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Tuesday, 28 February 2012

Smoking at the Movies – an Academy and Canadian disgrace.

Most of the big winning movies at this years Academy awards have significant images of tobacco smoking. A long standing debate, the analysis of the relative impact to tobacco at the cinema has become more sophisticated and demonstrates concerning trends.   81% of movies rated R in the US  have smoking imagery, 66% of PG-13,   and 27% of G or PG  movies.   This amongst an analysis of 1300 feature movies that accounted for over 95% of ticket sales in the US from 2002-2010.

A WHO report looks carefully at the issue Smoke free movies - WHO   and makes some very specific and targeted recommendations.   Internationally, there are countries that have taken up the challenge.  Nigeria and China are the leaders and have taken action to preclude smoking in domestic productions.   Other countries are taken aim at the industry, but the main tool available without US leadership is the ratings classification system. 

Did you realize in Canada, that 60% of the files rated “R” in the United States are considered acceptable for adolescent reviewing?   The number increases to 83% in the UK.   Recall that smoking imagery based on classification is on the basis of US classifications, hence Canadian adolescent tobacco image views that could reinforce smoking behaviours are much higher than peers to the south. 

The Canadian experience is detailed in a report by Physicians for a Smoke-Free Canada Smoking in American Movies, the Canadian Impact.  The report makes a claim of up to one-third of youth tobacco use can be attributed to exposure in movies, this corresponding to 43,000 premature deaths from tobacco in the future for today’s adolescents.  There may be some questions about the evidence supporting this attributable fraction, but it does attract attention to the issue.   The document provides a good overview of the Canadian film industry rating diversity and comparison to the US ratings as well as Canada's contributions as Hollywood North. 

Governments have been  attracted to the gloss of the movie industry as a form of monetary stimulus in conjunction with business development and tourism support.  Given the level of government support through a variety of measures including tax credits, one should think that there is a public good ability to impact both the use of tobacco and the subsequent viewing by youth of movies containing smoking.   Most of the business development work is done at a provincial level, and competition between provinces is fierce. The policy wonks would shun the thought of imposing a criteria that might be perceived as reducing the competitive edge to attract films, hence national harmonization and a common front would required.  Not likely to happen under the current leadership.  

The Canadian track record on promotion of the arts is legendary and to be commended.   In film alone, Canadians won the first three Leading Actress Oscars (Mary Pickford, Norma Shearer, Marie Dressler).  The National Film Board has received 72 Academy Award nominations and taken the Oscar 12 times. There are numerous Canadian Oscars in just about every category.   Check out a 2004 list by the CBC of Canadian winners Canada at the Oscars  .  Christopher Plummer’s 2012 award as the best supporting actor is the latest in this long list of outstanding Canadian achievements in film.

With such a marvellous track record, are we not capable of initiating some reform that links art and health, without jeers of compromising artistic freedoms from those that do not have to live or die with the consequences?  Perhaps some of the more recent award winners would likely have greater impact than the health advocates have.  

Monday, 27 February 2012

Safety promotion - reducing injuries on the road and at play.

Tragedy struck on the weekend with the derailment of a passenger train, the deaths of 3 engineers and 46 injured persons. The headlines will be filled for days and considerable time and resources will be spent on determining what happened and how to prevent a similar incident. At the same time, take a moment to remember that on any given day in Canada an average of 7 people die in motor vehicle collisions.  Just think what a difference we could make if the train derailment mitigation and investigative money were matched in dollars directed at further reductions in motor vehicle collisions.

While injury mortality and hospitalization rates continue to creep downwards (use the PHAC injury surveillance tool to explore national/provincial rates http://dsol-smed.hc-sc.gc.ca/dsol-smed/is-sb/c_time-eng.php ), progress in preventing injury has not happened with the same rapidity as it has for other illnesses.  Motor vehicle crash mortality rates have decreased over 50%, other causes of unintended injury have not been so dramatically reduced. In the embedded graphic, the green line represents Motor vehicle crashes which have decreased by almost 2/3rds.   All other unintentional injuries have only reduced by about ¼.  The red line represents all unintentional injuries including motor vehicle crashes. 

There are newer ways of protection from injury that have been and are being implemented.   Health Evidence has recently posted several and primary sources are included in this field that needs to be further padded.

Graduated licensing reduces crashes by 15.5 – 22%  Graduating licensing . The effect seems to be sustained beyond just the first year of driving as well.   The effect is similar for fatal,  injury and non-injury type of crashes.  There is a higher impact on night time and alcohol associated crashes, with benefits of 20-40%. Implemented in all provinces now (Nunavut has yet to take the plunge), it takes drivers through three phases of preparedness starting with accompanied driving; then limited numbers of passengers, no night time driving, no alcohol; before receiving full licensure.  The Cochrane review is well worth reading for the rigour and style if you have access Cochrane review - link may not work from some work sites and outside of Canada .

Speed cameras are not implemented in all provinces, having been subjected to political interference in an injury protection endeavour.   Resistance was based on the perception that speed cameras were merely an easy way of generating fine based income.  This review should provide further evidence for those jurisdictions that need proof that speed cameras save lives as they are associated with a 8-50% reduction in collisions, 11-44% reduction in fatal and serious collisions, and overall reductions in road speeds and proportion of speeders.  Speed cameras .    The full review is also in the Cochrane database. 

Bicycle helmet legislation increases usage, but impact on actual outcomes hard to measure  thought suggestive of benefit.   Bicycle helmet legislation   Not surprising given the relative infrequency of serious events and the methodological challenges in doing comparative studies.  

Speaking of safety helmets, helmet use in skiing and snowboarding showing a 35%-40% reduction in head injuries  amongst helmet users (full reference for those with library access CMAJ 2010, 182(4) pp 333-340)  .  This increased to up to 60% for studies looking specifically at children.   The effect is greatest for beginners and males, lacking significance with expert skiers and females.   

Protect yourself - buckle up and wear the gear....

Friday, 24 February 2012

Hot public health topics worth reviewing: Provincial budgets, low sodium diets, smoking cessation and perinatal indicators.

Its spring time and that means two major events.  Curling season is in full swing and provincial budgets are being released.  How has the provincial budget impacted public health in your province?  Send the quotes and details to drphealth@gmail.com.  

Some solid reviews published recently on some important topics that should impact our public health practice.  
Low sodium diets reduce blood pressure – something that has been recommended for decades, but the proof was evasive.   A metanalysis available at Health-Evidence.ca suggests a benefit in blood pressure for hypertensives, but associated with increases in triglcerides and cholesterol.   It doesn’t answer the question though if dietary intervention modifies clinical outcomes.   http://www.health-evidence.ca/articles/show/17687 

Proactive counselling helps with smoking cessation – another intuitive finding, and the data analysis is suggesting a benefit of up to 40% after over a year.   http://www.health-evidence.ca/articles/show/21788   Another in a series of studies speaking to reaching out to clients by the phone.   There are some pilot projects and increased dissemination of technology that supports chronic disease suffers, mostly COPD and CHF, in telephone follow up and remote sensing.   Such interventions tend to be daily and high tech.   What are the odds that any jurisdictions will spring for a low tech prevention program with high long term benefit?    If there are successful smoking cessation telephone follow-up programs in Canada, time to share them so that others can invest wisely – let us know.

There is a an interesting piece coming out of the British Medical Journal via CIHR on how Canada’s child health indicators may not be as bad as previously indicated because perinatal reporting in Canada is relatively good.  This moves Canada from a dismal 18th to a moderately poor 12th. Even better news for our southern cousins who move from 22nd to 11th in the revised data.    CIHR release of BMJ study on child health indicators. 

Wednesday, 22 February 2012

Oxycodone losing funding in many provinces and First Nations: A case of prescription drug abuse and the potential consequences of a poorly implemented policy change

Media watchers are abuzz with the bold actions in the last few days by Ontario, Saskatchewan and now the Maritime provinces to stop public funding of OxyContin and not fund the newer formulation OxyNEO. This follows a national decision to limit access to the newer formulation under First Nations non-insured drug benefits.   Updated: As of February 28, 2012 - BC is added to the list of provinces. 

Abuse and addiction to Oxycodone is significant public health concern.   Drug Overdose deaths increased after its introduction in 2000, and best estimates would be up to 2000 drug overdose deaths annually in Canada from opiate overdoses, of for which some attribute 30-40% to prescription opiates including oxycodone.   1-3% of the Canadian population are abusing prescription opioid drugs, that is almost a million individuals.   Even the lower limit estimates of 300 overdose deaths and 300,000 addicted persons to prescription opiates should raise alarms, bells and whistles. 

But let’s dig a bit deeper in the story.  The manufacturer has tried to reduce the harmful effects by developing a slower delivery mechanism that reduces the likelihood of overdosing.  Still effective as a pain killer, less potential for overdose.  A legitimate form of harm reduction.   Governments seize the opportunity and just decide to stop funding altogether.

Oxycodone was introduced as an analgesic alternative to morphine.   The widespread use and abuse of the drug is predominately secondary to prescribing practices by health care workers – not illicit distribution rings. 
There do not appear to be therapeutic plans to bridge those addicted during the phase out period for oxycodone.  Most provinces will likely continue prescriptions for current cancer and palliative patients currently using the pain medication as the form of transition and not use the drug for newer patients.  In essence just put those addicted by the health system in a state of distress.  

There is no doubt that abuse of oxycodone is rampant, with some estimates in certain communities in Northern Ontario reaching as high as 75% of the adult population.  Treatment is hard to obtain and many addicted persons probably need the benefit of methadone distribution for maintenance during rehabilitation – a service not available in most rural communities. 

The niche that opens will be an invitation to organized crime to fill in the missing distribution to meet the demand.  Perhaps a Catch-22 situation, but seemingly bizarre that the decision is made when a new product designed to reduce harm is being introduced.  No doubt the cost savings to the health care system in the short term might be an attraction, the long term consequences on society will not be insignificant – but will they ultimately be a benefit?  We are engaging in a massive social experiment without the knowledge of the society that will be impacted.

 DrPHealth celebrates its 5000th view today – thanks for your ongoing support and interest

Tuesday, 21 February 2012

Measles - The Moose is Loose

PHAC recently issued a travel advisory on measles globally as a reminder to travellers to be sure about immunity. PHAC travel advisory.    International travel has become the major contributor to importation of measles into Canada. 

Then as this posting went up, a report of spread of measles in the US related to the Superbowl.   Measles and Super bowl with at least 14 cases so far and more spread is likely given the number exposed

Great advances have been made in controlling measles in Canada, so much so we often forget the devastation that the disease reaped havoc prior to the ‘60s when 250,000-400,000 cases occurred in Canada annually.  Measles remains the number one vaccine preventable cause of death internationally with some 150,000-200,000 deaths per year.  The embedded graph provides the Canadian view of measles control, something that is replicated in most developing countries.

2002 the Americas were declared as measles free for indigenous spread.  Already in 2012 there have been nearly a 1000 cases in the Americas alone PAHO weekly reporting 

While it is difficult to be sure on numbers, Canada had 750 cases in Quebec in 2011 Quebec measles outbreak update, 79% of which were underimmunized.  BC in the wake of the 2010 Olympics saw 82 cases.   Both outbreaks sparked by importations into the country and then sustained local transmission.  Both outbreaks speak to the vulnerability of Canada that despite great immunization programs, sustained transmission can and does occur. 

The reproductive number of measles is estimated at 12-18 – meaning every case could potentially infect 12-18 non-immune persons.  Of course the propagation of the disease will occur when the probability that each case contacts at least one other non-immune person.  When population immunity levels begin to drop to where one in 20 is susceptible then the likelihood that each case will transmit to one or more people becomes more likely and propagation will occur.   (Simply put, but a close estimate).   Even the best 2-dose coverage levels in Canada are just over 90%, with about half of the underimmunized having had one dose of vaccine. 

Despite the international efforts to contain measles, dissemination and propagation continue to occur.   It remains a public health emergency and requires immediate mobilization to contain importations – just that the event would appear to be getting more frequent and the consequences are not just a few cases, but into the tens and hundreds before control is achieved.   On the positive side, the first decade of this century saw global measles deaths reduced by nearly 80% - short of the objective, but a huge improvement.  

More is available on measles in Canada at PHAC measles site, but as is typical of PHAC, that sense of declining success and building urgency is lacking.   

Monday, 20 February 2012

Aboriginal Health issues in Canada: A Collision of Collaboration, Multiple jurisdictions and the problem of too many cooks.

DrPHealth is material written for the audience of public health professionals in Canada.   Follow by subscribing, being a follower or following by email on the links at the very bottom of the blog.  You can also follow on Twitter @drphealth. 

Since the posting of the Smart Meter blog on February 3rd, there has been a significant shift in audience from Canadian viewers to the US. Clearly a hot topic on both sides of the border. 

Just an encouragement to continue to push the blog information to the Canadian public health community -   while all viewers are most welcome.  Sometime this week, the blog will exceed 5000 views – thanks for making it a valued contribution.

One of Canada’s greatest strengths is also its Achilles heel.   We are a “confederation”.  Originally a confederation of four provinces to which six provinces have been added and more formal recognition of the partnership of the 612 First Nations  (spread over 2,675 reserves of which some 120 are in urban settings), and three territories.  To this is added the governance structures of the Métis Nation settlements.   For a primer on Aboriginal Health issues specific issues see Aboriginal Health DrPHealth equity.  

The problem, while the original five governments (four provincial and one federal) might have functioned well under the concept of a confederation, theoretically change now requires agreement of all provinces (recognizing that Quebec retains a certain special status as well), and probably also the “vast majority” of First Nations and the territorial governments with acknowledgement of Métis structures. 

Put differently, it is amazing that we actually achieve anything in the country these days.  Of course the different levels of government have different responsibilities and our current federal government has demonstrated that it can act in a fashion not consistent with other governance levels, general public, or common sense.  Totally aside, kudos to the Ontario judge that refused to implement a mandatory sentence imposed by the Harper government because it was cruel punishment.

Where we trip over each other is when multiple jurisdictions may be involved in a similar issue.  First Nations Health is one of those collision sites.   Health is a provincial responsibility under the Constitution,  except of course on federal lands.  Reserves are one the federal lands.  Health transfer has shifted some resources and responsibilities for some of the First Nations to their self responsibility which means that Band and Council now are significant responsible parties as well.  Most provinces delegate some of their responsibilities to local health regions, retaining certain powers.   All of sudden you have a situations where federal, provincial, regional and band authorities may all be converging on an emergency health problem, this is a recipe for disaster. 

In fact, having six or seven agencies with similar responsibilities showing up to address an issue is not uncommon and more likely to occur into the future.   The ability to solve emergent challenges becomes the measure of our success, and Attawapiskat (Aattawapiskat and Social Justice DrPHealth)  might be a clear demonstration of this current lack of ability.   Conversely there are many examples of cross jurisdictional successes that are developing and will be the new models of the future. 

Local governance bodies, both First Nation and either local or regional government will likely become the foundational unit for success going forward. It is just the neighbourly thing to do, and isn’t that just so Canadian, eh?  This will require federal and provincial governments and agencies to devolve some of their historical roles and power  - that has the potential to be the major barrier to a smooth transition.  Power is sometimes equated with money, and decentralization is usually associated with a loss of efficiencies - hence conflicting values contribute to the policy change.  

We will need to learn and acknowledge the successes and experiences as this transition occurs and provide reassurances to others that local solutions will be the best solutions. And also learn at the local level, where centralization and efficiencies can be gained through collective/collaborative solutions. 

There are 1,172,785 registered Aboriginals in Canada. This  currently represents about 3.5% of the Canadian population.  Some 13% of the Canadian land mass is held as reserve lands. Aboriginal statistics in Canada on a BC website.  Learn more about our Aboriginal heritage and structures at Aboriginal affairs and northern development home page  

Thursday, 16 February 2012

Ontario Health Reform - Missing the impact of inequities

The Ontario release of a plan to rebalance the budget, with significant implications for the health care system (Drummond report) is receiving considerable attention.  The following is taken from a post that is so eloquently written and precise it deserves to be fully plagerized with full acknowledgement to the Wellesley Institute writers http://www.wellesleyinstitute.com/news/drummond-report/ 

The Drummond Report’s emphasis on reform and innovation in the way health care is organized and delivered is vital. The objectives of long-term planning, a shift to home and community care, prevention, and integration of health services are right on the mark. But a huge element is missing: equity. Equitable access to services, equitable outcomes and improved population health must also be fundamental goals of reform.

The report highlights that a small proportion of patients with complex needs account for a high proportion of overall health system costs and emphasizes that preventing ill health and controlling chronic diseases is crucial moving forward.

Good so far, but the distribution of ill-health is not random; a crucial element is the well-documented social gradient of health — the risk and burden of many chronic conditions and poor health more generally is far higher for marginalized populations, such as people with low incomes.
Innovation and reform are essential in the pursuit of high quality, responsive and patient-centred care, as well as system efficiency and sustainability. But we need to ensure that that the massive reforms being contemplated do not make access to health care less equitable or worsen the health of marginalized populations.

The Commission’s report emphasizes patient-centred care, and this is excellent. But equity in patient-centred care means ensuring that all Ontarians have access to high quality care. The report also highlights the importance of primary care. An equity approach would ensure that expanded family health teams, community health centres and other key reforms are concentrated in under-served and higher need areas to reduce inequitable disparities in access.

The report rightly points to the need for coordination and integration of services. We need to think broadly here. Discharging a patient into overcrowded or unsafe housing means that they are likely to end up back in the hospital, thereby undermining the savings and efficiencies the Commission is looking for.

Beyond Health Care

We completely agree with the call for a powerful twenty year vision for “a superior health care system.” But health is far more than health care, as the report acknowledges. The real determinants of health lie far beyond the health care system–in people’s employment, living conditions and opportunities. Poverty, economic inequality, deteriorating community infrastructures, lack of access to good public services, racism and social exclusion are the conditions that create and perpetuate health disparities in our province.

As a practical example, it is crucial to ensure equitable access to high quality diabetes treatment. But diabetes and other chronic conditions are tied to poverty and concentrated in poor neighbourhoods and marginalized communities. If we don’t improve access to good housing, adequate food, and safe neighbourhoods we will not be able to reduce these preventable diseases.

Drummond’s prescription for limited investment in social programs and reductions in other areas poses a real danger. Reducing vital support for affordable housing, safe communities, transportation, and other community infrastructure will undermine the foundations of strong and healthy communities. This will have an adverse impact on overall health and will increase health inequities — in turn, putting more pressure on the health care system.

The site promises more insightful critique of the Ontario plan and hence well worth watching in the upcoming days and weeks.  

Tuesday, 14 February 2012

Mental Health Promotion - Bell and Clara Hughes partner for all our benefit

Happy Valentine's Day.  What better day to speak to the antithesis of positive emotion as a reminder that we are not all so privileged to enjoy the health benefits of mental wellbeing and love on a daily basis. 

The surge of mental health promotion activity deserves recognition and acknowledgement to companies like Bell and individuals like Clara Hughes that have taken up the cause http://letstalk.bell.ca/ .  The normalization of acceptance of mental diseases has taken decades of work and still requires much more effort, but progress is being made.  It is not limited to back room discussions and hidden into the back pages of papers. Its front and centre on Dr. Oz, the View and in magazines.  

The message is Its okay to be diabetic, disabled or depressed;  Sjogren,  schizophrenic or sarcoidosis;    Anxious, Addison’s or anaphylactic.   At least it is a start of an inclusion message.  Considerable work still needs to be done on normalizing therapies, seeking treatment, and decriminalizing mental illness. 
We have progressed immensely in the past few decades on a road that speaks to inclusion and normalization, however the journey is far from complete.  Openness and the willingness to engage in challenging conversations will continue to smooth the path.

Which of us has not personally experienced a family member or friend suffer from a mental illness?  If honestly are not aware of anyone, you are in a small minority of the population.  One in five Canadians will suffer a bout of mental illness so we all have a role to play in normalizing the illness process.   2002 report on mental illness in Canada

The first place to clean up may be the health care systems itself.   Mental health therapies have increasingly been isolated from other components of health.  Documentation sealed in confidentiality even when diagnoses of greater consequence are increasingly transparent between health providers who collaborate on efforts to provide a holistic therapeutic environment for chronic communicable diseases, genetic disorders, multiple disabilities.  

The second place is for public health authorities to take a lead role in acknowledging the burden of illness carried by Canadians as integral to the public health control efforts of the country.  Rhetoric has been long over the years, but actions led by public health are limited.   Mental health promotion in Canada - Drphealth October 2011

In the meantime, the efforts of Canada’s most medaled athlete and others who have come forward to speak to their personal stories and experiences needs to be commended. Bell and other utilities have  become corporate models in the messaging.    Other public  leaders with personal experience should be welcomed to the podium to share their stories and come out from the shadows.  .  

Monday, 13 February 2012

Air pollution, health effects and the Air Quality Health Index (AQHI)

As noted previously, the AQHI is a uniquely Canadian approach to communicating the risk from poor air quality.  Communicating the risk of weather.  There are an estimated 4000-20000 Canadians who die prematurely each year from poor air quality.  The higher number comes from the Canadian Medical Association analysis http://www.cma.ca/icap .   Health Canada, Environment Canada and the Auditor General use numbers between 4000-5900.   Irrespective, the cumulative deaths from air pollution exceed or on par with all other weather related health impacts in Canada.  

Innumerable reviews of the health impacts of air pollution are available, a reasonable short synthesis at Health Canada health_effects of air pollution.   For the more enthralled in the topic, read the technical documents produced by the US EPA on specific pollutants.  All speak to the devastating impacts that deteriorating air quality has on human health. 

Most older air quality indices work by measuring a suite of pollutants and reporting  on the most severe on any one particular day – ignoring the contribution of other pollutants.  The old AQIs in Canada were actually at least 6 different indices.  To add confusion, what is reported in Canada as 50, is reported in the US as 100.   Other countries use similarly diffuse methods of communication which preclude portability

Unlike the other indices, the Canadian AQHI works by estimating the health impact by reporting the total effect as a surrogate measured by commonly monitored pollutants.  The AQHI is now available to just of 60% of the Canadian population, mostly thanks to the Weather Channel which is the most consistent form for reporting air quality nationally. Look for the AQHI on Canada's most visited website at the Environment Canada Weatheroffice http://www.weatheroffice.gc.ca/canada_e.html  

Ontario’s ego is a barrier to further implementation throughout the country.  It is only through the determined work of public health professionals in Toronto, Windsor, and a few other communities that the AQHI is available to those communities.   The Ontario Ministry of the Environment remains resistant to appropriately informing residents of the province of the risk they face from poorer air quality in the fashion received by most of the rest of the country.   The Ontario Ministry of Health and Long Term Care is complicit with the MoE stating the need for a full scientific review.  Of course, such bureaucratic rationalization is a great way to procrastinate and ultimately back away from unification of risk communication across the country. The AQHI is not prefect, but a lightyear ahead of other air quality indices in use currently. 

Similar resistance exists in parts of Quebec, although Quebec has aggressively attempted to communicate air quality risks for longer than most parts of Canada and switching modalities is somewhat more problematic as there is no attempt to hide the problem.

The science of air quality and health has advanced dramatically in the past decade.  Yet, many health care providers lack the information to adequately inform their patients/clients of how to manage health risks – and until we have a pan-Canadian risk communication tool, such dialogue is unlikely.  So, in the meantime, Ontario contributes to the death and disability of its own residents and those of the rest of the country.  Most of the country of which has openly adopted the importance of ensuring the public has the right to information on which to protect their health.  

Thursday, 9 February 2012

HIV disclosure before the Supreme Court - What are the implications for public health?

The supreme court has begun hearing arguments in a couple of cases where the fundamental question is whether persons with HIV infection are required to inform others who might think they are at risk?
Not an easy question, and the deliberations and decisions will probably be spilt in some fashion.  

At the extremes of the debate, there is sufficient case law that knowingly and intentionally infected someone with HIV is a form of assault. What is unclear is where the definition of assault no longer applies. 

At the other extreme is the right to confidentiality that rightly protects privacy in circumstances where no threat exists.   There is reasonable precedent on issues such as the reasonableness to inform the public of persons known to be an imminent threat to the danger to the public or specific persons.

That leaves a very broad grey zone between the extremes that is open to interpretation. 

Central to the HIV debate will be the question of what is a reasonable threat to others?  Switzerland was the first country to openly determine that persons infected with HIV but for which undetectable levels of HIV are  documented are not considered capable of infecting others.

There is a correlation between serum virological loads and risk for transmission.  Adequately treated persons with undectable viral loads who cease medication will have recurrence of detectable virus indicative that they were never “disease free”.   Persons on treatment may also develop resistance and require monitoring of viral loads – so duration from last viral load test becomes a variable of interest in the discussion. It is not definitively proven that "undetectable" levels are not associated with any transmission. 

What about the expectation that persons who engage in sexual relations undertake appropriate precautions to protect against being infected with a variety of sexually transmitted illnesses? or bloodborne transmissible illness?  We know that 20% or so of HIV infected individuals do not themselves know they are positive so taking reasonable precautions may be perceived as an expectation as well.  

Despite the decades of messaging on the importance of barrier protection, 30% of MSM acknowledge that their last sexual relations occurred without protection. 55% did not know the HIV status of the person with whom they were having sex.    A small proportion of HIV positives drug users admit to not discussing their HIV positive status with potential sex partners. 

So the courts will be weighing issues of intention, privacy, duty to protect others, risk, and reasonableness.   Thankfully the Supreme Court is constituted of the most learned jurists in the country and diversity of opinions is expected in contributing to these important decisions which will provide some guidance to public health practice and the expectations on what HIV positive clients will be expected to disclose. The legal definition is not based solely upon the consistent application of public health ethic principles which might have better informed this debate.  

Tuesday, 7 February 2012

Pertussis - is it time to consider more adult protection?

PHAC reports 1-3 infant deaths from pertussis annually in Canada. An equal number suffer irreparable brain damage from anoxic spells.  Not a massive amount, however certainly beats the impacts of tetanus and diphtheria. 

The rather dated PHAC information in the chart shows the overall incidence of pertussis in Canada over decades, with recent incidences of 2000-10000 cases annually.   

Despite tremendous gains in protecting infants, the current immunization strategy is somewhat short and requires some difficult questions to be asked.
First and foremost is the need for primary immunization of infants at a time where some parents are barraged with information on the risks of immunization.  Choices to avoid or defer infant immunizations put the very children at the highest risk of severe illness.   The failure to immunize amongst closely knit communities accentuates the risk within those communities should illness get established.

Herd immunity has clearly been a benefit nationally.  Secondary vaccine failure and the lack of persistent protection may be setting the stage for a future dangerous storm.  Breakthrough outbreaks are continuing to occur and should be a warning sign. Adult pertussis is being more frequently diagnosed, and likely increasing in incidence although surveillance is meager at best.  

Serious consideration needs to be given to the question of whether the adult Td (tetanus diphtheria) booster should be replaced with the TdaP (including ‘acellular’ pertussis vaccine) in routine adult immunization programs.   The current recommendations are for a single dose of acellular pertussis after the preschool/kindergarten vaccination, this is generally provided in Grades 7-9 (depending on province).  
Of course, trying to get accurate costs on the cost differential between the vaccines is challenging and guarded in business secrecy, however the differential may well warrant the shift.  

Recent outbreaks have punctuated the importance of both unimmunized children and adults as vectors in dissemination of illness.   As NACI meets this week, perhaps a topic for consideration?   While we are at it, it would be nice to have NACI minutes and actions posted for increased transparency in the decision processes NACI home site 

Addendum:  Please see the comment from NonStopGO.  The posting is a reflection of the knowledge the issue is one for debate and several strategies are being promoted - however the discussion has not engaged the general public health community in a meaningful fashion.  Using adult immunization is already being utilized for outbreak control in some settings. Thanks Nonstop  

Monday, 6 February 2012

Public Health hot topics

Certain tag words result in substantive increased activity on this site.  Poverty, Inequities and Fluoridation are examples.  Seems like Smart Meters also engender considerable interest within the blogosphere although no comments to explain why the surge of activity. 

Help DrPHealth continue to grow.   Please send the blog link to several public health colleagues.  Provide feedback in the form of comments, or privately to drphealth@gmail.com  .  Follow on twitter @drphealth

A few hot topics that have been building up as a set of short snappers:

Federal funding for important health improvement activities
The January 17th link spoke to a rare announcement by Minister Aglukkaq for a total of $300K Minister of health performance review and suicide release .  Looking at the issue of suicide which reaps some 4.5 Million potential years of life lost each year from the Canadian economy, that works out to some 6.7¢ per lost year of life invested in the future of Canada.   This week saw her involved in another announcement, this time for $67.5M to support personalized medicine.   The value of which on a potential year of life gained will be marginal.  Even if we are talking a few tens of thousand dollars for a potential year of life gained, it seems a bit odd.  Economist are often looking to that value number as one which represents a reasonable investment in improved health care.   Are we the only ones that see a bit of discrepancy in this inequity?

Motivational interviewing for obesity reduction:
It has been known for a long time that brief motivational interventions are reasonably effective in tobacco cessation.   The meta analysis estimated an effect size on BMI of 0.25 reduction.   Not much, but in the dearth of evidence of sustainable effects for obesity reduction, this is good news and a starting point. Motivational interviewing for obesity

Improving cancer screening rates:
Another synthesis analysis demonstrating value in client reminders, small media, and provider audit and feedback.   Insufficient quality research to provide judgement on mass media, client incentives, group education and provider incentives.   Of particular note is that provider incentives have been widely touted as a mechanism for improving rates, moreso that ensuring reminder systems are in place or undertaking “audits” of providers.   Improving cancer screening rates 

Alcohol interventions with youth
The persistent problems of youth behaviours associated with adoption of higher risk drinking practices makes the analysis of interventions worth staying current on.   While studies are of less than rigourous format (seems typical for interventions in real life where placebos are challenging), the consistent benefit of family based interventions shows promise.   Such efforts support alcohol and drug early intervention works in high schools – perhaps something that should be considered an integral part of the education system alcohol misuse in youth

Home visiting for alcohol and drug problems in pregnancy
The role of providing supports to new mothers is of considerable interest in many provinces.  This synthesis suggests that there is minimal value in home interventions where there are known high risk drug or alcohol problems.   Actually, if you read carefully most studies trended towards value, but not statistically significant – as such the authors conclude insufficient evidence and recommend further studying.   Given the importance of the service and the potential to save lives (RR 0.70 for infant death amongst program recipients, RR0.16 for foster care), seems like a logical area to invest a bit of money so that metaanalysis don’t misrepresent the findings because of the lack of statistical significance. home visiting for alcohol and drug problems in pregnancy

Friday, 3 February 2012

Smart meters –The role of public health in scientific controversy

Sorry, we are not going to enter into the debate if smart meters are safe or not.  There have been innumerable reviews on the topic already.   This blog is about the debate itself.
Several Canadian jurisdictions are grappling with hydro utilities that are implementing radio frequency (RF)transmitted metering.   Similar debates are occurring in the US.   Not that it can be proven, but the coordinated implementation and the concerted efforts to ensure scientific debate is somewhat limited might suggest that the industry is aligned in its efforts.   Irrespective, the response also led to multiple independent assessments of risk. 
In the midst of this IARC classified radio frequency as a possible carcinogen (category 2B) which actually means there is some suggestive evidence but insufficient to exclude that the relationship could be due to chance  IARC press release on radio frequency classification
The debate heated up recently again based on a communication from the American Academy of Environmental Medicine (AAEM) dated January 19, 2012. AAEM submission 
 Within the week,  letters to the editor and politicians are showing up across the continent claiming sufficient evidence to recall the meters. 
Some public health workers might be hightailing it and ducking the dualing war of words that is developing.  There is a critical review analysis that public health is best posed to contribute.  Certainly there is a role for resolving community conflict,  however  this issue is not going to engender friends.
There is a learning to be found in reviewing the AAEM communication.   The name of the organization AAEM seems to invoke some sense of credibility.   It is worth undertaking a review about whether their comments hold credence.   Four questions worth asking that likely apply to other situations 
  1. Is the communication actually reflective of what the organization actually stated?

  1. What is the reliability of the organization?

  1. Is there new evidence being presented that is not considered by previous assessments?

  1. Are there concerns with the assessment which the organization undertook?

So what can be found, although every reader is encouraged to do their own primary assessment. 
  1. The actual statement of the AAEM is a submission to the California Public Utilities Commission requesting a stop to further installation of meters until specific research was undertaken.  They also recommended that those submitting a request be permitted to restore to analog meters.   The statement quoted in the email is a valid quote from the letter it is however taken out of context in quoting the organization.  

  1. The organization appears to be properly constituted and has history preceding this issue. Reviewing the content, the membership and actions would raise questions that some of the other positions previously taken are not consistent with larger objective organizations reviewing similar positions and are not supportive of some well established and rigorously proven public health interventions and other issues where definitive evidence of health concerns have not been forthcoming. Eg.  opposition to water fluoridation, mercury fillings, GMO foods.   

The total number of positions taken by the organization over numerous decades is less than a dozen.

The investigation and interventions promoted by the organization may be seen as some as alternative or complimentary medicine. 

The bulk of the membership does not appear to include public health practitioners, epidemiologists or other content experts such as immunologists.

Based on several criteria, one should be very leery to accept the quality of the academic rigour of the positions.

  1. While the submission raises questions, it does not provide evidence of harmful effects – merely identifying knowledge gaps.   This contrasts with the more robust evidence utilized in reviewing evidence to date on the impacts of radio frequency fields.  It is noted that many scientific reviews of RF have also concluded that further studies are warranted to answer specific knowledge gaps.

  1. The AAEM statement is not an assessment of risk and the methodology is not subject to critical review.  As noted in question 3 it is a document that identifies concerns in the existing knowledge base for assessment and uses this as a basis to argue for further expansion of RF metering.

We in public health will often be presented controversial issues.  As one icon in public health once stated – the mistake is when we don’t get involved early enough.