An ‘apple a day’ keeps the prescription medications away?



Last week, a research article titled “Association between apple consumption and physician visits: appealing the conventional wisdom than an apple a day keeps the doctor away” was published online in the journal JAMA Internal Medicine. A great premise for a health research study, albeit the long research title. The article is written up in a clever, straightforward way – the authors propose, that,

“Although some may jest, considering the relatively low cost of apples (currently $1.13 per pound of Red Delicious apples), a prescription for apple consumption could potentially reduce national health care spending if the aphorism holds true.”

What did they do?

The article presents the results of a classic epidemiological study – a cross-sectional analysis of the U.S. National Health and Nutrition Examination Survey (NHANES). NHANES is a long-running nationally-representative survey of civilian, non-institutionalised American adults. The survey is conducted every few years, when a new random sample of the population is drawn. The authors of the study pooled together respondents from the 2007-08 and 2008-09 rounds of the survey, to get an eligible sample of 12,755 survey respondents (1). From there, they used data from 24-hour dietary recall questionnaires, demographics, health examinations, and health questionnaires completed by the survey respondents (1). After accounting for missing data, excluding all survey respondents who reported that their 24-hour diet questionnaire that they filled out was not representative of their usual diet, and those whose apple consumption came solely from apple juice and apple sauce, the study included 8,399 study participants (1).

The researchers estimated the total grams of raw apple consumed by each study participant during the 24-hour dietary recall period, by linking the reported foods to the U.S. Environmental Protection Agency’s Food Commodity Intake Database (1). They defined study participants as ‘apple eaters’ if the daily amount of apple they reported eating was equivalent to 149 grams (1 small apple). They investigated whether there could be a dose-response relationship between apple consumption and avoidance of health care visits by comparing the effect of eating 1 small vs. 1 medium vs. 1 large apple per day against eating no daily apples.

“Keeping the doctor away” was defined as successfully avoiding more than one visit to a physician in the past year. One physician visit was allowed, as American adults are recommended to visit their doctor each year for an annual health check-up.

What did they find?

The researchers estimated that 19.3 million U.S. adults are ‘apple eaters’, who consume about 26.9 million small apples daily, weighing 8.8 million pounds (1). In contrast, 207.2 million adults were estimated to be non-apple eaters – the majority of the population. Apple eaters were no more likely to avoid visiting the doctor than non-apple eaters (Odds Ratio = 1.19; 95% Confidence Interval: 0.93-1.53), regardless of the size of the daily apple (p-value for trend = 0.06). There was also no difference in overnight hospital stays or mental health visits between apple eaters and non-apple eaters. However, people who ate a daily apple seemed more likely to avoid taking prescription medications than non-apple eaters. When comparing ‘small’ and ‘large’ apple eaters against non-eaters, there were no differences in medication-taking, as the odds ratios were of small (but positive) magnitude and the 95% confidence intervals were wide, indicating imprecise estimates due to small sample size. However, the odds ratio for ‘medium’ apple eaters was positive and statistically significant for avoiding taking prescription medications, and the overall trend in the dose-response relationship between size of daily apple and odds of avoiding medications was statistically significant (p-value for trend = 0.02). Trend analyses, while reliant on p-values, are useful in small sample size situations where a linear dose-response relationship is plausible, as they indicate the overall relationship across categories of exposure (a.k.a. size of apple).



What does it mean?

Although there are limitations of this study – think of all the possible ways in which apple eaters could differ from non-apple eaters, that might also affect whether they might take prescription medications or not (aside from age, sex, race/ethnicity, education, body mass index, smoking status, and health insurance type, which were accounted for). Unmeasured and subsequently uncontrolled confounding in studies like this can always skew results. The study authors propose a prospective or experimental design for the future, to help reduce the likelihood of residual confounding and establish the correct temporality of the relationship – that apple eating comes before not taking medications, and not the other way around. Based on their results, the authors suggest an update of the well-known aphorism to be,

“If anything, apple eating may help keep the pharmacist away.”

It doesn’t quite roll off the tongue, but certainly gets one thinking about how and why these aphorisms come into use in the first place.



1) Davis MA, Bynum JPW, Sirovich BE. Association between apple consumption and physician visits: appealing the conventional wisdom than an apple a day keeps the doctor away. JAMA Intern Med 2015; doi: 10.1001/jamainternmed.2014.5466

Image sources

Fuji Apples: By Scott Bauer, USDA ARS [Public domain], via Wikimedia Commons

Prozac Pills: By Tom Varco (Own Work) [CC BY-SA 3.0 (], via Wikimedia Commons

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Games That Teach You Something About Public Health

Reading is great, but sometimes it’s more fun to learn by playing. Here are a few games that will end up teaching you something about public health:

Screenshot from Spent game

Spent: This game is for anybody who feels like they know how they would live if they were poor. Just don’t buy as much stuff, right? The game, created by an ad agency for Urban MInistries of Durham, starts you off with $1000 in the bank and asks you to choose a job. From there, you have 30 days’ worth of expenses and decisions. You win if you can make it through the month without going broke.

The game was informative, not just because of the statistics and facts sprinkled throughout, but because it hit hard emotionally. I won (one of the times I played it), and was even able to afford to help a relative buy medication toward the end, and take a community college course that could help me earn more money in the future. But to get there, I had to forgo health insurance, stop paying my gas bill, deny my kid the opportunity to participate in a sport (I couldn’t afford the uniform and physical), and when my pet got sick, it was cheaper to put him down than to pay for treatment.

For some decisions, you can ask a friend for help (to do laundry at their place for free, for instance)–but that required posting to Facebook or Twitter, something I hate to do because who wants to annoy their friends or explain to their friends what they’re doing? Point taken.

Screenshot of Vax game

Vax: This is a short, fast-paced game that pits you against an infectious disease. Your playing field: a network of susceptible people.

You get a head start, with a limited number of vaccinations you can give before the disease starts to spread. When you vaccinate somebody, they drop out of the network, their dot disappearing and the network breaking apart. Once the outbreak begins, your only tool is quarantine, which likewise drops people out of the network.

Strategies that win: vaccinating (or quarantining) people who have the most connections, which has the biggest impact on the route the disease can travel. If you can completely split the network into pieces, that helps you too. But beware: When you reach the “hard” level, you’ll find that some people in the network refuse to be vaccinated. The game was developed by Marcel Salathe’s epidemiology research group.


Gut Check – This one was designed by microbiologist Jonathan Eisen. It’s a “real” game, the website says, but “one might accidentally learn about concepts such as antibiotic resistance, hospital-acquired infections, prebiotics, probiotics, opportunistic infections and more.”

In this card game (which regretfully I have not played yet), you and friends each try to develop your own microbiome, filling it with beneficial species—but you can also play pathogens on your opponents, pass around antibiotic resistance plasmids, and spread germs in crowded places with the “airplane trip” and “go to work sick” cards. There’s even a homeopathy card for those turns when you’d rather not play anything at all.

The game is available as free downloads to print, and the makers are working on a professionally printed version too.

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Drink makers are squirrely about ingredients, even when they share nutrition info

Alcoholic beverage manufacturer Diageo made headlines recently for announcing they will put nutrition labels on their products, including Guinness and Smirnoff brands. But the buzz about nutrition information (which I wrote about, briefly, for Lifehacker) skipped over what should be considered a major omission: Drink makers still aren’t disclosing their ingredients in many cases. For at least one type of sugary liqueur, Diageo forgot(?) to list the sugar.

I took a look at Diageo’s nutrition website, Nutrition information, including alcohol content, calories, and other nutrients like carbohydrates, is all there. Unlike typical US “Nutrition Facts” labels, the types of carbohydrates and fats aren’t broken down, but totals are given. Many drink makers have this information available on their websites; it’s putting labels on the drinks themselves that’s rare. In fact, until 2013 they weren’t allowed at all in the US. (Meanwhile, some drinks, like cider and gluten-free beer, fall into a loophole requires nutrition labels.)

The pages for Bailey’s Irish Cream liqueurs look good at first glance, giving this information as well as an ingredients list: “Cream, Whisky, Natural Flavors.” But a major ingredient is missing: sugar.

There’s no way that any of cream, whisky, or natural flavors contain the listed amount of carbohydrates. And in fact, if you look up Bailey’s on its main website, a nutrition breakdown specifies there are 20 grams of sucrose per 100 mL (or about two teaspoons per shot)–which could only come from added sugar. (Cream doesn’t contain much sugar, and it’s not in the form of sucrose anyway.) Diageo did not respond to my requests for comment.

The rest of the DrinkIQ website is hit-or-miss, with ingredients lists sometimes reading simply “N/A” and, for the Johnnie Walker brands of scotch, the ingredients list is replaced with a short paragraph about the use of oak barrels and caramel coloring.

I searched in vain for drink manufacturers that consistently do a good job of publishing their ingredients (especially for non-beer drinks; some breweries do list theirs). Know of any you’d like to call out for doing a good job? Leave a note in the comments.

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A healthy society is a disaster resilient society

Today, we warmly welcome to the blog Professor Shinichi Egawa from the Division for International Cooperation for Disaster Medicine, International Institute of Disaster Science at Tōhoku University. His bio can be found at the bottom of this post.

Disasters are usually measured by the number of deaths, injuries and damage to property that they cause. But, do these measures truly express the magnitude of damage to people’s health and quality of life?


In 2011, the earthquake that struck the Pacific coast of Tōhoku, with a magnitude of 9.0 (Mw), was the largest to ever hit Japan and the fourth most powerful in recorded history. Strong national building codes protected most of the buildings in Japan from this devastating earthquake and saved many lives as a result, but the people affected by that disaster still suffer from chronic illnesses, mental problems, loss of family and exposure to nuclear power plant accidents—most notably Fukushima, which continues to pose contamination risks due to the severe infrastructure damage it incurred during the earthquake. The public health situation of a community is a key factor in measuring their resilience against disasters, and accordingly, the strengthening of mental and physical health must be made a priority when looking to curb the risks posed such disasters in the future.


Damage at Akai, Higashimatushima, Miyagi | Wikimedia Commons CC BY-SA 3.0 ChiefHira

On the other side, the process of rebuilding after a disaster is just as important as the capacity and resilience building processes that happen prior to a disaster. Health professionals have an important role to play in facilitating mutual, cooperative relationships with non-health professionals as they work together to help rebuild communities. Specialists, such as those involved in disaster medicine, need to forge partnerships with general health providers to create a unified approach to community resilience and rebuilding programs. The role the health professional plays is not only important in the acute response to injuries caused by disasters, but also in preparedness work, which is crucial to later making an efficient response to any disaster.


In Japan, for example, nation-wide disaster medical response systems have saved many lives. With the Tōhoku earthquake in 2011, systems such as disaster-base hospitals, disaster medical assistant teams (DMAT), staging care units (SCU), wide-area transportation systems, emergency medical information systems (EMIS) and disaster medical-public health coordinators worked efficiently in the immediate aftermath of the earthquake, saving countless lives and limiting the impact of the disaster.


Despite these efforts, however, the medical and public health needs of the affected people exceeded the relief capacities in place at the time and, indeed, for several months after the event. Mental health problems including post-traumatic stress disorder (PTSD), depression and alcoholism are still huge problems in those affected, and it will take years to find solutions to these issues. Medical and public health preparedness should be emphasized and prioritized in order to build resilience to disasters in the form of long-running, systematized global health programs.


During the International Symposium for Disaster Medicine and Public Health Management that took place last May, scientists and experts in disaster medicine and public health reached a consensus that health concerns should be imperative in the formulation of disaster risk reduction interventions. Prioritization of the people’s mental and physical health in the process of disaster risk reduction should be in included in frameworks and policy at all levels. Preparation for people who need special assistance, such as those with disabilities, children and women, elderly people, people with chronic illnesses, foreigners and travelers, cannot be made without their own participation in the process of disaster risk reduction planning.


To achieve the above, education and training of general health-care providers and the continued development of the field of disaster medicine and public health are the only methods that will lead to long-lasting implementation.


All of this will be in the spotlight at the 3rd World Conference for Disaster Risk Reduction taking place in Sendai, Japan this week. The Hyogo Framework for Action (HFA), endorsed by the UN General Assembly in 2005 to make the world more disaster resilient, will be revised in Sendai to reflect the post-2015 development agenda and give greater emphasis to the health of those vulnerable to the risk of natural disasters. The original HFA did not do enough to influence the design of existing national social protection mechanisms, particularly with regard to health programs and education schemes, which are crucial to building resilience to disasters. The new framework HFA framework under discussion in Sendai is meant to cover the next 20-30 years and will be expanded to include such important areas of social protection, like heath and education, effectively leading to the scaling-up of disaster resilience before disasters hit.


We, as health professionals, are striving to strengthen community resilience to disasters through the improvement of physical and mental health services. To do this, health professionals must be regarded as a key stakeholder working in concert with other professionals in the field of disaster risk reduction.


Professor Shinichi Egawa is Professor at the Division for International Cooperation for Disaster Medicine, International Institute of Disaster Science in Tohoku University – the epicentre of the 2011 earthquake and tsunami. Prof. Egawa leads efforts in Disaster Risk Reduction through his research in preparedness with a prioritisation in health as a central goal of risk reduction and management. He will be working closely with UNISDR on the new Hyogo Framework for Action that will be adopted this weekend in Sendai. He is also part of the Disaster Risk Reduction scientific committee at the forthcoming Forum 2015.

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How does the FDA regulate mobile medical apps?


Last month, the FDA released new guidance regarding the regulation of mobile medical apps, to replace its earlier version from 2011. Since that time, the amount of health and medical apps on the market has exploded, with the release of Apple’s Health app with iOS 8 cementing mobile health as ‘a thing’. Needless to say, it is about time for a regulatory update.

The FDA defines a ‘mobile medical app’ as a mobile app that is intended to either (1):

–       Be used as an accessory to a regulated medical device; or

–       Transform a mobile platform into a regulated medical device.

What is a regulated medical device? The FDA guidance states that (1):

When the intended use of a mobile app is for the diagnosis of disease or other conditions, or the cure, mitigation, treatment, or prevention of disease, or is intended to affect the structure or any function of the body of man, the mobile app is a device.

Leaving the sexist nature of this terminology aside, we can see that the FDA takes a very clinical perspective on what types of apps they consider as falling in their domain. This approach is practical. It means that they a priori alleviate themselves of responsibility for the numerous health apps continually being produced, which allows them to focus on those apps posing the greatest risks to users. An app which intends ‘to affect the structure or any function of the body of man’ is potentially much more impactful than a simple diet tracking app. Or is it? And is it debatable whether diet and fitness apps intend to alter the structure or function of man?

Apps, which the FDA will not regulate, but will ‘exercise enforcement discretion’ over, are those that help users to self-manage their disease or conditions without providing specific treatment or treatment suggestions, help users track or manage their health (e.g. trackers for diet, exercise, sleep, mood), apps that provide access to electronic health records, apps that help patients communicate with doctors (e.g. by providing videoconference portals or allowing patients to take snapshots of their symptoms), or those that perform calculation for things like body mass index or pregnancy due date (1).

Apps that are regulated are those that, for example, turn the mobile into a control for a medical device such as a blood pressure cuff or insulin pump, or transform the mobile into a medical device such as an electronic stethoscope or a blood glucose reader (1). The rationale for regulation of these latter uses is that these types devices are already FDA-regulated, and would pose a risk to patients if improperly functioning (1).

Does this mean there is no risk associated with the ‘softer’ uses of medical apps, which are not regulated? Of course not. The risk is lower, perhaps, but apps may contain false or misleading health and medical information, which could be improperly used if taken uncritically. The growing knowledge economy of our society means that education and literacy are far more important than ever before, and this is true down to such a small issue as using health apps on a mobile phone to gain a real personal benefit.

Recently, we have seen the FTC fine the makers of apps that purported to aid in detecting malignant melanoma, which would qualify as being a medical device (2). It will be interesting to see how the regulatory landscape evolves in the future, which will depend on whether there is real transformative power of these non-medical device health apps to influence people’s behaviour and health decisions.



1. U.S. Department of Health and Human Services Food and Drug Administration, Center for Devices and Radiological Health, Center for Biologics Evaluation and Research. Mobile medical applications: Guidance for Industry and Food and Drug Administration Staff. U.S. Department of Health and Human Services Food and Drug Administration. 2015.

2. Dredge S. FTC fines app firms for claiming their technology could detect melanoma. The Guardian. Wednesday Feb 25 2015. (accessed 02 March 2015).

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The dangers of doing nothing: What pregnant women need to know about clinical trials

KaitlinB9_9.jpgPlease welcome a guest post by Kaitlin Bell Barnett, who writes about health and medicine for various print and online outlets. She’s at work on a book about medications and medical care in pregnancy. Her first child is due in July.



Photo Credit: edoctorvn

New FDA guidelines say that clinical trial participants should know not just the risks and benefits of the study they’re enrolling in, but how those risks and benefits compare to the typical care they’d get at the doctor’s office. These recommendations, which are expected to be finalized later this year, seem reasonable enough at first glance. But, they’re likely to further hamper research in a population that’s already badly underrepresented in clinical studies: pregnant women.

Researchers already avoid conducting studies on pregnant women because of concerns about risks to the fetus. In clinical practice, this lack of research often translates into women foregoing care, since doctors know very little about how certain drugs could affect the developing fetus. Better safe than sorry, they reason.

Pregnant women’s lack of inclusion in formal studies doesn’t mean they’re not being experimented on. They are – just not in a systematic way that would help clarify how helpful or harmful medications and other interventions actually are. The average expectant woman takes three to five prescription drugs during her pregnancy, not to mention many over-the-counter herbs and supplements.

“It’s really problematic that we don’t know even the basic pharmacokinetics of how certain medications work in pregnant women,” says Miriam Kuppermann, head of the clinical research program for the University of California, San Francisco’s maternal-fetal medicine program. “There’s good reason to believe that those will be different in pregnant women because of all the pregnancy hormones.”

When it comes to disclosing the risks and benefits of the typical “standard of care”, as the proposed FDA guidelines recommend, researchers face a catch-22: How can they inform pregnant participants – or participants who may become pregnant during the course of the trial – about risks and benefits that simply aren’t known?

The key lies in how they communicate risks, and how they present the “standard of care” for pregnant women.

Pregnancy and Depression

Take the case of depression, which affects 12 to 15 percent of pregnant women.

Some recent studies suggest that SSRI antidepressants may increase the risk of first-trimester miscarriage, preterm birth, minor complications after birth, and that one drug, Paxil, increases the risk of cardiac defects. Other studies, though, have found no increased risk. And a substantial body of evidence shows that mothers who are depressed while pregnant have a higher risk of preterm labor, low birthweight babies and other pregnancy complications that can hurt the baby, especially if the mothers are too depressed to eat properly, exercise, go to prenatal checkups, and otherwise adequately care for themselves.

Clearly, more research is needed on the most effective ways to treat prenatal depression. Informed consent materials and procedures for a study of a drug or therapy should explain the reasonably foreseeable risks and benefits of that intervention – both to mother and fetus – based on any previous data.

Because there is no single, accepted standard of care for prenatal depression, informing women about their alternatives if they were to seek treatment at the doctors should cover all the major options: the effectiveness and risks of antidepressants, different modes of therapy – and of untreated prenatal depression.

Too Much Information

It’s easy to see how all this talk of risks and benefits, most of them still ill-defined, could overwhelm prospective subjects.

“If you don’t know the risks and benefits, then telling pregnant women that they need to weigh them is just a way of making them feel stressed out,” says Georgetown bioethicist Rebecca Kukla, who has sat on IRBs, the governing bodies for universities and hospitals that handle informed consent procedures. “It’s literally an impossible burden to follow.”

Doctors, researchers and bioethicists have already voiced concerns that the requirements to disclose yet more risks will trip up research, not just involving pregnant subjects (a public comment period on the guidelines ended last month).That situation is likely to be even worse when it comes to pregnant women, since the quality of data for commonly-used medications that constitute the standard of care are is of such poor quality, and because the risks and benefits for both the mother and fetus must be weighed.

“If it were to have a general chilling effect I could definitely imagine that it would it would have an even greater chilling effect on pregnancy, because everything does,” says Margaret Little, who runs Georgetown’s Kennedy Institute of Ethics and has written extensively about pregnant women’s participation in clinical research. “There’s such an aversion to doing [this research] anyway that it adds one more stone to the big pile of rocks that are keeping people from doing this.”

Indeed, research shows more information is not always more helpful when it comes to informed consent, says Kuppermann, who studies methods of presenting risks and benefits to trial participants. Sometimes, simpler is better.

The number needed to treat and number needed to harm

To avoid drowning subjects in a sea of statistics, researchers should more widely employ two easy-to-understand measures of risk and benefit: the Number Needed to Treat (NNT) and the Number Needed to Harm (NNH). The NNT captures how many people would have to take a drug or receive the treatment in order for at least one person to benefit. Its twin, the NNH, calculates how many people must be treated in order for one additional person to be harmed

One study showed, for example, one additional miscarriage for every 26 women treated with antidepressants (the NNH), while another review of multiple studies showed 1 additional person saw improvement in depression symptoms for every 5 people receiving antidepressants, compared to one person in seven for placebo. By providing both statistics, researchers can more clearly communicate how the benefits of treatment stack up against the risks.

Including the NNT and NNH stats along with succinct summaries of research findings regarding the effects on both mother and fetus would help pregnant women evaluate the risks and benefits of enrolling in the trial – and of the treatments they would likely receive (or not receive) in ordinary medical care.

Then and only then can pregnant women truly know what they’re getting themselves into – whether they choose to enroll in the study or go to the doctor.


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Will Google’s new health search function change the way we manage health?



Google says that one in twenty searches is for health information (1). For many people, the Internet has become the first port of call when a strange symptom, the common cold, or morbid curiosity in the ‘Google Images’ bar strikes. However, the ‘armchair medicine’ often doled out by the Internet, along with the unscientific popular health discourse introduced by the likes of Dr Oz, has made for murky waters of health information seeking (2).

How are we to find relevant, high-quality, and evidence-based health advice when the trillions of gigabytes of Internet space are loaded with misinformation?

Enter the brilliance of Google’s search algorithm. Google has just announced that they will now be adding health information directly into search results. It will be included in the Knowledge Graph – the little box that often appears in the upper right-hand corner, showing basic statistics and information about a subject. The health information will be sourced from a database fact-checked by physicians at the Mayo Clinic, adding credibility, quality, and a sound evidence base (1). That is, if it done properly, although there is no reason why it should not be.

This new search addition could be revolutionary, in terms of providing accurate health information to people who need it. In 2008, the U.S. Health Information and National Trends Survey (HINTS) found that while over half of the adult American population turns to the Internet first when searching for health information, trust in the Internet as a reliable source of information was low and had declined over the first decade of this century (3). People often leave Internet health searches feeling frustrated, confused, and likely no closer to the answers they are seeking (4). Given the major shift we are experiencing in online communication technologies and health information technologies – we may not be far off from being able to access our own electronic health records – information must be available in an appropriate and equitable way so that all people can use the power of technology to better learn about and manage their health.

Last year, the Pew Research Center found that 87% of all Americans now use the Internet (5). Ninety percent of them say that the Internet has been a good thing for them personally, and three-quarters say that the Internet has been a good thing for society (5). It seems as though Google’s new health search addition will contribute to this positive attitude – and to the ubiquity of this company in the digital information industry. The transformative power of Internet searching on people’s behaviour and health management is yet to be determined.


  1. Ramaswami P. A remedy for your health-related questions: health info in the Knowledge Graph.Weblog. (accessed 18 Feb 2015).
  2. Korownyk C, Kolber MR, McCormack J, Lam V, Overbo K, Cotton C, et al. Televised medical talk shows – what they recommend and the evidence to support their recommendations: a prospective observational study. BMJ 2014;349:g7346.
  3. Health Information National Trends Survey. Brief 16: Trends in cancer information seeking. (accessed 18 Feb 2015).
  4. Arora NK, Hesse BW, Rimer BK, Viswanath K, Clayman ML, Croyle RT. Frustrated and confused: the American public rates its cancer-related information-seeking experiences. J Gen Intern Med 2007;23(3):223-8.
  5. Fox S, Rainie L. The Web at 25 in the U.S. (accessed 18 Feb 2015).

Image: “Google” by Google Inc. Public domain.

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Let’s stop playing politics with vaccines

Sriram Ramgopal (guest poster)Please welcome a guest post from Sriram Ramgopal, a resident physician in the Department of Pediatrics, Children’s Hospital of Pittsburgh. He is interested in pediatric advocacy and is pursuing a career in Pediatric Emergency Medicine. 

Politically motivated fearmongering about vaccination is putting children in our community in danger. During the Republican presidential primaries leading up to the 2012 election, former representative Michelle Bachmann criticized Governor Rick Perry’s mandate for the HPV vaccine, which protects against a cancer-causing virus. She claimed at the time that she had met parents who believed that the vaccine gave their daughters “mental retardation.” These statements introduced a new precedent of injecting issues of vaccine safety into presidential politics. The American Academy of Pediatrics made emphatic statements at the time to clarify that the HPV vaccine does not cause mental retardation, but by this point the damage had been done: fear had taken hold in parents’ minds.

In 2015, with the presidential election around the corner and a widespread measles outbreak on our minds, the dangerous mix of immunization paranoia and politics continues. Senator Rand Paul, physician and presidential hopeful, claims to have met “many tragic cases of walking, talking normal children who wound up with profound mental disorders after vaccines,” a statement that is dubious at best. His words are grounded in a fraudulent study that has long since been retracted and its author now discredited. Governor Chris Christie has also entered into the debate by stating, “parents need to have some measure of choice in things as well, so that’s the balance that the government has to decide.” By employing the rhetoric of individual rights and a fear of big government, those in public office often attempt to score cheap political points and win public acceptance. Politicians like Senator Paul and Governor Christie are brandishing discredited ideas as tenable arguments against clear evidence-based recommendations to vaccinate, sowing confusion amongst parents.

According to the World Health Organization, measles is a leading cause of death worldwide, despite the universal availability of a widely researched and safe vaccine against it. The disease killed over 145,000 individuals, most of them children under 5 years of age, in 2013. Immunization against diseases like measles not only protects those that receive the vaccines but also helps to protect those who are not eligible to receive them, such as young infants and children with deficient immune systems. It is these children who are also at the highest risk of grave complications ranging from encephalitis to pneumonia, and depend on the rest of us to protect them.

It is no secret that vaccination rates across the country are falling. Based on CDC data, the nationwide measles, mumps and rubella vaccination rate among 19-35 month-olds is 91.9%, down from a rate of 92.3% in 2006. Rates are falling most in Ohio, Missouri, West Virginia, Connecticut and Virginia. It is very possible that more and more parents will choose to opt out of immunizing their children for fear of side effects, thanks to the dissemination of groundless claims. In response to the current epidemic, the American Academy of Pediatrics has released a recent statement once again exhorting parents to vaccinate their children, reiterating what they have said for decades: the measles vaccine is safe and effective.

We are already burdened with a wide number of celebrities, discredited researchers, and physicians relying on anecdotes and hearsay who are more than willing to use the vaccine controversy to gain quick publicity. Politicians should be clear to the public on the proven science of vaccines and should avoid muddying the waters further. It would be better for the candidates, too: it is widely believed that Michelle Bachman lost credibility because of her statements on vaccines in 2008. Senator Paul and Governor Christie should learn a lesson from her failure and be willing to communicate a clear message to the public: vaccines are safe and are effective at protecting against dangerous diseases. Unnecessary vaccine exemptions put our greatest asset – our children – at risk.

The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, the Children’s Hospital of Pittsburgh or the University of Pittsburgh.

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What I use the scientific literature for


Spandrels in the Arc de Triomphe | Wikimedia Commons CC BY-SA 3.0 Thesupermat

As a PhD student, it is fully accepted by myself and by society at large that I have a nerdy side. My dream job is to while away hours in front of my computer, thinking, analysing data, writing, re-writing, writing some more, and of course, reading academic literature.

The PLOS Integrative Paleontology blog recently discussed what the scientific literature is used for, and called for others to weigh in. Although the main metrics we use to gauge the consumption of academic literature are citations and article downloads, it’s difficult to truly discern the tangible impacts of scientific articles on the individual lives of those who consume it.

As a soon to be fully-fledged population health scientist, with toes dipping in the pools of health psychology and social epidemiology, I read and use scientific literature on a daily basis. Although I draw inspiration from many areas outside of science, the scientific literature is my bread and butter.

So here is what I use it for:

  •  My PhD research. This is the most obvious one. My research is on the changes to health literacy skills during ageing among the older population of England, and on the relationship between health literacy and health behaviours. I read and cite relevant articles for my work.
  • Side projects. Although I’m doing my PhD, I have several research projects on the side with other people in my research group. Although most are unpublished at the moment, they relate to my PhD research and to the type of work I want to do in the future.
  • Blogging. This third usage is less common for academics, but for me it’s a bit self-explanatory given this blog. I generally do two types of posts. The first is discussing any new public health research that is interesting, relevant and/or is making news headlines. The second type is a more in-depth piece on a general public health topic that draws from several evidence sources.
  • Figuring out what to do with my academic life. This point is only slightly tongue in cheek. As I prepare to move beyond my PhD, I’m constantly brainstorming research ideas in the back of my mind. Reading what others have done is always helpful and every now and then I read a gem of inspiration. Keeping on top of the literature is always important in the life of an academic, but it feels especially important now. I do my best to read from outside of my field to stretch the way I think about things.
  • Passion. Lateral thinking, discovery, and making a useful contribution to human knowledge are all reasons why we do we what do. I have a folder marked ‘interesting articles’ that have been influential on my thinking. I would recommend any of these articles to any population health science researcher with similar and especially to those with dissimilar inclinations to myself (apologies as some of these are not open access):

Who and what is a ‘population’? Historical debates, current controversies, and implications for understanding ‘population health’ and rectifying health inequalities” – Nancy Krieger. Emphasising the subjective, fluid, and sometimes arbitrary way in which populations are defined, and the resulting implications for the meaningfulness of population means, this review article should be required reading for any population health researcher.

The communications revolution and health inequalities in the 21st century: implications for cancer control” – K Viswanath et al. Just as the title says, this paper discusses how the ‘communications revolution’ that we are currently living through, with widespread and immediate access to people and information through mobile internet may have negative consequences for social equity in cancer control.

Fair society, healthy lives” – The Marmot Review. A landmark public health document detailing the link between health inequalities and social inequalities, and arguing for the reduction of health inequalities as an issue of social justice. The report delivers quantitative statistics and six actionable policy objectives to reduce health inequalities.

An anthropology of structural violence” – Paul Farmer. A physician and medical anthropologist, Paul Farmer argues how disease outbreaks, inadequate health systems, and health inequalities in present day cannot be understood without knowledge of the historical and political circumstances through which they arise. He focuses on Haiti, where the racist history and political economy of the country create public health problems that are a form of structural violence against vulnerable peoples.

The Spandrels of San Marco and the Panglossian Paradigm: a critique of the adaptationist programme” – Stephen Jay Gould and Richard C Lewontin. An exemplary piece of engaging scientific writing, metaphor, and an exercise in causal yet non-deterministic thinking, this paper introduces the biological ‘spandrel’ into Darwinian theory.

What do you use the scientific literature for?

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Why Measles Isn’t Just An Anti-Vaxxer Problem

like a present

Photo by Caselet, CC BY-ND 2.0

I have a little metaphor I use with my kid. When he asks why we get shots at the doctor, I remind him of all the super powers he has.

One day he got super powers against whooping cough and tetanus. Another time I explained that his baby brother just got super powers against rotavirus. I tell him about what these diseases are.

I told him about how I got chicken pox as a kid, just a few years before the vaccine came out, and how I was itchy and miserable for two weeks. He said, in a moment of reflection, that he was glad he got the shot that just hurts for a minute, and won’t have to get chicken pox for two weeks.

Super powers make a great metaphor, and I’ll keep using it, but it’s got a major flaw.

This post is dedicated to all the anti-vaxxers, vaccine choice proponents, and curious people everywhere who have wondered why parents who vaccinate are threatened by those who don’t.

It’s also dedicated to the anti-anti-vaxxers, people who think that those who skip vaccines are weeding themselves out of the population. (Anti-anti-vaxxers, while I admit to laughing at some of your memes–OK maybe a lot of them–you’ll catch more flies with honey and understanding.)

Three reasons disease outbreaks are not just a problem for anti-vaxxers

1. For a first look at why this situation isn’t so simple, check out this humor post about Why We Didn’t Vaccinate Our Child. It’s not what you think! The author writes that he is forgoing the Yellow Fever vaccine because yellow fever isn’t endemic to their area, the Andromeda Strain vaccine because it’s a fictional disease, and the pertussis vaccine because his child isn’t old enough for it yet.

A child has to be a minimum of 12 months old to get the Measles/Mumps/Rubella vaccine. If you show up at the doctor’s office the day before your kid’s first birthday, they’ll ask you to come back later. So kids are 12 months, maybe 13 or 14 before they get the shot. That’s a long time. Your one month old, your two month old, your six month old, your eleven month old, are all vulnerable.

(There is a measles-only vaccine that kids can receive at 6 months. If you spend time around Disneyland regulars, or if you’re traveling to countries where measles is common, ask your doctor about this shot.)

2.There are also people who have medical reasons why they can’t get vaccinated, or why they may be more susceptible to the disease even with vaccination. The last time I wrote about the flu vaccine, this was one of the comments:

I have a low immune system due to another illness and I appreciate it when others get the flu shot. My doctor recommends that all my family members get it for my protection.

And that’s good. I like it when others help to not kill me.

People who can’t get the vaccine rely on others’ immunity. Think of how many people are between you and the nearest measles spreader. Louise coughs on Jim who coughs on Agnes, who coughs on you. If they’re immune, you’re pretty well protected. If they’re all susceptible to the disease, that’s a measles highway.

(There are, of course, multiple pathways between Louise and you. If you’d like to play with scenarios, try the Vax game where you try to separate social networks to prevent the spread of disease. It’s quick and fun.)

3.And the third problem relates to that flaw in the super power story. In comic books, a super hero’s powers Just Work. They might be taken away by a bizarre accident or by the work of some villain, but Superman doesn’t bounce 95 bullets off his chest while, oops, five others get through.

But that’s how the measles vaccine works. The MMR protects 95% of people from measles, and 88% from mumps. For comparison, the flu vaccine is some 70% effective most years (less this season).

We know that five of the Disneyland cases occurred in people who has been fully vaccinated. That means that probably 95 other vaccinated folks were exposed but didn’t come down with the disease. Likewise, although many fully vaccinated hockey players got the mumps this season, they probably only made up 12% of the vaccinated players that were exposed. The other 88% can thank the nurses who brandished scary needles at them twenty years earlier.

People who are not fully vaccinated, or in whom the vaccine isn’t effective, are not only at risk themselves, they are also a stepping stone between someone with the disease and someone vulnerable. Your co-worker who skips the flu shot because he’s young and healthy and says he never gets sick? He might be fine, but could pass it on to his grandma who has lowered immunity, or to the pregnant woman in the next cubicle, or to the baby or the cancer patient he passes on the street mid-sneeze.

Vaccines are important because, with good coverage rates, the vulnerable folks are only the ones in those groups I mentioned: people who are too young for the vaccine, who can’t have it for medical reasons, and whose bodies failed to develop the super powers they was supposed to.

There’s no way around those numbers. But without knowledge and understanding of the risks, other people may opt out of vaccines, deepening the pool of susceptibles in the population.

And I mean we need to understand the risks of both the shot and the disease. No vaccine is 100% safe, but vaccines are far safer than the diseases they prevent. Measles kills 1 in 1000 children who get it. The MMR vaccine has nowhere near that level of risk.

So, anti-vaxxers, your children don’t catch measles and then take it home like a jar of fireflies to enjoy alone or with a few close friends. Instead, they may unwittingly spread it to babies, people with certain medical issues, and a small percentage of the people who have done all they can to try to protect themselves but in whom the vaccine doesn’t work.

And fully vaccinated fans of super powers, 5% of you are vulnerable to the next measles-toting kid who comes along, and you too might pass it to your baby or your immunosuppressed buddy.

Personal vaccination choices have a huge impact on public health, especially for measles where the average infected person spreads it to 12-18 others. Please choose responsibly.

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