Aetiology

The consequences of refusal

Thu, 22 Oct 2009 15:07:10 -0500

I've written previously about "chicken pox parties". These types of events are coming back into vogue (they were common in the days before the vaccine, when the only way to provide immunity was to be infected), as parents mistakenly believe that "natural exposures" to these pathogens are somehow superior--and safer--than vaccinations. Though the latest rage are "H1N1 parties", chicken pox parties are still around, and potentially being held at your local McDonald's by families connecting on the internet:

I am trying to put together a chicken pox party and am looking for someone to donate their chickenpox to the event. I was thinking of having it at McDonald or some place with toys to play on. if you know anyone who would like to contribute or would like more information on a time and place let me know.

This is, again, one of my biggest problems with those who refuse vaccines. They frame the issue as solely "my child, my choice." Which is fine, until you put that child in with the rest of society via school, or daycare, or even trips to McDonald's. These interactions include infants who are too young to get vaccinated; people with chronic conditions or who are receiving chemotherapy, and are therefore more susceptible to disease; or those in whom the vaccine just didn't "take" (my own measles titers were not high enough to be protective, I learned last year when I was preparing to go to Mongolia--despite having 2 doses of the vaccine), and on and on. Yes, you have the right to make decisions for your child--but parents should realize that this particular choice can put a lot of others in danger.

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Fear & vaccines

Wed, 21 Oct 2009 11:23:19 -0500

I realize that, despite the scientific evidence to the contrary, there is still a lot of fear and misunderstanding about vaccine safety. Two recent articles discuss this "epidemic of fear" and why it affects us all, the first here at Wired magazine, and the second here at the Gotham Skeptic. I especially like the second, which has some excellent points:

My pediatric practice is situated at the nexus of three Manhattan neighborhoods (the West Village, Chelsea, and the Meat Packing District) that seem to comprise just the right balance of wealth, edginess, and socio-cultural awareness that lends itself to this new mistrust of vaccines. But these neighborhoods are not unique. According to sources at the NYC DOH, the Upper West Side of Manhattan and Park Slope in Brooklyn are also hot-spots of parental vaccine resistance. What stands out about these neighborhoods, and others like them, is that they contain a high percentage of middle to upper middle class families that tend to be young, well educated, and liberal in their political and social views. Because I live in one of these areas, work in another, and fit this description pretty squarely, I can identify with the underlying tendencies at work behind the concerns of these parents. A healthy questioning of authority (doctors), an underlying mistrust in the competence of the government (the CDC), overt mistrust and a general level of cynicism of big business (the pharmaceutical industry), and a sense of empowerment that comes with one's social status, all contribute to this tendency to mistrust vaccines and those who recommend them. The difference between these concerned parents and myself (also a parent), is an understanding of the scientific method and the role it plays in this issue. One term that I have purposefully left out as a key element in this new epidemic is "skepticism." While many of these parents believe they are being skeptical of vaccines, their manufacturers and the agencies that recommend them, this couldn't be further from the truth. What they are being is misled and taken advantage of. They would actually be better characterized as anti-skeptics. To quote Brian Dunning of Skeptoid.com:

"The true meaning of the word skepticism has nothing to do with doubt, disbelief, or negativity. Skepticism is the process of applying reason and critical thinking to determine validity. It's the process of finding a supported conclusion, not the justification of a preconceived conclusion."
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Why I'll be getting my kids their flu vaccines

Fri, 18 Sep 2009 11:51:00 -0500

Taking a brief hiatus from my hiatus to discuss a question I've been asked a number of times in recent weeks by friends and family: what about flu shots? Are you getting one for yourself? Your kids? The answer is yes to both, with more explanation after the jump.

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Silence is the enemy

Mon, 01 Jun 2009 09:00:00 -0500

"I always think someone is following me and wants to rape me. It is better to die." --Darfuri refugee

Sometimes there comes a public health issue that's so big, so overwhelming, so heinous, that you just don't know where to begin discussing it. Nevertheless, the conversation should, and must, happen just the same. Silence may be easier, but speaking out is the only way to demystify the taboos and bring attention to what's going on for those who can't bring attention to it themselves. And maybe, just maybe, bring about some change.

It's no secret that rape happens during wartime. Certainly documents being discussed regarding our own soldiers' treatment of prisoners show that wartime rape--of either "the enemy" or even female colleagues--is not limited to rogue armies in far-off countries some Americans probably couldn't even find on a map. That doesn't make it any less inexcusable, or the crimes any less horrendous, just because we've done it, too.

A recent piece in the New York Times by Nick Kristof highlighted the extent of these rapes even after the war has stopped, discussing rape in Liberia. As Kristof notes, the war in Liberia ended officially in 2003 after 14 years. However, even today--6 years into peacetime--a high percentage of the female population reports a history of rape, including girls as young as 3 years old. Of 275 sexual violence cases treated in just four months' time in Liberia by Doctors without Borders, 28% involved children age 4 or younger, and a third involved children ages 5-12. Children are easy targets, and the most powerless of all possible victims.

Of course, rape is older than civilization itself, just like the view that women are second-class citizens (if we count as citizens at all). You may have heard about these types of rapes--of women, of children, by solo men or gangs; using only their bodies or using whatever object is handy, including guns or knives, to rape their victims--being carried out in Darfur, in the Congo, or elsewhere. Celebrities have written about it in excruciating detail, documenting some of the horrors: a child held and raped for 2 weeks, left alive but incontinent, humiliated, and shamed. 6-month-old infants raped. 80-year-old women raped and brutalized. 1,100 women raped every month in Eastern Congo according to United Nation estimates.

The situation in Darfur probably has received more international attention than other countries, yet still, little has been done--and the future of what *can* be done is uncertain, as many foreign aid groups were kicked out in March.

For those who have fled the brutality in Darfur, the situation remains bleak. A new report was just released documenting the issues Darfuri women face in refugee camps, including repeated rapes and a lack of any legal recourse either in their home country or in the camps. They are imprisoned--unable to help themselves by even getting firewood or tending to animals because of the potential for rape at the periphery of the camps--and have no one to turn to. Indeed, in many areas, the perpetrators carrying out these crimes are the very ones who are supposed to be protecting women--police, military and government officials, even teachers. In Liberia, despite having the first female president of an African country, little progress has been made in changing laws or attitudes about rape, and the country still lacks an adequate legal system able to adequately prosecute the small percentage of rapes that are reported.

What to do about this? That's what's kept me from writing more about this, I suppose--the sheer magnitude of what is happening, and the helplessness one feels when reading about it. With infectious diseases, though some of them are equally overwhelming, at least there is the hope of prevention via relatively simple devices (bed nets for malaria; condoms for HIV; isolation and medical treatment of TB, and of course the hope for vaccines, etc.) With systematic rape, there is no drug or vaccination to look for in the future. What is needed instead are shifts in attitude: more respect toward women; societal intolerance of such crimes by men; empowerment of women and girls; an understanding by family members of those who were raped; cessation of femicide. These are overwhelmingly difficult things to ask for, especially in countries fragmented by years of war and violence. How does one help to accomplish these things in far-off countries, when it's hard enough to be respected as a woman right here in the U.S.?

A recent editorial by the editors of PLoS Medicine provides some places to start:

Medical professionals are powerful lobbyists whose recognition of the devastation could galvanize support for the work of humanitarian organizations and advocacy groups in documenting sexual atrocities and holding states accountable when human rights and international law are violated. Together with medical journalists and editors they have done much to try to expose the devastation of sexual violence during conflict, but we can all do more to document and disseminate the research and accounts of health workers, nongovernmental organizations, and survivors.

And they're right. No, gang rape isn't exactly great fodder for cocktail parties. It's incredibly uncomfortable and depressing to speak about--and that's probably one reason it's gone on as long as it has, with relatively little attention. It's taboo to discuss--not only in countries like Liberia or Sudan, but here in the US as well. It needs to stop, and we can help make that happen. Talk to someone about this. If you can't do it in person, write a letter. Write your congressperson. Hell, write your mayor. Highlight it on your own blog. See if a local women's group--or any other group interested in global health or women's rights--has covered the issue recently, and if not, offer them any of the linked articles to spark the conversation. Email your local newspapers or TV stations. Send a mass email to your friends--this is certainly more important and worthy of their attention than the latest viral YouTube video, right?

Finally, keep checking back. This month frees up a bit of time for me, so I'll highlight some of the other posts on this topic around the blogosphere as I see them crop up, in order to keep the discussion going and look for other ways to help and other perspectives on the issues. I'll also write on some related topics. Additionally, keep an eye on Sheril and Isis's blogs for more posts and updates. Along with them (and potentially others, which I'll mention as I see them), I'll be donating any wages from the blog this month to Doctors Without Borders as a token of appreciation for the work they've done for the victims of these brutal crimes. I'll have a list of other charities you may want to consider in a future post.

Silence is the enemy. Speak out. Pass it on.

[Edited to add: Sheril has a list of participating blogs here, including NY Times author Nick Kristof with his post highlighting the movement. We now have a Facebook page for "Silence is the Enemy" here; and you can search Twitter using #silencehurts.]

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Bill Maher on swine flu and evolution

Tue, 05 May 2009 23:40:00 -0500

Now if he could just get his science straight when it comes to vaccination...but perhaps this mean he's changed his views on the germ theory?

(H/T Louis)

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Misc. links

Mon, 04 May 2009 14:10:00 -0500

Back to the grind this week unfortunately, but the swine flu/H1N1 story is still developing and still fascinating. The most recent numbers show 286 confirmed US cases in 36 states.

There are many remaining questions on the evolution and epidemiology of this strain--and many pundits sure they know what's going to happen next. Mike takes one of them down--Wendy Orent, who I've blogged about previously. Orent is claiming (based on a black/white version of the evolution of virulence in pathogens) that the spread of this strain is attenuating the virus, and that future outbreaks will be milder. Mike nicely explains why that may, or may not, happen--and why it's folly to predict with certainty either scenario at this point.

Unrelated to influenza, an editor at the Guardian is angry at anti-vaxers, after his young daughter (11 months old, too young for the MMR vaccine) has developed measles:

According to the Health Protection Agency there were 1,348 cases of measles last year, compared with 56 in 1998. In 2006 a 14-year-old boy died of measles - the first fatal case for 14 years. The reduction in herd immunity is causing unnecessary suffering.
The decision by many of my neighbours not to vaccinate their children is on a par with the drunk who decides to get into his car to drive home. It is a personally reckless action that also endangers the lives of everyone else on the road. Society should view the MMR refuseniks with the same degree of scorn.

Finally, the winners of the 2009 Alliance for Science Essay contest have been announced (H/T Panda's Thumb and Evil Monkey).

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Why are the schools closing and other good H1N1 links...

Sun, 03 May 2009 12:10:00 -0500

Over at DailyKos, DemfromCT has an excellent post explaining why it may be beneficial for schools to close temporarily, even if they only have one confirmed case of swine influenza: H1N1: Why Do Schools Close, And When Do They Open?

DarkSyde also has one up on the basic biology and evolution of the flu.

Nick Kristof discusses our lack of attention to public health and what it means in the event of a pandemic in today's NY Times.

[Updated: and via the comment theads, this post which further discusses what I mentioned here regarding testing--and how the confirmed cases are only the tip of the iceberg (complete with diagram!).

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Adamantane resistance in flu explained

Fri, 01 May 2009 10:45:00 -0500

Nick Anthis has a very nice (and very readable!) overview of why flu viruses (including the new A/H1N1 strain) are resistant to adamantane, one of the antiviral drugs that can be used to treat influenza infections.

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What does the WHO's pandemic scale mean? And why is anyone worried about this?

Thu, 30 Apr 2009 14:10:00 -0500

I've been seeing a lot of comments mocking the current outbreak of H1N1, and a lot of people (and journalists) who don't understand what "big deal" is about the "snoutbreak" of swine influenza, or don't get what the raising of the World Health Organization's pandemic alert phase up to 5 means. I noted here what the alert level meant, but wanted to discuss it a bit more in a full post; after the jump.

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Iowa investigating two "probable" swine flu cases

Wed, 29 Apr 2009 20:20:05 -0500

It was only a matter of time:

Iowa Gov. Chet Culver says the state has two probable causes of swine flu.
Speaking Wednesday at a Statehouse news conference, Culver told reporters that officials would know Thursday if the cases are swine flu.

Officials say one case was from a California resident who visited Scott and Clinton counties last week. The other was a woman who returned from Mexico and traveled through Johnson, Des Moines and Muscatine counties.

State Medical Director Patricia Quinlisk says both of the people infected were now recovering.

Should know by tomorrow if they are confirmed or not.

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Wired: H1N1 a hybrid of 2 pig isolates

Wed, 29 Apr 2009 14:20:00 -0500

Brandon Keim at WiredScience has a new article on swine flu genomics.

"This is what we call a reassortment between two currently circulating pig flu viruses," said Andrew Rambaut, a University of Edinburgh viral geneticist. "Why it's emerged in humans is anyone's guess. It hasn't been seen before in pigs as far as I know."
***

"The new neuraminidase gene that came in from Eurasian swine is one we've never before seen circulating in humans," said Rambaut. "That's one of the reasons it's spreading rapidly. Very few people will have any immunity to this particular combination, which is what gives the concern that this will be a pandemic rather than just a normal seasonal flu outbreak. It remains to be seen how much and to what extent there is existing immunity."

Story still evolving...Keim does mention that "a document released to scientists and obtained by Wired.com affirms their analysis." Could be out in the literature soon, possibly?

I was hoping to have a post up today with more thoughts on the whole pig issue, but no time to do anything but quick posts. Hopefully tomorrow...

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US up to 91 cases, including 1 death [Updated: New England confirmed cases]

Wed, 29 Apr 2009 13:40:00 -0500

The latest numbers of confirmed cases from the CDC were released about an hour ago. 91 cases have been confirmed, with the largest numbers in New York (51), California (14), and Texas (16). One new case has also been confirmed in Nevada, one in Indiana, one in Arizona, and 2 in Michigan; the other Ohio case I know of is still pending, apparently. Ongoing investigations are also taking place in multiple states, so expect the number to keep rising for the time being. [Update: 2 cases just confirmed in Massachussets, and three in Maine.]

The first fatality has also been reported: a 23-month-old child who had ~~recently traveled to Mexico~~ traveled to the United States from Mexico.

I've written previously about how difficult research in infectious disease can sometimes be, knowing that many of the isolates you're working with harmed or even killed someone, and changed someone's life forever. This child's influenza virus will now be marked with a lengthy name based on the date and location of isolation, and will be studied and dissected on a molecular level, and referred to in dry publications discussing the case--but that doesn't mean that those who carry out the research and write up the manuscripts in such clinical language are any less touched and upset when deaths like this occur.

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Swine flu--deja vu all over again?

Tue, 28 Apr 2009 23:35:00 -0500

Back in 2007, I wrote about an outbreak of swine influenza from an Ohio county fair. The peer-reviewed paper analyzing the swine influenza isolated from that outbreak has just recently come out. From the abstract:

The swine isolate, A/SW/OH/511445/2007 (OH07), was evaluated in an experimental challenge and transmission study reported here. Our results indicate that the OH07 virus was pathogenic in pigs, was transmissible among pigs, and failed to cross-react with many swine H1 anti-sera. Naturally exposed pigs shed virus as early as 3 days and as long as 7 days after contact with experimentally infected pigs. This suggests there was opportunity for exposure of people handling the pigs at the fair. The molecular analysis of the OH07 isolates demonstrated that the eight gene segments were similar to those of currently circulating triple reassortant swine influenza viruses. However, numerous nucleotide changes leading to amino acid changes were demonstrated in the HA gene and throughout the genome as compared to contemporary swine viruses in the same genetic cluster. It remains unknown if any of the amino acid changes were related to the ability of this virus to infect people. The characteristics of the OH07 virus in our pig experimental model as well as the documented human transmission warrant close monitoring of the spread of this virus in pig and human populations.

Meanwhile, I mentioned yesterday that gene sequences from the new H1N1 virus had been released. Sandy has taken a look at some of these, and compared them with H1N1 and H1N2 viruses from humans and pigs.

Yes, there is a point to the juxtaposition of these two points, and it's big--after the jump...

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Swine flu link roundup

Tue, 28 Apr 2009 20:00:00 -0500

Revere on quarantine versus isolation. This is a topic I've covered previously (here) as well, and an important distinction (though the two are often muddled together in the press).

Christine Gorman talks about getting the facts straight on swine flu, and offers up many additional resources to keep you updated.

Skepchick provides "Things More Likely to Save You From Swine Flu Than Homeopathy". Colon cleanse and chiropractic are noticeably absent...

1976 swine flu Public Service Announcements. They don't make 'em like that anymore... (h/t http://twitter.com/tomburket)

Finally, my colleague, Dan Diekema, a hospital epidemiologist extraordinaire here at the University of Iowa, has started a new blog: Controversies in Hospital Infection Prevention. Obviously, swine flu has been the big discussion in this area over the last few days, and Dan and his co-blogger, Michael Edmond, have several posts on swine flu and infection control. Stop by and check it out...

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Swine flu: Central & South America, Asia, New York update

Tue, 28 Apr 2009 15:35:00 -0500

Stories in Spanish: Costa Rica becomes the first Central American country to confirm swine flu ("gripe porcina"). A 21 year old who had traveled to Mexico is in stable condition. An additional 16 cases were examined but were negative. Brazil is also examining 11 travelers; cases are also being examined in Panama, Honduras, Argentina, and Uruguay, and Chile.

In Asia, South Korea is examining a possible case, while China's stepped up its efforts to look for cases (and blocked import of pork from the US and Mexico).

Most of the cases that are being examined have traveled to Mexico recently, but secondary spread may be occurring in New York City. 45 cases have been confirmed to date, but many more are suspected or have been alluded to in news reports. This extended human-to-human chain of transmission is the worrisome part--if this is efficient, it's going to be much more difficult to get ahead of the virus and minimize spread. Expect much focus in the coming days and weeks to be on contacts of infected cases, in an effort to determine the frequency of secondary transmission...

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