A rare, polio-like disease is emerging in California: what you need to know

Correction 28/02/14: The original article states that polio has been eradicated from all countries except for Afghanistan, Pakistan, and Nigeria.  An outbreak of polio was also detected in Syria in late 2013. Cases have also occurred recently in Cameroon and Somalia.

Over the past 18 months, up to 20 young children in California have fallen ill with a polio-like disease.  The major symptom is paralysis.  This potential outbreak is concerning for several reasons: polio was eliminated in the United States years ago, and all of the children had been vaccinated against polio.  A team of researchers has been investigating the new cases, with research still ongoing according to the Centers for Disease Control and Prevention in Atlanta.  Public health officials and researchers warn that the cases are extremely rare, but whether they are isolated or if they indicate an impending full-blown outbreak is still unclear.

Here is what you should know now:

Is this a polio outbreak?

No.  Thanks to vaccination programmes, polio no longer exists in most countries.  Polio has not been seen in the United States since 1979 .  The virus responsible for the current illness has been identified as enterovirus-68 (EV-68) in a detailed analysis of five cases.  Along with the polio virus, EV-68 belongs to the enterovirus family.  Enteroviruses commonly have cold-like symptoms and can carry a risk for nerve problems and paralysis.

What are the symptoms?

Doctors suspect that the initial symptoms are similar to that of a cold, but so few children have fallen ill that it’s difficult to establish a common thread of disease progression among them.  The cases have all been diagnosed at a later stage, which makes it difficult to identify what the early symptoms are.  Paralysis of at least one limb is common to all children who have fallen ill with EV-68.

What exactly is going on?

A physician and researcher at Stanford University, Dr Keith Van Haren, and his colleagues began noticing some children unusually falling ill with a polio-like disease in their medical centres.  Dr Van Haren notified the California Department of Public Health, which has been monitoring the cases.  They have not yet identified any potential cause of the virus common to all of the children who have fallen ill. Samples from around 20 children with polio-like symptoms that were submitted to the California’s Neurologic and Surveillance Testing Program are still being analysed for presence of the EV-68 virus, and the public health department is still monitoring potential causes.  In sum, it’s still early days.

Should I be worried?

In short, no.  The Centers for Disease Control and Prevention are not looking country-wide for cases of EV-68, so there is no national response needed at this point.  Dr Van Haren has stated:

 We want to temper the concern, because at the moment, it does not appear to represent a major outbreak but only a rare phenomenon.

If you don’t have children and don’t live in California, then there is probably no need to worry.  If you are interested, keep following the news as more information is sure to come through as researchers find out more.  If you do have children, this point made by Dr Van Haren is important:

We would like to stress that this syndrome appears to be very, very rare.  Anytime a parent sees symptoms of paralysis in a child, the child should be seen by a doctor right away.

There you have it.  We may be watching an emerging new disease outbreak in real time, or, more optimistically, we may be sensitively monitoring isolated cases of a rare disease.  Either way, the physicians whose sharp judgement picked up these unusual disease cases should be applauded, and are a credit to public health in America.

 

References

Barbara Bronson Gray. Mysterious polio-like illness strikes kids in California. WebMD News [Internet]. 2014 February 23 [cited 2014 February 26]. Available from: http://www.webmd.com/children/news/20140223/mysterious-polio-like-illness-strikes-kids-in-california

James Gallagher. Rare ‘polio-like’ disease reports. The BBC [Internet]. 2014 February 24 [cited 2014 February 26]. Available from: http://www.bbc.co.uk/news/health-26289614

Laila Kearney. Polio-like illness seen in up to 25 California children. Reuters [Internet]. 2014 February 25 [cited 2014 February 26]. Available from: http://www.reuters.com/article/2014/02/25/us-usa-california-illness-idUSBREA1O03V20140225

Polio-like disease appears in California children. The CBC [Internet]. 2014 February 24 [cited 2014 February 26]. Available from: http://www.cbc.ca/news/health/polio-like-disease-appears-in-california-children-1.2549884

Rare polio-like disease strikes five kids in California. Medical News Today [Internet]. 2014 February 14 [cited 2014 February 26]. Available from: http://www.medicalnewstoday.com/articles/273091.php

Category: Epidemiology, Health systems, Infectious disease | Tagged , , , , , , | 1 Comment

Where I politely explain to a politician that they’re wrong

Last week, I was forwarded an opinion piece written by the Honorable Leo Glavine for the King’s County News. Now, if there’s one thing that I hate, it’s when people who are in positions of power, wealth and/or privilege tell “the others” how to live their lives – whether that be “work harder,” or “be healthier,” with absolutely no idea or acknowledgement about their own privilege.

In short, the road to health that many prescribe to the unhealthy is a two step model:

1) Be healthy
2) Don’t be not healthy

Which is why, when I read pieces that blame the poor or unhealthy for their situation, it makes me very angry. And you wouldn’t like me when I’m angry.

The Joggins Fossil Cliffs UNESCO World Heritage Site | Photo via NovaScotia.com

The Joggins Fossil Cliffs UNESCO World Heritage Site | Photo via NovaScotia.com

But lets get back to Mr Glavine’s commentary. In case you didn’t know, Mr Glavine is the Minister of Health and Wellness for the Province of Nova Scotia, and has been in politics since 2003. Prior to that, he was a school teacher. By all metrics, he’s very popular in his riding – winning the last election with a whopping 74% of the votes.

Mr Glavine starts off his piece rather innocuously, stating that the objectives of government are to represent the people, to provide services, and to take care of their health. We’re in agreement there. He also points out that they have to do more with less funding, and that will require creative and innovative thinking to continue to provide services for the populace. So far, we’re on the same page, and I don’t envy how difficult it is to balance all those demands.

And then things take a wild left turn.

WARNING: If you are drinking anything, now is a good time to put down your glass.

“Canadian banking systems are highly regulated to help thwart abuses. Clients must be approved before receiving financial assistance. They must prove that they practice a healthy financial lifestyle before being able to borrow money … Imagine if healthcare worked like banks. Patients would have to prove they practice a healthy lifestyle before receiving assistance. They would have to prove that they practice the basic tenets of proper eating and exercise. “

WHAT.

To call this myopic would be generous. To say it misses the underlying problems would be generous. It would be like seeing that someone has a flat tire and offering them pancakes. It makes absolutely no sense, and starts the victim blaming this article is rampant with. Now, Mr Glavine then acknowledges the ridiculousness of this viewpoint, but then goes on to say:

“These people need help to break unhealthy habits, because the consequences of smoking, uncontrolled eating and avoidance of physical activity deplete funds that could otherwise go toward saving lives and finding cures. Then there are people who are cognizant abusers of the system. “

The first excerpt was him being factitious and providing a deliberately provocative example. This however, is clear victim blaming. If only you stopped smoking, if only you ate healthier, if only you got more physical activity, we’d all be fine. That’s all a great pipe dream, but the evidence is simply not there.

Lets start with smoking. Data suggest that 42.7% of all adult smokers in the US are trying to quit, and that only 4-7% can quit without medication or other help, and EVEN IF we give people intensive behavioural counselling and pharmacological treatment, this increases to… 20-25%. Yup, if we give people the very best in support and help, only 1 in 4 make it. How about healthy eating? Well, the data suggest that to healthy rather than unhealthy will cost you around $550 extra per year (and link to BMJ Open article, published under open access) So, unless you’re willing to help people afford to eat healthier through subsidies of healthy foods, providing them with the skills to cook healthy or a livable wage, the problem won’t fix itself. I’m not saying we shouldn’t give people support but implying that it’s as simple as “just have a little more willpower,” does a great disservice to the underlying issue.

Unfortunately, that’s what is being proposed. The “lazy, unmotivated person” who is a drain on our healthcare dollars is a character that people can despise and vilify. The populace can assign blame to this criminal mastermind for their lack of effort and desire to get healthier, along with stigmatizing them even further (in this narrative, they are also twiddling a moustache while eating pizza and potato chips).

The underlying issue here is a poor understanding of the social determinants of health – defined as what leads to health, what impacts our behaviours, and what factors result in illness in our society. It’s not as simple as one person deciding to “take responsibility for their actions” and “pull themselves up by their bootstraps.” These are nice slogans and political buzzwords, and look nice on a photo of a sunset on a beach somewhere, but are ultimately meaningless. We’ve covered the idea of social determinants of health extensively on the blog, but it’s still not something people outside of public health are familiar with. It falls to us to educate others about the multifaceted nature of health, and how dangerous preconceived notions can be.

Given the opinion piece opened with a story, I thought it appropriate to end mine in a similar way. This story is the opening to Inside the Outbreaks, and has been called the Parable of the Clinician and Epidemiologist:

The Brown River usually flows lazily through the middle of town. But today it is a torrent carrying human bodies. Some, still alive, are gasping for air and thrashing the water.

Approaching the river to enjoy lunch on its banks, two doctors, horrified by what they see, begin to haul people out of the water. There are no signs of violence, but the victims’ eyes are glazed, their weak pulses racing.

The doctors cannot keep up with the flow of bodies. They save a few and watch helplessly as the others drift beyond them.

Suddenly, one of the doctors lowers an old man to the ground and starts to run. “What are you doing?” yells the other doctor. “For God’s sake, help me save these people!”

Without stopping, she yells back over her shoulder, “I’m going upstream to find out why they’re falling in.”

Looking at why people are unhealthy rather than blaming them for their circumstances is the only way we’ll ever be able to help. Victim blaming and assuming their character, rather than their circumstances, are solely responsible for their conditions is not only callous, it’s an easy way to perpetuate the cycle of inequality that got us here in the first place.

Category: Determinants of health, Epidemiology, Science Outreach, Time trends | Tagged , , , , , , , , , | 2 Comments

Breaking the cold chain: Why ditching refrigerators is a big deal for Africa

Children showing their vaccination cards. Photo from the Meningitis Vaccine Projects, all rights reserved, used with permission.

Children showing their vaccination cards. Photo from the Meningitis Vaccine Projects, all rights reserved, used with permission.

Every day during a vaccination campaign, a health care worker in rural Africa hops on a motorbike early in the morning. She rides maybe an hour and a half over dirt roads to the district capital, where the refrigerators are functional. She picks up a batch of meningitis vaccines and fresh ice packs, and heads back to the health center, where she can divvy up her cargo among teams that are heading out to local villages. Armed with heavy coolers, they make their way, often going miles on foot if they don’t have a motorbike or if the route would have them crossing log bridges or hiking up mountains. Only then, possibly hours down the road, can the three-person team set up shop and give the first of their 200 or more shots for the day.

Across the widest part of Africa runs a narrow band ominously nicknamed the meningitis belt. Here, meningitis A seasonally sweeps through villages. It is spread by a bacterium, and causes inflammation in the membranes that surround the brain. Even with treatment, it can result in brain damage. Children and adults are both susceptible. A typical case costs a family $90, according to a study done in Burkina Faso, where that amount represents three to four months’ income. It can push poor families even deeper into poverty, as they sell tools and livestock to pay for care for a sick baby.

That’s why the meningitis A vaccine is administered in massive campaigns. One in Chad ran for just ten days and immunized 1.8 million people, much of that through outreach like what I’ve described here. Adults and children over a year old can receive the vaccine, and it’s extremely effective. But the need to keep the vaccine vials cool is a major problem in getting the shot to everyone. The outreach team can only travel so far in a day—about four to five hours—because they’ll have to pack up and return to the center to pick up fresh ice and vaccines the next morning.

Many of Africa’s health centers have refrigerators and ready access to electricity or kerosene to run them, but others (2 out of 14 in the Banikoara district in Benin, for example) do not. This week, the World Health Organization published a bulletin describing just how much time and effort it takes to maintain the “cold chain.” That’s the continuous refrigerated environment a vial of vaccine inhabits from its manufacture in India, through international shipping, to the health centers and its final ride in a cooler to the moment it’s injected into somebody’s arm. The cold chain is, the report concludes, an enormous drain of resources.

Happily, the report has a counterpart, published this week in Vaccine: a success story from a meningitis campaign in Benin where workers had permission to keep the vials out of the cold chain for up to four days at a time. “Many vaccines today have some stability we’re not taking advantage of,” says Simona Zipursky, a program coordinator at the World Health Organization, which worked with a nonprofit called PATH on this project. They didn’t reformulate the vaccine, which normally comes with a label stating it should be kept at 2-8 degrees C (about 36-46 degrees F). Instead, they consulted documents from the vaccine’s development that showed it could stay stable, with no change in its chemistry (and presumably no change in safety or effectiveness) if it was kept at warmer temperatures. Since the vaccine is manufactured in India, they approached Indian regulators with this information, and were able to get a new label stating that the vaccine could be used in a “controlled temperature” chain, where it could stay out of the fridge for four days, so long as the temperature never exceeded 40 degrees C (about 104 F).

The new label made a huge difference. Centers didn’t have to freeze dozens of ice packs every morning, so they could get started earlier. And outreach teams targeting distant villages didn’t have to return home each night, but could keep vaccinating and move to another, more remote village in the morning. Over the course of the four days they could make a loop through the countryside and vaccinate people they never could have reached under the cold chain system.

Health care workers spend a lot of time on logistics, Zipursky says. Supervisors can’t supervise while they’re running back and forth delivering ice packs. The same worker who provides vaccinations and keeps an eye on their temperature (and who, studies show, spends 20% of her time on “cold chain logistics”) is taking time out from prenatal checkups or dispensing malaria medication to do it. Get rid of the cold chain, the WHO calculated, and campaigns could reach more people with vaccines costing half as much.

After the controlled-temperature experiment, the health care centers in Benin returned to business as usual: in this case, a polio vaccine campaign with the regular cold chain. Despite concerns that workers might get confused and think all vaccines could be left out in the heat, the polio campaign went without a hitch. Follow-ups on the meningitis campaign showed that nobody who got the controlled-temperature vaccine contracted meningitis that season, indicating that the vaccine maintained its efficacy as promised. Over 15,000 vaccines were given, and only a handful had to be discarded for surpassing the four-day limit.

The next step is to pursue the controlled temperature chain strategy for yet more vaccines. They might try HPV next, says Zipursky, because it’s another vaccine adminstered by traveling teams. Regulatory hurdles must be cleared individually for each vaccine, but the benefits of the controlled temperature approach are hard to ignore: when asked if they’d like to do their next campaign this way, 98.7% of supervisors and 100% of vaccinators said yes.

Category: Uncategorized | 5 Comments

‘I wish I had breast cancer’

Earlier this month, Pancreatic Cancer Action launched a controversial advertising campaign featuring the image above.  The campaign depicts bleak, pity-inducing photos of pancreatic cancer patients.  This one shows Kerry, a 24-year old woman stating, “I wish I had breast cancer”.  The campaign has exploded in the media over the past fortnight, with angry statements from breast cancer charities and even a death threat against Kerry for wishing she had breast cancer in place of her pancreatic cancer diagnosis.  The question underlying the entire backlash is whether we should be pitting cancers against one another.

Breast cancer charities have spoken out against the ads. Samia al Qadhi, Chief Executive at Breast Cancer Care said:

“Unless you have experienced it yourself, it’s impossible to fully understand the huge challenge faced by women who wake up every day to the brutal reality of breast cancer…  Breast cancer still kills 12,000 women each year and more than 30,000 are living with a terminal diagnosis.  It is unhelpful to pit one cancer against another.  Most of us know someone who has been affected by this dreadful, life threatening disease and know the impact it can have on those affected and their loved ones.  We all need to do more to raise awareness of signs and symptoms of many cancers and the importance of early diagnosis”

The purpose of the pancreatic cancer campaign was to raise the awareness that while the survival rate for breast cancer is about 85% and for testicular cancer (the target of another ad featuring a man) is about 97%, the survival rate for pancreatic cancer is a mere 3%.  A diagnosis of pancreatic cancer is basically seen as a death sentence. We don’t hear very much about pancreatic cancer in the news or from charities (what colour would the pancreatic cancer ribbon be?) because it’s a rare cancer.  It affects fewer people than breast cancer: 8 women per 100,000 in the UK were diagnosed with pancreatic cancer in 2011, compared with 125 per 100,000 diagnosed with breast cancer (Cancer Research UK).  Does this give pancreatic cancer campaigners the right to proclaim ‘their’ disease is worse than breast cancer, and therefore more deserving of charity money?

Some positivity has come out of this debacle: people are talking about pancreatic cancer.  Pancreatic Cancer Action’s website has received an over 200% increase in web traffic (likely to be higher by now), with a particular spike in visits to the page describing symptoms of pancreatic cancer.  The charity is taking advantage of this attention by launching a second wave of their advertising campaign, which will focus on symptom detection:

The symptoms of pancreatic cancer are:

-          Persistent, new onset upper abdominal or upper back pain

-          Jaundice – yellowing skin or eyes, itchy skin

-          Unexplained weight loss

-          Foul smelling stool that won’t flush easily

Pancreatic Cancer Action states:

“Due to lack of awareness of the disease and symptoms, people are often diagnosed too late for surgery, which is currently the only cure.  The average life expectancy most people face is just four to six months”

Opening a dialogue whereby people can debate ethical issues about the way we see and talk about the different types of cancers, the stories we tell ourselves about each, and the taboos surrounding health issues is a positive thing.  The fact that awareness is being raised about a rare cancer type that kills due to lack of symptom detection and late diagnosis is even better. Perhaps this entire controversy will save a few lives.  If it does – was the shock value worth it?

Category: Cancer, Uncategorized | 7 Comments

Dengue: Why You Need to Know About It

Public Health Perspectives is pleased to welcome Dr Jessica Taaffe to the blog to discuss dengue fever. For more about Dr Taaffe, see the end of this post.

Dengue is no joke – it causes a “bone-breaking” illness and fever that basically wipes you out.  Several members of my family in Paraguay can attest to that (this country is currently experiencing the “worst epidemic in history,” with over 4,500 cases from July to November 2013, and the season isn’t over yet).  The disease starts with one dengue virus-infected mosquito bite.  Four to ten days later, sickness may start with a mild headache, but this quickly progresses into high fever (up to 106F!) and an incredibly painful headache with muscle, bone, and joint pain.  The associated limb pain is so agonizing that the disease became known as ‘breakbone fever,’ even though no bones are actually broken.  Most people recover within a week or so, but it can leave them weakened for weeks afterward. And, if you’ve been infected once, this doesn’t mean that you are immunologically protected from infection again.  In fact, if the second infection originates from a different serotype than the first infection, you’re at risk for severe dengue.  That’s right, severe dengue.  As if the symptoms from uncomplicated dengue weren’t severe enough, a second infection could result in hemorrhagic fever or shock.  Severe dengue requires hospitalization and can be life-threatening, among whom a great many affected are children.

 

Dengue is mostly found in tropical and sub-tropical climates, and the mosquitos carrying it are able to survive in urban habitats in those climates.  Although most of dengue cases exists in Southeast Asia and Latin America, incidence has been increasing over the past few decades, including spreading to new areas, which now alarmingly includes autochthonous (locally acquired) dengue outbreaks in Florida, Texas, and Hawaii since 2001.  Even more so, local transmission of dengue was reported in France and Croatia in 2010.  And, climate change isn’t helping – rising temperatures may allow dengue virus transmitting mosquitos to persist longer and geographically expand their domain.  What’s even scarier is that Aedes aegypti, one mosquito species capable of transmitting dengue, has recently been found in California. This means that local transmission of dengue could also become established on the West Coast.

 

The WHO reports that over 2.5 billion people (that’s over 40% of the world’s population) are at risk for dengue (meaning, they live in an areas with dengue transmission), and an estimated 50-100 million infections occur worldwide each year. This, though, is likely an underestimate, as much of dengue illness is underreported, especially since up to one half of infections are asymptomatic (ref: CDC).  Indeed, a study published in Nature earlier this year, estimated the total global burden to be 390 million, with only 96 million being apparent through clinical illness.  Dr. Donald Shepard of Brandeis University further expanded on this topic at the past American Society of Tropical Medicine and Hygiene (ASTMH) Annual Meeting (I attended this wonderful science and global health conference in November, and much of what I’ll mention here was discussed at this meeting).  His analyses using expansion factors (a value multiplied to reported cases to give a more accurate estimate of infection incidence) in Southeast Asia suggested that, on average, only 13.2% of clinical dengue episodes are reported to surveillance systems.  There is also great variance among regions in the expansion factor value (7 for South East Asia, 25 for the Americas, and 130 for South Asia), demonstrating how factors contributing to underreporting (misdiagnosis, poor surveillance systems, availability of rapid diagnostic tests, unhospitalized cases missed, etc) differ across the world.

 

If you like to travel internationally, you should know that travelers are not only at risk for the disease, but also help spread it.  Dengue is the second most common cause of fever in people returning from Australia, and it is found in travelers from South East Asia almost three times more than malaria, said Dr. Annelies Wilder-Smith of Singapore’s Nanyang Technological University at the ASTMH conference, referring to GeoSentinel surveillance data.  Smith also discussed how international travel has been responsible for the spread of dengue globally, through both introduction of mosquito vectors and the virus itself.  One of dengue’s mosquito vectors, Aedes albopictus, was first introduced into the Americas in 1985 through ship travel (tires containing stagnant water served as mosquito breeding ground), and the 2012 dengue outbreak in the European island of Madeira could be traced back to airline travel from Venezuela.  The link to travel was so strong in the latter case that it was airline travel data that first identified the outbreak origin. This was later confirmed by molecular epidemiological data that showed sequence similarity between the Madeira dengue viruses to those circulating in Latin America.  Travel has also promoted the introduction of new dengue serotypes into regions of the world in which they previously did not exist.  Remember my earlier point of the increased risk of severe dengue through cross-serotype infection? Certainly, more than one dengue serotype in any one region is just bad news.

 

We have no vaccine, we cannot predict who will get severe dengue, nor do we know how to ameliorate the clinical severity of the disease.  If you get dengue, there is no treatment to stop the disease.  Basically, you have to let it take its (painful) course and hope it doesn’t progress into severe dengue.  Oxford University’s Dr. Bridget Willis explained at the ASTMH conference that efforts to suppress the immune response (responsible for clinical symptoms) with corticosteroids or inhibit the viral life cycle with anti-virals have not panned out.  And while many dengue vaccine candidates are in the pipeline, we are just not there yet.  The most developed dengue vaccine candidate from Sanofi Pasteur disappointingly protects only against three out of four of the predominant serotypes, leaving out the most pathogenic serotype, DENV 2.

 

But, I don’t want to be completely depressing about dengue – let’s put a positive and hopeful spin on this.  Dengue is becoming “An Increasing Global Health Problem” (the aptly named title of a two part symposium series at the ASTMH meeting this year) and people are starting to take notice.  The dengue sessions at ASTMH were very well attended, if not packed, and a number of media sources have recently taken interest.  More attention given to the growing problem of dengue can hopefully promote our efforts against it.

 

Biomedically, we need to better understand the disease, in order to develop appropriate vaccines and therapeutics against it, including clinical management of disease; increased investment in dengue research and development is imperative here.  From a public health perspective, more accurate estimates of the burden of disease, both clinically and economically, may convince policy makers to ramp up national and international efforts to control spread of disease.  At the local level, measures to improve vector control, through pesticide use or community outreach campaigns to reduce stagnant water sources, may help address local dengue epidemics.  Additionally, biomedically-driven solutions, such as the introduction of genetically-modified mosquitos, whose offspring cannot survive, or Wolbachia-infected mosquitos that resist dengue infection, into natural mosquito populations could aid public and environmental health programs in the future.

 

My purpose with this post is to build awareness of dengue, including where we stand globally in our efforts against it.  I don’t expect this post to mobilize communities, governments, and international organizations to address the global dengue epidemic; that’s already being carried out by other excellent groups, initiatives, and organizations (Eliminate Dengue and Dengue Vaccine Initiative are two examples).  However, I sincerely hope that whatever your background (scientist, clinician, global/public health profession, policy maker, member of general public, etc), you give dengue a second (or first) thought.  This is a global disease that is not going away anytime soon, and awareness is the first step in addressing it.

 

About Jessica

IMG_4786Dr. Jessica Taaffe is a biomedical scientist committed to advancing global health through scientific practice, communication, and advocacy.  An expert in non-human primate immunology, she currently researches severe malaria anemia in monkeys at the National Institutes of Health and focused her PhD on HIV/SIV immunopathogenesis at the University of Pennsylvania. Dr. Taaffe is also a scientific writer/consultant for The World Bank.  An avid fan of social media, she can be found on Twitter (@JessicaTaaffe), Tumblr (http://www.tumblr.com/blog/signoradavinci), and LinkedIn (http://www.linkedin.com/in/jtaaffe), sharing her wide variety of passions, from science and global health to music and fashion.  Views here and on social media are her own and do not reflect policies or opinions of her employers.

Category: Determinants of health, Epidemiology, Guest Posts, Nutrition | Tagged , , , , , , , , , , , | 1 Comment

When Vitamins Backfire

Vitamin Packaging

Concept packaging by Colin Dunn, CC-BY

Bad news for athletes this week: two studies show that vitamin supplements can interfere with the benefits of exercise. While vitamins are safer and cheaper than many other supplements sold to athletes, these studies add to the growing body of evidence that more of a good thing isn’t necessarily better. And even though we think we understand what vitamins do, their real-world effects highlight how murky our understanding of human biology really is.

Take the study that came out Sunday on Vitamin C and E supplements. As antioxidants, these vitamins are often recommended as recovery aids and for general health. But the new study seemed to show the opposite effect: the supplements interfered with runners’ training (as measured by molecular markers, though not performance tests) The authors write “The exact mechanism behind this effect is not possible to decipher. However … we assume that the antioxidants attenuated the generation of reactive oxygen and/or nitrogen species.” In other words, the vitamins neutralized the free radicals that are generally thought of as bad guys. But free radicals may be a good thing in the context of exercise, and antioxidants a bad choice.

The other recent study was apparently meant to rubber-stamp a Dole product, mushroom powder containing high doses of Vitamin D2. It likewise backfired on the subjects who took it, in this case NASCAR pit crew athletes. The D2 was supposed to convert to D3 in their bodies and this, in turn, was supposed to decrease muscle damage and help them recover faster from their strenuous workouts. Instead, it lowered D3 and increased muscle damage, and ultimately made no difference in strength.

In December, an Annals of Internal Medicine editorial cried out: Enough is enough: Stop wasting money on vitamin and mineral supplements. The authors concluded that multivitamins don’t prevent dementia, heart disease, or cancer; but certain vitamins can be harmful in large doses. The jury is still out on Vitamin D, they wrote, but for all the rest, taking them on top of a reasonable diet carries no benefit and may be harmful.

Squeaky clean?

I’m not calling vitamins useless; they’re crucial for treating deficiencies, and preventing deficiencies in populations at risk. For example, the World Health Organization recognizes Vitamin A deficiency as a public health problem in more than half of all countries, and the leading cause of preventable blindness in children. To combat it, they promote breastfeeding, nutrient-rich diets, and, yes, supplementation.

But the situation is very different for well-fed health seekers. Studies that intended to test how well Vitamin A can prevent lung cancer in smokers ended up showing that Vitamin A supplementation increases the risk of cancer.

And there’s the conflict: while public health messages promote vitamins to correct deficiencies, the actual health-seeking public latches on to vitamins as squeaky clean supplements that can do no wrong. Take them as insurance against gaps in your diet, suggest many experts.

A similar logic is behind the alleged trend of getting a Vitamin B12 shot if you’re feeling “sick and tired of being sick and tired.” (Reality check: this only works if you have a real deficiency, which most people don’t.) Likewise taking Airborne if somebody around you is sick; its main ingredient Vitamin C doesn’t actually keep you from getting sick. But at least you feel like you’re doing something, right?

I can’t help thinking vitamins are a pawn in non-health-related schemes: selling products that look better because they’re fortified (my favorite example: Diet Coke Plus), or selling something that makes you feel like you have an edge over the competition (as in athletic supplements) or power against disease (like Airborne). Vitamins are approved as safe, so manufacturers can easily sell them with claims hinting at health. You can make money selling Airborne. A pamphlet on hand-washing would probably work better to prevent catching a cold, but is hardly as lucrative.

[Correction: About an hour after this post was first published, I added the clarification about molecular markers in the second paragraph]

Category: Uncategorized | Tagged , , , | 3 Comments

The Bone Crushing Hit: How can you cheer when people are getting seriously injured?

As I write this post, I’m sitting here watching the 49ers take on the Seahawks. It’s been a great game so far, although the sheer number of injuries have been terrifying, culminating in an absolutely horrific injury to 49ers linebacker NaVorro Bowman where his leg bent in ways it shouldn’t under any circumstances.


 

Like a lot of people, I like sports. In fact, I was one of the 56 million people who tuned into that NFC Championship game mentioned above – more than the entire population of Spain, and the total population of California and Florida together. Getting together with friends, watching football, hockey, UFC, or any other sport is one of my favourite passtimes. The drama that comes along with professional sports in the form of redemption stories, a veteran’s final chance at a title, and the bad blood associated with historic rivalries all lead to a great afternoon/evening/day. In addition, there’s the sheer skill and athletic ability of the competitors and watching years of practice and training pay off. Along with this comes one of the most exciting things for any spectator, especially those who like football or hockey, to witness.

The Bone Crushing Hit.

You know what this is. A player gets the puck/ball and runs towards the goal/endzone, and a defensive player absolutely destroys them. You’re sitting at home, miles away, and you cringe with the sheer impact. It makes every highlight reel, and transcends sports, appearing on highlights reels for the NHL and the NFL. Sometimes this is illegal but more often than not, it’s perfectly legal, and considered “part of the game.” This is where I have trouble.

I live in two worlds. In the first, I like sports, for all of the reasons listed above. In the second, however, I am a public health professional. And when I see a guy get hit into the boards, a helmet to helmet collision, or when I see a player’s head snap back with the sheer force of impact, my first thought is for their brain and the potential for there to be serious, long term, damage. The kind of effects this can have is illustrated in this great piece by ESPN on Chris Pronger, a player who is retired* from the NHL, and suffered several hits to the head.

With the Superbowl and the Winter Olympics starting next month, I’ve been thinking a lot about how to reconcile these, seemly opposite, perspectives.

One approach, especially by sport “purists” is that it’s part of the game, and these adverse events are simply aberrations. Frankly, I hate this perspective. Yes, some injuries are unavoidable and will happen regardless (NaVorro Bowman’s injury at the top of the article is one of them). They also argue that these athletes are being paid for their services and know the risks when they start playing. However, there are injuries that are preventable. We should be looking ways to minimize injuries, and at the very least, exploring all options.

The approach taken by many major leagues now is to start teaching healthy ways to tackle and hit players starting at a younger age. This, combined with changes in equipment, could, in theory, result in lower injuries as these kids age. But even this has its detractors. Something like visors in the NHL has been talked about for years, but only now has been made mandatory, and even then, there is clause whereby it is optional for current players. And fighting still exists in the NHL, despite the clear health risks associated with being punched in the head repeatedly (Disclaimer: Those videos include people being knocked out and blood). Even when the evidence is there and suggests that we should make changes, changes don’t happen.

The third approach is simply to ban all contact. As much as I am averse to injuries, this isn’t a practical suggestion. For one, it would fundamentally alter certain sports, such as football. So this is a non-starter.

It’s hard to balance the world of the sports fan with the world of the public health person, and while watching sports I’ll catch myself asking “how can I support this?” knowing full well the consequences of these behaviours on the athletes in questions. Somewhere between the second and third approach above there has to be a happy medium. The fact is that many young kids will emulate what they see on TV, and the massive hits we see on TV are only the tip of the iceberg – there are injuries occurring the whole way from the professional to the amateur ranks. Sure, some of these changes may mean that the sport is less entertaining for fans. But the fact is, if it means that young athletes are able to live out their lives without suffering from concussions and other symptoms, and the only price is “entertainment,” I’m okay with that.

*Pronger is not officially retired, due to what this would be mean for his team from a salary cap perspective. But he has stated he will never play again, so not retiring is just a way to circumvent this regulation.

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H1N1 is back. Here’s what you need to know.

From CDC

This is H1N1. Micrograph from the CDC.

How bad is the flu this year?

Well, it’s H1N1. Remember that from 2009? I’ve written before about my pilgrimage to the first H1N1 vaccine clinic in my area and how President Obama rolled up his sleeve for the camera. That year, H1N1 caught everyone by surprise. Starting the following year it was rolled into in the regular flu shot. Which is a good thing because H1N1 has returned as the dominant strain this year.

Which, in turn, means trouble. This year, most flu hospitalizations are in young and middle-aged adults, which is drastically different than in typical years, where adults over 65 are most at risk. That means that young(ish) healthy(ish) people who usually don’t worry about the flu, are now the ones who should worry. Yes, people die from the flu – tens of thousands in the US per year, although the number varies by a lot.

Can I still safely get the flu shot?

Probably. It’s recommended for everyone 6 months and older. If you’re curious, the CDC has a great rundown of the different flu shots, how they work, and how safe and effective they are for various groups of people. Benefits outweigh risks for almost everyone.

Pregnant women who get the shot are even providing protection to their newborns, and yes, the shot is safe during pregnancy. (What’s not safe during pregnancy? Getting the flu. Especially with H1N1, pregnant women are at more risk of complications, which can include miscarriage, as in this woman’s tale.)

Depending on the vaccine and the year, the flu shot prevents the flu 70-90% of the time according to the World Health Organization, or 60% according to the US CDC. That’s a lot less than a hundred percent, sure, but it’s also a lot more than zero. Among the elderly, getting a flu shot reduces flu deaths by 80%. (Stats from WHO). And no, the flu shot can’t give you the flu. That myth, and many more, are debunked here.

What if I get the flu?

There is an antiviral treatment for the flu, which is especially effective if you can get it as soon as symptoms start. It’s recommended for people who are at risk of serious complications, including pregnant women, nursing home residents, and people who are hospitalized, immunosuppressed, or dealing with serious illness to begin with.

If you just want to feel better at home, bad news: Vitamin C doesn’t do much (and most of the almost-promising research is based on the “common cold,” not influenza.) A review of oscillococcinum, P. quinquefolium, Sambucus, and Kan Jang found “no compelling evidence” that they do anything for flu symptoms.

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India is Polio Free

A child receiving the polio vaccine

A child receiving the polio vaccine | Image courtesy of the CDC Public Health Image Library

Two weeks into 2014, and we have already received one of the best public health stories of the year: India is polio free.  For a country that accounted for over half of the world’s polio cases until 2009 (1), this achievement is remarkable. The last recorded case occurred three years ago, on 13th January 2011, when an 18 month old girl was diagnosed with polio in Howrah, West Bengal (2).  Since then, no other cases have been recorded over a three year period and India is set to be declared officially polio-free after samples are tested by the World Health Organization next month (3).

 

Polio is a crippling, life-threatening disease caused by the poliomyelitis virus.  Polio is transmitted through contaminated food and water, and mostly affects children under age five.  Common symptoms include headache, lethargy, and gastrointestinal upset, but paralysis and permanent disability occur in some cases (4).  Polio was a huge public health problem worldwide, until a vaccine was developed in 1957 by Jonas Salk.  For more info on Salk, check out our history of epidemiology series.  In 1988, the forty-first World Health Assembly adopted a resolution for the global eradication of polio (4).  Since then, polio has decreased by 99% worldwide (4).  However, polio lingered in India.  India’s high population density, slum pockets, and poor sanitation, combined with poor health infrastructure and a diverse population with varying attitudes toward the vaccine made for a ‘perfect storm’ for polio to spread (5, 6).

 

The Oral Polio Vaccine (OPV) | Image courtesy Wikimedia Commons

The Oral Polio Vaccine (OPV) | Image courtesy Wikimedia Commons

 

How has India overcome these hurdles to polio eradication? India’s government and health system collaborated with international organisations including the World Health Organization, Rotary International, and UNICEF in a fine logistical feat to immunise the nation’s children.  Young children under age five are the target for vaccination to eradicate the disease, as they are the most vulnerable.  An initial key piece of the puzzle was generating data: who needed vaccination, and where.  In 1997, the National Polio Surveillance Project was established by the World Health Organization and the Indian government.  Data from this surveillance system informed the country’s medical surveillance officers, government officials, and thousands of volunteer vaccinators of where the areas of highest risk where, and in turn where to distribute the vaccine (6, 7).

 

A major victory in the eradication was the targeting of marginalised and mobile communities within India.  For example, families in Uttar Pradesh were refusing the vaccine for their children, doubting its effectiveness and some suspecting rumours that the vaccine caused impotence (6).  UNICEF set up social mobilisation networks to specifically target these social groups and dispel myths about the vaccine (6, 7).  Other public awareness methods, such as the famous Indian film star Amitabh Bachchan lending his image to the polio eradication efforts as a UNICEF Goodwill Ambassador certainly helped (8).  Over time, the concerted effort of international health organisations, the Indian government, the millions of dollars and vaccine doses donated to the effort, and uncountable numbers of volunteers have led to the zero cases of polio in India today.

 

Polio eradication in India may be one of the top public health stories of the century, and will be surpassed once global eradication is achieved.  Polio remains in endemic in Nigeria, Afghanistan, and Pakistan.  Populations in these countries can be difficult to reach due to war, geographic instability of their people, and poor health infrastructure.  Fortunately, the World Health Organization has recently announced that over 23 million children in the Middle East will be vaccinated against polio, in the largest-ever vaccination campaign (9).  Because of its proximity to countries such as Pakistan, India runs the risk of re-infection in the population and is running polio campaigns in 2014-15, where 2.3 million vaccinators will immunise 172 million children (6).  With these further efforts, India is a lesson in exquisite public health planning and cooperation across organisations with the daily efforts of individual people working for a common goal.

 

References

  1. Al Jazeera. India marks three years without polio. Al Jazeera. 13 January 2014. http://www.aljazeera.com/news/2014/01/india-wins-battle-against-polio-201411355459437799.html (accessed 15 January 2014).
  2. Subhendu Maiti. Close to victory: India will officially be declared polio-free from today. Hindustan Times. 13 January 2014. http://www.hindustantimes.com/india-news/close-to-victory-india-will-officially-be-declared-polio-free-from-today/article1-1171899.aspx (accessed 15 January 2014).
  3. BBC News India. India hails polio-free ‘milestone’. BBC. 13 January 2014. http://www.bbc.co.uk/news/world-asia-india-25708715 (accessed 15 January 2014).
  4. World Health Organization. Poliomyelitis: Fact Sheet No. 114, April 2013. http://www.who.int/mediacentre/factsheets/fs114/en/index.html (accessed 15 January 2014).
  5. Michael Sheldrick. 1.2 billion reasons to celebrate: India set to be polio-free. The Guardian. 13 January 2014. http://www.theguardian.com/global-development-professionals-network/2014/jan/13/lessons-india-polio-free-landmark (accessed 15 January 2014).
  6. Patralekha Chatterjee. How India managed to defeat polio. BBC. 13 January 2014. http://www.bbc.co.uk/news/world-asia-india-25709362 (accessed 15 January 2014).
  7. UNICEF. From 200,000 to 0: the journey to a polio-free India. http://www.unicef.org/india/Polio_Booklet-final_(22-02-2012)V3.pdf (accessed 16 January 2014).
  8. UNICEF. Amitabh Bachchan launches new Polio Communication Campaign. http://www.unicef.org/india/media_7464.htm (accessed 16 January 2014).
  9. World Health Organization. Over 23 million children to be vaccinated in mass polio immunization campaign across Middle East. 9 December 2013. http://www.who.int/mediacentre/news/releases/2013/polio-vaccination-20131209/en/ (accessed 16 January 2014).
Category: Determinants of health, Health systems, History of Public Health | Tagged , , , , , , , , , , | 1 Comment

The worst thing you can eat is sugar.

Removing sugar from the food industry could reverse the obesity epidemic

Removing sugar from the food industry could reverse the obesity epidemic

 

A couple days ago, a group of leading medical and nutrition experts released a call for a 20-30% reduction in sugar added to packaged and processed foods over the next 3-5 years (1).  The expert group, ‘Action on Sugar’, estimates that this change would result in a reduction of roughly 100 calories each person eats per day, and will eventually reverse the obesity epidemic (1).  Wow.  The media has picked up on this statement in a huge way, with headlines like ‘Sugar is the ‘new tobacco’ (2), and ‘Sugar is now enemy number one in the western diet (3).  While these headlines sound sensationalist, they are right.

 

A sickening amount of sugar is added to many processed foods (1).  Some culprits are obvious.  There are 9 teaspoons of sugar in a can of regular Coke or Pepsi, but others are surprising.  Heinz tomato soup has 4 teaspoons of sugar per serving.  Add two slices of white bread to that soup at nearly a teaspoon of sugar, another teaspoon or two in your coffee or tea, and that’s your entire daily sugar allowance.  Sugar should comprise no more than 5% of daily energy intake, which is about 6 teaspoons per day for women and 8 teaspoons per day for men (3).

 

And what is the big deal about sugar? A calorie is a calorie – right?  Well, not so much.  The calories provided by sugar are void of nutrition.  ‘Action on Sugar’ (1) states it best:

Added sugar is a very recent phenomenon (c150 years) and only occurred when sugar, obtained from sugar cane, beet and corn became very cheap to produce.  No other mammal eats added sugar and there is no requirement for added sugar in the human diet.  This sugar is a totally unnecessary source of calories, gives no feeling of fullness and is acknowledged to be a major factor in causing obesity and diabetes both in the UK and worldwide.

Humans have no dietary requirement for added sugar.  Dr Aseem Malhotra, the science director of ‘Action on Sugar’, emphasizes that the body does not require carbohydrates from sugar added to foods (3).  Furthermore, high sugar intake may reduce the ability to regulate caloric intake (4), with consumption of sugar leading to eating more sugar, overeating, and ultimately to weight gain (5).  Added sugar therefore presents a ‘double jeopardy’ of empty caloric intake that triggers further unnecessary consumption.

 

Dr Malhotra states that sugar is in fact ‘essential to food industry profits and lining the pockets of its co-opted partners’ (3).  The sugar/food industry has tremendous power, sponsoring high-profile sporting events, gaining celebrity endorsements, and employing psychological techniques in their ubiquitous advertising.  Maliciously, they target children, who are vulnerable to advertising and to giving in to a sweet tooth (6).  The politics of the sugar industry have been covered by this blog in another post.  Essential to their tactics is heavy resistance against the scientific links between sugar and obesity.  The American Sugar Association website states that ‘sugar is a healthy part of a diet’ (7), and Sugar Nutrition UK states that ‘the balance of available evidence does not implicate sugar in any of the ‘lifestyle diseases’‘ (8).  On top of that, the food industry sponsors scientific research that is biased towards showing no link between sugar and adverse health problems.  Last month, a large evidence review found that research on sugar-sweetened beverages and obesity is more likely to find no association between the two when funded by the food industry (9).

 

Clearly, we have a long way to go in fighting against the paradigm of today’s food environment, which is largely dictated by the industry.  ‘Action on Sugar’ has some important aims to this end: in addition to reducing sugar in processed foods by 20-30%, they aim to reach a consensus with the food industry that sugar is linked obesity and other negative health effects, to improve nutritional labelling of added sugar content using a traffic light system, and to ensure that scientific evidence is translated into government policy to reduce sugar.  Their full list of aims can be found here (10).  These aims are likely to be successful, as they are modelled off of sodium reduction efforts that have led to an estimated reduction of sodium in packaged foods ‘between 20 and 40%, with a minimum reduction of 6,000 strokes and heart attack deaths per year, and a healthcare saving cost of £1.5 billion [approx. $2.5 billion USD]’ (1).

 

So what can we do, as individuals? The first step is educating oneself, so if you’ve read this far then you’re one step ahead.  Always read nutritional labelling on packaged foods carefully to determine how much sugar is in what you’re eating.  Katharine Jenner, nutritionist and campaign director of ‘Action on Sugar’ states that you can ‘wean yourself off the white stuff’ by cutting down on using it at home, but the main source of sugar in our diets remains that added during the processing of manufactured food (1).   The best thing is to heavily cut down on packaged, processed foods in favour of whole, unprocessed foods.  Do this, if not only for your individual health, but to stop supporting an industry that compromises the well-being of the world’s population for financial profit.  The worst thing you can do is eat sugar.

 

References

  1. Action on Sugar. Worldwide experts unite to reverse obesity epidemic by forming ‘Action on Sugar’. http://www.actiononsalt.org.uk/actiononsugar/Press%20Release%20/118440.html (accessed 12 January 2014).
  2. Poulter S. Sugar is the ‘new tobacco’: health chiefs tell food giants to slash levels by a third. Daily Mail. 09 January 2014. http://www.dailymail.co.uk/health/article-2536180/Sugar-new-tobacco-Health-chiefs-tell-food-giants-slash-levels-third.html (accessed 12 January 2014).
  3. Malhotra A. Sugar is now enemy number one in the western diet. The Guardian. 11 January 2014. http://www.theguardian.com/commentisfree/2014/jan/11/sugar-is-enemy-number-one-now (accessed 12 January 2014).
  4. Davidson TL, Swithers SE. A Pavlovian approach to the problem of obesity. Int J Obes Relat Metab Disord 2004;28(7):933-5.
  5. Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr 2004;79(4):537-43.
  6. Calvert SL. Children as consumers: advertising and marketing. The Future of Children 2008;18(1):205-34.
  7. The Sugar Association. Balanced Diet. http://www.sugar.org/sugar-your-diet/balanced-diet/ (accessed 12 January 2014).
  8. Sugar Nutrition UK: Researching the Science of Sugar. Sugar & Health. http://www.sugarnutrition.org.uk/Sugar-and-Health.aspx (accessed 12 January 2014).
  9. Bes-Rastrollo M, Schulze MB, Ruiz-Canela M, Martinez-Gonzalez. Financial conflicts of interest and reporting bias regarding the association between sugar-sweetened beverages and weight gain: a systematic review of systematic reviews. PLOS Med 2013; doi: 10.1371/journal.pmed.1001578
  10. Action on Sugar. Aims. http://www.actiononsalt.org.uk/actiononsugar/Aims%20/118439.html (accessed 12 January 2014).

Image source

Category: Determinants of health, Epidemiology, Food industry, Industry, Nutrition | Tagged , , , , , , , , | 32 Comments