.
It isn’t about grasping;
the hand itself seems
almost blurred now,
softened, though
tentative only
because so much will
must be summoned,
such attention brought
to the work—which is all
he is now, this gesture
toward the restless splendor,
the unruly, the golden,
the animal, the new.

Mark Doty, “Atlantis” from Atlantis: Poems. Copyright © 1995 by Mark Doty.
Source: Atlantis (HarperCollins Publishers Inc, 1995)