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Celebrity and science: the vaccination controversy

Posted by on August 19, 2013 Comments Off on Celebrity and science: the vaccination controversy

Bill Maher is witty and funny–particularly if you are not politically or religiously conservative.

However, the closest he will get to being a virologist is when a video clip of him goes viral.

In 2009 he provoked a controversy by tweeting that anyone who got a flu shot was an idiot. In a blog post on November 15, 2009 he backed off a bit, but defended himself by:

  1. I’m a comedian
  2. I tweeted it, didn’t say it on my show.
  3. Saying there are questionable things about vaccines.
  4. Endorsing a group opposing vaccinations.

It was a non-apology worthy of a Washington official. The truth is that while Bill Maher is neither an authority nor an expert on vaccines, he has influence based upon his celebrity. And, as a result, he can influence many people who should get vaccinated but are undecided, as can any other celebrity. After all, who likes hypodermic needles except for the rare needle freak? We all want some cover for deciding to avoid needles.

We may all be grateful that celebrities are not the go-to experts on health care for most parents; however, a 2011 University of Michigan study found that 1 out of 50 parents rely on celebrities a lot for information, and that 1 out of 4 rely on celebrities some.

MichiganVaccineSurvey2011

One of the sources that Maher cited was the National Vaccine Information Center (NVIC). It is reasonable that individuals who have suffered side effects from vaccines or any other medication might band together to ask that there be full disclosure on the risks as well as every effort to promote safety. Unfortunately, NVIC goes a step forward, suggesting that vaccination is a matter of preference rather than necessity. It is a bit like receiving a full glass of water and obsessing about the emptiness between the top of the water and the lip of the glass.

A key paragraph in their statement of purpose:

This traditional paternalistic medical model is increasingly being rejected by today’s more educated health care consumers and, along with this challenge, is also an historic challenge to the supremacy of the allopathic medical model as the only means of maintaining health and preventing disease. The movement toward a more diversified, multi-dimensional model health care system is a phenomenon occurring not only in the United States but in many technologically advanced countries.

In short, it is a rejection of science in favor of some other belief system for medical care. The United States makes ample allowance for alternative belief systems; however, alternative behaviors are circumscribed. If you wish religion taught in the schools, you must attend a parochial school, not a public one. Similarly, if you want to attend a public school, then a vaccination prerequisite is reasonable, particularly when you have private alternatives, including home schooling available. Even that stretches the limits, because unvaccinated people lower the safety of everyone. Since vaccines are not 100 percent perfect (and what is in this world?) we depend on an adequate percentage of vaccinated people to prevent an epidemic among those who are only partially protected by vaccines against communicable diseases such as polio, diphtheria, and influenza.

This is “herd immunity,” or:

Indirect protection against disease that results from a sufficient number of individuals in a community having immunity to that disease. With enough immune individuals, the transmission of a disease can be reduced, thus limiting the potential for any one individual to be exposed to it. Herd immunity does not apply to diseases, such as tetanus, that are not spread via person-to-person contact.


One of the best and simplest ways to lower healthcare costs and to improve public health is to increase our rates of vaccination. Consider this: do businesses pay for flu vaccinations because they are loving and generous, or because it will lower absenteeism and paid time off?

All That Jab – one more reason to vaccinate

Posted by on August 12, 2013 Comments Off on All That Jab – one more reason to vaccinate

Those who look toward the scientific for explanations know that only UFOs and and political assassinations attract more conspiracy theories than vaccines do.

The challenge of conspiracy theorists is similar to the challenge of mental illness–no amount of evidence contrary to a deeply held view is sufficient or dissuasive. Astute observations are followed by non-sequitur conclusions, or either-or alternatives with no room for gray in between the black and white alternatives.

Nonetheless there is heartening new evidence that influenza vaccines are benign for pregnant women–or as Reuters put it:

Pregnant women who get flu shots are at no greater risk for complications like high blood pressure, urinary tract infection or gestational diabetes, according to a new U.S. study.

The study of Inactivated Influenza Vaccine During Pregnancy and Risks for Adverse Obstetric Events, which will appear in the September issue of Obstetrics & Gynecology found In this large cohort, influenza vaccination during pregnancy was not associated with increased risks for medically attended adverse obstetric events.

Often such studies are handicapped by small sample bias, not enough people studied to draw a strong conclusion, even if statistically significant. Not the case here, as the authors report that their study group was 74,292 vaccinated females matched on age, site, and pregnancy start date with 144,597 unvaccinated females.

One might ask, “Why bother? So, I get the flu while pregnant–one more nuisance.” The same article in Reuters Health addressed that question:

For a pregnant woman, contracting the flu is “really dangerous,” according to Dr. Laura E. Riley, medical director of labor and delivery at Massachusetts General Hospital in Boston.
Pregnant women with the flu are at greater risk of death, respiratory disease requiring hospitalization and premature labor and delivery, Riley told Reuters Health.
The risk-benefit ratio was already clear, she said, but collecting new safety data is always good.

On the positive side, the benefits of vaccination accrue not only to the mother but to the baby:

“Flu shots protect pregnant women, their unborn babies, and even protect the baby after birth,” Kharbanda said.[lead author Dr. Elyse Kharbanda of Health Partners Institute for Education and Research in Minneapolis, Minnesota]
Babies don’t receive vaccines until six months of age, so they are vulnerable to catching the flu in the first six months of life, he said. But previous studies have found that some of the protection passes across the placenta to the baby and can help shield them from flu after birth.
“What mother doesn’t want to do that?” Schaffner said [ Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University Medical School in Nashville, Tennessee]. “There should be no hesitation for women getting the vaccine.”

There is no reason for a pregnant woman not to get vaccinated against the flu; there is every reason to avoid possible consequences of not getting vaccinated; and, if not for you, then for the benefit of your baby, who does not need the flu while getting used to living outside the womb.

Patriotism and Healthcare

Posted by on August 5, 2013 Comments Off on Patriotism and Healthcare

The furthest left button on my car radio is tuned to C-SPAN radio. It could easily be tuned to National Public Radio if I lived elsewhere.

As I have long been curious about public policy issues, it is a matter of course for me to see what is playing when I start my car engine.

On Wednesday July 24, I heard an interview with Jim McDermott on the implementation of the Patient Protection and Affordable Care Act (PPACA) or Obamacare.

Jim McDermott is a partisan Democrat, who has represented the Seventh District of Washington since 1989. He mixes it up with the Republicans on numerous occasions, actively participating in the partisan back and forth that is national politics in the US. Part of his presentation that day were partisan talking points that we are accustomed to hearing from public office holders of both major parties.

Something else caught my attention. McDermott pointed to a change in our view of the obligations of citizens to the Republic and to our society. Since the end of the military draft, wars have been fought with minimal inconvenience to the civilian population, engendering an atomistic individualism, all of us isolated and alone sharing a space and looking out for ourselves.

Here is how he put it at the 8:48 minute mark of C-Span’s National Journal on July 24,2013:

It’s a much larger problem than just healthcare. When we ended the draft in 1975, we said to all young people in this country you have no responsibility for your country. You are an individual. You can live in any way you want. You don’t owe anything to your country. So we raised a whole generation, actually two generations of people who do not see themselves as responsible for their neighbor. We have young people who figure if I get hurt, if I am on my motorcycle and get into an accident, they will take me down to the emergency room, they’ll patch me up. I will not have money to pay for it, but somebody will pay for it and everybody in society who has health insurance is paying an extra $1000 a year for these kids who refuse to anticipate that something might happen to them. Young people get cancer, young people have skiing accidents, young people have all kinds of problems and they just act as though somebody else will take care of it. That’s not right. Part of the bill says you have the responsibility to pay for the possibility that you may be . . . “We require them with automobiles. We do not let people drive without auto insurance. It’s not your problem because someone else will pay for it. We say you have to have auto insurance.

Were it not for the partisan wrangling on Capitol Hill, are these not conservative values of individual responsibility and citizenship that all but the most ideological acolyte of Ayn Rand could agree to?

Plato addressed similar questions in his dialogue: Crito. Socrates had been condemned to death. His friend Crito attempted to convince him to flee into exile rather than accept that penalty. As part of a lengthy discourse about law and society, Socrates responded by imagining an argument with laws of the society:

Then the laws will say: ‘Consider, Socrates, if we are speaking truly that in your present attempt you are going to do us an injury. For, having brought you into the world, and nurtured and educated you, and given you and every other citizen a share in every good which we had to give, we further proclaim to any Athenian by the liberty which we allow him, that if he does not like us when he has become of age and has seen the ways of the city, and made our acquaintance, he may go where he pleases and take his goods with him. None of us laws will forbid him or interfere with him. Any one who does not like us and the city, and who wants to emigrate to a colony or to any other city, may go where he likes, retaining his property. But he who has experience of the manner in which we order justice and administer the state, and still remains, has entered into an implied contract that he will do as we command him. And he who disobeys us is, as we maintain, thrice wrong: first, because in disobeying us he is disobeying his parents; secondly, because we are the authors of his education; thirdly, because he has made an agreement with us that he will duly obey our commands; and he neither obeys them nor convinces us that our commands are unjust; and we do not rudely impose them, but give him the alternative of obeying or convincing us;–that is what we offer, and he does neither.

In order to uphold his agreement with his society, Socrates chose to accept its death sentence rather than flee. We are not faced with such stark choices in 21st Century America. We have on occasion leaders and laws preferred by others, but we agree in our democratic contract to accept them, so long as we retain the right to speak out against them and to elect different representatives on a regular basis. Such is our obligation to respect Obamacare, which is the law of the land.

We do not have to go out on a battlefield shouldering a weapon to be patriotic. We do not even need a war or an enemy or an adversary to be patriotic. It can be sufficiently patriotic to respect the laws, particularly those that assign us social responsibility, for like Socrates, we have accepted all the bounty of this society, and it would demean us not to accept the accompanying responsibilities.

Disease and National Defense

Posted by on July 29, 2013 Comments Off on Disease and National Defense

In Biblical times, where historical accounts and historical myth sometimes mingle, there are accounts of great armies being destroyed by disease. Conflicting accounts of the siege of Jerusalem circa 701 BCE by the Assyrian king Sennacherib are of that nature.

Fast forward two thousand years. Evans, Kleinman, and Pagano write:

In 1334 an epidemic struck the northeastern Chinese province of Hopei. This “Black Death” claimed up to 90% of the population, nearly five million people. The epidemic eventually reached and decimated Tartar forces that had been attacking Kaffa, a Genoese colony on the Crimean Peninsula. In 1347, the departing Tartars catapulted plagueinfested bodies into Kaffa. The Genoese quickly dumped these bodies into the sea, however it was too late. Four ships escaped back to Italy carrying the plague that in just two years killed one-third of the European population.

The relationship between disease and national defense is not a new one in the US. Just a simple web search revealed this 72-year-old article from the American Journal of Public Health on the dangers of venereal disease to military preparedness. Another article in the Journal of the American Medical Association (JAMA) of the same year reports that venereal disease has been a concern of the US Army and Navy since 1778.

There is continued concern about the impact of infectious disease on national defense, for example, the emergence of antibiotic-resistant pathogens and the threat from tick-borne diseases, and from influenza.

Indeed, with anthrax and ricin scares, preventing and managing bio-terrorism is a major part of contemporary national preparedness.

In addition, the Department of Defense is participating in prevention initiatives. As Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs in the Department of Defense, put it:

At the Department of Defense, we’ve moved from a concept of health care to health, meaning that we understand health really is a much more involved concept other than just freedom from disease. It relates to healthy communities and healthy and active lifestyles and also addresses mental wellness and spiritual wellness as well. For us to create a fit and ready force, we need to make sure that we’re paying attention to all these dimensions of health and wellness.

All of these efforts center upon a single premise: national defense depends upon maintaining the health of the civilian and military populations.

That raises an important question: does it matter whether the threat to our health is a foreign enemy, a small band of domestic terrorists, or what we do to ourselves?

As we eat too much, as we eat too much of the wrong foods, as those foods provide biological encouragement to continue those habits, as we exercise too little, and as we create our own national health epidemic, is that not more than what any adversary could do to us?

Or as Walt Kelly’s cartoon Pogo once famously stated: We is met the enemy, and he is us.

Leptin and Ghrelin and Fat, oh my!

Posted by on July 22, 2013 Comments Off on Leptin and Ghrelin and Fat, oh my!

I am so embarrassed.

I have been confusing ghrelin and leptin, as we all do from time to time.

Still, I am very embarrassed.

I know that they are appetite-related hormones, and there was recent news about them. And, it seems I am not alone in the confusion.

But, first let’s go to the news desk.

An international team with principal investigator in the United Kingdom has published A link between FTO, ghrelin, and impaired brain food-cue responsivity in the Journal of Clinical Investigation.

In lay terms, as that is my language, what the study found was that individuals with the genetic indicator FTO, known for a tendency to obesity, are less satisfied after eating because of higher levels of ghrelin, a hormone that increases appetite.

Ghrelin has been known about since 1999, and there has been considerable debate about the possibilities of a ghrelin-antagonist to address obesity in a pharmaceutical. The alternative would be a leptin-stimulant as it is leptin that gives us the feeling of satiety after eating.

One of the two approaches, or both, is likely to lead to a very effective pharmaceutical approach to obesity.

But, back to my confusion for a moment. A 2010 Spanish study found that after weight-loss dieting, lower levels of ghrelin and higher levels of leptin were associated with gaining back the lost weight. Furthermore, the ghrelin was significant for men while leptin was statistically significant for women.

Oh, my. I am very confused.

The things we already know–but don’t often do

Posted by on July 15, 2013 Comments Off on The things we already know–but don’t often do

There is the old Middle Eastern story of the one who journeyed East in search of wisdom. He came upon a stone where he read, “Turn me over.”
He picked up the stone and read on the underside: Why do you seek new knowledge when you do not use that which you already have?

A recently reported Swedish study that followed 71,000 individuals over a 13-year period found that consuming less than five daily servings of fruits and vegetables was associated with higher mortality and shorter survival periods. Those eating one serving of fruit daily lived 19 months longer on average, while those eating 3 servings of vegetables lived 32 months longer.

Now by itself, this is not very surprising. We know that heavy meat consumption is linked to colorectal cancer, particularly in combination with genetic mutations, as described in a recent issue of Smithsonian Magazine. So, the possibility that a different diet would be protective, even by contrast, makes some sense.

Fornaciari subsequently analyzed bone collagen of King Ferrante and other Aragonese nobles, revealing a diet extremely reliant on red meat; this finding may correlate with Ferrante’s cancer. Red meat is widely recognized as an agent that increases risk for mutation of the K-ras gene and subsequent colorectal cancer. (As an example of Ferrante’s carnivorous preferences, a wedding banquet held at his court in 1487 featured, among 15 courses, beef and veal heads covered in their skins, roast ram in a sour cherry broth, roast piglet in vinegar broth and a range of salami, hams, livers, giblets and offal.)

In a similar vein, one out of three Americans suffers from hypertension (high blood pressure), a major risk factor for serious cardiovascular events such as stroke and heart attack. A recent study in JAMA showed that 18 months after the beginning of a study in which the experimental group did home blood pressure monitoring along with pharmacist case management, 71.8 percent had controlled blood pressure compared to the control group with usual care at 57.1 percent.

It would be easier if we had pills that would lower our body weight or a vaccination against high blood pressure. We don’t. But we have knowledge that we are not using: walk more, eat less processed foods and more whole grains, vegetables, and fruits, monitor blood pressure and pulse regularly. No, it is not magic–just the best that we can do.

Two things that might help

Posted by on July 8, 2013 Comments Off on Two things that might help

Two recent studies have yielded two tips that might help make your weight loss program work. They are not magic nor pharmaceutical. I confess that they confirm my own biases and experience, which does not make the findings any more valid.

The first study, which appears in the June 26, 2013 American Journal of Clinical Nutrition (AJCN), is a survey of eleven studies on water consumption and weight reduction.

This review found that increased water consumption was associated with greater weight loss. The reviewers conjectured that either the water satisfied hunger cravings, or that the water substituted non-caloric fluid intake for equivalents that might contribute 400-500 calories per day.

The second study, published online June 3, 2013 in the International Journal of Obesity showed a decreased appetite for food following strenuous exercise. The findings from this study are more limited and guarded: it only studied 17 individuals, and ran counter to other studies that showed no relationship.

We need to hope that something will work to help us reverse the trend toward greater obesity. A Rand study by Sturm and Hattori, published online in September 2012 by the International Journal on Obesity showed the accelerated trend toward obesity in the United States beginning in 1987.

Obesity Change 1987-2010

For example, there is a 13-fold increase of BMI > 50 shown by 1200 on the index above.

While the trend in the following table slowed slightly after 2005, there was still an increase of 70 percent increase in those with BMI > 40 so that 15.5 million Americans or 6.6 percent exceeded that BMI.
Obesity 2000_2010

Something has to give–and it better not be more waistlines.

PTSD: Military and Civilians

Posted by on July 1, 2013 Comments Off on PTSD: Military and Civilians

As I was surfing my car’s radio dial for some music–not much luck at the time–I heard a DJ defending his decision to discuss PTSD in the military. I guess some other listeners had been unsuccessful in finding music but found a serious discussion of trauma and war on a music show unacceptable.

What used to be called “shell shock” or “battle fatigue,” has the medical diagnosis of Post Traumatic Stress Disorder (PTSD). It is the kind of thing that got General George Patton in trouble, when he slapped a soldier suffering from it.

In many areas of brain disorder (ADHD, bi-polar, OCD, and PTSD), we can now provide a medical diagnosis rather than a moral diagnosis. Suffering from one of these disorders is no more evidence of moral shortcomings than diabetes, heart disease, or cancer–just different organs involved.

PTSD results from a shock or trauma–perhaps war is the most common and severe emotional trauma. I regret to note that having a volunteer army has resulted in the unintended consequence of making troops expendable to the civilian population. Now, we think nothing of sending them into combat with minimal reason or provocation, as they are volunteers, while we are in no way inconvenienced by doing so–no rationing, no higher war taxes, zilch.

As a result, we have decade-long wars (2 at last count in recent years) that cannot help but create PTSD along with other casualties of confict. And, of course, we need to make sure those needs are met along with the amputations and prostheses that the civilian population associates with war. The Veterans Administration (VA) maintains a National PTSD Center, and I have no idea how good the programs are, but they can be found by consulting the VA PTSD Locator

A related point, however, is that civilians as well as military are subject to the traumas that trigger PTSD. As the National Institute for Mental Health notes:

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.

While our primary concern may be with the direct effects (psychological and emotional) of PTSD, just this week an Emory University study of identical twin Vietnam War veterans found that risk of heart attacks was more than doubled in those with a history of PTSD.

Mental illness or brain disorders of any type require considerable investment of resources, professional and financial, to address. As a society we have dragged behind on this–mental health parity laws at the state level commonly had loopholes for high financial impact. There is a federal law in place, but it is not clear how effective it is. Change is occurring, but slowly.

Just within the past week, we learned that the California Department of Managed Health Care had imposed the second largest fine ever on Kaiser Permanente for failure to provide long term mental health care.

This country was founded by emptying Europe’s jails, and has been populated by escapees from prisons and hospitals around the world, along with other immigrants. As a nation, we have our share of people with “issues.” Some of the benefit has come from their creativity and willingness to challenge frontiers; however, in the 21st Century we need to help those folks adjust to what passes for civilization. Our veterans deserve it, but so do a lot of civilians, too. Let’s work to see they receive the necessary services–having mentally stable neighbors and colleagues improves life for all of us.

Illusion and Health

Posted by on June 24, 2013 Comments Off on Illusion and Health

A recent University of Texas study about the gap between perception of adequate exercise and optimal diet and the reality of an individual’s regime sent me googling.

I remembered a similar meme about body image. My memory was that men do not see how fat they are, and women imagine themselves fat when they are not, leading to anorexia.

Here are a few of them, and there are no doubt more:

Those studies raised an important question: how do reality and perception diverge when it comes to health?

So, let’s look at the University of Texas study from the Journal of Women’s Health, entitled Lifestyle and Cancer Prevention in Women: Knowledge, Perceptions, and Compliance with Recommended Guidelines.

Among those who believed that good diet and physical activity prevented cancer, the study found discrepancies (I have color-coded them) between what they believed they were doing and were actually doing as shown in the following table:

Women's Perceptions JWH 20130610

It can be seen that while 85 percent believe they are consuming a healthy diet, only 8.5 percent are eating an adequate amount of fruits and vegetables. While 73.1 percent reported engaging in physical activity to prevent cancer, only 31.5 percent were active enough to have a positive impact.

The study found that the significant predictors of the discrepancy were education, and to a lesser extent race-ethnicity independent of education. While the authors speculate about the reasons for those findings, they are clear and unambiguous about the implications, which I quote at length with the footnotes removed:

This finding has important public health implications. The first implication is that women in the current study reported understanding that engaging in regular physical activity and eating a healthy diet are important behaviors for cancer prevention. Thus, media campaigns and targeted public health messages should focus on the importance of specific frequencies and durations of recommended behaviors (i.e., 5 a Day for Better Health), and place less emphasis on the general importance of health behaviors. This may help attenuate the “underdosing” observed in the current study. Current public health efforts are focusing on making community-wide changes to reduce obesity and improve health.19 These efforts may be enhanced by promoting awareness of potential discrepancies between perceptions of behavior and actual behavior and by highlighting practical ways to integrate specific cancer prevention behaviors into daily life at adequate levels. Furthermore, they should consider the imbalance between educational resources for healthy eating and physical activity and barriers to these behaviors (i.e., society encourages the overconsumption of unhealthy food; low access to fresh produce and places to exercise safely sometimes exists). Given that women often serve as “gatekeepers” of health behavior within their families, efforts to address these discrepancies among women may ultimately have a positive downstream effect on men and children. Because dietary habits are often solidified in childhood, the discrepancies observed in this study could potentially set children up for a lifetime of poor health behaviors. These findings add to the body of existing literature indicating that although health-relevant knowledge and attitudes are generally positively associated with the practice health behaviors, the associations are only modest.

Results further indicated that the observed discrepancies for diet and physical activity were significantly more common among women with less education and among members of racial/ethnic minority groups. This is consistent with a large body of research supporting a social gradient in health (i.e., lower socioeconomic position and minority status are associated with poorer health behaviors and poorer health outcomes). One explanation for this is differential exposure to obesogenic environments. That is, individuals with low socioeconomic status and racial/ethnic minorities have less access to healthier foods such as fruits and vegetables due to higher cost and lower access to grocery stores that carry fresh produce. They also have fewer safe places to engage in physical activity. These women may be particularly vulnerable to perceiving that they are engaging in specific diet and physical activity behaviors to help prevent cancer. However, they may lack the opportunity to fully engage in preventive behaviors, thus failing to engage in such behaviors with sufficient frequency and duration to reduce their cancer risk. Such women may need to be specifically targeted for intervention and may benefit from tailored messages and interventions regarding diet and physical activity.

Do we not all know friends and family and clients who believe they are eating well and exercising adequately, but do not understand why their weight keeps rising, with the attendant complications? Our challenge as a society is not only to find ways of addressing the health problems that are undermining our economy and personal functioning that underpin our nation, but to communicate those findings in a way that is unambiguous and specific. The challenge of communicating the findings of a solution to the public health issues may be even more daunting than isolating those causes.

Doing the porcelain dance

Posted by on June 17, 2013 Comments Off on Doing the porcelain dance

As a general rule, food-borne illness, commonly called “food poisoning,” has remained fairly constant over the years. Indeed, since 1996 only one pathogen has shown considerable increase.

Based on 19,531 cases from Foodborne Diseases Active Surveillance Network (FoodNet) the CDC found:

Food Illness Trends 1996_2012

If Vibrio were a stock instead of a pathogen, you would have wanted to buy in around 1996 as it has enjoyed a considerable rise. Perhaps, like me, you wondered what Vibrio was. Most of the others have been in the news media or are simply well-known.

The trend continued in the period 2006 to 2012:

Foodborne Illness 2012

Vibrio is a genus of bacteria–one species causes cholera. This species Vibrio parahaemolyticus, however, likes sea water so much that it hangs out with oysters. If you get this infection, antibiotics do not help, so you drink liquids and wait it out.

Vibrio

By contrast, another species Vibrio Vulnificus can respond to anti-biotics. Among healthy people, the experience is likely to be the same as for Vibrio parahaemolyticus, but for those with compromised immune systems, immediate medical attention is indicated. Fortunately, this seems to be the more rare form of non-cholera Vibrio, and the incidence is much less frequent, generally occurring in the Gulf States.

One mystery in the data: incidence of Vibrio is higher among adults over 65 years old. While it can be contracted by an open wound in the wrong sea water, most Vibrio results from consumption of raw oysters or other uncooked seafood. I have not been aware of any trend to gulping raw oysters among seniors, but as the boomers enter old age, maybe they are going for anything that might keep the Sexy Sixties going. It would be of interest to see the geographic distribution of these cases–are there a lot of them in South Florida, for example?

Be careful out there.