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    Saturday, May 25, 2002

    "Assisted" Suicide: Tim Blair has a post about a woman who became a poster-child for the Australian euthanasia movement, and recently killed herself with an overdose of barbiturates. Her autopsy report is in. (via Glenn Reynolds)

    posted by Sydney on 5/25/2002 05:23:00 PM 0 comments

    Whooping Cough Ascendant: People who make it their business to track infectious disease trends around the world say that whooping cough is on the rise. Some speculate that this is because of waning immunity from the shot, others that the pertussis bacteria is becoming more clever at evading the immune system.

    One factor that isn’t mentioned explicitly in the article is the use since 1996 of the acellular pertussis vaccine instead of the whole cell vaccine. The pertussis vaccine is made of pertussis bacteria that have been killed. In the case of the whole cell vaccine, the whole dead bacterial cell is used. In the acellular version, just parts of the bacteria that are believed to be responsible for provoking immunity are used. The whole cell vaccine has more side effects than the acellular version, which in initial studies was found to be just as efficacious as the whole cell version. It made sense to switch to an acellular vaccine that would have fewer side effects while providing the same protection. The studies of its efficacy, however, were limited to infants. No studies were done to see how its immunity lasted into adulthood. This could very well be why our immunity is waning.

    The other factor, that is discussed in the article, is the shortage of pertussis vaccine. Normally, a child would get three doses of pertussis vaccine in the first year of life, one in the second year, and a fifth dose just prior to going to kindergarten. Thanks to vaccine shortages, we’re only giving the first three doses right now. This leaves a host of young children in daycare and public schools with waning immunity and a perfect environment to spread pertussis around. Vaccine manufacturing evidently isn’t all that profitable for drug companies, and fewer and fewer of them are doing it. We have shortages in this country of diptheria, tetanus, pertussis, measles, mumps, rubella, and influenza vaccines. It’s a public health matter that needs to be urgently addressed by the CDC, but one that it continues to ignore beyond making recommendations for delaying immunizations. It would be a far better thing for our congressional leaders and public health officials to concern themselves with insuring vaccine availability to the American public than to concern themselves with obesity, mammograms and the latest celebrity disease. Is anyone out there listening?
    posted by Sydney on 5/25/2002 01:52:00 PM 0 comments

    Nicotine Water: What a strange idea. I have to wonder how much of a kick you can get out of nicotine in water. I know it's absorbed by the oral mucosa, but I wonder how much of it survives the gut when it's ingested, and how much of it gets absorbed on the way down, especially when it's diluted in water. Still, it is a little stinky to put a known carcinogen in a drink and sell it, don't you think?
    posted by Sydney on 5/25/2002 06:49:00 AM 0 comments

    From the Weird and Wacky Department: Something you shouldn’t try at home, and a whole new meaning for the term "man's best friend".
    posted by Sydney on 5/25/2002 06:46:00 AM 0 comments

    News From Down Under:The Australians are having a malpractice crisis of their own.
    posted by Sydney on 5/25/2002 06:43:00 AM 0 comments

    Friday, May 24, 2002

    Chris Rangel has some thoughts on the obesity hormone. He's right. Although I made light of it in my post, the real culprit is caloric intake and lack of exercise, and we only fool ourselves if we believe otherwise.

    posted by Sydney on 5/24/2002 08:21:00 AM 0 comments

    Dental Curio: That picture to the right at this site is a street dentist's hat from the early nineteenth century.
    posted by Sydney on 5/24/2002 06:54:00 AM 0 comments

    Medical Community Anti-semitism Update: I missed this editorial last month in The Lancet, that's distinctly anti-Israeli in its tone, but a lot of people lambasted the journal for its bias this week. (link may require registration, but it's free).

    One of the letters,however,is even more anti-Israeli than the original editorial. To our shame, it is signed by many American doctors, most with positions in departments of public health at some of our “finest” universities. Their most ludicrous statement:

    “Members of the public-health and medical community issue an urgent appeal to the citizens of Israel and our colleagues around the world to demand a halt to the systematic violation of medical neutrality by the IDF at the command of their government. The gratuitous and wilful disruption of water supplies, electric power, and, through long-term and severe curfews, collection of refuse, combined with the destruction of the public-health and medical infrastructure present grave threats to the civilian population.

    A similar call to the Palestinian people to demand their government ends the violence and respects medical neutrality is now impossible because of the systematic destruction of civil authority by IDF and Israeli Government actions. Wherever and whenever control becomes feasible, we appeal to the Palestinian people and our colleagues around the world to demand the Palestinian authorities ensure the safety of all medical and first-responder staff as well.”

    Those Israelis. They’re preventing the Palestinians from hearing the pleas of the civilized world for peace and tolerance. Surely, if they could only hear us they would stop the suicide bombing. Sheesh. What planet do these people come from? Oh, that’s right, the planet of Schools of Public Health. Someone needs to tell them that infrastructure gets destroyed by wars, that's how wars are won. Destroying an enemy's infrastructure is not the same as specifically targeting their medical facilities or intentionally preventing them from tending to their sick and wounded. Oh, yeah, and someone needs to tell them that blowing up civilians repeatedly is a definite threat to public health.

    Just for the record, here are the signatories of the letter:

    “Signatories of the statement are: William Bicknell, Lewis Pepper, H Patricia Hynes, Richard Campbell, Richard Clapp, Thomas Webster, Nerissa Wu, Leslie Boden, Rana Charafeddine, and Robert Fredericksen, Boston University School of Public Health; Allen E. Silverstone, State University of NY, Upstate Medical University, Syracuse; Victoria Ozonoff, Massachusetts Department of Public Health; Max Pepper, School of Public Health, Craig Slatin and Charles Levenstein, Lowell, and Janice G Raymond, Amherst, University of Massachusetts; Howard Hu, Leslie London, Don Milton, Richard Levins, Eileen McNeely, Melissa Perry, Harvard School of Public Health; K H Barney, American Medical Resources Foundation; Anthony Robbins, Beth Rosenberg, Tufts University School of Medicine; David Wallinga, Institute for Agriculture and Trade Policy; Ted Schettler, Boston Medical Center; Dan Wohlfeiler, Robert Harrison, and R Ruth Linden, University of California, San Francisco; Lori Dorfman, Berkeley Media Studies Group; Robert M Gould, Kaiser Hospital, San Jose, CA; Tim K Takaro, University of Washington Schools of Medicine and Public Health and Community Medicine; Steven Wing, Annelies Van Rie, Trude Bennett, Kathy Rose, Carl Shy, Peter Dorman, University of North Carolina; Mark Eisenberg, Massachusetts General Hospital, Harvard Medical School; Bill Ravanesi Health Care Without Harm; Arthur Mazer and Kathleen H Mazer, Massachusetts Public Health Association; Blanca Estela Lemus Ruiz, Universidad Michoacana de San Nicolas de Hidalgo, Mexico; David Barkin, Universidad Autonóma Metropolitana, Xochimilco Mexico; Bill Patterson, OH+R; Wendy Orr, University of the Witwatersrand, Johannesburg; Howard Frumkin, Rollins School of Public Health, Emory University; John Morawetz, ICWUC; June M Fisher; Darius D Sivin, Johns Hopkins-Bloomberg School of Public Health; Dianne Plantamura, New England College of Occupational/Environmental Medicine; Joyce C Lashof, School of Public Health, U C Berkeley, CA; Cathy Walker, National Health and Safety Director, CAW-CANADA; Moira Cunningham and Enrico Cagliero, Harvard Medical School; Sonia Baur, Garberville, CA; Peter Kandela, Ashford, UK; Rodney Ehrlich, University of Cape Town.”

    By the way, this editorial was written April 13, a full two weeks before the Jerusalem Post exposed a movement afoot in the World Medical Association to oust the Israel Medical Association from the organization. (the link to the original newspaper story no longer works, unfortunately, but I quoted a lot of it in the original post.) This editorial makes me think the movement was very real, and not the “hoax” that the WMA says it was.The original Jerusalem Post story had said that the motion to oust the Israelis had been introduced by the British Medical Association. I'm sure the editors of The Lancet are prominent members. Luckily, the anti-semitic groups within the WMA were shouted down by other, more just-minded medical associations within the organization, and from without. For more information on the dust up, click here.
    posted by Sydney on 5/24/2002 06:39:00 AM 0 comments

    Why We're Fat: Our bodies won't let us loose weight. I've always suspected my body, not my mind, was sabotaging my weight loss efforts.
    posted by Sydney on 5/24/2002 06:38:00 AM 0 comments

    Mutant Mosquitoes: Genetically altered mosquitoes may be used to fight malaria. The only question is can we overcome our memories of those mutant insect movies from the sixties to accept such a thing?
    posted by Sydney on 5/24/2002 06:35:00 AM 0 comments

    Things You Always Suspected Department: It is possible to be bored to death.
    posted by Sydney on 5/24/2002 06:33:00 AM 0 comments

    Prostate Cancer Update: More news from that oncology conference in Florida. (They must have reporters there from every news organization.) Prostate cancer screening may not save lives, and doesn’t have to be done every year. I don’t expect we’ll be seeing any congressional hearings on PSA testing, however, like we did for mammograms.
    posted by Sydney on 5/24/2002 06:31:00 AM 0 comments

    Thursday, May 23, 2002

    Serendipity, the Mother of Invention: The story of the invention of a painless needle.

    posted by Sydney on 5/23/2002 07:54:00 AM 0 comments

    Devouring Monster Update: Smallpox Images courtesy of WHO.
    posted by Sydney on 5/23/2002 06:41:00 AM 0 comments

    Bioterror Bill Passes: The House passed a bioterror bill yesterday, now it's on to the Senate. The bill gives more money to the CDC to revamp their labs, stockpile drugs, and vaccines and "contain" infectious diseases. It would also:

    ".... provide extensive new training and tools for local public health authorities, the "first responders" to an attack with anthrax, smallpox or other lethal agents. Hospitals also would get help preparing for an emergency surge of critically ill patients"

    I just hope those local public health authorities use the money for bioterror and not to bolster their pet projects, like fighting obesity and urban sprawl.

    Meanwhile... the CDC continues to focus on lifestyle issues.
    posted by Sydney on 5/23/2002 06:39:00 AM 0 comments

    A Grain of Salt: Don’t believe everything you read on the internet about health. According to the Onion, don't believe everything you read about the Brady Bunch, either.
    posted by Sydney on 5/23/2002 06:37:00 AM 0 comments

    Celebrity Medical Watch: Michael J. Fox and Muhammed Ali pressure Congress for more Parkinson's disease money. The Parkinson’s disease organizations sure did hit the jackpot when these two came down with it.

    posted by Sydney on 5/23/2002 06:35:00 AM 0 comments

    Meridia, the weight loss drug, is in trouble again. Public Citizen, a consumer watchdog group, claims they failed to reveal serious side effects, including death, among users. The FDA says it's investigating.
    posted by Sydney on 5/23/2002 06:34:00 AM 0 comments

    There’s not a string attuned to mirth but has its chord in melancholy-Thomas Hood, Ode to Melancholy: My heart sank when I saw that the United States Preventive Services Task Force is recommending that doctors screen everyone for depression. Their recommendations:

    “Two questions ought to become part of the basic repertoire of every patient visit, the task force recommended in an announcement that coincided with the American Psychiatric Association's annual meeting here: "Over the past two weeks, have you felt down, depressed or hopeless?" and "Over the past two weeks, have you felt little interest or pleasure in doing things?"

    If a patient answers yes to either question, the task force recommended that doctors offer patients written or oral questionnaires. These ask more specific questions and establish whether the problems are transient or persistent. If the problems have lasted throughout the previous two weeks, and have interfered with the patient's ability to perform day-to-day tasks, doctors may make a diagnosis of depression.”

    It would be the rare person who could answer “no” to either of those questions. If I follow their guidelines, I’m going to be giving lengthy questionnaires to the majority of my patients and running hopelessly behind as a result. I’m also probably going to be overtreating a lot of people for depression. The U.S. Preventive Services Task Force knows this. The guidelines state:

    “The potential harms of screening include false-positive screening results, the inconvenience of further diagnostic work-up, the adverse effects and costs of treatment for patients who are incorrectly identified as being depressed, and potential adverse effects of labeling. None of the research reviewed provided useful empirical data regarding these potential adverse effects.” (italics mine)

    So why did they come out with this recommendation if they don't know what its adverse effects will be? It’s so unlike them. They are usually very good about basing screening recommendations on sound evidence, but lately they’ve been very sloppy. Their recent politically correct decision on mammograms entirely ignored the evidence-based recommendations of the respected Cochrane group. Now, they come out with a less than thoroughly evaluated recommendation on screening for depression, a cause that was dear to the heart of former Surgeon General David Satcher. I’m beginning to lose respect for the Task Force. They’re becoming too politically vested. I guess I’ll have to look to the Canadians for sensible guidance on evidence-based preventive health.
    posted by Sydney on 5/23/2002 06:30:00 AM 0 comments

    Wednesday, May 22, 2002

    Derek Lowe at Lagniappe also has some things to say about news from the American Society for Clinical Oncology meeting. This time it's about the "hot", "new" cancer drugs.

    posted by Sydney on 5/22/2002 02:45:00 PM 0 comments

    JAMA's weekly art history lesson.
    posted by Sydney on 5/22/2002 02:33:00 PM 0 comments

    Those Pesky Poxes: Here's a review of a book about the smallpox epidemic in colonial America, Pox Americana: The Great Smallpox Epidemic of 1775-82. I haven’t read it yet, but I’m planning to.
    posted by Sydney on 5/22/2002 02:32:00 PM 0 comments

    Of Breasts and Ovaries: Research released this week at an oncology conference and published in the The New England Journal of Medicine, suggests that women who have a gene mutation that predisposes them to breast cancer may benefit from surgical removal of their ovaries.

    When I heard this story, my first reaction was a knee-jerk anti-male-medical-establishment rejection of it worthy of Jane Fonda and the Our Bodies ,Our Selves crowd. After all, no one ever suggests that men have their testicles removed to save them from future prostate cancer. But then, I gave it a little more thought, and my feelings about it softened. After all, the studies only look at women with specific gene mutations that put them at higher than average risk of breast cancer and ovarian cancer. It isn’t quite the “those organs are bound to get cancer some day anyway, so you might as well take them out.” approach to hysterectomy and oophorectomy that I heard so often as a medical student from older (male) surgeons and gynecologists. It isn’t quite that, but it’s close.

    The BRCA1 and BRCA2 gene mutations do increase the risk of getting ovarian or breast cancer. They do not predestine the carrier to having the disease. The BRCA1 mutation increases the lifetime risk of breast cancer to 50-85%, and the lifetime risk of ovarian cancer to 20-40%. Those are wide ranges. That means we aren’t sure exactly by how much the risk is increased, but that it is significantly increased. Similary, the BRCA2 mutation increases the risk of breast cancer to 50-85% and the risk of ovarian cancer to 10-20%. The studies in question took samples of women who tested positive for either of these mutations. They then offered them the choice of surveillance or of total oophorectomy. In one of the studies, the women were divided into a group of 98 women who had their ovaries removed and 72 women who didn’t. The sans ovary group had three women (3%) who developed breast cancer within two years of follow-up. The surveillance group had eight women (11%) who developed breast cancer in the same time frame. Four of the women who kept their ovaries went on to develop ovarian cancer. The other study looked at more women over a longer period of time, but concentrated more on the risk of ovarian cancer. It compared 259 women who had already had an oophorectomy to a group of 292 women who still had their ovaries. Both groups had mutations in the BRCA1 or BRCA2 gene. Six women (2.3%) who had their ovaries removed were discovered to have undetected ovarian cancer at the time of surgery. Two women (0.8%) developed peritoneal cancer, a cancer of the lining of the abdominal wall and outer bowels that could be caused by wayward ovarian cancer cells. They were not the same women who were diagnosed with undetected cancer at the time of their surgery. In the surveillance group 58 (20%) developed ovarian cancer within eight years. The study doesn't say if any of them developed peritoneal cancer. Interestingly, they also looked at a subgroup of patients regarding the risk of breast cancer. They had to exclude patients who had previously had a mastectomy or had a personal history of some sort of breast cancer when the study was begun. That left them with a group of 99 women who had no ovaries, and 142 women who still had them. Of these two groups, 21 women (21%) in the sans ovary group developed breast cancer, and 60 (42%) in the control group developed it. In both studies, the majority of women did not go on to develop breast or ovarian cancer even if they kept their ovaries.

    An accompanying editorial in the New England Journal of Medicine comes down in favor of bilateral oophorectomy to reduce the risk of breast cancer in carriers of these two mutations. That’s fine, as long as the doctor who is doing the recommending makes it clear that oophorectomy isn’t entirely benign and that it’s not a foregone conclusion that a woman with the gene mutations is going to develop breast cancer. Nor is taking out the ovaries a guarantee that she will not develop breast cancer at some point. It only reduces the risk that she will. Removing the ovaries increases the risk of cardiovascular disease and osteoporosis. It can cause hot flashes, sexual dysfunction, weight gain, and sometimes a general sense of overall unwellness. Not everyone experiences this, but a significant number of women complain that they “just don’t feel like themselves” afterward. For some women, it may be worth it to eliminate the chance of developing ovarian cancer, or to reduce the risk of developing breast cancer. That choice, however, is a highly personal one, and it should be made with a full and complete understanding of its risks and benefits.
    posted by Sydney on 5/22/2002 09:52:00 AM 0 comments

    Physician Weblogs: I found another physician blogger last night - DB's Medical Rants. Check it out.
    posted by Sydney on 5/22/2002 06:52:00 AM 0 comments

    Tuesday, May 21, 2002

    History of Smallpox and Smallpox Vaccination: An online exhibit from UCLA on the history of smallpox and smallpox vaccine (warning:gruesome pictures), and the history of vaccination in the US from the Harvard Medical School Rarebooks and Special Collections (not so gruesome pictures). I think we are entirely too complaisant about this disease. It’s been too many years since it has ripped through the world for there to be any sort of collective memory of it. But, reading about it in the words of the people who lived with it, you can’t help but realize how horrible it must have been. These were people, after all, who lived before the age of antibiotics and antiseptics, and daily faced the threat of death from infections that we treat as minor annoyances. The fact that smallpox stood out as the “devouring monster” from all the others says a lot about its seriousness. Then, too, when was the last time a medical advance was celebrated so publicly and so enthusiastically as the discovery of vaccination was? Jenner seems to have been treated as a hero, with medals being struck in his honor and his hair being saved and passed around. It must have been worse than we can ever imagine to have been so feared and its conquest so celebrated.

    posted by Sydney on 5/21/2002 07:58:00 AM 0 comments

    Yada,Yada,Yada: The public service ads designed to turn teenagers against drugs aren't working. The ads designers are scratching their heads over this one:

    "It is unclear exactly why the ads haven't lowered drug use by kids in any measurable way. Antismoking campaigns and campaigns touting seat belts have been shown to be effective in getting adults to change their habits.

    Mr. Walters suggested that the ads' messages were "too indirect" to have an impact, and speculated that the commercials might be doing more harm than good. "If an ad answers a question that a child doesn't have, there's a chance you'll incite his or her curiosity," he said."

    Mr. Walters must never have lived around kids, or been one for that matter. The philosophy behind these drug adds overlooks one key aspect of teenage behavior: kids tend to do the exact opposite of whatever an adult tells them to do. It's the definition of cool.
    posted by Sydney on 5/21/2002 07:50:00 AM 0 comments

    Supreme Evil Medical Watch: Osama's kidney disease. Personally, I like to believe he's nothing but dust on a mountain by now.
    posted by Sydney on 5/21/2002 07:48:00 AM 0 comments

    Monday, May 20, 2002

    Smallpox Counterpoint: Dr. Ross Silverman has the following to say about smallpox vaccine and the public good:

    "I have several concerns about both a "mass vaccination" strategy, as well as the informed consent/"give the people what they want" strategy as you propose.

    First, you present your argument as if a smallpox attack is a given. While I appreciate the gravity of the situation -- 119 million or so unvaccinated individuals in the U.S., unknown protections for those vaccinated 30+ years ago, high contagion rate, 30% mortality & high levels of debilitating morbidity for the infected, the difficulty, if not impossibility, of giving
    potentially hundreds of millions of people 15 scratches each in a very short period of time -- it is still a largely theoretical threat. In my opinion, "educating the people on the risk of the vaccine and the disease" would have to include some information about the risk of attack. Otherwise, we're asking the government to put themselves in the position of creating a public
    health panic based on little evidence in order to get people to subject themselves to the shots.

    Second concerns the herd immunity argument you raise to protect the immunosuppressed/unimmunized. As I'm sure you know, a voluntary immunization program likely won't cut it for "herd immunity" purposes, unless we are able to scare the bejeezus out of the American public and frighten everyone to get vaccinated (and downplay the very real and very serious side effect threats of getting vaccinated). It will take 80-85% vaccination coverage to achieve herd immunity for smallpox, according to the CDC. Furthermore, a voluntary vaccination program likely will increase the chances of the immunosuppressed/unvaccinated of being infected by those choosing to get vaccinated (unless, of course, we can assume that every person getting a new vaccination will be able to completely avoid the immunosuppressed while they're still contagious). Furthermore, in many
    states, there is a religious and philosophical exemption to vaccination available, and some states, like Wisconsin, have even added a philosophical exemption to their proposed Model State Emergency Health Powers Acts, so that, even if we were to vaccinate everyone, there would still be a good percentage of people with non-medical reasons who would "opt out" of the vaccination.

    Finally, there is the ability of the health care community/government to minimize the side effects of vaccination. In order to minimize severe side effects, we need to have on hand a sufficient supply of Vaccinia Immune Globulin (VIG). These supplies, like the smallpox vaccine, are also controlled by the CDC; however, unlike smallpox vaccine production, VIG can
    only be produced from people recently vaccinated against smallpox. Therefore, our supplies of VIG are likely insufficient to adequately address the likely number of side effects we will face should we embark on a mass vaccination campaign. Except for a few stray CDC cites and the DA Henderson et al article in 1999 JAMA titled "Smallpox as a Biological Weapon," very
    few pieces on smallpox vaccination have addressed this issue."

    I have more faith in the ability of the general public to act for the greater good in the face of a crisis. I am also less sanguine about the risk of an attack. While I don't think that we should force anyone to have the vaccine who doesn't want it, I do think that if the public is given the straight facts about the lethality of smallpox and the risks of the vaccine the majority would choose to be vaccinated, and we would see rates approaching the 80-85% needed for herd immunity. After all, smallpox is much deadlier than any of the other diseases we ask people to be immunized against, and so, much more worth the risk. As for the immunocompromised, yes, they will be put at some risk from their vaccinated fellow citizens, but that risk pales in comparision to what they would face in an epidemic among an unimmunized public. No one can guess or predict what the chances are that a smallpox attack will occur. In times like this we have to assume the worst. Failure to do so would result in more of an outcry (and justly so) than we are seeing now over the intelligence community failures and 9/11. In the case of a smallpox attack, as it stands now, we would have imagined the worst and failed to act to prevent it.

    posted by Sydney on 5/20/2002 09:52:00 PM 0 comments

    A Pox on All Those Poxes

    A couple of readers e-mailed me about my previous post on smallpox vaccination. One correctly pointed out that if universal smallpox vaccination were offered, those who couldn’t be immunized would be protected by herd immunity. This is most certainly true. Another brought up the possibility of genetically redesigned smallpox that would be resistant to the vaccine. That, I think is less likely given the large size of the smallpox virus and the cross-immunity of the vaccine for several types of pox viruses. I thought the smallpox vaccine issue, however, deserved more attention.

    First, some historical perspective, straight from the horse’s mouths:

    On the disease:

    The havoc of the plague had been far more rapid: but the plague had visited our shores only once or twice within living memory; and the small pox was always present, filling the church-yards with corpses, tormenting with constant fears all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover.
    -Macaulay, Thomas Babington. History of England, chapter XX. London; 1848

    On innoculation and vaccination:

    The small pox, so fatal and so general amongst us, is here rendered entirely harmless by the invention of ingrafting, which is the term they give it. There is a set of old women who make it their business to perform the operation every autumn….The old woman comes with a nutshell full of the matter of the best sort of smallpox, and asks what veins you please to have opened. She immediately rips open that you offer to her with a large needle…and puts into the vein as much venom as can lie upon the head of her needle, and after binds up the little wound with a hollow bit of shell.
    -Montagu, Mary Wortley. Letter to Sara Chiswell, 1717. [Reprinted in Letters of Lady Mary Wortley Montagu, letter 31. 1779.]

    Medicine has never before produced any single improvement of such utility. You have erased from the calendar of human afflictions one of its greatest.
    -Thomas Jefferson, letter to Edward Jenner, 1801.

    Smallpox and smallpox vaccine. The greatest scourge of mankind and the greatest medical intervention to ever be introduced. Smallpox, with its thirty percent mortality rate, is the only infectious disease to have been completely eradicated from nature, and now it only exists (we hope) in laboratories in the United States and Siberia. Last week, the World Health Organization voted not to destroy those laboratory stocks. We'll never know all the politics behind that decision, but they claim that it was to allow further research into better vaccines and better treatment of smallpox. Destroying the last remaining virus stockpiles would, of course, render the need for vaccination and treatment needless. Needless, that is, unless they have good reason to think that somewhere, someone else has some smallpox virus that they plan to use for evil ends. If the latter is the case, then the CDC should stop dithering and debating and offer the vaccine to the public, for surely it won't be matter of "if" they use it, but of "when".

    When the CDC developed its current recommendation of quarantine and “ring vaccination” in the event of a smallpox bioterrorist attack, there was not enough vaccine available to vaccinate everyone in the country. Ring vaccination refers to the policy of vaccinating all exposed people , all contacts of exposed people, and all contacts of those contacts to try to contain the infection. It is, to say the least, logistically difficult. Given the limited vaccine supply, it was the best that could be offered. But now, we know we have other options. Last month, researchers announced that diluted vaccine can confer as much protection as the traditional dose. They calculated that using diluted vaccine could potentially increase the known available useable store of vaccine from 15 million doses to 150 million doses or more. At around the same time, Aventis, the maker of smallpox vaccine, found some 90 million doses in one of their warehouses. With dilution, that stock could be stretched to 900 million doses, four times the number needed to vaccinate the entire US population. The company has donated it to the United States, but so far no one has offered universal vaccination to its citizens.

    The smallpox vaccine actually isn’t made from the smallpox virus at all, but from the cowpox virus, vaccinia. (Thus the word “vaccine.”) Like the smallpox virus, the cowpox virus is a very large and complex viral molecule. It’s very close in structure to the smallpox virus; close enough to fool the body’s immune system into thinking cowpox and smallpox are the same virus, but different enough not to have the same lethality, or even to naturally infect people. The vaccine is what is called an “attenuated vaccine”, which means that it consists of live virus grown over and over in animal cells until it loses its potency without losing its ability to induce immunity. In a way, this is an advantage to us as we prepare to defend against those who would manipulate such things to cause us harm. Because the vaccine is a large virus molecule, produced in a cell culture, it’s difficult to guess what part of it would need manipulating to make the smallpox virus capable of escaping the immune system, while maintaining its virulence and lethality. I’m not saying that it couldn’t be done, only that it would be extremely difficult and unlikely.

    The fact that it is a live virus also means that there are more side effects from being vaccinated. A successful vaccine causes a local reaction and scarring at the site of innoculation. It also can cause fever and malaise. Because it is administered by scratching the virus into the skin, the virus can also be picked up and transferred to other parts of the body easily. For example, scratch the site of the injection then rub your eye, and you could get a cowpox infection in your eye. It can also result in a diffuse cowpox rash that is annoying but not fatal.

    The vaccine is not without some serious side effects. Because it is a live virus vaccine it cannot be given to those who have inadequate immune systems, (HIV infection, chemotherapy for cancer, certain arthritis drugs, long term steroid use, and pregnancy). It also is not recommended for people with atopic dermatitis or eczema. For some reason they are prone to a widespread skin involvement by the vaccinia virus. These same people are also at risk for complications if exposed to people who have been immunized. They would, however, also benefit from widespread public immunization in that they would be less likely to come into contact with a natural case of smallpox, which would certainly be fatal for them.

    Although the rate of side effects with smallpox vaccine is higher than we have become accustomed to with our modern immunizations, the incidence of severe complications is still extremely low, especially when compared to the thirty percent death rate from natural smallpox infection. The two most serious adverse reactions are encephalitis and progressive vaccinia, both of which can result in death. Encephalitis occurs when the cowpox virus infects the brain. It happens in roughly 12 out of one million people who are vaccinated for the first time, and in two out of one million who are vaccinated for a second time. Of those who are unfortunate enough to get this, 15% to 25% die, and another 25% have neurological deficits. Progressive vaccinia occurs when the vaccinia virus causes a serious local reaction at the site of the innoculation. The skin and muscle die, and the reaction can spread, and be potentially fatal. It occurs at a rate of 1 to 2 per one million first time recipients of the vaccine, and 6 to 7 per one million repeat vaccine recipients. It seems to be limited to people with defective cellular immunity, a condition that is not always recognized and is entirely different from the other usual immune deficiencies.

    Overall, the CDC estimates that there would be about one death per one million first-time vaccine recipients, and one death per four million people receiving the vaccine for the second time. That means that if we assume the highest fatality rate, we could expect about 290 deaths nationwide if every man, woman, and child in the United States were vaccinated. The actual number would probably be lower since those with contraindications would be excluded from getting the vaccine, and a significant number of us would have the lower mortality rate of second time recipients. Compare that to the fatality rate of having smallpox. Thirty out of every one hundred infected people die. From a general population standpoint, if a city is struck with a smallpox epidemic, and its citizens aren’t vaccinated, we can expect to lose five percent of the population. That would be 5,000 people in a city of 100,000. Expand that to several large cities and the loss would be devastating.

    The CDC says it expects to have 286 million doses of vaccine available by the end of the year. That’s still enough to vaccinate the US population, but by far less than could be available with the use of dilution. It also says it is debating a revision of its smallpox vaccination guidelines. They’re going to hold public forums to get our input, then discuss it among themselves again.They won’t reach a decision on recommendations until sometime in June. Meanwhile, the rest of us are kept out here at risk. Given the tenor of the times, it would be in everyone's best interest to speed the process. It would be far better for them to handle smallpox like the public health risk that it is. Educate the public on the risks of both the disease and the vaccine, and let each individual decide whether or not to be vaccinated. It’s the least we deserve.

    Clarification: My wording wasn't clear in the paragraph about smallpox mortality. The death rate is 30% in people who are actually infected. Not everyone in a city with a smallpox contagion is going to catch it, so the overall mortality for a population center would be less than that. In any given population that undergoes an epidemic of smallpox, the best guess is that the overall mortality of that population would be about 5%.
    posted by Sydney on 5/20/2002 07:09:00 AM 0 comments

    One patient's experience with clinical trials.

    posted by Sydney on 5/20/2002 07:04:00 AM 0 comments

    New cancer drug in the works. This certainly sounds promising. Anything that improves the way cancer patients feel while at the same time improving their survival has to be applauded, even if that survival is only improved by a few months.
    posted by Sydney on 5/20/2002 07:04:00 AM 0 comments

    Sunday, May 19, 2002

    Much Ado About Nothing

    “Of nursing children.
    Oh! what a raket do authors make about this, what thwarting and contradicting, not of others only, but of themselves. What reasons do they bring why a woman must needs nurse her own child? Some extorted from divinity. Sarah nursed Isaac, thereof every woman must nurse her own child. Why is it not as good an argument, that because David was a king and a prophet, therefore every man must be a king, and every king a prophet.
    And on the other side: it would make a dying man laugh, or a horse break his halter, to hear how they thwart all this again. Say they...the child draws his conditions from his nurse...Alcibiades being an Athenian, was so strong and valiant because he sucked a Spartan woman. Cornelius Tertius strained all the wits to find out the reason, why the Germans are such strong boned men: and the result of his weak and tired brains was, because they had sucked their own mother. And why had not Alcibiades bin so if he had sucked his.”

    -Nicholas Culpeper,Culpeper’s Book of Birth, 1651. On the breastfeeding controversy of his day.

    The World Health Organization, which has long been a watchdog for the infant formula industry in the developing world, now turns its attention to the use of infant formula in North America. Two Western breastfeeding advocacy groups, the National Alliance for Breastfeeding Advocacy (United States) and the Infant Feeding Action Coalition (Canada), presented reports at the recent WHO annual general assembly decrying the advertising of infant formula in the United States and Canada. They blame the formula manufacturers for the fact that only one in eight women in the US still breastfeeds by the time her baby is six months old, and they want the United States and Canada to adopt the rules and regulations governing formula advertising as set forth in the World Health Organization’s 1981 International Code of Marketing of Breast-milk Substitutes. The code is so draconian it’s easy to understand why the United States voted against it. Among other things it says that:

    Formula companies may not promote their products in hospitals, shops or to the general public.

    They can not give free samples to mothers or free or subsidised supplies to hospitals or maternity wards

    They can not give gifts to health workers or mothers.
    (those handy little diaper bags and cute little teddy bears are forbotten)

    They can not promote their products to health workers: any information provided by companies must contain only scientific and factual matters (no detailing doctors, no free samples for the poor)

    Baby pictures may not be shown on baby milk labels.

    Now, we’re not talking about the advertising and promotion of a drug, here, we’re talking about the advertising and promotion of food. Why should there be any restrictions on its promotion?

    The use of infant formula over breast feeding can pose problems in developing nations where safe water is hard to come by, and where an available supply of formula isn’t always guaranteed. In Armenia, in 1988, after a devastating earthquake, infant formula was shipped to the country for relief purposes, and its use heavily promoted, but contaminated water and an inadequate supply of formula led to an increase in infant mortality. Of course, these conditions aren’t seen in most Western countries. The United States and Canada have abundant supplies of safe water and easy access to plenty of formula. We also have a lot of mothers who must work outside the home to keep kith and kin together, making it impractical and often almost impossible to continue breastfeeding for the WHO recommended six months.

    Don’t get me wrong. I favor breastfeeding, both from a medical and a personal standpoint. Medically, I feel it’s by far the most nutritionally sound choice for a baby. Breastmilk, after all, is designed for human infants, and formula companies are continually striving to improve their products by making them closer to breast milk. Studies suggest that breastfed babies have fewer ear infections, bond more closely with their mothers, have fewer allergies, and have less colic. Recently, one study even suggested that breastfed infants grow up to be smarter than their formula fed peers, albeit by only a few points on the IQ scale. Personally, having breastfed three of my children, I can say that it was by far the best method, for the sole reason that it allowed me to be as lazy as I wanted to be while feeding the baby. Those night time feedings could be done in my sleep. I didn’t have to get out of bed and warm up a bottle. I just picked the baby up out of his crib, put him in bed with me, and went back to sleep while he nursed. I didn’t have to spend time in the evenings preparing bottles for the next day’s feedings. I didn’t have to spend time washing and sterilizing bottles. I didn’t have to exercise regularly to lose weight because lactation burns up an average of 500 calories a day. (I always weigh about twenty pounds less than my usual weight when I’m breastfeeding). Best of all, I could read books and breastfeed at the same time. Everyone respects the privacy of a nursing mother, so some of my best reading was done during my maternity leaves while the children nursed.

    Having said all of that, though, I have to acknowledge that breastfeeding isn’t for everyone. If breastfeeding came to us all as naturally as breastfeeding advocates would have us believe, how do you explain the existence of wet nurses throughout history? If breastfeeding is everything it’s cracked up to be, why did formula ever come into existence? For whatever reason, be it the physical design of their breast, their lifestyle, their family situation, or just personal preference, some women just aren’t able to or don’t want to breastfeed. This, too, I know from personal experience. For, although I nursed three children, I have a fourth that was exclusively bottlefed after the first week of life. Of the three I did nurse, only one took to it readily. The other two were a constant struggle for the first several weeks. Neither of them were easy to nurse until they were about two months old. In the meantime, I nearly drove myself, and my husband, insane trying to get them to breastfeed. I was too stubborn and too invested in the idea that “breast is best” to give up the effort. Suffice it to say that I turned to bottlefeeding in my second child only after the most difficult and harrowing experience with breastfeeding I’ve ever had. And you know what? He did fine. His infancy was uneventful. He was my most complacent baby. He’s the only one of our children who doesn’t have allergies. I can’t remember the last time he was sick. He’s never had an ear infection. He’s emotionally closer to me than any of the other three, and as far as his intelligence goes, he’s on or above par compared to his siblings. In short, he explodes every preconceived notion about the benefits of breastfeeding. He is not alone. The truth is, if clean water and formula are available, babies do just fine on formula feedings. That's why our government spends as much as it does on infant formula, so it can be provided to poor women under the WIC program if they choose not to breastfeed.

    So, why all the fuss about formula advertising and promotion, especially in the West where formula can be used safely and effectively? The formula companies actually bend over backwards to acknowledge the benefits of breastfeeding. Just click here to see what the makers of Enfamil have to say on the subject. Similac doesn’t approach the subject with quite as much breast boosterism, but it does acknowledge the superiority and advantages of breastfeeding. This is truth in advertising to a degree rarely seen in most products, and never seen in drug advertising. But, of course, breastfeeding advocates have an agenda. They believe with all their hearts that breastfeeding is not only the best choice, it’s the only choice. If given the chance, they would impose their views of parenting and motherhood on every woman. We would all be forced to nurse our babies for the requisite six months. Work and family and personal preference be damned. Witness the appointment in Wales of a "breastfeeding tsar" last week. Their language betrays their intent. Luckily, we live in a nation that is free to ignore the WHO and doesn’t have to rely on it for healthcare money and assistance, unlike developing countries. Otherwise, we too, would be forced to live by the breastfeeding militants’ rules.

    posted by Sydney on 5/19/2002 09:42:00 AM 0 comments

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