SB 277 protects kids + gets us useful public health data

While I was busy reading everything written about the King v Burwell decision and celebrating a massive human rights win, California governor Jerry Brown eliminated “personal belief” vaccine exemptions. California now joins Mississippi and West Virginia as the only states that require vaccines for all children unless contraindicated due to medical necessity.

The most important result of the passage of SB 277 is that it says, boldly and definitively, that vaccines are not only safe and necessary for protecting an individual child, but that the safety of the population will not be threatened by pseudoscience and conspiracy theories.

Even if the law doesn’t significantly change vaccination rates, its passage elevates the status of vaccines. It says to California parents you can believe whatever outrageous ideas you want, but your anti-science views cannot endanger other people, especially other children.

SB 277 implementation also gives officials an opportunity to research the ways that vaccine legislation impacts public health. Wired puts it nicely:

Whether or not the law has a significant effect on the health of California’s kids, this is a prime opportunity to carefully study the effects of legislation like this on both vaccination and disease rates. Health officials would love to know for sure that SB277 will have a meaningful impact on public health. But they can’t. It’s notoriously hard to draw connections between statewide vaccine laws and disease numbers.

This is awesome! Ending the personal exemption means that all kids enrolled in public school must receive all vaccinations. And we’ll be able to get good data on potential connections between legislation, vaccination rates, and disease outbreaks. End of story. Right?

Not necessarily.

There seems to be a loophole that will allow doctors who have inexplicably been converted over the anti-vaccine cause and who believe that a vaccine may harm a child to give medical exemptions. 

Presumably, this exists because some kids are just flat out allergic to some vaccines (on a personal note, I’m allergic to the pertussis vaccine so I depend on herd immunity, myself).  I haven’t found much analysis of this caveat aside from general statements about not giving a vaccine to kids who are allergic to it. I wouldn’t be surprised if we see families seeking exemptions through a doctor who believes vaccines are harmful for all children and who are then being kept from enrolling their children in public schools.

I’m eager to see how this unfolds, both among pro- and anti-vaxxers and as a new way of understanding how policy decisions impact public health. California, thank you for giving this a shot for the rest of us, and thank you for taking a stand against the nonsense bubbling up across the country.

Reflections on writing every day

Today is day 28 of my 28 Day Writing Challenge. I am so glad I decided to tried writing every day--I haven’t done anything like this before and I’ve learned a lot about my writing process, time management, and capacity to push through writer’s block and brain fatigue. Reflections on writing every day

Reflections:

  • I put together an editorial calendar for the month. I found it helpful, especially as a place to put links to articles that inspired writing topics, but I didn’t stick to it 100%.
  • It’s really hard to squeeze daily writing into a hectic schedule. Not only do I work full time, but because I work in Maryland and live in Philadelphia, I only see my husband on the weekends. Because we have limited time together, I found it difficult to make time to write on Saturdays and Sundays.
  • I often began a piece at night and then finished it before work the next morning. After work, I would start the next day’s.
  • Sometimes, due to the time restraints, I didn’t have the time or bandwidth to write an in-depth post.
  • I missed a few days. Not too many, but a few.
  • Likewise, having to produce a piece every day meant that, even though I tried to keep a few days ahead, I didn’t always have enough time to research as much as I would have liked.
  • I also didn’t have much time to let a piece sit so I could come back to it the next day with fresh eyes. There are almost certainly stylistic faux pas and grammatical errors that I would have caught if I’d been able to self-edit.
  • That said, there are some pieces that I’m proud of writing and plan to expand upon in the coming weeks. The most popular post I’ve ever written: “Eating clean” is dangerous to your health. The antimicrobial resistance series (Part I, Part II, Part III). Suicide prevention gets a new partner: Facebook.

I’m not going to continue posting every day. It’s just not sustainable for me at this point. However, I plan to write (at least) two pieces per week, one of which will be an in depth, longer exploration of a topic.

I want to be sure that I am producing quality work, not just quantity. I take writing seriously, and while I’m glad I did this as a kick in the pants to get me back into it, I think my work will improve if I can take time to write, rewrite, and rewrite again.

Thank you for coming on this journey with me. It’s been fun, and I’m glad you were here with me.

Suicide prevention gets a new partner: Facebook

If you or anyone you know is having thoughts of self-harm, please reach out to organizations like the National Suicide Prevention Hotline or call their hotline directly at 1-800-273-TALK (8255). If you or someone you know is in immediate danger of self-harm, call 911 immediately. Your life is worth living and you don’t deserve to suffer.


Generally, my Facebook newsfeed is filled with silly photos of people waiting for the subway, declarations of love for a person’s partner, and snarky comments about current events. Sometimes, however, I see comments that make me concerned about someone’s mental health. I’ve been fortunate not to have seen anything that I felt needed to be reported, but I know that’s not the case for everyone.

Facebook announced yesterday that they are partnering with Forefront, Now Matters Now, the National Suicide Prevention Hotline, save.org, and other mental health organizations to create a more effective reporting program for people whose friends are expressing suicidal thoughts on Facebook.

When someone sees a friend's (let's call him Gerald) troubling post, they will have the option to report it directly to Facebook. Right now, at the upper right hand corner of every post, there’s a little downward arrow that, when you click on it, allows you to choose the option to report the post for potential suicidal content. (I haven’t been able to find screenshots of what that screen will look like, and the capability has not yet been activated on my account so I couldn’t make any of my own.)

The post will then be reviewed by “teams working around the world” to determine if the post does in fact imply that Gerald is in danger of self harming. If so, the next time Gerald logs into his account, he'll see this:

Facebook suicide prevention screen 1facebook_suicide_prevention_2facebook_suicide_prevention_3 Source: Huffington Post

One of the things that seems most promising is that Gerald doesn’t seem to have the option to dismiss these screens. He will have to at least click through the resources in order to get to their newsfeed. Hopefully, this will help reach some people who need help but aren’t able--for whatever reason--to ask for it or recieve it.

I also hope that Facebook is planning to critically evaluate this change. There are lots of unintended consequences that could arise from this new reporting system: a drop in posts containing potentially suicidal content, quick click-through speeds that imply users aren’t actually reading the resources, and gross misuse of the capability that floods the reviewing teams, making effective review difficult or impossible.

And when Facebook evaluates the initiative, I hope they make that information public. Because social media can provide a platform for mental health intervention, we need to know if a huge intervention like this is actually successful.

To learn more about this Facebook change, check out the Facebook Safety post explaining what’s happening.

Come on, brain, work!

I'm working on two pieces that aren't quite ready. One has already been through three drafts. The other is far from finished--I have the skeleton but I need to flesh it out. But now I have to get to work and neither is even close to ready. I'm frustrated and hoping that spending the workday paying attention to other things will allow my brain time to unconsciously figure out how to deal with the problems in the current drafts. Writing every single day is hard. Harder than I thought it would be.

Did you forget about Ebola?

Ebola Ebola was big news in 2014. But we seem to have lost interest in it, especially now that no one in the US is being treated for the virus. While the number of cases in African countries is dropping, the epidemic and its repercussions are far from over. In fact, there are still important developments happening every day.

A promising new treatment An experimental antiviral drug has shown potential for treating early cases of Ebola. Favipiravir, which has also shown to be effective against influenza, West Nile, and yellow fever as well as other viruses, seems to drastically reduce mortality in patients who are not yet seriously ill. It doesn’t seem to help patients with severe Ebola infection. One of the most important advantages of favipiravir is that it is a pill. Other potential therapies must be kept frozen and are administered through infusion, leaving the health care worker at risk for needle sticks.

Red Cross aid workers suffer from attacks in Guinea In Guinea, public misconceptions about the role of aid workers and the mode of Ebola transmission have led to attacks on Red Cross and other volunteers conducting safe burials of deceased Ebola patients. While many Guineans understand and accept the practices the Red Cross uses to disinfect homes and bury Ebola victims, some are concerned that the Red Cross is actually spreading the virus. This has resulted in an average of 10 attacks per month. The Red Cross is warning that the violence against its volunteers is hampering its ability to contain and quell the epidemic.

Maybe Ebola can be transmitted through aerosols, but probably not One of the best things about this 28 day writing challenge is that through my research I found Carl Zimmer. I aspire to his level of health writing clarity and scientific rigour. His piece “Is It Worth Imagining Airborne Ebola?” does an excellent job of outlining the concerns expressed by a few scientists while also offering the counterpoints that help give those concerns context. Before you get carried away with alarmist headlines, take a look at what he has to say.

From soap and water to soap opera Sierra Leone is starting to move from the traditional forms of public health communication to a more innovative medium. Celebrities are partnering with a major bank to create a soap opera designed to help prevent transmission, explain treatment and safe burial practices, and dispelling myths about Ebola. One of the twelve episodes focuses on quarantine by centering around a family who is under quarantine. Through this storyline, the actors explain what happens during a quarantine and why adherence to it is crucial. In the major city of Freetown, the soap opera is broadcast on television, while in more rural areas, it plays on the radio.

Right now, the Ebola epidemic seems to be waning. However, this epidemic will resonate throughout the region for decades. Even as new public health issues surface, we would be well-served to remember what has and is happening in this part of Africa.

Awesome Infographic: Sleep

As someone who has trouble falling asleep no matter how tired I am or what time I have to wake up in the morning, I'm hyperaware of how much we need sleep…and how easy it is to not get enough. This awesome infographic from National Heart, Lung, and Blood Institute highlights the health problems associated with sleep deprivation and the research being done to develop treatments. Sleep info graphic

Raw milk, cholera, and Appalachia: Cool stuff I read this week

I came across a bunch of interesting articles and bits of news this week, and I thought I’d share them with you. Spend your lazy Sunday catching up on current events. The Dietary Guidelines Advisory Committee released its recommendations this week. They encourage us to eat less sugar and saturated fat, but say we don’t really need to worry about our cholesterol intake.

There’s a new rapid test for Ebola.

Speaking of Ebola, Al Jazeera America ran a fascinating and discouraging two-part series on the social implications of the epidemic.

Although Haiti has improved its infrastructure in response to the epidemic, cholera is still a major problem in the country.

This interview with the Baltimore City health commissioner Dr. Leana Wen reminds us that public health isn’t just about Ebola and cholera and measles--it’s also about rat control and the social determinants of health. [Audio and abridged transcript.]

Flu season is starting to wind down.

The first broad study of two kinds of muscular dystrophy was published, revealing important epidemiological information about the disorders.

Despite some progress, Appalachia is still teeming with health disparities and poverty.

There’s a new tickborne virus in town.

For goodness’ sake, stop drinking raw milk. Pasteurization exists for a reason!

More than 25% of Americans with diabetes are undiagnosed. That’s 8.1 million diabetics who are not receiving treatment or making lifestyle changes.

Thank you, Alan Cumming, for using humor to highlight just how ridiculous the FDA’s new ruling restricting gay and bisexual men from donating blood unless they have been celibate for a year.

Alan Cumming Celibacy Challenge

 

Come back tomorrow for another Awesome Infographic!

John A. Rich: Black men, trauma, and nonviolence

Now that I’m out of grad school and back in the workforce, I can appreciate the unique public health perspective that Drexel’s School of Public Health imparts upon its students. Other schools don’t focus as heavily on health disparities, trauma, and adverse childhood experiences. One of the reasons these issues are at the center of Drexel’s philosophy is because of the presence of the Center for Nonviolence and Social Justice, headed by John A. Rich, MD, MPH. John Rich, director of the Center for Nonviolence and Social Justice

Dr. Rich grew up in a middle-class home--his mother was a teacher and his father was a dentist. After completing his undergraduate degree at Dartmouth and earning his MD at Duke, he became an emergency room doctor at Boston City Hospital.

While at Boston City Hospital, Rich saw a steady stream of young Black men come through the emergency room with stabbing and gunshot wounds. He also began to realize that everyone, including the other medical staff, saw these men as perpetrators rather than victims. The general consensus was that these men had done something to get themselves injured instead of what was obvious to Rich: these young Black men were truly victims.

Because of his compassionate streak, Rich began interviewing these men to learn more about their lives and what led to them returning to the ER over and over. He learned that the injuries that brought them to him were often due events outside their control--a robbery, a few wrong words to the wrong person, a simple accident that escalated to violence. After talking with them as they received treatment, Rich realized that the men were suffering from post-traumatic stress syndrome. Even worse, their injuries were stitched up and they were sent right back out to the same environment that brought them to the ER.

Rich wrote a book about these experiences called Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men. I read this book as part of a class I took with Sandra Bloom (who works closely with Rich). Reading it was easily the most emotionally moving and motivating activity I participated in at Drexel.

In 2006, Rich was awarded a MacArthur Fellowship for his work:

John Rich is a physician, scholar, and a leader in addressing the health care needs of one of the nation’s most ignored and underserved populations—African-American men in urban settings. By linking economic health, mental health, and educational and employment opportunities to physical well-being, Rich’s work on black men’s health is influencing policy discussions and health practice throughout the United States...By focusing on the realities of the lives of young African-American men, John Rich designs new models of health care that stretch across the boundaries of public health, education, social service, and justice systems to engage young men in caring for themselves and their peers.

Now, Rich is a professor and head of the Health Management and Policy department at Drexel University School of Public Health. He is also the director and founder of the Center for Nonviolence and Social Justice, a non-profit dedicated to applying principles of non-violence and trauma-informed care to public health practice and evaluating the results of the programs that embody those values.

While I was completing my MPH, I unfortunately did not work with Rich--in fact I'm not sure I ever even met him. However, I had the good fortune of having Dr. Jonathan Purtle, who worked closely with him and others at the Center, as my academic advisor. Honestly: reading Rich’s book and working closely with his colleagues changed the way I understand public health, and, frankly, myself and the world around me.

John Rich has changed the way we understand urban Black men’s health. As the gospel of trauma-informed care spreads throughout public health, medicine, and public policy, I hope we will see a more compassionate view of Black men radiate throughout these institutions. We know that what we’ve been doing for these men hasn’t been working--and John Rich has shown us how to make changes that will actually help.

Part III: The terrifying realities of antimicrobial resistance that will keep you up at night

As promised, today’s post will focus on the terrifying realities of antimicrobial resistance. I'm generally not an alarmist, but these two issues are Not Good. We are on our way to a post-antibiotic age of medicine.

The terrifying realities of antimicrobial resistance that will keep you up at night

CRE: Carbapenem resistant enterobacteriaceae This week, I saw headlines about a “nightmare bacteria” that killed two people and infected at least five more. Turns out the nightmare wasn’t such a surprise—the infections were caused by carbapenem-resistant enterobacteriaceae, or CRE.

Enterobacteriaceae are a family of bacteria that includes familiar disease-causing bugs including as Salmonella, E. coli, Enterobacter, and Shigella as well as other bacteria that don’t make us sick. In fact, some of the bacteria found in this family live benignly in the digestive tracts of humans and animals. Others, however, can cause serious illness or death.

What’s particularly frightening is that carbapenems, a particular class of antimicrobials, are usually used as the last-ditch effort to fight infection when other antimicrobials have failed. Bacterial infections treated with carbapenems are nearly always resistant to multiple other drugs. This means that if bacteria are resistant to carbapenems, they’re almost certainly resistant to all other antimicrobials. There are a few drugs that are used to treat CRE, though none of them are particularly effective. If those fail, you're in big trouble.

That’s right: CRE are resistant to basically every antimicrobial. If you get a CRE infection, your chances of survival are 50-50.

CRE are a serious threat to hospital patients. People are unlikely to come across CRE in their daily lives. However, people who are receiving hospital treatment are vulnerable to CRE infections.

I haven’t found any direct evidence linking CRE directly to animal agriculture. However, because carbapenem is only used when all other antimicrobials fail, if the bacteria weren’t already resistant, carbapenem wouldn’t have to be used in the first place! If you’d like to learn more, I recommend starting with Carl Zimmer’s piece “The ‘Nightmare Bacteria:’ An Explainer.”

Foodborne illness is a direct result of animal agriculture When you get food poisoning, it doesn’t matter whether the culprit is ground beef or cantaloupe: the microbes that traveled from your salad to your stomach came from the fecal matter of an animal. Maybe it was the cow you were eating, or one of its neighbors, or maybe it was an animal whose manure runoff contaminated the ground that the cantaloupe grew on. Either way, your gastrointestinal distress is tied directly to the bugs living in the digestive systems of agricultural animals.

CDC estimates that 48 million, or 1 in 6, Americans get a foodborne illness each year. Antimicrobial-resistant infections from food cause 430,000 illnesses each year in the US. Multi-drug resistant Salmonella causes 100,000 illnesses annually. Some strains of illness-causing microbes are becoming less resistant, while others are getting stronger.

A white paper from the Center for Science in the Public Interest shows a bleaker picture. It identifies 55 foodborne illness outbreaks from 1973 to 2011 that were associated with antimicrobial resistant microbes. Foods most likely to be implicated in these outbreaks were dairy, ground beef, and poultry. More than half of the outbreaks were due to multi-drug resistant microbes.

Maybe even more concerning is the fact that 58% of the outbreaks in that 38 year period occurred between 2000 and 2011. That’s right—more than half of foodborne illness outbreaks caused by drug resistant microbes since 1973 have occurred in the 21st century. The number of human illnesses caused by food contaminated by resistant microbes is on the rise.


This series has raised a lot of questions for me, and I plan to continue exploring this issue. Are there any related questions you’d be interested in having me research? I’ll totally do the work for you!


Special thank you to John Phillips for setting me straight on carbapenems. He's going to be a great pharmacist.

Part II: Evidence of the link between animal agriculture and antimicrobial resistance

Yesterday, I wrote about the basics of animal agriculture and antimicrobials. Today, I’ll dive deeper into the issues.

Part II: Evidence of the link between animal agriculture and antimicrobial resistance

What is antimicrobial resistance and why should I care about it? Antimicrobial resistance occurs when microbes have developed the ability to evade antimicrobials, survive antimicrobial treatment, multiply, and infect others. Microbes are able to survive partly because antimicrobial treatment may kill off the sensitive microbes and leave the more adapted ones to adapt to the antimicrobial and multiply.

Microbes can become resistant to multiple drugs. This makes the infection difficult or impossible to treat. By its very nature, an infection will spread to others, endangering more people with resistant infections.

The FDA has a pretty great video explaining the process of antimicrobial resistance.

Is there any evidence of association between antimicrobial use in animal agriculture and antimicrobial resistance in humans? Yes. Most of the evidence is based on studies of foodborne illness such as Salmonella and Campylobacter because the foodborne route is the most common way that resistant microbes are transferred from animals to humans.

Some resistant bacteria will themselves endanger human health. Others which cannot make humans ill will share their resistant genetic code with microbes that can make humans ill. These previously vulnerable, pathogenic microbes become resistant when they receive the resistant genes.

Using antimicrobials at sub-therapeutic levels to enhance growth means that all bacteria in an animal’s body is regularly exposed to low levels of antimicrobials. The most susceptible microbes will be killed or incapacitated, but the surviving ones will become increasingly resistant to the antimicrobial used.

How does using antimicrobials in animal agriculture contribute to human foodborne illness? The CDC report “Antibiotic resistance threats in the United States, 2013” outlines exactly how these two issues are related:

  1. Antimicrobial-resistant microbes may be formed through biological (e.g. selective pressure, mutations) or human (e.g. antimicrobial misuse, inadequate diagnostics) avenues.
  2. Antimicrobials used in animal agriculture kill off susceptible microorganisms while allowing resistant microbes to survive.
  3. Resistant microbes can be passed from animals to humans through fecal or other forms of contamination of food.
  4. When humans eat contaminated food, they develop infections (e.g. coli) that cannot be treated with antimicrobials. For generally healthy people, this may not be problematic, as their immune system will fight the infection itself. However, some people will need a boost from antimicrobials—antimicrobials that are now useless.

Beacause of this strong connection between animal antimicrobial use and human illness, CDC recommends that antimicrobials are used only to treat infections rather than to enhance growth. The CDC calls this antibiotic stewardship. 

What are some other ways animal agriculture-induced antimicrobial resistance affects human health?

  • Infections that would not have otherwise occurred
  • Treatment failures
  • Increased severity of infections (Source.)

Is animal agriculture the only cause of antimicrobial resistance? Definitely not. The other major contributor to antimicrobial resistance is improper human medical use. For example, when doctors prescribe antibiotics for a viral infection, the antibiotic will not treat the viral infection. However, the antibiotic may kill off a few bacteria from a minor bacterial infection, leaving only the remaining bacteria resistant to the drug.

 

Come back tomorrow for Part III: The Stuff That Will Keep You Up At Night