Category Archives: Health

How to fix the anti-vax problem.

I just watched a report on ABC news about anti-vaxers causing the current and alarming measles outbreak. It was a reasonable report for MSM though I missed large parts of it because I was multitasking ineffectively. But an idea came to me that would go a long way to manage this problem of anti-vaxers threatening everyone else’s health and well being. Lives, even. They are threatening our lives.

Here’s the deal. Most public schools have a mealy-mouthed policy that allows people to send their kids to school unvaccinated because they are dumb asses. That’s a problem and that should be addressed, but I don’t expect it to be because school administrators are usually easily managed by whackaloon parents if the whackaloon parents organize sufficiently. Unions are already organized as entities and have the potential to change policies. So lets look at the union route.

In states with teachers’ unions, here is what I recommend. The health and well being of the teachers is a workplace thing. They should be protected against disease, injury, death, etc. in the workplace. The anti-vax supporting policies of the school — i.e. that students must get vaccinated unless their parents are morons — place teachers in danger.

So set up a system of appropriate compensation. I recommend the following.

1) If any teacher comes down with a communicable disease covered by vaccines for which there are any students who have opted out, the teacher gets $10,000. Proof of a link is not needed, and there need be no identified “case zero.” Parents are too good at hiding sickness in their families, and the necessary investigation into sickness would be very costly and highly problematic.

2) If a death occurs in that teacher’s family owing to said disease, the teacher is compensated by $100,000,000.

3) This would apply as well to all staff, and visitors.

4) If a student in the school comes down with any of the communicable diseases and this is known to the union, every teacher and staff member gets an extra $1,000 per week in salary during the period of possible infection, to be determined by reference to a lookup table developed by health professionals.

This seams reasonable given that that school administrators clearly feel that their students and faculty are at risk. They should agree to this demand by the union because there will never be a payment. Right?

Crohn's Disease: Which came first, dysbiosis or inflamation?

Sounds like kind of a technical question.

In Irritable Bowl Disease, including Crohn’s Disease, it may be the case that bad bacteria cause intestinal wall inflammation. Or, inflammation could allow bad bacteria to do better than good bacteria. And, that might be an oversimplification because there could be other factors as well, including genetic predispositions.

Many younger people who present with various abdominal symptoms are treated with antibiotics. These antibiotics could disproportionately favor bad bacteria.

Whether from inflammation, genes, or use of antibiotics, it does seem that “dysbiosis” (having bad bacteria along with the good ones in your gut) is a problem.

The results of a large study are now being released that looks at this problem in a way that might untangle some of these questions. From Science (News):

The research, which involved 668 children, shows that numbers of some beneficial bacteria in the gut decrease in Crohn’s patients, while the number of potentially harmful bacteria increases. The study could lead to new, less invasive diagnostic tests; it also shows that antibiotics—which aren’t recommended for Crohn’s but are often given when patients first present with symptoms—may actually make the disease worse.

Some potentially harmful microbial species were more abundant in Crohn’s patients, such as those belonging to the Enterobacteriaceae, Pasteurellaceae, Veillonellaceae, and Fusobacteriaceae; numbers of the Erysipelotrichales, Bacteroidales, and Clostridiales, generally considered to be beneficial, were lower. The disappearance and appearance of species can be equally important, says Dirk Gevers of the Broad Institute in Cambridge, Massachusetts, who performed most of the work. “There has been a shift in the ecosystem, which affects both types.”

The subjects tended to not have been treated with antibiotics, or at least, not much (yet), but there was variation and those who had received more antibiotic treatments seemed to have more dysbiosis.

The dysbiosis was also more pronounced in patients who had received antibiotics. “This study confirms that these drugs don’t do any good to people with Crohn’s disease,” says gastroenterologist Séverine Vermeire of the Catholic University of Leuven in Belgium, who was not involved in the study. “We knew antibiotic use increases the risk to develop the disease; now we know they can worsen it, too.”

The main outcome of this research may be the development of easier to implement and more reliable diagnostic techniques. But it also seems to advance understanding of Crohn’s. What this study does not do directly, though, is address the strange epidemiological signal whereby Crohn’s seems to be increasing in western populations. Something we are doing may be involved. Most people seem to assume this is dietary, but I won’t bet a dime on that. This could have to do with all sorts of other practices that ultimately influence gut flora, from hand washing and diapering practices to food related but not strictly dietary choice related changes, such as how bacteria is removed from food during processing.

Vermeire says it’s a “missed opportunity” that the researchers didn’t look at the patients’ diets. “That could have helped elucidate why this disease occurs so much more in the Western world than elsewhere.” In 2011, Vermeire’s group published a study showing that healthy family members of Crohn’s disease patients have a slight dysbiosis as well. Vermeire is convinced that even in these families, it’s not genetics but some lifestyle factor that causes the phenomenon. “If we could identify the dysbiosis in an early stage, and we knew the causative factors,” she says, “we could prevent disease occurrence by bringing about lifestyle changes.”

Stem Cells Approved By Vatican May Not Exist

… which would be really funny because … well, you clearly see why this is funny.

Christian groups and sects are often opposed to the use of biological tissue that would otherwise be discarded in research and therapy including “stem cell research.” This is because they think some of that biological tissue could be future parishioners, or because they watched too many Disney movies involving fairies. Or something. Anyway, there is this one kind of stem cell that exists among regular cells that can be extracted from the body of a living, breathing already signed up parishioners and the use of these stem cells to cure horrid diseases and such would not violate anyone’s sensibilities. So The Church has (more or less) said OK to that. The problem is, they, these stem cells, might not actually exist. From a news report in Nature:

Proponents of very small embryonic-like cells (VSELs) extracted from bone marrow say that the cells have the potential to transform regenerative medicine. A trial has begun in Poland, and cell-therapy company Neostem in New York is planning another in Michigan.

But in a major blow to the field, a paper published on 24 July in Stem Cell Reports suggests that the diminutive stem cells are not real1. Led by Irving Weissman, a prominent stem-cell researcher at Stanford University in California, the study is the fourth to refute the cells’ existence — and the most thorough yet.

It will be interesting to see how this works out.

MERS-CoV, The Haj, and the remote chance of a killer global pandemic

It seems to me that the science of epidemiology is a lot like being in shoe sales in a country on the pacific rim. You never know when the other shoe is going to drop, but you know it will. Our species (humans) is numerous, contiguous, and dense (in more ways than one). This means that a highly virulent pathogen could spread across the globe and kill a gazillion people before we could do anything to stop it. Yet, such a thing has not happened in modern times, meaning, since the widespread and easy flux of population provided by the airline industry at several scales of space.

At the present time we (humans) are faced with yet another threat of pandemic disease, this time from the coronavirus MERS-CoV. Spoiler: It is very unlikely that MERS-CoV is going to be a major pandemic because it does not seem to be all that virulent, in the sense that it does not seem to spread easily from one person to another. When it shows up in a population, it does not seem to spread around quickly. On the other hand, it is human-spreadable, similar coronaviruses are virulent so maybe this one could evolve to be so, and the mortality rate is so far an alarming ~50%. And, there is another complication. MERS-CoV is very likely to be carried from its homeland in the Middle East to several other countries by the mass movement of pilgrims returning from The Haj.

A recent study in PLoS Currents Outbreaks (yes, that’s a clumsy phrase, not a typo) looks at the situation. Researchers use reasonably good (but limited) data on air travel to estimate the number of people who will return-travel form the major Middle Eastern pilgrimage sites between June and November. They look at relative rates of return-travel to each area, and at health care expenditures per capita as a way of estimating the ability to address an influx of deadly disease-carrying return visitors, in each country.

16.8 million travelers on commercial flights departed Saudi Arabia, Jordan, Qatar and UAE for an international destination between June and November 2012. 7.5% had final destinations in countries that were low income, 47.4% lower-middle income, 17.3% upper-middle income and 27.8% high income. 51.6% had final destinations in just eight countries: India (16.3%), Egypt (10.4%), Pakistan (7.8%), the United Kingdom (4.3%), Kuwait (3.6%), Bangladesh (3.1%), Iran (3.1%) and Bahrain (2.9%; see Table). Individual cities with the highest travel volumes include Cairo, Kuwait City, London, Bahrain, Beirut, Mumbai, Dhaka, Karachi, Manila, Kozhikode, Istanbul and Jakarta, each of which received more than 350,000 commercial air travelers from MERS-CoV source countries between June and November 2012. Furthermore, an estimated 8.7% of foreign Hajj pilgrims in 2012 originated from countries that were low income, 56.4% lower-middle income, 27.3% upper-middle income, and 7.6% high income. 60.7% of foreign pilgrims originated from just eight countries – Indonesia (12.4%), India (10.1%), Pakistan (9.9%), Turkey (7.8%), Iran (6.5%), Nigeria (5.7%), Egypt (5.5%) and Bangladesh (2.9%). A bubble plot depicting the volume of international travelers departing Saudi Arabia, Jordan, Qatar and UAE from June to November 2012, the estimated number of foreign pilgrims performing the Hajj in 2012 and estimated healthcare expenditures per capita in 2011 is shown in Figure 1.

Fig. 1: Country-Level Destinations of Air Travelers Departing MERS-CoV Source Countries*, Origins of Hajj Pilgrims†, and Healthcare Expenditures per Capita‡ * Final Destinations of Air Travelers Departing Saudi Arabia, Jordan, Qatar and the United Arab Emirates via Commercial Flights between June and November 2012† Estimated for 2012 ‡ Sizes of the circles are proportionate with healthcare expenditures per capita as estimated by the World Bank, 2011
Fig. 1: Country-Level Destinations of Air Travelers Departing MERS-CoV Source Countries*, Origins of Hajj Pilgrims†, and Healthcare Expenditures per Capita‡
* Final Destinations of Air Travelers Departing Saudi Arabia, Jordan, Qatar and the United Arab Emirates via Commercial Flights between June and November 2012† Estimated for 2012 ‡ Sizes of the circles are proportionate with healthcare expenditures per capita as estimated by the World Bank, 2011

The researchers note that MRS-CoV has the potential of being a pandemic disease, and that understating population movements that could underly its spread is essential. The key points here seems to be that there is an intersection between countries that have a lot of pilgrims returning from MERS-CoV source areas and a low probability of detecting and containing cases of international spread because of inadequate health care systems. Related to this, they also identify possible blind spots in the global health care industry. For example:

The four countries with confirmed cases in returning travelers…the United Kingdom, France, Italy and Tunisia…account for an estimated 7.1% of the final destinations of all international travelers departing the MERS-CoV source countries since September 2012 (each of which are high or upper-middle income countries). By comparison, India, Pakistan and Bangladesh represent the final destinations of an estimated 27.7% of all international travelers over the same time period (each of which are low or lower-middle income countries), but have not reported cases of MERS-Co. Although not definitive, these findings could indicate the presence of epidemiological “blind spots” to MERS-CoV as a result of limited infectious disease diagnostic and surveillance capacity.

So, we’ll see how this goes.

Above I note that despite the obvious risk of a global pandemic of something spreading across the human population there really hasn’t been one, but I think this should be put in context. We have had widespread and multi-layered (in terms of economic and other strata) air flight for less than fifty years, but that air travel has probably not penetrated all regions of the world until the last 25 years or so. Pandemics with really large death tolls, however, are very rare. The HIV/AIDS pandemic is a slower moving but very deadly one, and is the largest in modern times, and it started in 1981 and was certainly facilitated by the ability of humans to travel. The previous large pandemics that could possibly have been facilitated by air traffic in a major way were two flue pandemics, in 1968 and 1957, each very small compared to HIV/AIDS but effective at a much higher temporal rate. The previous pandemics that were very large, but prior to major air travel effects, most likely spread internationally with boat traffic, were the famous 1918 flu pandemic and the less famous 1889 flu pandemic, and a handful of near-million death level cholera pandemics, in 1899, 1881, and the 1850s.

So, during the 163 years from 1850, worldwide pandemics that killed 6 figures and above happened about 8 times. That’s about every 20 years. So, when we look back at the history of air travel, which has allowed the ready movement of large numbers of people across a wide range of social and economic categories living in most populated areas, we should not be surprised at the number of pandemics. It is hard to put a year on when humans became as internationally mobile as they are today, but the east-west divide was a major factor dampening movement until the 1990s. One could say that the current highly mobile situation dates to about 1990, and is thus, just over 20 years long. In other words, the rough time scale of the emergence of diseases with the ability to spread widely and quickly, using cholera and flu as a proxy for “disease” is once every 20 years, and the situation in which the Giant Killer Pandemic in which human population is measurably reduced because of a disease we can’t control for several years could occur is recent. I quickly add that Cholera is a lousy proxy for such disease because it is readily treated these days and its initiation and spread is only partly related to human movements. It may well be that the frequency of the evolution of a spreadable pandemic disease is much longer than 20 years.

There are shoes. They can drop. They seem to drop slowly, infrequently, but as time has passed over the last few decades the potential severity of such an event has clearly gone up in some ways while our ability to control disease through treatment and vaccination has probably stabilized or even gone down.

MERS-CoV is probably not the next pandemic. But the idea of there being such a pandemic, and even a pandemic with previously not seen qualities because of our denser than ever, larger than ever, and more connected than ever population is nothing to sneeze at.

Khan, Kamran, Jennifer Sears, Vivian Wei Hu, John S Brownstein, Simon Hay, David Kossowsky, Rose Eckhardt, Tina Chim, Isha Berry, Isaac Bogoch, Martin Cetron. 2013. Potential for the International Spread of Middle East Respiratory Syndrome in Association with Mass Gatherings in Saudi Arabia. PLoS Curents Outbreaks. July 17, 2013. Full Text here.

More on river blindness and related diseases

We were talking about River Blindness.

Trigger Warning: The video below is not for general consumption. Having said that you may want to watch it. The first part depicts the reactions of a handful of celebrities watching a series of shots depicting seven different related tropical diseases, and I must say, having seen all of these diseases in person (and having treated some of them, and had mild versions of a couple myself) that these particular videos show the worst side of it. But still, a very large number of people (according to the source of the video, about a billion) have some form of these diseases, mainly in Africa but also in Central and South America and Asia. The celebrities are: Emily Blunt (“Salmon Fishing in the Yemen,” “Devil Wears Prada”); Eddie Redmayne (“Les Miserables,” “My Week with Marilyn”); Tom Felton (“Harry Potter” series); Yvonne Chaka Chaka (South African pop star); Tom Hollander (“Pirates of the Caribbean,” “Pride and Prejudice”); and Priyanka Chopra (leading Bollywood actress and international recording artist).

The last part of the video is the same celebs giving a pitch for you to pitch in and donate some money and spread some awareness.

The project that produced this video is called End7, a reference to ending all seven diseases. What they say is mostly true: You can treat these diseases very inexpensively. At present, the pharmaceuticals are well known and inexpensive. However, people with advanced stages of some of these parasitic infections can’t be treated easily if at all because the treatment may involve causing effects that result in very severe immune system responses. The idea is to treat children, more or less prophylactically, so they don’t develop the advanced versions.

The disease are:

  • Elephantiasis
  • <li>Roundworm</li>
    <li>River Blindness</li>
    <li>Snail Fever</li></ul>

    A Test For River Blindness

    River blindness, also called Onchocerciasis, is the result of the infection of several different eye tissues by the nematode Onchocerca volvulus. The bacterium Wolbachia pipientis lives symbiotically in the gut of the nematode, and escapes the small roundworm to cause an inflammatory response in human tissues, which results in damage to the tissue. These infections can occur in a number of different human tissues causing a variety of effects, but when the eye tissues are involved, the result can be river blindness. It is endemic and widespread in several areas of Africa, as well as more restricted areas in South America and the Middle East.

    ResearchBlogging.orgTreatment of the disease involves killing the bacterium, which in turn kills the host nematode, using various anti-biotics. However, as we have learned over recent decades, widespread use of antibiotics can be less than ideal because this can cause selection for resistant strains so that treatment can become generally ineffective across an affected population. Ideally, there would be a reliable test for river blindness infection that would allow more targeted use of treatments. Continue reading A Test For River Blindness

    Should they allow pigs at the State Fair, and what if they do?

    The State Fair is about to start up here in Minnesota, and the top epidemiologist at the University of Minnesota has very clearly stated that the swine should be excluded this year in order to avoid swine to human transmission of a flu virus that has been showing up in increasing numbers lately. I’ve blogged about this before, and here is an update with new numbers. Also, I’ll address a few questions I’ve heard asked.

    How many people have been affected with the new Influenza A (H3N2) Variant Viruses (“H3N2v”)?

    The CDC reports that 12 people were known to have been affected in 2011, and 225 in 2012, most of which have been affected in the last several weeks, indicating a sudden outbreak. However, that number is a minimum as more cases are known than reported in that CDC report. We may have one or two cases in Minnesota that have not been included yet.

    Who is getting this flu?

    There are two categories of people that make up most of those affected: 1) People who work with swine and 2) People who came into contact with swine at county or state fairs or similar venues.

    Among those who are getting the flue, more may be children. It is thought that perhaps many adults have a immunity to this variety that children don’t have.

    Does the new swine flu pass from human to human?

    Yes and no. There are a handful of cases of humans having this flu who probably got it from someone who, in turn, got it from a pig. However, there is not a pattern of sustained human-to-human transmission at this time. However, that can change. The new flu variant has a mutation that is believed to be helpful (to the virus) in human-to-human transmission, and the fact that there are a couple of cases of this shows that is is possible. The reasons that the normal flu season occurs in the Northern Hemisphere during winter may relate to factors that enhance human-to-human transmission, and those factors to not pertain at this time since it is still summer. It is possible that this flu would spread more readily among humans as conditions change. Also, flu viruses change over time to become more or less likely to spread. This flu must be watched carefully.

    People are saying that this is a mild flu. Is that true?

    No, that is absolutely not true. The flu appears to be an average flu, like any year’s typical seasonal flu, in how icky it is to get it. Rumors that it is a “mild” flu probably come from the fact that it is not a killer flu, like some are that jump boundaries between species. Which may relate to the next question…

    Where does this flu come from?

    A simple version is that over several years, it started in humans, infected pigs (and went away in humans) and is now re-infecting humans after a period of time of not being able to make that jump. Influenza is like that. This also explains the fact that some adults seem immune to the flu; they had this one (well, one kinda like it anyway) already, or an earlier vaccination is helping.

    Should they allow pigs at the Minnesota State Fair?

    Personally, I think it is overcautious to disallow pigs. But I think we should be overcautious and disallow them. I agree with Michael Osterholm that this is “an unprecedented situation globally.”

    What about taking precautions like washing your hand after petting the pig?

    Well, yes, please do wash your hands after petting the pig, but it won’t help much. The flu is probably airborne. Also, officials say they will keep the sick looking pigs sequestered or send them home or something, but there is evidence that pigs with this flu don’t necessarily look sick. In short, the precautions that are being shuggested by State Fair officials and the State Health Department are not expected to be effective.

    Are you, Greg, going to the State Fair?

    Of course. But I will not be visiting the Big Pig or his little friends. Nor will anyone else in my family. We will not, however, be avoiding swine entirely. If there is Bacon on a Stick, that will be good. Or corn dogs. I believe they include pig.

    Background information:

    Epogen, Procrit and Aranesp: ineffective, too expensive, and dangerous?

    The Washington Post has an article out (an “exclusive”) about three drugs used to treat anemia that their investigative reporting seems to show are less effective and more dangerous than people thought. Here’s the dramatic intro from the WP’s article:

    On the day Jim Lenox got his last injection, the frail 54-year-old cancer patient was waiting to be discharged from the Baltimore Washington Medical Center…. a nurse said he needed another dose of anemia drugs.

    His wife, Sherry, thought that seemed odd, because his blood readings had been close to normal, but Lenox trusted the doctors. After the nurse pumped the drug into his left shoulder, the former repairman for Washington Gas said he felt good enough to play basketball.

    The shots, which his cancer clinic had been billing at $2,500 a pop, were expensive.

    Hours later, Lenox was dead.

    This is a very interesting article, and it will be very interesting to see how this plays out. Big Pharm is the bad guy, The Taxpayers are getting bilked, and innocent bystanders like Mr. Lenox are the victims. This could be a very important piece of journalism which will change the world in a positive direction, or it could be a misunderstanding of the way drugs and the drug industry and related medical practice all work. The implications, accusations even, that are being made are pretty serious. Drug companies engineered the pricing and dosage so that doctors would make money if they prescribed these drugs, and this kept the drugs flowing despite evidence that maybe they should be used less or not at all. Even “beaurocrats” and Congress were in on the conspiracy. Drug makers ….

    …offered discounts to practices that dispensed the drug in big volumes. They overfilled vials, adding as much as 25 percent extra, allowing doctors to further widen profit margins. Most critical, however, was the company’s lobbying pressure, under which Congress and Medicare bureaucrats forged a system in which doctors and hospitals would be reimbursed more for the drug than they were paying for it.

    … and so on and so forth.

    I worry about this kind of finding for two reasons. First, all the usual bad guys are the bad guys and all the usual victims are the victims, so everyone is going to get all breathless and bent out of shape over this, even if there is really no story here. That’s one reason I worry. The other reason is that this could all be real…there could be a problem exposed here that needs to be fixed, but because it looks like the usual bashing of the medical profession, wagons will be drawn into circles and smart looking medical professoinals are going band together to convince, for example, the skeptical community that this is just a bunch of yellow journalism.

    In other words, I suspect we are about to see an all out tribal war. What we really need, of course are facts and reasonable interpretations.

    I’m looking forward to the input of Science Based Medicine bloggers on this.

    The Cure for Everything

    Timothy Caulfield’s book, The Cure For Everything: Untangling Twisted Messages about Health, Fitness, and Happiness, attempts to be a corrective in the area of personal heath (as in diet and exercise) management.

    From the publisher: “In The Cure for Everything, health-policy expert and fitness enthusiast Timothy Caulfield debunks the mythologies of the one-step health crazes, reveals the truths behind misleading data, and discredits the charlatans in a quest to sort out real, reliable health advice. He takes us along as he navigates the maze of facts, findings, and fears associated with emerging health technologies, drugs, and disease-prevention strategies, and he presents an impressively researched, accessible take on the production and spread of information in the health sciences.”

    Skeptical? No problem! Super Skeptic Desiree Schell will be interviewing Caulfield this Sunday on Skeptically Speaking. Also, Scicurious will be talking about Coffee. I won’t want to miss that.

    Details for the show:

    #166 The Cure for Everything

    This week, we’re looking at what the evidence has to say about common claims about diet, exercise, weight loss and other hot health topics. We’re joined by health law professor Timothy Caulfield, to talk about his book The Cure for Everything! Untangling the Twisted Messages About Health, Fitness and Happiness. And on the podcast, researcher and science blogger Scicurious looks at a new study of coffee consumption, and the effect it may – or may not – have on life expectancy.

    We record live with Timothy Caulfield on Sunday, May 27 at 6 pm MT. The podcast will be available to download at 9 pm MT on Friday, June 1.