Category Archives: CDC

Addiction: Twenty-first Century Style

Posted by on November 19, 2013 Comments Off on Addiction: Twenty-first Century Style

Technology is wonderful, ever moving forward. Now that cigarettes and other tobacco products have been thoroughly discredited as nothing more than a dirty 20th Century addiction, the purveyors of nicotine addiction have developed the e-cigarette for the 21st.

None of that harmful tar. None of that distasteful, annoying smoke. Just pure pleasure, as innocent as sucking a straw.

The Food and Drug Administration (FDA) is not convinced and is expected to issue regulations shortly.

E-cigarettes are a battery-powered device, about the size of a cigarette, that heats a nicotine-laced liquid into a vapor to be inhaled.

First, the FDA will not be able to regulate e-cigarettes as medical devices. That was decided by the DC Court of Appeals in Sottera, Inc v. FDA at the end of 2010. That means that restrictions will be similar to tobacco products rather than to nicotine patches.

Second, there will be considerable debate about the relative safety of e-cigarettes. While it is true that the tar and smoke is missing, it is unclear what the effects of the vapor components are both or the “vaper” and those around him.

A 2012 study at the University of Perugia (Italy) concluded:

The e-cigarette seems to give some advantages when used instead of the conventional cigarette, but studies are still scanty: it could help smokers to cope with some of the rituals associated with smoking gestures and to reduce or eliminate tobacco consumption avoiding passive smoking. However, the e-cigarette causes exposure to different chemicals compared with conventional cigarettes and thus there is a need for risk evaluation for both e-cigarettes and passive steam exposure in smokers and non smokers.

In August, 2013 respected researcher Igor Burstyn of the Drexel University School of Public Health issued a study financed by The Consumer Advocates for Smoke-free Alternatives Association (CASAA), an advocacy organization of the e-cigarette industry. Burstyn’s work and presentation is rigorous, but it is a technical study, not the peer-reviewed journal article considered the gold standard among researchers. While finding that the contaminants are generally safe, Burstyn:

  1. does not evaluate the risk of nicotine exposure to the person “vaping.”
  2. notes the difference in standards between exposure to a willing user and more stringent standards for an unwilling bystander.

Burstyn report

This approach to secondhand vapors provides a legal and philosophical foundation for applying existing tobacco regulation to the newer nicotine delivery systems.

Third, the e-cigarette industry is following the lead of the tobacco industry in its advertising. Note the remarkable parallels in Cigarette Flashbacks, a presentation by three Democratic members of the House Energy and Commerce Committee.

Fourth, there is widespread concern about the marketing and increased consumption of e-cigarettes by teenagers. Ninety percent of adult smokers had begun smoking in their teen years. The issue is well summarized by Health.Howstuffworks.com Flavoring the vapor with chocolate, caramel, strawberry, and bubble gum suggests a conscious attempt to lure youth into early addiction for later profits. Similar concerns have been expressed about the flavorings in hookah smoking as well. The Centers for Disease Control and Prevention recently issued a report on the percentages of teenagers using flavored tobacco products, nearly half of the consumption is flavored.

In the Jewish tradition, consumption of dairy and meat products together is forbidden. Technically, it would be permitted to have soy cheese on a hamburger, but the rabbis have forbidden that as well, because the appearance of violation by believers might encourage others to violate the prohibition.

It is clear that the appearance of smoking cigarettes should be treated no differently than the consumption of cigarettes. The difference between suggesting “Reach for a Lucky instead of a sweet,” and “E-cigarettes have no tar or smoke,” is minimal.

The FDA should treat e-cigarettes as tobacco products, and the several states should follow the examples of Utah, North Dakota, New Jersey, Arkansas, and the District of Columbia in banning indoor use in public places. Additionally, sales to minors should be banned as well as Internet sales since age-verification is not possible on line. In short, we need to bring these products under the same regulations as their tobacco cousins–NOW.

Three research pieces with a lot of heart

Posted by on September 10, 2013 Comments Off on Three research pieces with a lot of heart

Often the most heartening news comes from health research. The past couple of weeks have revealed three worthy of note. All three involve prevention measures, two before a heart attack, and one after.

First, the US Centers for Disease Control and Prevention estimate that 200,000 deaths from heart attacks can be avoided annually. The preventable deaths are concentrated in three areas.

The first area is age, where preventable deaths are concentrated in the 45-64 age cohort.
Preventable deaths by age

The second area is race, where African-American men are at the highest risk of preventable death, 143 out of 100,000.

Preventable deaths by race

Finally, the deaths are concentrated geographically in the South-Central Region.
Preventable deaths by region

Second, a study from Britain and India, published in the Journal of the American Medical Association (JAMA) found that a single pill or “polypill” with fixed doses of aspirin, anti-hypertensive, and cholesterol-lowering drugs was statistically more effective than offering separate prescriptions. While physicians point out that this approach limits flexibility, greater variation of dosage combinations in polypills is a promising approach.

Polypill study

Third, a study in JAMA Internal Medicine found that even after a heart attack, better diet, as measured with Alternative Healthy Eating Index (AHEI 2010), resulted in lowered mortality.

The good news is that either before, or failing that, after a heart attack, the good practices of medication adherence and reduction of risk factors such as poor diet, can improve our survival as individuals. Furthermore, we can move the needle in a better direction by focusing our educational and interventional efforts on those under 65, African-American, residing in the South-Central United States.

Herd Immunity — How vaccines avoid thinning the herd

Posted by on September 3, 2013 Comments Off on Herd Immunity — How vaccines avoid thinning the herd

Part of the difficulty in making a case for universal vaccination against dangerous disease is a lack of understanding of probability. Since there are few certainties in life, except its eventual end for individuals, we are constantly calculating probabilities. What is the probability that I will get to the other side of the street before that oncoming car arrives? What is the probability that the wheel stop on my number or that I will draw the card needed to complete my hand? What is the probability that the game I am going to attend will occur or get rained out? And, of course, what is the probability that the suggested intervention will cure my disease rather than kill me or leave me permanently debilitated?

Some probabilities are more difficult to calculate than others: what are the odds that I will die from prostate cancer, and what are the odds that the operation will leave me impotent? how do I calculate the best course when my choices are an operation with an 80 percent success rate that leaves another 15 percent paraplegic and 5 percent dead? How about the same operation with 93 percent success, 5 percent paraplegic, and 2 percent dead?

The more complex the alternatives, particularly when they are being balanced against complex outcomes from non-intervention, the more difficult it is for us to make a rational decision.

That leads to a discussion of vaccination. Let’s consider a disease such as smallpox, which has killed 100s of millions of people. Not everyone got smallpox. Not everyone who got smallpox died from it–estimates are that about 30 percent, or 3 out of every 10 died. Now, consider that not everyone who gets a vaccination gets 100 percent immunity. Some people get partial immunity. Some very small percentage may not produce antibodies in reaction to the vaccine. Some people actually die of the side effects of the vaccination.

As an individual, you might think, well, it’s not great but 70 percent odds of surviving are better than none, and maybe it will miss me altogether, so why should I vaccinate? Of course, smallpox has been eradicated, and we don’t have to make that kind of determination any more since the dangers of side effects from the vaccination exceed the danger of contracting smallpox, particularly in the United States where the last documented case appeared in 1949.

If you were a free individual, not part of a society, not part of the possible transmission stream of a disease, then no one is likely to care too much what you decide? However, if you are reading this, you are part of a society providing this message to you via a societal mechanism. As part of that society, you have obligations to others in the society, including children, yours and others, who once were considered private property but are now considered individuals with rights, albeit limited compared to adult rights.

The concept of “herd immunity” goes directly to the questions posed and to your obligations within the society.

Herd Immunity Concept

Those who are vaccinated provide a barrier to illness for those who are not:

Consider:

Assume you have 5 friends who do not know one another, and that everyone has 5 such friends.

Assume that vaccinations give almost 100% immunity and that the corresponding disease gives almost 100% probability of infection if you come in contact with a person who has it.

Now, if 80 percent of people are immunized against the disease, it is quite possible that one of your friends is not immunized. However, if 80 percent of that person’s friends are immunized, there is now only 1/5 times 1/5 or 1/25 = 4 percent chance of the disease vector reaching you. It may be that you friend’s friend has friends with 100 percent immunity, all five of them immunized, and the further you are socially from the source of infection, the lower your odds of becoming infected–even if you are not immunized. You are protected by herd immunity.

However, consider if only 60 percent of people are immunized, then 2/5 times 2/5 is 4/25 or 16 percent chance of becoming infected. That is 4 times your chance of infection from a secondary friend, as in the first example. The degree of herd immunity is a complicated calculation depending upon the percent immunized and the way the disease is transmitted. Your chance of infection depends on those factors as well as your social distance from the source of the infection.

For an animated look at the concept, click on “Play Animation” in the three scenarios of The History of Vaccines: Herd Immunity.

Here are the thresholds for different diseases as estimated by the Centers for Disease Control (CDC):

Herd Immunity Thresholds CDC

Think about flu shots for a moment:

  1. The vaccine is based upon recent mutations of the virus, so you might catch a virus that is not part of the vaccine.
  2. Not everyone gets 100 percent protection from a vaccine–it may be sufficient to protect against some strains and give partial protection against others
  3. In part, because of herd immunity, not everyone exposed to influenza is infected

So, we have friends and relatives drawing the wrong conclusions (e.g. the vaccine caused me to get influenza), based on an association of factors that are coincidental or subject to an alternative explanation, such as a new strain or partial immunity. For most young people, the flu is an occasional inconvenience rather than life-threatening; however, their failure to vaccinate exposes others whom they could be protecting by a simple annual injection. Let’s spread the word–it might not save those young individuals–just an older person, or an asthmatic standing close to them.

Vaccination–Now and Then

Posted by on August 26, 2013 Comments Off on Vaccination–Now and Then

Smallpox was long one of the scourges of humanity, killing millions throughout history. Early attempts were made to combat it through “variolation,”inoculation with the scabs of the disease. Such efforts began at least a thousand years ago in China. ChineseVaccination

Without images to guide us, it is easy to think of smallpox as chickenpox that kills. Not exactly. Besides the fact that smallpox does not concentrate on the torso, the number of pustules seems much more severe to my eye. Here is a child in Bangladesh in 1973 with smallpox. This is what we no longer fear because of vaccination:

Child_with_Smallpox_Bangladesh

Vaccination is relatively new in human history–the United States of America is older. Just before and after 1800 Edward Jenner, noticing the apparent immunity to smallpox of milk maids, experimented with inoculation using the relatively benign disease cowpox to which they had been exposed. It was not until 1840 that the British government routinely provided the means for inoculation, as the medical establishment had been slow to accept Jenner’s findings.

Nonetheless, the disease that killed an estimated 400,000 Europeans annually at the time of Jenner’s discovery, was still able to kill several hundred million in the 20th century.

The last documented case of smallpox occurred in Somalia in 1977. By 1980 the World Health Organisation (WHO) was able to declare smallpox eradicated. Consequently, routine smallpox vaccination was discontinued in the 1980’s as the statistical danger from the vaccination (14 to 52 per million per the CDC) exceeded the danger of the disease.

I would prefer to be able to present a time series of smallpox cases, but have been unable to locate one this week. Failing that, here is the impact of vaccination in the US on numerous diseases during the 20th Century, worth considering when someone questions the value of vaccination.
Vaccination_US_thru1998

Are we doing ourselves in faster than we think?

Posted by on May 6, 2013 Comments Off on Are we doing ourselves in faster than we think?

We know that our health is adversely affected by obesity, a sedentary lifestyle and fat consumption, not to mention tobacco and lack of access to healthcare. These factors are holding down what should otherwise be continued gains in life expectancy. They also adversely affect those who survive: the strains of obesity on the skeletal structure, emphysema from tobacco consumption, chronic heart disease, cancer that takes over lives, etc.

Recent studies indicate that not only are we experiencing indirect and long-term impacts on our lives and health, but the rate of suicide is increasing, surpassing deaths by motor vehicles in 2009. What adverse lifestyles are not doing to us in the long-term, we are doing directly to ourselves in the now.

The recent CDC study Suicide Among Adults Aged 35–64 Years — United States, 1999–2010 showed that the largest increase in the suicide rate was among whites between ages 45 and 64, in contrast to the common concern about teen and geriatric suicide.

In general, the suicide rate is related to stressors and the availability of means. The following chart, with data from the National Vital Statistics system, is from that CDC study:

Suicide by Sex and Means 1999-2010

Noteworthy are the increased use of firearms, which account for about half of all suicides among men, and suffocation (euphemism for hanging). The study lists the rates of suicide by state as well as the rate of increase from 1999 to 2010. I wondered about the ownership of firearms in those states.

I found that the study, “Association of suicide rates, gun ownership, conservatism and individual suicide risk,” was published online in the journal Social Psychiatry & Psychiatric Epidemiology in February.

The title a bit provocative, but if the availability of firearms reflects the political views of a population, and if the availability of firearms is related to the suicide rate, then it is possible to find statistical correlations among the three, without implying that a particular political view is suicidal or causes suicide any more than suicide causes a political view.

The study by researchers at the University of California, Riverside presented the following map of suicide rates by state:

Suicide_2000_2006

The map seems to show higher rates in states where one might expect more gun ownership, but, being a data person, I did a little experiment of my own.

I ran a couple of regressions, down and dirty, not up to publishable, academic standards. I used MS Excel, probably acceptable for this purpose but not a tool I would use for a publishable regression analysis.

My data sets were gun ownership from the Behavioral Risk Factor Surveillance System for 2001 and Median Income from the US Census Bureau for 2006. First, regressing gun ownership by state on income found that income was a significant factor, inversely related to gun ownership, and explaining 35 percent of the unexplained variation. This is not surprising as rural states are generally poorer and are more likely to have traditions of gun ownership for protection as well as for hunting.

It also meant that the cross correlation of income and firearms ownership might cloud the findings when I looked at the suicide rate from the latest CDC report and its separate relationships to the two factors. Those figures were for only 39 states, so that is how I handled it. My informal findings were that gun ownership rates were strongly correlated with the suicide rate, p=.00025 with R squared =.308, accounting for 30.8% of the unexplained variation. Income was inversely related to suicide and was much weaker, with p=.045 and R squared = .104.

Now, you might say, “Oh, suicide is related to economic factors. With recent economic challenges, of course suicide is rising.” You would be correct. Researchers from Rutgers have provided a graph of the relationship between suicide and unemployment.

Suicide and Unemployment
Source: Social Fact: The Great Depressions?

That is not, however, the public health issue, as there will always be stressors causing suicide. We need to find a way to block access to guns in the same way that we block access to bridges for suicidal people. Of course, there are a lot more guns than bridges. In the United States we ban automatic weapons from private ownership, so the issue is not whether the right to bear arms can be restricted: the entire debate is how extensive those restrictions should or should not be. The data on suicide suggests that greater restrictions on access would have a positive public health impact.

Where are those calories are coming from?

Posted by on February 28, 2013 Comments Off on Where are those calories are coming from?

Hint: it’s fast food. A recent Centers for Disease Control and Prevention (CDC) study found that over a 3-year period 11.3 percent of calories came from fast food.

That surprises no one. There were, however, two interesting points made:

First, while adults have decreased their intake of fast food, consumption by youth has increased. As consumption of fast food declines with age, it is not clear to me whether the decline is true progress or related to the aging of the population.

The second takeaway from the study is more intriguing, as shown in the following summary of study findings:

CDC_NatHealthSurveyNutrition_201302

I have highlighted the finding at the bottom of the graphic.

When it comes to fast food: the more you eat, the more you gain; the more you gain, the more you eat.

If someone told you that the more heroin, opium, etc. you consume the more you want, you would not be surprised.

Are you as surprised as I am to find a study that shows the same is true of fast food?

Since we regulate addictive drugs, there is an argument to be made that addictive substances consumed as food could be regulated as well. I do not know what that regulation should consist of, only that we have a tradition of regulating addictive substances, assuming that the individual is incapable of self-regulation in the face of addiction.

As is frequently the case, the questions that arise are more intriguing and clear than the answers.

Source: NCHS Data Brief ■ No. 114 ■ February 2013

Flu season: where statistics and anecdote meet

Posted by on January 14, 2013 Comments Off on Flu season: where statistics and anecdote meet

No missing that it is flu season. Like hurricanes in Florida, fires in California, and tornadoes in Oklahoma, either the media reminds us or our friends do.

Massachusetts just declared a flu emergency. The Centers for Disease Control and Prevention (CDC) map showing that there are widespread flu cases in 41 states is on all the news media websites and news reports. And the flu deaths have just surpassed the 1 of 14 deaths threshold to officially be called an epidemic.

There seem to be a lot of people with the flu or flu-like symptoms, which seems strange. The flu vaccine is not something new. It is readily available, far more cheaply than getting the flu is. If you are an hourly worker, it costs the equivalent of 1-2 hours of work, but the flu costs you 8 hours of work.

I think there are four reasons why there is so much flu.

1. Many people do not get the flu shot even when it is available for free, as in many workplaces. There is magical thinking involved. The vaccine is dangerous, they think, or, “it will make me get the flu.” Often there is a fear of needles.

Comparing vaccination rates from November to the previous year, they are about the same: less than 3 out of 8 people. By March of last year, less than 1 out of 2 individuals had been vaccinated. Trends from November to March are likely to be similar this year.

Flu_vaccinations2012
The next two reasons are a bit more complicated.

This table shows the reports of testing of flu strains around the country totaling over 9,000 tests with slightly less than a third positive. There are about 4 times as many Type A as Type B positive tests. Of course, many people with the flu do not get tested. They may call their doctor, who either prescribes an anti-viral or tells them it is too late, that they should drink plenty of liquids, and look for the signs of pneumonia.

Flu_week52_1

So, the next reason is:

2. People contract a virus that is not influenza.

The next image shows tests done at the CDC for different strains. The sample is much smaller, about a seventh of the previous number of positive tests. Note that strains of both Type A and Type B influenza were identified. About a fourth are Type B.

Flu_week52_2

And here are the strains in the 2012-2013 vaccine:

On February 23, 2012 the WHO recommended that the Northern Hemisphere’s 2012-2013 seasonal influenza vaccine be made from the following three vaccine viruses:
an A/California/7/2009 (H1N1)pdm09-like virus;
an A/Victoria/361/2011 (H3N2)-like virus;
a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses).

Note the absence of B/Victoria lineage from the vaccine, so the final reason:

3. People contract an influenza virus for which they have not been vaccinated–even though they received this year’s flu vaccine. There has been talk of a vaccine with four strains (quadri-valent) rather than the current three strains (tri-valent), but none yet operational in the US.

4. Even those who get the flu shot do not get perfect immunity. Immunity depends on the weakened or killed virus stimulating the production of antibodies. Everyone’s immune system is different, and those with weaker responses get less protection. Indeed, older folks get a strengthened vaccine now, so that aged immune systems can be stimulated to trigger an adequate response. Also, the antibodies stimulated tend to stay concentrated in the bloodstream, not the lining of the lungs where the virus enters.

Conclusion: The flu virus is inconvenient at best and deadly at worst. You may not get adequate protection from the vaccine, but you get zero protection without it. And get the pneumonia vaccine as well, if you haven’t already: real good chance of a secondary infection if you get the flu and haven’t gotten the pneumonia vaccine.

There was a time when FAT City was something good.

Posted by on December 12, 2012 Comments Off on There was a time when FAT City was something good.

No more.

We are FAT City. It is bad. It is getting worse. Here’s what it looks like geographically:

Map of Obesity in the USA 2011

The map shows the problem in 2011, but it does not show the growth of the problem over time. Exploring that growth is part of the search for the cause and the solution.

If being overweight were just an aesthetic choice, no one would care. If being overweight were totally beyond the control of individuals, we would simply live with it as we do other things beyond our control, such as the limits of our life span.

But, the problem of obesity has an impact on our entire society and is at least in part modifiable. It makes finding soldiers who can pass basic physical exams scarcer than would otherwise be the case, and it puts a burden our health care system, both payers and providers, particularly public programs such as Medicare and Medicaid.

While we will want to consider diabetes, heart disease, and cancer, as well as other preventable causes of death and disability, in discussing the health of our nation, they are affected profoundly and substantially by the prevalence of obesity in the society. There are a considerable number of obesity-related illnesses,
and they impact our health, our longevity, our national budget, and our family budgets.

So, initially I may be writing a bit more about obesity than other health challenges, but we will get to them as well in the fullness of time.

What the health is this blog about anyway?

Posted by on December 10, 2012 Comments Off on What the health is this blog about anyway?

Murray Feshbach, Vladimir Treml, Barbara Anderson, Brian Silver

Who are these guys?

In the 1970’s and 1980’s these scholars documented the declining life expectancy in the Soviet Union. Ten to twenty years before its demise, they demonstrated that the USSR was drinking itself to death.

In the US we are eating ourselves into history’s dumpster—unless we stop the trends.

Obesity leads to diabetes, heart disease, back problems, cancer, and others. We are having an epidemic of obesity. It is a big problem. It is not the only problem—just a big one.

As our belt sizes grow, the health care needs of the baby boomers will grow beyond our ability to meet them. There will be neither enough dollars nor enough people to take care of those with chronic illness.

The problem is too big for a simple solution, like the latest diet or routine liposuction. The consequences are too great for the luxury of magical thinking—if we don’t think about it, it will go away. It won’t, as anyone who has tried to lose 10 pounds surely knows.

In order to manage, if not solve a problem, we need to:

1. Agree there is a problem
2. Define precisely what the problem is
3. Determine what tools we have to meet the problem
4. Agree on the best tools or remedies to use
5. Apply all appropriate remedies to reduce the uncertainty of the outcome

While this challenge is less dramatic than those we regularly see headlining news stories, it is my belief that it is the most serious threat to our nation. As such, it must be a national priority and must be addressed at the national, regional, state, local and personal levels, by both governmental and non-governmental organizations, including private businesses.

It is the purpose of this blog to address the American health crisis in the context of the five points of problem-solving mentioned, including the evidence of the problem, possible causes of the problem, and actions we might take. I plan to provide links to the latest research as well as the initiatives of others.

Let’s get started: Background of the Problem