Category Archives: Health

Why do some vaccines not work well in certain contexts?

Rotavirus vaccine is very effective in preventing this diarrhea inducing stomach illness in children in developed countries. But it appears that in certain poorer regions, i.e. Bangladesh, the same vaccine has a reduced effect, inducing sufficient immunity in fewer than half of the children who receive it. In the early days of the polio vaccine, a similar pattern was observed.

Why is this? What can be done about it? What does it all mean?

We interviewed Carina Storrs — who visited the affected areas and has been writing about it over recent weeks — here, at Ikonokast. Carina is a scientist-turned-science-journalist, and has done some excellent reporting on rotavirus vaccine. Have a listen.

WHO tells us about red meat and processed meat cancer risk?

See what I did there?

As you know, the UN WHO International Agency for Research on Cancer has listed Red Meat as Group 2A (probably carcinogenic to humans) and processed meat at Group 1 (causes cancer).

And everyone is upset. The most common reaction to these listings is to criticize WHO. The least common reaction to these listings is to learn what the listings are, what they mean, what they mean to you, to the meat industry, to cancer research, and all that. Here, I will try to provide some perspective on some of this.

WHO is probably more likely to list something as cancer causing

It is probably true that the WHO IARC is somewhat biased, in that they are more likely to attribute possible carcinogenic effects to things than other similar groups. There are many substances and behaviors listed by WHO as possibly or probably cancer causing that are not similarly identified by, for example, the US EPA. This does not mean that WHO IARC is more likely to be wrong. It just means that your reaction to a possible agent being listed by WHO should be to understand this bias, but not to assume you know what the bias means. If every single cancer-watching agencies was biased in one direction, we’d have a problem. If all cancer-watching agencies always drew the same exact conclusions form the disparate research, we’d have a conspiracy. If the range of cancer-watching agencies produces a reasonable range of decisions, we’d have real life.

Here is something you should keep in mind when comparing across agencies. Many US federal agencies are led and staffed by industry experts. Where do you get industry experts? From the industries these agencies regulate. Where did the industries get them? They got them from PhD schools, where they quite possibly paid for their higher education with grants from the industry and worked in labs paid for in part by those industries, while working on grants from the industry. This is likely more a thing in the US than in other countries that contribute expertise and do research. It is also true that US regulatory agencies are notably biased in the opposite direction of WHO.

US regulatory agencies will be staffed by well meaning well trained people who know a lot about how the industry works. That is a good thing. US regulatory agencies will be staffed by people who owe their careers to the industry, and are likely to have warm fuzzy feelings about the industry. That is likely to lead to some bias.

On the other hand, in other parts of the world, wooish thinking seems to permeate science and governmental agencies more easily. If you look at the research and regulations, related to EMF risks (like power lines and cell phones and such) you’ll see a gradient where some areas of Europe have both evidence (from research) suggesting EMF-health risks and regulations related to this, and other areas of Europe where the evidence shows now risk, to the US where we by and large don’t regulate EMF using these risks as factors. A sensible view of the research tells us that EMF does not have the alleged health risks.

The reason this is important is that WHO is an international body, so we are going to see a range of industry-fuzzy vs. woo-fuzzy fringes surrounding a hopefully larger and sensible scientifically oriented core. This is also important because of this: if every regulatory or research agency or institution in the world really were funded by the industries they study, and no other research was done by anybody, problems will arise. So go ahead and be annoyed at WHO, but also appreciate this relationship.

It is not about how bad the cancer risk is

As a substance or behavior moves from Group 3, through Group 2B and 2A, to Group 1, this does not mean that it is thought to be increasingly cancer-causing. What it means is that the certainty that the substance or behavior cases cancer, no matter how small the effect, has increased. A given agent may increase the risk of a certain kind of cancer by 50%, which sounds bad, but the original probability of cancer being caused by that agent may be tiny. So, in effect, a tiny risk has been increased to a tiny risk. According to WHO, “The classifications reflect the strength of the scientific evidence as to whether an agent causes cancer in humans but do not reflect how strong the effect is on the risk of developing cancer.”

This is not about your bacon

I find it amusing that the Internet Reaction to these listings is so widespread and negative, even angry, and at the same time so poorly informed. This is amusing because we are just coming off a way over the top Bacon Worship phase.

I stopped eating bacon about four months ago. Do you want to know why? Because of all the pictures of bacon, excessive bacon, things made out of bacon, bacon being fetishized and revered like it was a god or something, on Facebook and elsewhere. I got tired of bacon. I was reminded of a friend’s comment. He was raised in a Kosher household. He told me, “I don’t have any food taboos, I don’t keep kosher. But if I walk into a house where someone is cooking ham, I want to throw up.”

(OK, I did have a BLT the other day. But it was hard.)

The point is, do think about the nature and cause of your reaction, if you are having a hissy fit about WHO and meats. Are you objecting to the WHO IARC criteria, which you’ve carefully studied and understand, or are you simply being sensitive about your stupid bacon fetish? Think about it.

Some food research is probably inherently wrong

I just want to throw this in. If you feed human food, especially cooked food, especially food not made of raw grains, to rats and mice, they might get sick, while a human being fed the same things won’t. Why? Because humans invented cooking possibly as long as two million years ago, and have adapted to cooked foods which seem to cause nasty problems for some lab animals. And humans and their ancestors have always eaten at least some meat. And we are not rodent granivores. So, I don’t know how much animal evidence is being used to change the groups for meat and processed meat, but I personally prefer to disregard rodent data on human diet. It seems to be almost always misleading. Just sayin’

IARC Groups

Just so you know, here are the IARD Groups

Group 1: The agent is carcinogenic to humans. This category is used when there is sufficient evidence of carcinogenicity in humans. In other words, there is convincing evidence that the agent causes cancer. The evaluation is usually based on epidemiological studies showing development of cancer in exposed humans. Agents can also be classified in Group 1 based on sufficient evidence of carcinogenicity in experimental animals supported by strong evidence in exposed humans that the agent has effects that are important for cancer development.

Group 2 This category includes agents with a range of evidence of carcinogenicity in humans and in experimental animals. At one extreme are agents with positive but not conclusive evidence in humans. At the other extreme are agents for which evidence in humans is not available but for which there is sufficient evidence of carcinogenicity in experimental animals. There are two subcategories, indicating different levels of evidence.

Group 2A: The agent is probably carcinogenic to humans. This category is used when there is limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals. Limited evidence means that a positive association has been observed between exposure to the agent and cancer but that other explanations for the observations (technically termed chance, bias, or confounding) could not be ruled out.

Group 2B: The agent is possibly carcinogenic to humans. This category is used when there is limited evidence of carcinogenicity in humans and less than sufficient evidence of carcinogenicity in experimental animals. It may also be used when the evidence of carcinogenicity in humans does not permit a conclusion to be drawn (referred to as “inadequate” evidence) but there is sufficient evidence of carcinogenicity in experimental animals.

Group 3: The agent is not classifiable as to its carcinogenicity to humans. This category is used most commonly when the evidence of carcinogenicity is inadequate in humans and inadequate or limited in experimental animals. Limited evidence in experimental animals means that the available information suggests a carcinogenic effect but is not conclusive.

Group 4: The agent is probably not carcinogenic to humans. This category is used when there is evidence suggesting lack of carcinogenicity in humans and in experimental animals.

Crowd Sourced Award Winning Wines Support Prostate Cancer Research

A guest post by Robet Hollander, Winemaker

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2redWinery, makers of the award-winning Ziniphany© Zinfandel and #2red is 38% towards goal on Indiegogo with all proceeds supporting prostate cancer research through the Robert and Susan Hollander Foundation, an IRS approved 501c3 organization. Campaign supporters, in exchange for their tax-deductible support, can secure wine from the 2015 vintage or from the award-winning wine library of 2redWinery.

Robert Hollander, the winemaker and principle of 2redWinery, started small-volume winemaking in 2007 to indulge a long-standing passion. Passion changed to purpose in 2010 after he was diagnosed with prostate cancer at an incurable stage. Dr. Hollander, a highly-regarded clinician/teacher at the Gainesville VA Medical Center, affiliated with the University of Florida, then created the Robert and Susan Hollander Foundation to fund prostate cancer research. “After that, it just made sense to fund the Foundation with my winemaking. It gave my wine a dual purpose, not just to make a great wine I was proud of, but a wine that served a special purpose,” Hollander observed. In the two years the Foundation has been operational, unrestricted grants have been provided to researchers at MD Anderson Center and the Cleveland Clinic.

Dr. Hollander’s campaign goal is $35000 with all proceeds above production costs supporting prostate cancer research through the Foundation. Contributions to the campaign are processed by FirstGiving and are tax deductible. Rewards for campaign supporters include wine from the upcoming 2015 vintage or wines from the award-winning library of 2redWinery. “It’s a win-win-win-wine,” according to Hollander.

See Campaign: http://www.igg.me/at/2redwinery.com

Robert Hollander Winemaker, 2redWinery
President, Robert and Susan Hollander Foundation
doctorbobster@gmail.com
http://www.igg.me/at/2redwinery.com
https://youtu.be/zu7Bf5RubpI
https://www.facebook.com/doctorbobster

Does Cell Phone Use Cause Cancer? No.

Josh Harkinson at Mother Jones recently posted an item called “Scores of Scientists Raise Alarm About the Long-Term Health Effects of Cellphones.” I like Josh’s work, but there are some problems with this article I want to point out, some of which parallel problems in the more general discussion of cell phone safety.

Before looking at the Mother Jones piece, here’s the bottom line: There is no known mechanism by which cell phone use can lead to cancer (usually, brain cancer is of concern). There have been many studies on this and related issues. They vary in quality and in what they look at. The studies that seem to indicate an increase in some kind of cancer with cell phone use would indicate a shift from a very very very unlikely chance of cancer to a very very unlikely chance of cancer. So if there is an effect reflected in this research, it is very small. The studies that seem to show a link are generally done by a limited group of researchers, use methodology that is not reliable and can not be used to attribute cause, and are situated within a literature that includes many studies that show no link. Different studies that may show a link between cell phone use and cancer often indicate a link to a different cancer. And, tellingly, brain cancer rates over recent decades are basically flat, cell phone use explosive. If cell phones increase the risk of brain cancer, it is a phenomenon that a lot of research has failed to clearly demonstrate, and if the effect is there, it is very small and entirely unexplained by physics or physiology.

Josh Harkinson discusses an important topic but does so that in a way is uncomfortably click-baity. (I assume this is in part the effect of the editors who chose the title and possibly the accompanying graphic). The title implies that science raises a concern (an alarm) and the article is accompanied by a doctored photograph of a woman using a cell phone; She is wincing as though suffering a health effect and red cell phone cancer-kooties are seeping into her head right there in the picture. The subtitle invokes the children: “Children in particular may be vulnerable.” And, the article begins with an appeal to the latant distrust, “Are government officials doing enough to protect us.”

The article stems from a letter signed by “195 scientists from 39 countries” who “have collectively published more than 2,000 peer-reviewed papers on the subject.” How many scientist deal with the topic of non-ionizing radiation (the kind of kootie stuff that emanates from your cell phone) interacting with tissue (what your head is made out of)? I’m not sure, but a Google Scholar search on the term “biological health effects non-ionizing radiation” yields over 14,000 results. There are probably tens of thousands of scientists who work in the general area of radiation-cell interaction. This is a huge and important area of research. Various kinds of radiation have health consequences. Radiation interacting with tissues is a widespread form of therapy and imaging (everything from x-rays to MRI). The properties of various kinds of radiation and the activity of molecules in cells is part of a lot of basic research in a lot of fields. Here in Minnesota, there are probably way over 200 scientists who routinely engage in research either about or relying on the basic physics and physiology of radiation-cell interaction. It is a big area, only some of which directly addresses health effects of non-ionizing radiation, but even that small percentage involves a lot of work, many research labs, a large number of scientists, and a lot of publications.

The letter and information about it can be found here. Watch the video. Note that the “scientists” are actually “scientist and engineers,” an unintended dog-whistle indicating the padding of consensus claim. The letter is not about people holding cell phones to their heads. It is about EMF in general (with a focus on cell phones), and suggests that the ambient EMF including power lines are the problem. This borders on Chemtrail like ideation. I strongly recommend you watch the video. Critically.

A letter with under 200 signers (across 39 countries) who claim to have published a couple of thousand papers on a topic is numerically weak. The reality and importance of anthropogenic global warming is a scientific consensus. Even so, climate science denialists have come up with lists and letters like this with much more impressive numbers, but thay amount to nothing. There are a lot of scientists out there. There are about seven million scientists. It is not hard to find a couple hundred who strongly believe something that many many more don’t accept as likely. Josh’s article does not address this context, and probably should.

That cell phones may cause cancer has been officially designated by the World Health Organization as “possible.” That sounds bad. But people need to understand, and Josh did not point this out, that the “possible” category includes anything where there is virtually any research indicating a possible link, even crappy research, and even if the research exists among a huge body of research that fails to indicate a link. There are many different categorizations of cancer risk, and different organizations maintain these definitions and lists. The International Agency for Research on Cancer, part of WHO, has these categories:

Group 1: Carcinogenic to humans
Group 2A: Probably carcinogenic to humans
Group 2B: Possibly carcinogenic to humans
Group 3: Unclassifiable as to carcinogenicity in humans
Group 4: Probably not carcinogenic to humans

Items in group one are really problems. They cause cancer and include such things as silica dust, Radon, Soot, Tobacco, and Thorium. Group 2A (Probable) is pretty long and includes a lot of nasty stuff with multi-syllabic names, as well as ultraviolet radiation. Being a hairdresser is a probable cause of cancer because of exposure to chemicals, as is working in a petroleum refinery, or being a shift worker involving changing time of work on a regular basis. These are things that we may want to worry about, but that people still argue about, but, as they say, probably are linked to cancer.

Group 2B, “possible,” the list cell phones are in, is very long, over 900 items, of which about a third are specifically considered possibly linked to human cancers (the others not linked to humans). This list also includes a lot of scary looking stuff, but for which there is insufficient research to actually make the link. Vinyl acetate is an example. It is a liquid precursor for a polymer used to make a lot of stuff. Wikipedia tells us, “On January 31, 2009, the Government of Canada’s final assessment concluded that exposure to vinyl acetate is not considered to be harmful to human health. This decision under the Canadian Environmental Protection Act (CEPA) was based on new information received during the public comment period, as well as more recent information from the risk assessment conducted by the European Union.” So that is an example of a scary sounding thing for which some research may have shown a cancer link but that was ultimately determined by at least one major agency to not be cancer causing. Potassium bromate. Used for a lot of things, it is in some of your food (baked goods mainly). It is banned in many countries, not in the US. In theory, it is broken down during baking. Coffee. Coffee has been some research indicating a link between coffee consumption and bladder cancer, but other studies show a reduced risk of intestinal cancer. Overall, the evidence for any of this is weak.

Group 2B listing is used when there is limited evidence of a cancer link and usually insufficient evidence for a cancer link in lab animals. Let’s put a finer point on it by looking at what the UN says about the 2A and 2B categories (emphasis added):

Group 2A: The agent is probably carcinogenic to humans.

This category is used when there is limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals. In some cases, an agent may be classified in this category when there is inadequate evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals and strong evidence that the carcinogenesis is mediated by a mechanism that also operates in humans. Exceptionally, an agent may be classified in this category solely on the basis of limited evidence of carcinogenicity in humans. An agent may be assigned to this category if it clearly belongs, based on mechanistic considerations, to a class of agents for which one or more members have been classified in Group 1 or Group 2A.

So, if you want to be careful, avoid Group 2A items. They may cause cancer, and you should worry about them.

Group 2B: The agent is possibly carcinogenic to humans.

This category is used for agents for which there is limited evidence of carcinogenicity in humans and less than sufficient evidence of carcinogenicity in experimental animals. It may also be used when there is inadequate evidence of carcinogenicity in humans but there is sufficient evidence of carcinogenicity in experimental animals. In some instances, an agent for which there is inadequate evidence of carcinogenicity in humans and less than sufficient evidence of carcinogenicity in experimental animals together with supporting evidence from mechanistic and other relevant data may be placed in this group. An agent may be classified in this category solely on the basis of strong evidence from mechanistic and other relevant data.

If you focus on the word “cancer” Group 2B may be scary to you, but many items on this long list are those for which we simply can not say there is no research project ever done that showed a possible link.

Josh notes that “For decades, some scientists have questioned the safety of EMF, but their concerns take on a heightened significance in the age of ubiquitous wifi routers, the Internet of Things, and the advent of wearable technologies like the Apple Watch and Fitbit devices, which remain in close contact with the body for extended periods.”

This points to a possibly unintended side effect of unnecessary concern over non-ionizing radiation. Non ionizing radiation is radiation that does not alter matter at the sub cellular level in a way that can lead to cancer or other negative effects. See this writeup for more detail on this important difference. All radiation reduces in its strength dramatically with distance. As your smart phone and your wi-fi router exchange information (when it is using that pathway to interact with the internet) the energy that comes out of the box across the room and the energy that comes out of the smart phone in your hand, at the point of, say, your nose (a proxy for your brain that allows us to discount the effects of your skin, skull, and dura matter reducing the signal) are many orders of magnitude different. Conflating concern over a cell phone pressed to your head with concern for wi-fi routers is like conflating concern over drowning in a pool with concern over drowning in the vapor that evaporated from the pool that give you that dank feeling as you sit nearby drinking your iced coffee drink form a polyvinyl acetate cup.

Except there really is a demonstrable risk of drowning in a pool.

This is a problem because there is a movement to remove wi-fi from all public spaces over health concerns. That is crazy talk. I wish Josh had noted that in his piece. The people who signed this letter are those same people … who want to remove wi-fi from your coffee shop.

A very very small number of researchers want to move cell phones from Group 2B to Group 2A, but even as they are asking for this, continued research on the cancer risk of cell phones a) fails to produce a mechanism by which this can happen despite a great deal of knowledge about radiation-tissue interaction and b) continues to show a possible link only in studies that are inherently flawed in their methodology. Such studies, mainly case-control studies, rely on people recalling their use of cell phones. People with brain cancer are asked to recall their cell phone use, and matched randomly chosen people without brain cancer are asked to do the same thing. (Not all studies are done just that way but key studies of relevance here were.) That is a great way to get a preliminary look at a possible health issue, but it is simply not how the actual connection between a substance, a technology or a behavior and a health effect is made.

We understand a lot about energy-tissue interaction. If non-ionizing radiation from cell phones caused cancer, we would have an inkling of the mechanism. We don’t. Cell phone use has exploded in recent decades, brain cancer has not. If cell phones caused brain cancer, it would be a visible epidemiological phenomenon. It is not.

I’ve been told (and some checking on the internet has indicated this is maybe important) that some of the material used to make cell phones comes naturally along with some radioactive isotopes. It is possible that these isotopes are not always removed properly. I do not know this is the case, but it is an interesting idea. A while back a shipment of cell phone cases that happened to be radioactive was located (and refused). Holding a radioactive cell phone case to your head several hours a day may be a health risk, though again, I don’t know this to be a fact, it probably depends on all sorts of things. The cell phone-cancer link is so weak that it may be a result of research bias, random effects, recall bias, or some effect related to the use of the cell phone but not to the non-ionizing radiation.

Smart phones are becoming so ubiquitous that they could almost be considered a key trait of our species. It is smart to be smart about smart phones. Worrying about the cancer link is probably not exactly stupid, but it isn’t particularly smart either.


This video addresses many of the topics I touch on here, and more:

Americans should eat less meat, sugar, refined grains

The US Office of Disease Prevention and Health Promotion, Department of Health and Human Services, has issued a report recommending that Americans eat less meat. The executive summary of the report is here (pdf), and the web site for the report is here. It says,

The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meat; and low in sugar sweetened foods and drinks and refined grains. Vegetables and fruit are the only characteristics of the diet that were consistently identified in every conclusion statement across the health outcomes. Whole grains were identified slightly less consistently compared to vegetables and fruits, but were identified in every conclusion with moderate to strong evidence. For studies with limited evidence, grains were not as consistently defined and/or they were not identified as a key characteristic. Low- or non-fat dairy, seafood, legumes, nuts, and alcohol were identified as beneficial characteristics of the diet for some, but not all, outcomes. For conclusions with moderate to strong evidence, higher intake of red and processed meats was identified as detrimental compared to lower intake. Higher consumption of sugar-sweetened foods and beverages as well as refined grains was identified as detrimental in almost all conclusion statements with moderate to strong evidence.

Research Suggests Healthcare Workers Could Balk At Treating Ebola Patients

Given the current and developing situation in Dallas, where two health workers have become infected with Ebola while caring for a patient, it is reasonable to ask if health workers might decide to call in sick for a few months until this whole highly infectious often fatal disease thing blows over. Daniel Barnett, of the Department of Environmental Health Sciences at the Johns Hopkins Bloomberg School of Public Health, has looked into health workers’ unwillingness to report to work when there is a potential for infectious-disease transmission to themselves and their family members.

The health workers I know tend to run into burning buildings or jump into frozen lakes and such to rescue people, so I can’t see that happening. Apparently it has been an issue in Spain and in West Africa. I can’t explain Spain, but things are so dismal in West Africa that it is not at all unexpected. But what about in the US?

So far there doesn’t seem to be an issue according to Barnett’s research, but he cautions that continued willingness to work with Ebola patients here is not assured. In an earlier study, Barnett and colleagues found that one-third of workers at a large U.S. urban medical center would be unwilling to respond to a severe infectious disease outbreak.

“An individual’s personal perception of the importance of his or her work during the response phase and his or her sense of confidence in performing this role effectively, are among the most powerful determinants of willingness to respond,” notes Dr. Barnett. “Our research also suggests that familiarizing health responders with laws and policies designed to protect their wellbeing in an emergent infectious disease event is important for bolstering response willingness,” Barnett adds.

Barnet notes that for training to be effective it must provide clear guidance on infection control protocols and instill a clear understanding of outbreak response duties. I asked him about the domestic side of this, about training of health workers regarding in relation to thier behavior or decision making when they are off duty. This seems to have arisen as an issue with the second Ebola-infected worker in Dallas, who took an air flight after starting a fever (if reports are accurate) and before diagnosis as having the disease.

“Preparedness and response trainings on emergent infectious diseases need to cover not only work-related protocols,” he told me, “but also address behavioral elements outside of the healthcare setting in the interest of public health. To date, there’s essentially been no research or ‘environmental scan’ on the extent to which such trainings actually encompass behaviors and practices outside of the health care workplace. However, this type of training on precautionary measures outside the workplace is essential. It needs to be imbedded into trainings and harmonized across healthcare institutions to ensure consistency.”

Update on West Africa's #Ebola Outbreak: Getting worse

The news is bleak. I don’t have a lot of confidence in the reported numbers. At one time it was said that on a nice Saturday in the summer, four out of five cars driving around in downtown Boston were looking for a parking place. This is somewhat like the situation in Liberia and possibly other affected areas. There may be as many Ebola victims driving around in taxis looking for a clinic as there are in clinics. Or maybe a fewer. Or, maybe more. Maybe a lot more.

But, we have to work with the data we have. There are two charts based on the information provided by WHO for up through September 6th. I’ve projected each data set out 90 days. Since there is no abatement in frequency of new cases, and in fact the number continues to increase on average, and since WHO is claiming that the situation in the worst hit areas is pretty much out of control, a 90 day projection seems reasonable. In other words, there is no reason to think that the relative rate of new infections is going to change because of any outside intervention or internal change in the situation.

The first chart shows the number of new cases. This varies a great deal from report to report. Some of that variation over time is probably real, reflecting the internal complexities of disease spread. But I suspect it is mostly administrative. If a bunch of cases don’t get into one report, the get into the next report. This explains a nearly perfect alternation between increase and decrease between successive reports.

Screen Shot 2014-09-10 at 1.03.44 PM
The second chart shows the number of cases over time, accumulated. This Projected outwards, we can guess that by around the beginning of 2015, there will have been over 10,000 people who have been infected by Ebola in West Africa (including Nigeria and Senegal as well as the main area of the outbreak), and over 5,000 deaths. Since I know you are curious, if this is projected out over a year or so, the number of infected people goes to between 60,000 and 70,000. I have no idea if this is realistic.

Screen Shot 2014-09-10 at 1.02.24 PM

The situation is bad and getting worse.

About that disease outbreak in the US #Enterovirus #EV-D68

This is the time of year parents start scanning their facebook feeds and other sources of information for what to expect our children to get sick with, how badly, and when. For a couple of years in a row, a few years ago, we were getting hit with a norovirus, causing diarrhea, vomiting, and a lot of lost daycare or school days. This year we are seeing reports of an outbreak of the scary-sounding “Enterovirus EV-D68.” Hundreds of kids are sick enough to get treatment in several states, currently Colorado, Iowa, Missouri, Kansas, Oklahoma, Illinois, Ohio, North Carolina, Georgia and Kentucky. (By the time you read this more will probably be added to that list.)

This virus is part of a large family of viruses that includes a lot of diseases, some pretty benign and some more serious. But the best common name for this particular virus, the one that includes this type of virus as well as several others, is the dreaded “Common Cold.”

This is probably a bit worse than the regular common cold for some people, indicated by the number of hospitalizations, some of which include pretty serious cases. The peak season for this type of virus is September, though it is sometimes called a “summer cold” because it starts to spread earlier in they year. It also seems like this particular virus is spreading quickly and hitting communities with large percentages. But, it is not clear how different than usual this is. CNN quotes Dr. Mary Jackson, an infectious disease expert, “It’s worse in terms of scope of critically ill children who require intensive care. I would call it unprecedented. I’ve practiced for 30 years in pediatrics, and I’ve never seen anything quite like this.” She is based at a hospital in Kansas City, Missouri, where about 15% of the patients who came in have been placed in intensive care, of about 475 treated as of a couple of days ago.

So there are two things you need to know. First, this is probably a normal cold spreading more widely and quickly than other years. Second, there is probably a higher incidence of more serious infections with this cold, so be more vigilant and go ahead and set your parental trigger for calling in your child’s sickness to a more sensitive level.


Image above from here.

And, there are a few things you need to do. First, update your kid’s “cover your mouth when you cough” training. Second, update your kid’s “wash your hands a lot” training. Third, keep your kid home when sick to the extent that you can.

Just to be clear. EV-D68 is not common. When I say it is a version of the “common cold” I mean that it is one of many viruses, a diverse group, that are on the list of things that cause what we call “a cold.” The specific enterovirus EV-D68 might be pretty rare, which may be why reactions to it can be worse. There is a very small number, up until now, of confirmed cases of it world wide, but only a tiny percentage of instances of the common cold are ever tested to see what the exact cause is.

This is the time of year kids (and teachers) go back to school to learn new things and exchange pathogens. Expect a lot more of this over coming weeks.

Personally, I think everyone in the whole world should stock up of food and water and quarantine themselves form all other humans for 14 days. Inside, with a good mosquito net. Imagine how many human-reservoir or insect-human reservoir disease would go extinct!?!? Of course, then no one would have a well developed immune system after a while and we would all die but for a while it would be great!

#Ebola: Second, possibly third outbreak, West African outbreak growing

The number of people known or suspected to be infected with Ebola in the West African outbreak is increasing, and the rate at which it is increasing is increasing. About 40 new cases are being reported per day on average, but the number of new cases has been going up by a few a day.

However, it is still unclear that these numbers represent what is actually happening on the ground. There is little confidence that the WHO has a good idea of who is currently stricken with the disease, and efforts to contain those who are have had mixed results.

A second outbreak is now occurring in the DR Congo (formerly Zaire). This is a second separate outbreak. So, it is NOT correct to say that Ebola has spread into the Congo. It didn’t. It emerged there independently.

What are the chances of that happening? I have long maintained that the conditions for Ebola spreading into human populations include factors that make the overall chance of that happening, for a large region, go up enough for multiple simultaneous epidemics to be more likely than chance might suggest. Perhaps I’ll discuss my reasoning for that another time. In any event, the DR Congo outbreak, about which we know very little so far, appears to be a different strain of Ebola, so this is not the Wester African Ebola spreading to Central Africa.

There are reports of a third outbreak of an unknown disease that might be Ebola also in the DR Congo. But that could be a lot of things. Including Ebola… so we shall see.

Also, there is one new case in Nigeria, after a period of several days with no new cases.

Ebola Perspective: Risks of spread to the US and elsewhere

LATEST UPDATE HERE

It is true that this particular outbreak of Ebola has taken health officials somewhat by surprise. It is impossible to know, but I suspect that if you had asked a few ebola experts, a year ago, if there could be an epidemic that would spread across three or four countries, infect a couple thousand people, and last with no sign of letting up for a few months (that is the current situation, more or less), most would say no, probably not, though it is within the range of possibilities. Does the fact (assuming it is true) that this particular Ebola outbreak is unprecedented and kinda over the top even for an over the top disease like Ebola mean that there is something different about this Ebola or this outbreak? That is a question that may be on your mind.

Another concern is the possibility that since this outbreak involves populations with more mobility including via aircraft than previous outbreaks that the Hollywood Scary Fiction scenario could happen. Here’s how that goes. Someone infected with Ebola, but not symptomatic, gets on a long plane flight, maybe with a few legs and layovers. They start to get sick on the first flight, and after changing planes twice and being very sick for the last leg, they get off the plane and collapse, are taken to a local hospital very far form the Ebola epidemic where no one is expecting Ebola, spend a little quality time in the waiting room, and are finally put in an in-patient unit in a room with two or three other people. Hundreds of people have been near this person. The patient threw up in the bathroom of each of the airplanes he was on, and later someone filled the sink in the same bathroom and used the water in the basin to wash his or her face. He drooled on his pillow while sleeping in his seat, and somehow the person next to him ended up with that pillow and slept on it for an hour. He threw up on some nurses and some orderlies had to clean up his diarrhea in the hospital a few times. And so on. By the end of all of this, a half dozen people are infected with Ebola, including a personal trainer, a grade school teacher, and four nurses. That’s just the first scene in the movie, long before the character played by Morgan Freeman is on the scene, and when the character played by Morgan Freeman shows up, you know things are getting serious.

A variant of that concern is this: Two aid workers helping with the Ebola epidemic, Americans, catch Ebola and are very ill. It is decided to fly them back to the United States for treatment. This brings Ebola into the US, where it could spread to other people because, well, because Ebola! But is this a realistic concern or just a Hollywood studio’s wet dream?

At this point in the epidemic we are seeing the usual bifurcation of reaction among the general public, sciency bloggers, and the press. On one had there is growing panic, people either being very scared, for real, or people or press outlets shopping fear on the market because it sells. On the other hand there is the stern corrective statement that all your fears are invalid, Ebola isn’t going to get out of hand, isn’t going to get to the US, there is nothing to worry about.

At the same time there is a parallel and equally bifurcated rhetoric about the bigger picture, about dealing with Ebola as a public health problem. On one hand you have people asking for a vaccine, or some sort of cure, to address this thus far orphaned disease, because they are worried about it. On the other hand you have people noting that Malaria kills millions a year, and most years, Ebola kills no one, and when there is an outbreak, it only kills dozens or hundreds, except this last time which is still only many hundreds dead and the very low three figures sickened.

Every one of the above mentioned concerns is valid and invalid at the same time, and every one of the reactions to the current Ebola crisis is both correct and incorrect at the same time. Let me explain.

What is the meaning of the bigness and badness of the Ebola 2014 outbreak?

There may be new things to learn about Ebola from this outbreak, but that won’t be until after the dust has settled and scientists have had a chance to look more closely at the data, and the virus, and everything else. But there does not seem to be anything new or unusual about the disease, and I don’t think there is any major difference in how the outbreak is being handled. But there are two differences from earlier outbreaks, one of which is certainly relevant to the large size of this event, the other perhaps important but as yet unclear.

<li>Most, really all, prior outbreaks occurred in areas where the affected population was relatively thinly scattered on the landscape and the movement of people in and out of the area was minimal and slow. This outbreak is happening where there are much larger concentrations of population and a lot of movement of people.  This has simply upped the chance of transmission in close quarters (higher density) and made for opportunities for spread to previously unaffected settlements.</li>


<li>There has been resistance to health workers coming into some villages.  This story is spreading around as though it was a major thing, that large areas were becoming dangerous or difficult for health workers to enter or work in.  We need to be cautious in drawing conclusions from the news.  It is very easy for westerners to slip into blaming the natives for their own difficulties and contrasting native ignorance with Great White Smartness.  There may well be areas where this is happening or important but until there is some actual unbiased carefully collected and evaluated information on this, please don't draw conclusions.  If you hear about something that looks like a great story, there is a good chance that it is a great story.  Emphasis on "story." </li>

This particular Ebola outbreak is really like all the others, but jumbo size.

Could sick aid workers being brought to the US spread the disease here?

No.

You can stand in a room with a person infected with Ebola ten feet across the room from you, and stand there for hours, without a mask, and you will not, can not, get Ebola. It simply isn’t transferred that way. Clean up Ebola vomit, Ebola diarrhea, physically move Ebola victims from bed to bed, give them a sponge bath, tend wounds or other injuries, insert and remove IV’s, handle the bodies of recently deceased Ebola victims, and especially, give traditional treatment to those bodies which, as is done in many cultures, which may involve cleaning and even internal cleaning or handling of organs, etc. etc., and you’ve got a reasonable chance of getting Ebola. Even then, the number of health care workers who actually get Ebola is probably very small. Tragic and horrible when it happens, but a few out of thousands most directly exposed and at risk for months is a small number.

The people who are being transported to the US are isolated, in negative pressure facilities, and are being handled with kid gloves. Well, latex gloves, actually. They can not infect anybody but their immediate caretakers, and those individuals are very well protected.

There is a risk of a different sort, though. While these particular patients are being handled with great care, there are healthy helpers, medical workers or others, who have been working with Ebola patients and seem to have not contracted the disease, who are occasionally wandering off to their respective homes and, I’m pretty sure, not being quarantined. I am not sure if all the people involved in helping in West Africa are being tested or properly watched. They may be, but there is some evidence that this is not the case. I’d like to learn more about that, and I hope we don’t learn anything the hard way.

One US based doctor has returned to the United States and decided to quarantine himself. Alan Jamison will keep himself separate from society for 21 days since his last potential exposure to Ebola.

If he is doing this on his own, there is the implication that doctors or others who were working with Ebola victims are being allowed two wander off and commune with the rest of us with the prospect that they are infected and eventually could spread the disease. However, I’m not sure that this is true. I don’t know that Dr. Jamison was not tested, I don’t know how much exposure he had and I don’t know what the procedure is for managing this potential problem. This is one guy who may be making hay where there is no grass. Worst case scenario, though, is that a health worker gets sick, the beginnings of Ebola like symptoms emerge, and the health worker gets treated. Nobody who has been working with Ebola patient is going to get a head ache, feel like throwing up, and say to themselves, “Hmm. I wonder if I’ve got allergies or something?”

We should be worried about people wandering off, leaving the sites of the outbreak, generally. That’s clearly how this has spread to begin with. This applies to health workers and regular people. It applies to journalists in the field. We should not assume, but we can reasonably hope, that people are doing the right thing. But even when they don’t, remember, this is not measles, which is highly contagious.

(Also, in case you didn’t know, Ebola is of course already in the United States. See this.)

Can the scary hollywood scenario happen?

Yes, of course it can. There is nothing in that scenario, taken on its own, that can’t happen. Bodily fluids get around. People are confined on aircraft, share a bathroom, and occasionally eat each other’s cookies by mistake. I don’t think there is any scientifically valid way to suggest that people who are symptomatic with Ebola are anything but a nightmare on a regular airplane flight, hanging around in airports, sharing cabs, et. When I hear international health experts saying that the chance of Ebola transmission on an airplane is pretty much non existent, I want to ask them: Ok, so, you’ll be entering and leaving the sick rooms of Ebola patients, maybe taking your kids along because it’s Follow Your Parents to Work Day, and maybe even have your kid sit next to the patient in bed and read them a story, without any protective gear at all. Right? No, absurd.

However, the crazy scenario I gave you above, with the vomit and the pillow and the bathroom, requires a lot of things to go wrong in sequence, which is pretty unlikely. Also, the worst case scenario is that a few people end up with Ebola. It would be very hard for that to spread in the US. We’re too good on our health care, even when it seems we are not. On the other hand, if an air route with a symptomatic Ebola patient is sending people to any of many other places, with high population density, little education or information about things like Ebola (or even a belief that it is not a disease you get from other people) and no monitoring, I’d worry that smaller outbreaks could show up in other countries or other cities, in West Africa, elsewhere in Africa, or beyond. You can say that chances are it won’t happen. But it did happen. Ebola is in multiple countries spreading from multiple sites in West Africa.

I’m pretty sure the people who deal with Ebola, though, try to not take chances. Rhetoric to the contrary is to avoid panic. Avoiding panic is good, and in fact, panic is unnecessary. Ebola is not that contagious. But somewhere between being concerned and avoiding panic by making it sound like Ebola refuses to pass from person to person on air planes, there is clearly something lost in translation.

Who cares about Ebola, it is not Malaria!

To me this is one of the most insidious problems we have and it doesn’t just apply to Ebola vs. Malaria. Let me give you an example from an entirely different area.

How much money have spent on the science of subatomic physics, say, just in the US. And, what are the benefits? More importantly, what were the benefits that were specified at the outset of various research projects, and which of those have been realized?

The answer to that second question is probably zero, zero. No benefits were specified, and thus, any gained don’t count. You are probably thinking, “No, wait, what about the knowledge, and all that stuff!?? That was surely specified in the grant proposals!” No doubt, but simply advancing knowledge is not a benefit. How do I know that? Malaria! Those physicists may have advanced our knowledge, and as a side effect invented the DVD and stuff, but nobody cured Malaria. Therefore it doesn’t count.

Sounds like an incredibly stupid argument, doesn’t it?

Now, side step over to Ebola. Is creating, say, a vaccine to address Ebola worth it? No! Why? Because Malaria! Malaria is way bigger, kills more people, is a truly serious public health problem, Ebola is rare. So if you’ve got some research money don’t spend it on Ebola, spend it on Malaria.

That would be the smart thing to do!

This is also an incredibly stupid argument, for a few reasons. The only reason you can compare Ebola and Malaria is because they are both diseases. They aren’t even the same kind of disease, they don’t have the same geographical spread (though it is overlapping). But they are diseases, so when we consider spending resources on research in one, it is natural to compare to the others. But they are also two different things. If I had a million dollars in the bank of my Malaria Vaccine Research Institute and gathered all the scientists together and said, “OK, folks, until we’ve spent this one million dollars, I want you all working on Ebola instead of Malaria, K?” they would look at me funny for a while and then call my wife to take me home. Ebola is a virus, Malaria is a cellular organism. They are very different things. The expertise and lab equipment would not be in my Institute. I might as well tell my scientists to spend a million dollars working on the next generation of high definition TV. That would be cool! And, suggesting that we compare the costs and benefits of that project to working on Malaria or Ebola would be dumb.

One of the benefits of working on a vaccine for ANY virus is advancing knowledge of vaccines for viral disease generally, and we have a lot of work to do on vaccines for viral diseases. Perhaps work on Ebola would have some great side benefits. Indeed, money spent on a vaccine for Ebola would very likely produce … wait for it … a vaccine! Money spent working on a vaccine for Malaria has thus far failed to produce squat.

A vaccine for Ebola is probably relatively easy to develop. Ebola is not a human disease. It comes from an animal reservoir. Ebola, if hit with a vaccine in human populations, can’t evolve resistance to that vaccine (or other treatment). Humans have little or no history of immune response to Ebola, and a very long (in essence, multi million year long) history of immune response to Malaria and its cousins. Developing an Ebola vaccine would be like putting up a childproof gate in your house, where the 2 year old is Ebola and the childproof gate is the Vaccine. Developing a vaccine for Malaria is like trying to stop a squadron of Navy Seals from penetrating a drive-in theater at a date and time of their choosing.

This is why literally billions of dollars has been spent … billions, seriously … on developing a Malaria vaccine and there isn’t one. I would venture to say that if we looked at the part of the money spent on Malaria research in general (including vaccines) that covered just couriers and postage over the years, we’d have enough to fund a full on Ebola vaccine development program. Maybe not. Maybe you’d have to add in a few percent of the money spent on conferences (which are very important, I’m not saying they are not) by Malaria scientists. There is probably more money being spent right now on retirement payments to retired scientists who spent most of their time working on Malaria than needed to build an Ebola Research Center that could get a vaccine out there in a few years. Seriously. Please don’t compare Malaria to Ebola and use that to suggest that we should ignore Ebola. The crumbs that fall off the pieces of Malaria cake at the Malaria birthday party would be enough to handle Ebola. (Bonfire of the Vanities Reference.)

But still, why should we bother with Ebola?

Why bother with any disease? Why not figure out which one disease causes the most mortality or morbidity, and disallow any research on anything else? Then, when that is solved, move on to the next one. There are several reasons to not do this. First, it might not be possible to solve the big bad disease quickly, or ever, so the entire research program would spin its wheels forever. Second, the second and third and way down to the tenth or twentieth diseases are all real disease people really get and that really cause suffering. While the argument that spending excessively on a rare disease is a poor choice, spending a modest amount on a very addressable problem that is also small is exactly what we should be doing. Third, you can and should think of some of this as pure research. Pure research is where scientists seek out the answers to questions in a special category of question: Questions that scientists ask. No other criteria need apply. Scientist tend to ask questions that are at the edge of knowledge, or perhaps that are hanging around this or that water hole of ignorance. Scientists ask the questions they ask because they have two characteristics: There is something unknown, and there is something about that unknown thing that is knowable. With research. Usually.

Now go back to Ebola again. Doesn’t somebody want to know about Ebola? Of course they do. Ebola is one of a family of viruses, the Filovirus family, that includes some pretty benign viruses and a handful of nasty ones (Ebola isn’t the only one). In the past there was a lot of research interest in the filovirus family for use as a biological weapon. Imagine making an Ebola like virus that spread though the air! You could really kick ass, militaristically speaking, with such a weapons. But, fortunately, we as a species have recently decided to not view biological weapons as legitimate. Research on biological weapons continued, of course, long after they were outlawed because we assumed we needed to “understand them” (make them and test them on rats) in case the other guys were making them, so we could deal with them. But I’m pretty sure most of that research has gone by the wayside as well. I would not be surprised, and I’m not much of a conspiracy theorist so I don’t want to emphasize this too much, if a lot of the work to make an Ebola vaccine was in a file drawer somewhere.

Also, there is the simple stark reality of Ebola. If you are a typical American you may not care about Ebola because it is in a different country and won’t get here and there are other problems. But say you are like my neighbor here in Coon Rapids, Minnesota, Decontee. Decontee is Liberian. She is part of a large Liberian community here in the Twin Cities. Many Liberians are American Citizens with strong ties to Liberia. There is constant travel back and forth. I asked a Liberian guy I know where he gets his sombe (a wonderful traditional West and Central African dish) and he said “From my grandmother.” “Does she grow it?” “Yes. In Liberia. I get it when I go there.” The point is, there is a lot of back and forth. To be an American who is Liberian is to be a member of a community of people who is currently, at this very moment, threatened with Ebola. People in your community, in your family, can get Ebola. Decontee’s husband and her sister in law both got Ebola and died of it last week. Ebola is a problem that affects communities that are Diaspora that include our very neighbors and friends. It should not be an orphan disease.

So wait, there was way too much nuance and possibly contradiction here, what am I supposed to think?

I don’t want to tell you what to think.

But in this case I’ll make a suggestion.

Do not be worried about the health workers being brought back to the US. Indeed, at this point, openly worrying about this can do little more than make you look a bit dumb and a bit insensitive.

Yes, worry about the possibility of Ebola getting “out” to pretty much anywhere, elsewhere in Africa, to the US, etc., because it can. But don’t worry too much. The chances are low. Forget about this “Oh, Ebola is not transmitted between people on airplanes” magical thinking. Of course it is. But Ebola is always hard to transmit, even on airplanes. In other words, be realistic.

Forget about this comparison between Ebola and Malaria. When the Malaria people turn up a vaccine after spending billions of dollars of research money we can make a comparison. At the moment, Ebola is probably a vaccine-ready disease, and Malaria is not. You are comparing apples and oranges. No, worse than that. They’re both fruit. You are trying to compare, in a cost benefit analysis, the efficacy of spending money on a new car vs. working out whether or not it is worth clipping coupons when you go to the grocery store. Why are you doing that?

But, if you are a member of a community like the various African communities in the US, then you do indeed have more of a concern. Not so much that travelers will bring Ebola to your doorstep, though that is a tiny bit more likely for you than for some others, maybe. But because your community is being directly affected because your community lives in two worlds, and one of those worlds is being invaded by a monster.