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.

Friday Five: Veterans, birth, ACA, Politifact, #HealthPolicyValentines

It's back by popular demand! (Okay, maybe only Carmen asked if I was ever going to write another Friday Five, but she's so awesome that she counts as at least ten people.) Each Friday, I use five sentences to summarize and comment on five important, interesting, or just plain amusing health stories from the week. Obama signs vet suicide prevention act Yesterday, President Obama signed the Clay Hunt Suicide Prevention for American Veterans Act, legislation aimed at improving the VA’s mental health care and removing barriers that prevent veterans from seeking treatment for mental health conditions. Death by suicide is particularly high among veterans over age 50. While their wish to end their lives may not be directly related to their service, the VA has a responsibility to care for veterans who qualify for VA care and are in need of it. The VA is notoriously problematic, and I hope that the newly-required external audits built into this Act will keep it accountable. After asking them to do what nearly every other American refuses to do, we continually fail our veterans--this Act is just a fraction of what they deserve.

Birth: Home versus hospital A short literature review by Dr. Rikki Lewis reveals interesting findings about the complexities and controversies surrounding home birth.

  • In the US, home births increased by 29% between 2004 and 2009.
  • Among studies investigating the risks and outcomes of home birth, there is little consistency in patient selection and the necessity of reporting infant deaths after transport to the hospital means that those deaths are reported as hospital deaths rather than deaths at home.
  • Policies for deciding to take a woman laboring at home are much clearer in the United Kingdom than in the US.
  • Home births are far less expensive than hospital births, which average about $20,000.

As the hospital versus home birth debate continues, it will be important to use correctly interpreted research as the basis for argument.

ACA open enrollment ends on Sunday The last day to sign up for insurance through the Marketplace is Sunday, February 15. According to the awesome website ACAsignups.net 10.5 million people have already signed up. Originally, the Department of Health and Human Services estimated that 13 million people would receive coverage during the open enrollment period, but later readjusted the estimate to between nine and ten million. If you need insurance and haven’t signed up, do it now...don’t procrastinate! (Also, can we take a moment to wonder why the “marketplace.gov” doesn’t redirect to healthcare.gov? Missed opportunity!)

 

Politifact takes on measles and vaccines One of the best, most useful sites ever, Politifact, evaluated the truthfulness of public statements about measles and vaccines. While their website could use a redesign to make articles like this one easier to read, the information they’ve provided is really valuable. They’re successful in debunking the “vaccines have mercury” claim and Rush Limbaugh’s accusation that Obama’s immigration policy allowed measles to enter the United States through Mexico. Politifact also highlights some of the true statements made by Megyn Kelly and other cable news pundits. While you’re reading their website, take a look at their ratings of statements about health care in general.

Health policy nerds love bad jokes Valentine’s Day isn’t only about romantic love. It can also be a time for you to express your deep, abiding passion for one of the nerdiest arms of public health: policy. Back in 2011, Emma Sandoe started the hashtag #HealthPolicyValentines so we could enjoy gems such as:

and

Groan worthy? Maybe, but totally great anyway.

Have an awesome Friday. I'll be back here tomorrow with a Valentine's Day-themed post!

Study shows no link between HPV vaccine and increased sexual activity

Big news on the sexual health front: a new longitudinal study was published yesterday in JAMA showing that young women who have received the HPV vaccine are no more likely to contract other STIs than unvaccinated women. While it is never a good idea to make generalizations about anything based on one study, this particular one seems well-designed and will hopefully lead to further study on this question. 'The Public Vaccinator' by Lance Calkin. Credit: Wellcome Library, London.

HPV causes cervical, vaginal, and anal cancer and has been connected to various head and neck carcinomas. The vaccine protects against four strains of the virus most often responsible for those cancers. To be clear: the HPV vaccine is a vaccine against cancer. Despite the potential benefits, many parents (and non-parents) fear that by giving their child the HPV vaccine, their child will feel free to engage in risky sexual behavior.

Because of this fear, HPV vaccine uptake has been abysmal in the United States. Only about half of young women and one-third of young men have received the first dose of the HPV, and even fewer have completed the three-dose series.

Looking at a sample group of women over 208,000 women aged 12-18, researchers found that young women recieved the HPV vaccine were no more likely to seek treatment for chlamydia, gonorrhea, herpes, HIV/AIDS, or syphilis than were unvaccinated women. That’s right, there was no evidence that getting the HPV vaccine increased the likelihood of being diagnosed with an STI.

Using pharmacy claims, researchers also determined that vaccinated women were more likely to use oral contraceptives. 17.9% of vaccinated women across age ranges received a prescription for hormonal birth control while 9.2% of unvaccinated women did. This could be due to a few factors: young women who intended to engage in any sexual activity were more likely to request the vaccine as well as contraceptives; the HPV vaccine was suggested by doctor during appointments for acquiring contraceptives; or parent perception of daughters’ likehood of being sexually active influenced their decision to vaccinate or seek contraceptives for their child.

There are, of course, some limitations to this study. The researchers were only able to access records, so by design they missed undiagnosed STIs, may have included STI screenings rather than diagnoses, and omits the use of non-prescription contraceptives like condoms. Researchers were also unable to use records from anonymous clinics. Researchers also could not acquire information about SES and motivations for receiving the vaccine. This study also does not look at young men in the same age range, which would give a more complete picture of how HPV vaccine impacts adolescent sexual activity.

The psychology of vaccine risk perception is fascinating. Beyond the concerns of “naturalness,” parents who are less inclined to vaccinate may feel more responsible for potential injury to their child if the injury is connected to a vaccine rather than to a disease that could have been prevented by that vaccine. A parent whose child has a seizure after the HPV vaccine may feel more responsible for that event than if the child contracts HPV. I wonder how the parents would feel if, after a decade, their child is diagnosed with an HPV-related cancer.

To an extent, I get it. I’m not a parent, but I do possess empathy and can imagine how frightening parenting must be. The world seems full of danger, and parents want to do everything in their power to keep their children safe. Sometimes not acting--not vaccinating--seems safer than risking the side effects of the vaccination or of the disease itself.

Fearing risky adolescent sexual activity also makes some sense to me. Most parents don’t want to see their child become a parent during their sophomore year of high school. Most parents don’t want their child to live with HIV or herpes.

But nearly everyone becomes sexually active at some point in their lives, and about 70% of people have their first sexual experience before age 19.  Half of sexually active men and women will have HPV. That means that means that when parents decide not to vaccinate their children, they allow their children to have a one-in-two chance of contracting HPV. And while most cases of HPV clear up on their own with no adverse effects, there are more than 33,000 cases of HPV-related cancer diagnosed each year in the United States.

No study can stand alone. We should not take the results of this study and make bold proclamations about young women’s behavior and sexual activity. I do believe, however, that this robust study provides some much-needed evidence that reducing young women’s risk of infection does not turn them into crazed sex machines making risky choices. I look forward to subsequent studies that can provide more evidence for parents to use to make informed choices.

Note: I know that women over age 18 don’t need parental permission in order to get the vaccine and may be more inclined to seek it out. But this study looked only at women under age 18, so I stuck to that age group as well.

Friday Five: Salmonella, abortion, bubonic plague, rabies, Tom Hanks

Each Friday, I use five sentences to summarize and comment on five important, interesting, or just plain amusing health stories from the week.  

Government shutdown, Foster Farms, and drug-resistant Salmonella

Foster Farms—a chicken processor who was the source of a Salmonella outbreak earlier this year—has been implicated in selling meat that has sickened at least 278 people in 17 states. Although the processor insists the problem is due to consumers insufficiently cooking their chicken, they have decided to revamp their procedures rather than be shut down by the USDA. This particular outbreak consists of seven strains of Salmonella, four of which are drug resistant—and due to the government shutdown, the CDC cannot properly investigate the problem and may be missing information that could reduce illness or save lives. This is a perfect example of a useful government program that should be funded regardless of politics…salmonella doesn’t care if you vote red or blue.

 

Abortion news

There’s lots going on this week regarding abortion. A woman who will have to leave the country to terminate her pregnancy since she is carrying twins who have anencephaly is highlighting Northern Ireland’s total ban on abortion. Ohio passed a budget that included three abortion restrictions, and the ACLU is suing the state, claiming the rules have nothing to do with the budget and are unconstitutional. The Nebraska Supreme Court upheld a ruling stating a pregnant foster child was not mature enough to elect to have an abortion, so she must deliver the baby and place it for adoption. Arsonists have tried to attach the Planned Parenthood in Joplin, Missouri twice in one week. Finally, some good news: California expanded access for abortions by allowing nurse practitioners, physician’s assistants, and certified nurse-midwives to perform abortions.

 

Bubonic plague may be an issue for Madagascar

Unless Madagascar gets its rat population under control, it’s likely to face a bubonic plague epidemic starting this month. That’s right, the Black Death is endemic in the island nation. Rats abound in the main prison, and the concern is that if the bacteria is introduced to those rats, the fleas they carry will be able to spread bubonic plague to inmates, employees, and visitors. And you can’t just kill rats—you have to kill the fleas, too. No word on what’s being done to avert this potential disaster.

 

Rabies vaccines are way too pricey

Fewer than 10 people have been documented as surviving full-blown rabies, but if a person who has been bitten receives the rabies vaccine before serious symptoms develop, they are likely to survive. Rabies kills about 24,000 people, mostly children, annually across Africa (approximately 26,000 die in Asia). Rabies experts at a conference this week in Dakar, Senegal suggested the best preventive measure is to tie up dogs since the post-bite treatment is cost prohibitive to most people who are bitten in Africa. The treatment requires four or five injections that cost about $13 each. Seems to me that rabies vaccine manufacturers Sanofi Pasteur and Novartis should be striking a deal with someone to lower these costs and save a huge number of lives.

 

Tom Hanks has Type 2 diabetes

During an interview with Dave Letterman, America’s favorite actor Tom Hanks announced he has Type 2 diabetes due to years of uncontrolled high blood sugar. Hanks doesn’t blame his weight fluctuations for movie roles, but says, “I think it goes back to the lifestyle I’ve been leading since I was probably seven, not 36.”  He joins the ranks of Paula Deen, Randy Jackson, Billie Jean King, Patti LaBelle, Larry King, and 25.8 million Americans. Can you imagine if Paula Deen, Larry King, and Tom Hanks did a diabetes prevention campaign? That’d be TV ratings gold.

http://www.youtube.com/watch?v=wBhZoTN2bvM

 

Friday Five: National Immunization Awareness Month

national immun awareness monthThis week’s Friday Five focuses on five important or interesting facts about vaccines in honor of National Immunization Awareness Month. Most of the sections are adapted just slightly from other sources. You can find the original source material by clicking the link next to each subheading.  

How do vaccines work? (History of Vaccines)

Vaccines work to prime your immune system against future “attacks” by a particular disease. When a pathogen enters your body, your immune system generates antibodies to try to fight it off…Vaccines work because of this function of the immune system. They’re made from a killed, weakened, or partial version of a pathogen. When you get a vaccine, whatever version of the pathogen it contains isn’t strong or plentiful enough to make you sick, but it’s enough for your immune system to generate antibodies against it. As a result, you gain future immunity against the disease without having gotten sick: if you’re exposed to the pathogen again, your immune system will recognize it and be able to fight it off.

 

What is herd immunity? (Vaccines Today)

Herd immunity is a form of immunity that occurs when the vaccination of a significant portion of a population (or herd) provides a measure of protection for individuals who have not developed immunity. It arises when a high percentage of the population is protected through vaccination against a virus or bacteria, making it difficult for a disease to spread because there are so few susceptible people left to infect…These include children who are too young to be vaccinated, people with immune system problems, and those who are too ill to receive vaccines (such as some cancer patients)…The proportion of the population which must be immunized in order to achieve herd immunity varies for each disease but the underlying idea is simple: once enough people are protected, they help to protect vulnerable members of their communities by reducing the spread of the disease. However, when immunization rates fall, herd immunity can break down leading to an increase in the number of new cases.

 

Do children get too many shots? (from CHOP Vaccine Education Center)

Newborns commonly manage many challenges to their immune systems at the same time. Because some children could receive as many as 25 shots by the time they are 2 years old and as many as five shots in a single visit to the doctor, many parents wonder whether it is safe to give children so many vaccines…From the moment of birth, thousands of different bacteria start to live on the surface of the skin and intestines. By quickly making immune responses to these bacteria, babies keep them from invading the bloodstream and causing serious diseases. In fact, babies are capable of responding to millions of different viruses and bacteria because they have billions of immunologic cells circulating in the bodies. Therefore, vaccines given in the first two years of life are a raindrop in the ocean of what an infant’s immune system successfully encounters and manages every day.

 

What do vaccine preventable illnesses look like? (Immunization Action Coalition)

Most people in the US have never seen a case of polio or diphtheria. This photo gallery may help remind us why immunizing against these diseases is so important.

 

How can we lessen the pain of getting shots? (CHOP Vaccine Education Center)

(This is important for scaredy-cats like me.)

For most children, getting vaccines simply means the pain of getting a shot. Although pain is to some extent unavoidable, there are a few things worth trying in older children.

Blowing away the pain

One technique is called "blowing away the pain." Just before the shot, take out a feather, tell the child to take a deep breath, closing his eyes if he wants, and then to blow out...blow, and blow on the feather until you or the nurse tells them to stop. The distraction of blowing on the feather has been shown in one study to lessen the amount of pain perceived by the child.

Cold versus pain

Another idea is to swab a small amount of alcohol on the forearm of the opposite arm that will receive the vaccine. The child then blows on the alcohol before and during the shot. Our bodies don't feel cold and pain in the same place at the same time. Rather, when confronted with the choice of cold or pain, the body picks cold. So the feeling of pain from the shot will be reduced.

EMLA cream

For older children with severe phobias to needles, you might consider the use of an EMLA patch applied to the skin. The limitation of this technique is that the patch (which helps to numb the area) must be applied at least one hour before the injection. Also, EMLA cream works to decrease pain caused by injections under the skin (called subcutaneous injections), but doesn't lessen the pain of vaccines given in the muscles.

Friday Five: Chicago, ACA, firefighters, prescription drugs, vaccine recall

Each Friday, I use five sentences to summarize and comment on five important, interesting, or just plain amusing health stories from the week.  

Fourth of July shootings in Chicago

This Fourth of July weekend is proving to be deadly for Chicago. Yesterday, eight people were killed and more than 30 were hurt in shootings across the city. The youngest victim is just five years old, and was shot while attending a party in a park with his family. These shootings are a disgrace, as is the lack of national coverage of the violence permeating Chicago. Victims’ stories should be plastered across every news station and website, and the nation should be reviving the post-Sandy Hook gun conversation in light of this inexcusable violence.

 

Another ACA delay

The Obama administration added to the confusion surrounding the Affordable Care Act by pushing the employer mandate deadline back one year to January 1, 2015. Another instance of caving to private sector demands means increased misunderstanding for the public. The law was incredibly complicated as written, and the administrative tweaks, House repeals, and flat-out lies disseminated by the media ensure that nobody has any idea what’s going on. The ACA is the single most important change to health care the US has seen since 1965, and its frustrating to watch it falter. Hopefully, the exchanges will still open as scheduled on October 1.

 

Firefighters killed in Arizona fires

Nineteen elite firefighters were killed on Sunday battling a blaze that is still only 45% contained. Their deaths have reminded us that the people suffering from these fires are not only those who lose their homes, but the people who are willing run into the flames to try to protect those homes. We’re learning about the hotshot teams specially trained to fight wildfires, an aspect of firefighting that was unknown to many people. I’ve been trying to imagine what it’s like to do what these teams do: go out to the fire, live near it for days, battling it while awake and smelling it while you sleep. I am in awe and very grateful.

 

More ‘scripts, more problems

This was a big week for news about prescription drugs. A brief rundown:

  • 70% of Americans take at least one prescription a day, mostly antibiotics, antidepressants, or painkillers
  • The number of fatal overdoses in women quadrupled between 1999 and 2010, and approximately 42 women die daily from overdoses
  • The FDA busted 1600 illegal online pharmacies

 

Hepatitis B Vaccine recall

Merck issued a recall this week for one lot of the Hepatitis B vaccine Recombivax. The issue is not with the vaccine itself, but with the glass vials that may easily crack. Merck is concerned about the sterility of the vaccine, and the FDA assures consumers there’s no need to be revaccinated if a doctor administered one of the recalled lot. The anti-vaccine websites I visited seem to have not picked this up yet, so maybe this vaccine news won’t be misconstrued. We can only hope.

In honor of yesterday's Fourth of July holiday, here's a little Katy Perry to get you dancing:

http://www.youtube.com/watch?v=QGJuMBdaqIw