Dr. Buttery's Public Health BLOG

For most Americans mosquitoes are linked to Malaria. A few may think of equine encephalitis with its periodic outbreaks seen mostly in the Southwest, or West Nile Virus. The newest disease starting to spread, more so than avian influenza, is Chikungaya which has appeared recently in Italy and has symptoms similar to Lyme disease. Dengue fever, also spread by mosquitoes has been increasing in Brazil with more than 60,000 cases in 2007. Rather than worrying about Avian influenza, a darling of the media and politicians, we should be concerned about both Dengue and Chikanguya spreading into the US.

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People can be their own worst enemies. In a fascinating report from the MMWR is a case of multiple exposures ro rabies from a stray kitten picked up and petted at a mutistate softball turnament. 27 persons were identified as having exposures that warranted PEP: one from South Carolina, 15 from Georgia, and 11 from North Carolina. In New Hampshire, in 1994, approximately 600 persons received PEP after potential exposure to a single rabid cat, at a cost of approximately $1 million for biologics alone. Measures to reduce rabies exposures among humans by promotion of responsible pet ownership and routine vaccination of cats remain public health priorities. Children should be taught to be cautious in their interactions with animals, especially those that are unfamiliar, to avoid potential exposures to rabies and other infectious diseases.

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In this week's JAMA Matthew Hansen, M.D., an OHSU resident in emergency medicine, conducted the study with colleagues while he was a medical student at Case Western Reserve University in Cleveland. They reviewed the electronic medical records of more than 14,000 children ages 3 to 18 who were seen by a pediatrician at least three times for well-child visits between June 1999 and September 2006. They found that found that only about one in four children with hypertension is diagnosed with the condition.

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At the 2007 International AIDS Society in Sydney according to Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, "Three years ago, fewer than 300,000 people in the developing world were receiving the anti-retroviral drugs that help treat the virus. Last year, 2.2-million people in developing countries received the drugs. However, for every one person that you put in therapy, six new people get infected."

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The AAN has published a new clinical guideline on Lyme disease. The guideline finds that conventionally recommended courses of antibiotics are highly effective for treating nervous system Lyme disease. However, there is no compelling evidence that prolonged treatment with antibiotics has any benefit in treating symptoms that persist following standard therapy. The AAN also has a 60 second PSA on lymre disease on its web site

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Today the WHO published its 3rd World Health Statistics Update. All of us should examine this valuable resource, particularly the "Ten statistical highlights in global public health."

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Due to increasing resistance to some antibiotics the CDC has just issued updated recommendations for treatment of GC and associated infections.

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In this week’s BMJ [BMJ 2007;334:662-663 (31 March)] A fascinating review of development of a British Genetic Database and discussion of the pros and cons of such data bases from both epidemiologic and privacy view points. Well worth reading

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In an article in the NEJM this week [Volume 356:1204-1205 March 22, 2007 Number 12] JF Modlin discusses the epidemioogy of Enterovirus 71 which can mimic poliomyelitis and believes it would be prudent to add enterovirus 71 to the list of emerging infections that threaten us, develop a plan to respond to an outbreak, and take the first steps toward developing a vaccine.

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From the University of Queensland, Australia research by the Asia Pacific Studies Collaboration (APCSC) confirms that cigarette smoking substantially increases the risk of dying from lung cancer in both Australia/New Zealand (ANZ) and Asia, and importantly highlights the continuing popularity of cigarette smoking across large parts of Asia, including China, where the harmful effects of smoking are still not widely appreciated, further; giving up smoking can reduce the risk of dying from lung cancer by up to 70%

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From the WHO today we learn that Tuberculosis has become one of the world's leading infectious killers - second only to HIV/AIDS.

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From the CDC today--The three most common forms of acute viral hepatitis in the United States – hepatitis A, B and C – declined dramatically between 1995 and 2005, with hepatitis A and B at the lowest levels ever recorded since the government began collecting surveillance data more than 40 years ago, according to the Centers for Disease Control and Prevention (CDC).

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QFLU is a new daily collection and analysis service specifically established to support pandemic flu planning. It has been set up by the University of Nottingham and EMIS (the main supplier of general practice computer systems within the UK) in collaboration with the Health Protection Agency. Currently, QFLU is a not-for-profit network of over 3,300 general practices spread throughout the UK covering a total population of almost 22 million patients (> 25% of the UK population).

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From ProMed today a note about neurocysticercosis, a brain infection caused by a pork tapeworm, which is a "growing public health problem in the United States," especially in states bordering Mexico, where the disease is endemic. Cysticercosis, an infection which can also harm eyes and muscles. "Recent data indicate cysticercosis is an important cause of death in California,"

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From Stanford School of Medicine never-smokers get lung cancer more often than thought, with women even more at risk than men. For women, the lung cancer incidence rate in never-smokers ranged from 14.4 to 20.8 cases per 100,000 person-years. In men, it ranged from 4.8 to 13.7 incidents. The authors infer that around 8 percent of lung cancer cases in males and close to 20 percent of cases in females are among never-smokers.

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From the Feb 9 MMWR In 2004, poisoning was second only to motor-vehicle crashes as a cause of death from unintentional injury in the United States. Nearly all poisoning deaths in the United States are attributed to drugs, and most drug poisonings result from the abuse of prescription and illegal drugs

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From the NIH we learn that newly analyzed data shows that the number of women who die from heart disease has shifted from 1 in 3 women to 1 in 4 — a decrease of nearly 17,000 deaths from 2003 to 2004. Elizabeth G. Nabel, M.D., director of NHLBI said that “To see such a significant reduction in deaths underscores that the efforts of many individuals and organizations to raise awareness, improve treatment and access, and inspire women to take action are truly saving lives.�

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George Washington University School of Public Health now provides access to Public Health Grand Rounds on the Intenet. The current grand round is on Cardiovascular DIsease in Women. It is excellent and recommended to all. Now we have two sources, UNC & GW. The GW grand rounds are broght to us via the Kaiser Family Foundation.

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From Washington University in St. Louis
COPD is the 4th leading cause of death in the US and the 2nd leading cause of disability
COPD kills more than 120,000 Americans each year. That's one death every 4 minutes
More than 12 million people are diagnosed with COPD
An additional 12 million likely have COPD and don't even know it

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A new study from the Harvard School of Public Health reported today using a systematic review and meta-analysis of epidemiologic data to quantitatively assess the association between smoking, passive smoking and indoor air pollution and TB. They found consistent evidence that smoking is associated with an increased risk of TB; they also found that passive smoking (secondhand smoke) and the burning of biomass fuels was associated with an increased TB risk.
Ref: “Tobacco Smoke, Indoor Air Pollution and Tuberculosis: A Systematic Review and Meta-Analysis,� Hsienho Lin, Majid Ezzati, Megan Murray, PLoS Med 4(1): e20.

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From the Medical College of Georgia: by age 10, some black children already have high nighttime blood pressure, an early signal of impending cardiovascular disease, a new study shows. As they grow up, black children also show greater increases in nighttime blood pressure, according to a study that followed children’s blood pressures over 15 years. At night, blood pressure should drop because the body is resting, says Dr. Gregory Harshfield, director of MCG’s Georgia Prevention Institute and a co-author on the study published in the Dec. 19 edition of Circulation, the journal of the American Heart Association.

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In Science last week (Science 22 December 2006:Vol. 314. no. 5807, pp. 1884 - 1886) a paper by Erik van Nimwegen explains how genetic drift is different from genetic shift and the annual changes in the Influenza A (H3N2) virus.

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A study in JAMA today (JAMA. 2006;296:2832-2838) suggests that vitamin D levels and development of Multiple Sclerosis (MS) are related. Because this is an observational study cause and effect cannot be determined. The study was well designed but the senior author cautions that use of vitamin D supplements for MS prevention should not be undertaken until efficacy is proven. How long will it be before we see vitmain D pushed by the vitamin industry, and will this negate the abilty to study cause and effect?

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A food borne outbreak from norovirus, apparently due to infected food handlers, at an Olive Garden restaurant in Indiana has been reported. Several hundred patrons have become ill. This outbreak emphasises the need for careful scrutiny of worker's hygienic practices. Handwashing basins should be visible to the staff and management. Any staff leaving work areas must be required to wash hands thoroughly, in view of others, before starting food handling again. Workers harboring infectious agents may not show. or report, symptoms. Managers may need better training in worker observation.

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The FDA is investigating a Norovirus outbreak which has been associated with raw, frozen oysters on the half shell from South Korea. Eight individuals have been confirmed as becoming ill as a result of consuming the raw oysters at a private event in Woodburn, Oregon. On December 8, FDA testing of oysters from the same production lot showed positive results for norovirus. While raw oysters on the half shell are considered a delicacy they filter huge amounts of water and are frequently associated with disease outbreaks.

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A study published in the November 2006 issue of Cancer Epidemiology shows that cigarette smoking and concurrent infection with high levels of the virus associated with cervical cancer can increase cancer risk by as much as 27 times, Performed at the Karolinska Institutet in Stockholm it suggests that both may create a biochemical synergy that propels the disease. The researchers looked at “Pap� smear examination data from 105,760 Swedish women and identified 499 women with cervical cancer in situ, along with 499 cancer-free women as controls. For these women, they compared their smoking behavior with concentrations (known as viral load) of HPV-16, the viral strain most associated with cervical cancer. The researchers found that a combination of high viral loads and smoking during the time they were initially examined resulted in very high risk of later cervical cancer.

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In JAMA, today is a report of a study to test whether midlife biological, lifestyle, and sociodemographic risk factors are associated with overall survival and exceptional survival. High grip strength and avoidance of overweight, hyperglycemia, hypertension, smoking, and excessive alcohol consumption were associated with both overall and exceptional survival. In addition, high education and avoidance of hypertriglyceridemia were associated with exceptional survival, and lack of a marital partner was associated with mortality before age 85 years. Risk factor models based on cumulative risk factors (survival risk score) suggest that the probability of survival to oldest age is as high as 69% with no risk factors and as low as 22% with 6 or more risk factors.

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In JAMA, today, is an article on overuse of screening for PSA in men over 70 years of age, many of whom may not live another 10 years. While this study was conducted among a cohort of male veterans over 70 years of age, the results might well apply to the overuse of PSA screening among primary care physicians nationwide.

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One more study, this time from Harvard School of Public Health, on nutrition and diet. Can oen believe anything from nutritionists? They are as correct as weather forecasters! In the first study to look at the long-term effects of low-carbohydrate diets, researchers from the Harvard School of Public Health (HSPH) found no evidence of an association between low-carb diets and an increased risk of CHD in women. Their findings did suggest, however, an association between low-carb diets high in vegetable sources of fat and protein and a low risk of CHD.

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From the University of Michigan this week: Lung cancer is the No. 1 cancer-related killer in the United States. And while men are more likely to die from lung cancer than women, the trend is starting to change. “If you add up the number of people in the United States who die of breast cancer, prostate cancer, colon cancer and pancreatic cancer, the number of people who die of lung cancer is greater than all of those combined,� says Gregory Kalemkerian, M.D.. “Almost twice as many American women die from lung cancer every year than from breast cancer. I think that statistic says it all: Women are at high risk for developing lung cancer, particularly those women who smoke, and there is a greater risk of dying from lung cancer than from breast cancer,� Kalemkerian adds. The lesson: Stop smoking. Any time you look at the risks in lung cancer, it’s dominated by smoking: 90 percent of people who get lung cancer are smokers or former smokers.

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From today's BMJ: Only 7% of spending on health research goes on needs of poor countries

Tobacco will kill 50% more people in 2015 than HIV/AIDS and will be responsible for 10% of all deaths
Deaths from traffic will increase from 1.2 million in 2003 to 2.1 million in 2030
Deaths from cardiovascular diseases will increase from 17 million in 2003 to 23.3 million in 2030
Deaths from cancer will increase from 7.3 million in 2003 to 11.5 million in 2030
Monitoring Financial Flows for Health Research 2006: Behind the Global Numbers is available at www.globalforumhealth.org.

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A new study from University of California, San Francisco demonstrates that the health status of young adults is far worse than that of teens, with mortality rates more than double due in part to increased rates of injury, homicide and suicide, according to a new analysis by UCSF adolescent medicine researchers. Among their findings:

• Young adults, defined as 18 to 24 year olds, have triple the suicide rate of adolescents, with young men’s suicide rate six times greater than that of young women, (approximately 19 versus 3 per 100,000).

• Unintentional injury is the leading cause of death for young adults, about 70 percent of which is attributable to motor vehicle accidents, with a high percentage of those involving alcohol use.

• Homicide rates peak in young adulthood. Young men’s homicide rate is six times higher than that of young women. Among all young men the rate is 27 per 100,000; for young women it is 4.6 per 100,000. It is 111 per 100,000 for young African American men.

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A study from the University of Rochester Medical Center published in the Sept 1 issue of the international Journal of Cancer finds that "people who are routinely exposed to lead on the job are 50 percent more likely to die from brain cancer than people who are not exposed, according". The death rate among people with jobs that potentially exposed them to lead was 50 percent higher than unexposed people, and the number of deaths was larger than in many previous studies.

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Many in Publlc Heal;th have been concerned about the socioeconmic differentials in prevelance of disease and disability. Now from the NEJM this week, Meredith Minkler et al. report on whether a gradient in disability exists in the United States among persons with middle-class and upper-class incomes, not just lowest incomes.
A social-class gradient was observed for both men and women between the ages of 55 and 84, a gradient that held true even at the upper rungs of the socioeconomic ladder. For example, in comparison to persons between the ages of 55 and 64 who lived at 700 percent of the poverty line or above, persons of the same age but below the poverty line had six times the odds of reporting a functional limitation. With increasing income, the odds ratio declined. A significant gradient was present up to, but not beyond, the age of 85 years.
Ref:Volume 355:695-703 August 17, 2006 Number 7 Meredith Minkler, Dr.P.H., et Al - Gradient of Disability across the Socioeconomic Spectrum in the United States

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In an expanded use of epidemiology a report from UNC today shows that billing data routinely collected by primary care providers can help public health authorities detect outbreaks of emerging infections.
The researchers compared the primary care practice data to similar data collected during the same period at UNC Hospitals' Emergency Department. The team found spikes of activity during the year, with increases occurred first in the primary care practice. This suggests that the practice may have seen patients with influenza earlier than the emergency department. The researchers conclude that it is feasible to implement surveillance in primary care practices at low cost and with minimal staff effort.

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A report from UCLA published in today's NEJM shows that MRSA is the most common cause of skin and soft-tissue infections among patients presenting in emergency rooms across the country. MRSA is resistant to the antibiotics used for years to treat these skin conditions, such as cephalexin and dicloxacillin.

"The study points to the rising prevalence of this type of MRSA and the need for clinicians to culture infections and make sure the proper antibiotic is administered to treat MRSA," said Dr. Gregory J. Moran, the study's principal investigator and a clinical professor of medicine in the department of emergency medicine and the division of infectious diseases at Olive View–UCLA Medical Center.

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Clarification of a recent report of swans with H5 and N1 subtype viruses. This release from the USDA may help you to calm fears of citizens who ask the health department about the report. Evidence of LPAI H5N1 has been found on two occasions in wild birds in the United States. In 1975 and 1986, it was detected in wild ducks. These detections occurred as part of routine sampling. LPAI H5N1 has also been detected in Canada, most recently in 2005.
Fact Sheet: AVIAN INFLUENZA Low Pathogenic H5N1 vs. Highly Pathogenic H5N1 Latest UPDATE August 14, 2006

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Research from Imperial College, London, shows how certain genetic strains of common STDs can be used to track community spread of an STD and apply public health interventions.
Rresearchers from Imperial College and the Health Protection Agency used molecular typing to analyse different strains of gonorrhoea. Out of a total of 2045 strains recovered in London during a six month period, they were able to identify 21 prevalent strains, each infecting between 20 and 124 individuals. Seven of these strains were almost exclusively from homosexual men, while the other 14 were from almost exclusively from heterosexuals, suggesting very little spread of gonorrhoea between different behavioural groups.

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In “Protecting Young Women from HIV/AIDS: The Case Against Child and Adolescent Marriage,� (published by the Guttmacher Institute) Shelley Clark of McGill University et al. analyze data from national surveys from 29 countries and find that:
Marriage exposes young women to frequent, unprotected sex, especially when the couple wants to have children. In most countries, more than 80% of adolescents who had had unprotected sex in the last week were married.
Husbands of adolescent wives tend to be much older (by 5-14 years, on average) and more sexually experienced then their wives and are therefore more likely to be HIV-positive. Adolescent brides are also more likely to marry into polygamous unions.
Adolescent wives are often cut off from formal education as well as other public sources of information such as regular television and radio programs. In all 29 countries, women who married as adults stayed in school longer than young women who married before they turned 18.
Even when they are aware of HIV risk, most young married women rely on remaining faithful to their husbands—and their husbands remaining faithful to them—as their sole protection from the virus.
The reseach continues with recommendation to prevent this spread of HIV.

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Whooping cough “endemic� among UK school children, say experts. Whooping cough in school age children with persistent cough: prospective cohort study in primary care BMJ Online First

Nearly 40% of school age children in the United Kingdom who visit their family doctor with a persistent cough have evidence of whooping cough infection, even though they have been fully immunised, finds a study published on bmj.com today.

These startling results suggest that whooping cough is endemic among young children in the UK, with important implications for clinical practice and immunisation policy, say the authors.

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An article in today's JAMA states that In 2006 in the United States, it is estimated that lung cancer will cause 73 020 deaths in women, proportionately only slightly fewer than the estimated 90 470 deaths in men. Lung cancer now accounts for more deaths in women than any other cancer, more even than the second and third cancer killers (breast and colon cancer) combined

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Should we lower cholesterol as much as possible? BMJ Volume 332, pp 1330-2

New US recommendations for lowering cholesterol levels would increase the risk of harmful side effects with no overall reduction in deaths, warn experts in this week’s BMJ.

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From HSPH this Monday A prospective study of 42,847 middle-aged and older U.S. men participating in the Health Professionals Follow-up Study has found that a healthy lifestyle is associated with a lower risk of coronary heart disease (CHD), even among men taking antihypertensive or lipid-lowering medications. The research, which is the first to look at the role of a healthy lifestyle and CHD in men in this age group, is published in the July 3, 2006, online edition of Circulation.
One mroe study that puts reponsiblity for health on the individual's shoulders. Insurance companies need to place a dividend on healthy lifestyles, just like they do on use of seat belts.

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A study reported in the Lancet this week shows how knowledge about Kuru, may be used as a template for vCJD.
Between 1957 and 2004, the total number of cases of kuru exceeded 2700. The lower limit of incubation time may be as few as 5 years. Although the mean incubation time is 12 years, Collinge and colleagues also discovered incubation times above 50 years. They conclude that existing models and estimates of the vCJD epidemic could be “substantial underestimations�. This study provides a unique insight into the natural history of human prion disease. It combines cultural, clinical, genetic, and pathological evidence to draw a highly informative picture of great contemporary value.
RERF:The Lancet, Volume 367, Issue 9528, 24 June 2006-30 June 2006, Pages 2068-2074

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Another diet myth:
The review, published in the March 2006 issue of the British Nutrition Foundation's Nutrition Bulletin, examines more than 30 studies conducted over the past 30 years (with more than half published in the past decade) and concludes that the dietary cholesterol in eggs "has no clinically significant impact" on coronary heart disease (CHD) risk.
More importantly, the authors, Dr. Bruce Griffin and Dr. A. Lee of the Centre for Nutrition & Food Safety, School of Biomedical & Molecular Sciences, University of Surrey, UK, stated, "to view eggs solely in terms of the effects of their dietary cholesterol… is to ignore the potential benefits of egg consumption on coronary risk factors, including obesity, diabetes and metabolic syndrome."
Eggs are naturally nutrient rich. One egg provides 13 essential nutrients -- including high quality protein, choline, folate, iron and zinc -- for only about 75 calories. Experts recommend choosing nutrient dense foods, such as eggs, to help get needed nutrients without excess calories.

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Just reported from the Institute of Cancer Research in the UK are the results of the largest ever genome-wide scan for lung cancer-susceptibility which found 64 specific sequence changes in the genome that can affect an individual’s risk of lung cancer.The researchers found 64 specific changes that affect lung cancer susceptibility. The changes are “low-penetrance alleles� meaning that individually they only contribute to the development of cancer in a minor way.
The researchers found 64 specific changes that affect lung cancer susceptibility. The changes are “low-penetrance alleles� meaning that individually they only contribute to the development of cancer in a minor way.
Professor Richard Houlston from The Institute said, “The exact nature of lung cancer susceptibility is extremely complex, it is important to remember that tobacco smoke is far and away the biggest risk factor for lung cancer. Whilst our research indicates that certain individuals could be at a higher risk of developing the disease it has been proven that the majority of cases of lung cancer are caused by tobacco smoke.�

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Scientists at UAB today discussed a crucial missing link in the search for the origin of HIV-1, the virus responsible for human AIDS. That missing link is the natural reservoir of the virus, which the team has found in wild-living chimpanzees in southern Cameroon.
Although researchers have long suspected that HIV-1’s origins lie in some way with chimpanzee infection through a closely related virus SIVcpz (simian immunodeficiency virus from chimpanzees), only a few captive apes had been found to harbor SIVcpz.

In the study, UAB Professor of Medicine Beatrice H. Hahn, M.D., and her team conducted the first-ever molecular epidemiological survey of SIVcpz infection in wild-living chimpanzees in west-central Africa. By analyzing ape fecal samples collected by trackers from the forest floor in remote jungle regions of Cameroon, Hahn and her colleagues were able to detect SIVcpz-specific antibodies and nucleic acids (viral genetic information) in as many as 35 percent of chimpanzees in some ape communities.

But how did it get from Cameroon to San Fransicsco, where humans with the disease were first decribed, and why the 25 year gap?

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