Welcome to DrPHealth

Please leave comments and stimulate dialogue. For those wanting a bit more privacy or information, email drphealth@gmail.com. Comments will be posted unless they promote specific products or services, or contain inappropriate material or wording. Twitter @drphealth.

Thursday, 30 August 2012

The race to be worst - negative incentives as a public health driver

The Ontario Common Front, a collaboration of social action groups released a provincial assessment with the claim that Ontario is falling behind other provinces in their social programming.  It is a good read, and filled with wonderful tidbits of information.  Falling Behind.  Of particular interest are the analyses of the impact of the 1990’s “tax cut competition” that has greatly impacted provincial government revenues, contributing to the compromised ability to mitigate the recessive economic period that we continue to struggle to climb out of. 

Just to remain equitable and not covet Ontario’s claim to fame on the worst record on social programming.  Here are a few other claims about being at the bottom of the stack for the provinces only (ie not including the territories)

BC:  child poverty after taxes, drivers, minimum wage and a list at BC - The worst record in Canada   

Alberta : worst and rudest drivers

Saskatchewan – both worst roads and worst impaired drivers may contribute to the documented worst injury rates, scenery (yup – somebody actually polled on it), family violence

Manitoba – hip replacement waiting time, child poverty before taxes.

Quebec – worst managed province, least  friendly

New Brunswick – fiscal management

PEI – minimum wage, quality of life, mental illnesses

Nova Scotia – performing economy

Newfoundland and Labrador – perhaps perfect in almost every way.  Still - worst on myocardial infarction events, stroke events, C-section rates

There are multiple efforts that attempt to measure the best locations, most liveable cities, most equitable societies, most caring communities.  When playing with statistics and numbers, there will be a top and a bottom impacted by individual or organizational biases that selectively present data to support their position.  Whether looking at the Fraser Institute or various poverty coalitions – data presentation becomes skewed .

Even our esteemed Statistics Canada is subject to subjective filtering.  For a discussion on how poverty and income are measured and interpreted, two contrasting opinions written a decade apart by senior Statistics Canada staff Zhang 2010 Fellegi 1997 which contain similar concepts but reflect changing perceptions.  

Who really wants to be worst?  Change is stimulated by success and positive reinforcement – not focusing on the negative.   Shaming political leaders does invoke a stimulus that may lead to short term change, but rarely long term sustained improvement

Tuesday, 28 August 2012

Circumcision - back on the chopping block

Circumcision protagonists and agonists alike will be filling the twitterverse and blogosphere with reaction and comment on the latest professional foray into the supposedly redundant flap of penile skin.  Certainly within hours of the American Academy of Pediatrics position statement, the media coverage was matched by blogs and retweets announcing and denouncing the recommendations.  The AAP website appeared to have been overwhelmed.  Such is the passion of the foreskin debate. 

To chop or not? Is a question that parents and professionals alike have grappled within over the decades, and the rationale ranges from religious expression and children’s rights through to prevention of cancer and HIV infection.  

Begin with the AAP statement and technical report AAP statement page with access to technical and lay documents  Note that the AAP take a cautiously supportive position stressing that there is more than science to the decision and ultimately the choice is up to parents.   The media reaction has jumped on the first statement, that current evidence is such that health benefits outweigh the risks. 

Circumcision rates in the US have been slowly decreasing and are about reported at about 60%.  While open to some question, Canadian rates may be half this based on the maternity experiences survey which likely was biased towards informed new mothers Maternity experiences survey page 267.  Other estimates would still put Canadian circumcision rates slightly higher, however as most provinces have delisted as an insured service, accurate statistics are lacking. Disconcertingly, the AAP statement quotes Canadian rates as unaffected by delisting with minimal actual documented support for the statement.

The evidence on which the benefits outweigh the risks is worth noting.

·        40-60% reduction in HIV acquisition in circumcised heterosexual males in Africa. 
·         No impact on males who have sex with males has been noted.
·         Reduced transmission of HPV and herpes simplex to female partners
·         No impact on syphilis, gonorrhea or Chlamydia transmission
·         Non-significant reductions in penile cancer, and any benefit disappears when phimosis is excluded as a condition that requires separate treatment.
·         A Ugandan/Kenyan study demonstrating less pain with intercourse for circumcised versus non-circumcised males. 
·         Good to fair evidence that North American sexual function is unaffected. 
·         A preponderance of evidence that circumcision protects against male UTI development, and perhaps the strongest argument in favour of the recommendation.

There are numerous flaws with the modelling that was used to predict a potential 15.7% reduction in US HIV lifetime risk in males. 

On preventing penile cancer, studies vary from estimates of 909 to 322,000 circumcisions required to prevent one case of penile cancer, and amongst these the complication rate would be respectively 2 to 644 infants. The case for preventing UTIs being more solid.  

The AAP statement appropriately cautiously interprets some aspects of the data and reinforcing informed parental decision making, it may also wander too far in coming to conclusions.  On the other hand, the evidence supporting circumcision as protective from certain diseases does seem to be mounting. 
Note there should be cautious application of the AAP analysis to the Canadian demographic given some important relevant differences in demography. The Canadian Pediatric Society is also maintaining a wary view of the AAP position New U.S. guidelines for male circumcision show health advantages

Of just as much interest, is the rapid migration of the ambivalent AAP messaging by the media, blogs and Tweets into polarized camps of support or opposition based on what were likely pre-existed biased positions. Thanks to the AAP for at least an attempt at applying scientific method to the debate, but it is okay occasionally to actually say "we don't know". 

Monday, 27 August 2012

Mandatory influenza immunization – a time that finally has come (or has it?)

So BC has made the leap into the unknown.  In an announcement on August 23, BC is requiring health care workers to either be vaccinated, or where masks for the duration of the influenza season.  BC media release 
Sounds like rationale thinking, and ultimately something that will end up before the courts.  While BC may be the first out of the starting block, it is not the only jurisdiction to have pondered the question, just the first to not shy away at the brink (yet). 

There is no doubt that the highest risk clients for complications from immunization are found in health care settings.   Residential care environments and collective living arrangements are prime settings for the spread of many germs, including influenza.  Influenza vaccination is good, but not great – and its effectiveness is lowest in the very population that is at the highest risk.

So the alternate strategy of “cocooning” becomes important.  Cocooning is somewhere between individual protection and herd immunity.   Protect the herd, and those at risk are likely to achieve some level of protection – a phenomenon seen frequently with universal immunization programs.  The few provinces with universal influenza immunization (Ontario in particular) may claim some benefit from universal programs, but only achieve coverage in half the population, a rate that is about 50% higher than provinces with targeted programming. 

Cocooning provides a shell of protection around those at highest risk.  Influenza vaccine, while beneficial at a personal level for all, highly recommended for those at any risk – is also recommended and often provided in Canada to those who live or work with those at highest risk.   This later group is the “cocoon”.  While the recommendation has been written for many years, uptake in this “cocoon” group is not great.   Health care workers in particular have notoriously dismal uptake, often in the range of 40-50%.  There are of course exceptions with some facilities doing very well, and others that clearly do not take seriously the threat of the illness.  

Of course, there are competing sides in the debate.   Most notably in favour would be the experts in infection control whose 2011 statement reaffirms the importance of health care worker immunization   SHEA statement.  On the flip side is the Cochrane reviews Cochrane summary and access point (written as first author by a University of Calgary internist) which typically of Cochrane,  found limited controlled trial evidence of effectiveness of health care worker immunization.  

The methodological challenge of course, is only a small fraction of health care facilities are affected by outbreaks during a year.  A facility ultimately is a single event since the outcome of individuals in a facility is highly correlated – hence the study must recruit many facilities.   Having said that, while no formal study is undertaken, someone should be able to pull together facility immunization rates and look at events in a case control approach over multiple years. 

That BC has taken the leap of faith is commendable.   The question now is whether others take a wait and see approach, or can public health emulate what the addictions community did with OxyContin and dive in head first concurrently across the country? 

Thursday, 23 August 2012

West Nile virus - is it time you rolled up your sleeve to donate?

CDC is reporting a surge in WNv cases this year, the second highest year on record CDC surveillance sites.  Most of the cases to date have been just west of the Mississippi, which for followers of WNv is a major dividing point for the illness on the continent. In Canada that dividing point is the start of the prairies, however interesting the dominate disease activity has been east of the Manitoba:Ontario border.  Canada’s somewhat dated surveillance system can be found at Canada weekly reports  which operates up to two weeks delayed. 

Springtime tends to be bring thaws, rains, marshy lands and mosquitoes.   If we have been successful in communicating anything in the past few years in North America, it is that mosquitoes are very capable to carrying diseases, and the story of West Nile Fever is a fascinating one in of itself.  Just in its 13th year since likely landing in North America via transatlantic flight, it is spread almost continent wide and caused significant devastation, sparing only Newfoundland, Alaska and the Territories.

Wikipedia offers a classic medical textbook description of the illness although the entry is dated.  Wikipedia.

Missing from many of the public health sites and material written on WNv are some key points.  How many of the following dozen points were you aware of?  (leave a comment about your knowledge level as an informed reader)

·         The neuroinvasive illness results in over 50% of cases with persistent neurological deficits after one year, many of which have yet to resolve, many of which are quite debilitating.  

·         While the classical description of the febrile illness is one of a self-limiting illness, closer inspection of the cases finds a significant minority with persistent symptoms such as fatigue and ‘minor’ neurological deficits which last weeks, a year or longer. 

·         The natural reservoir of West Nile virus are healthy birds.  Only a few species (crows being the most notable) suffer illness and succumb.  The seemingly healthy birds may transport the virus very long distances.

·         Those mosquitoes that swarm us in the wet season are predominately Aedes.  The lone flyer at dawn and dusk is likely Culex and the one more likely to be carrying WNv

·         Mosquitoes only travel a few hundred meters in their lifetime – they are not the natural source of the virus, just the executor of the final blow.

·         It takes prolonged heat to encourage sufficient generations within a year (usually four) of mosquitoes that they bite a less preferred food - human blood.  

·         Bird deaths and mosquito pool identification tend to precede human or equine illness during a summer – it is a rare situation that humans or horses get ill without evidence of the virus in the area (but it does happen!!)

·         Usually human transmission is likely to occur in Canada in mid to late August and cases identified late August through mid-September.   These tend to be times where little about personal protection is communicated.

·         Late season mosquitoes go into a phase called diapause which is sometime in early September and driven by light hours in a day.  Once in diapause they do not feed further, but prepare to try to overwinter in a state of hibernation.  The odd hibernating mosquitoe with WNv may survive to feed on a human in the spring and transmit the illness.

·         Even during outbreaks, only a very small proportion of mosquitoes are positive for WNv (~1%)

·         Where human outbreaks have occurred, the vast majority of the population (85-98%) remain susceptible, suggesting that many recurrent outbreaks may be needed to develop a level of protection commiserate with the natural distribution areas for WNv in Europe. 

The US media are just picking up and carrying messages on WNv risk this year.  Expect the anxiety to spill over the border, just as the peak for human transmission in Canada is likely to occur. 

On the issue of blood feeds, do support the Canadian Blood Services through regular blood donations.  The voluntary nature of the Canadian blood system means we all need to do just that - roll up our sleeves for our neighbours.  

Canada update as of August 22

Quebec: 5 human infections, 1 positive horse, 8 positive mosquito pools and 2 positive birds have been reported.

Ontario: 49 human cases; 4 travel related, 312 positive mosquito pools and 9 positive birds have been reported.

Manitoba: 5 human cases and 98 positive mosquito pools have been reported.

Saskatchewan: 1 positive horse and 4 positive mosquito pools have been reported

US update to August 22
1118 human cases of illness has been reported, 629 (56.3%) have been reported as neuroinvasive and 41 deaths have been reported.  

Tuesday, 21 August 2012

Public health in the news; Legionella, ATVs, vaccines and autism, Oxycotin, radon

Leading the headlines is an outbreak of Legionella disease from an unknown source in Quebec City.  At least 3 deaths and 40 illnesses so far have been reported.   Legionella is often airborne spread but associated with water systems and humid environments such as humidifying and air conditioning systems.  Legionella in Quebec City  Montreal Gazette coverage. As of August 27th 8 deaths and 104 illnesses. 

Only a few provinces have moved forward on requiring helmets and licensing for off-road vehicles.  It was disheartening to learn of the personal tragedy of a public health icon in Canada.  Dr. David Swann who put his career on the line for supporting greenhouse gas emissions, was fired as a Medical Officer of Health and subsequently went on to run for, and remained in the Alberta opposition, including a stint as leader of the opposition.  Dr. Swann recently lost his nephew in an off-road ATV incident.  Calgary Herald and ATV death  How many more tragedies do we count before off-road vehicles are treated as the dangerous machines that they can be?

Anyone who follows vaccines closely will be familiar with the notorious Dr. Andrew Wakefield.  In essence a lobbyist for the parents of autistic children who believed that the autism was caused by the MMR vaccine.  Fifteen years later, hundreds of millions of dollars in scientific studies, innumerable expert panels, and the myth persists as proof it is harder to disprove something that to enshrine something as fact.   Wakefield recently lost a libel action against the BMJ http://www.bmj.com/content/345/bmj.e5328 .  The action was lost on a legal point, the court had no jurisdiction over the British defendants.  It has resulted in resurfacing the myth and resurrection of the controversy.

This site has spoken several times to the negative consequences of the switch from Oxycotin with minimal supports in place DrPHealth February 2012 .  Sure enough, more evidence of destructive consequences of the ill planned change comes in evidence of migration to heroine in several communities Oxycotin replaced by heroin

Health Canada is pushing the radon issue again, and thankfully as it does not reach the radars of many Canadians.  With reduced tobacco use, radon has inched its way up to claim 16% of the lung cancer market .  radon and lung cancer 

Monday, 20 August 2012

Eggceptional news: Its no yolk. The myth has been laid

In just four days, this posting has become the 7th most visited post on this blog - a measure of the interest and likely concern about the original report.  Please forward the link to colleagues, and follow drphealth.blogspot.com regularly, or on Twitter @drphealth. 

The recent news on the supposed finding that egg yolks are as bad for you as smoking has spread through the media faster than avian influenza.  No doubt some folks have sworn off egg yolks and modified their egg cracking behaviours, the egg marketing people are plucking their feathers in disgust and the battle lines are being drawn for what should be an eggciting debate. 

The article prepublished on-line in Atherosclerosis, followed a group of 1262 healthy people attending a prevention clinic in London,  Ontario.  The author, a neurologist, has argued repeatedly for the value of following carotid plaque formation as a risk factor for strokes for which there is reasonable evidence of a relationship - however showing causation and definition of the correlation is still open for some debate.   The abstract is available and those that can access the full article are highly recommended to do so.  Atherosclerosis article on egg yolks

The weak study design was based on a single recall questionnaires of behavior looking at egg eating habits and using this to define into two groups, those with two or less yolks a week, and those with 3 or more.  After carotid plaque formation was then measured and simple analysis of smoking and egg consumption adjusting for age and gender against the outcome of plaque size.  Most first year students would immediately flag numerous major design flaws in such an approach. Not bad for a fishing expedition, but wanting in terms of drawing conclusions.

Of the two groups apparently those with low egg consumption (n=388)  had a mean of 125 ± 129 mm2, and those of the egg eating group (n= 603) 132 ± 142.  Oops, somewhere we lost nearly 300 study participants.  Assuming that the written range is based on a 95% confidence interval around the standard deviation (the most conservative of the assumptions),  the t-test of these means has a probability of 0.15 – or not significant.  Granted, the presented data don’t allow  adjustment for age, gender and smoking status – but the lack of raw statistical significance against the findings when supposedly only age was adjusted and where the probability is apparently p<.0001  should raise some feathers.  (also technically since the confidence intervals include zero, it is questionable whether the appropriate statistical approach (ie. using a Poisson distribution) might have been better).

Are you sensing something rotten in these eggs?

Noting as well that the absolute difference between the two groups is only a 6% margin of difference.   The conclusion is that this difference is comparable to that of two-thirds of that of plaque formation for tobacco users.  In fairness to the author, they make no blatant claims that egg consumption is as bad as smoking, in fact they recommend prospective studies and being sure to adjust for some measure of weight (which seems to be a critical covariant in this debate). While the full article is not the most eloquent of scientific writing, and critical appraisal gurus will have a hay day de-constructing innumerable problems, the most grievous of transgressions occurred after the publication was printed on-line. 

The problem seems to have arisen when the University of Western Ontario communications folks took a crack at releasing to the lay media UWO communications release crowing in the headline that research finds egg yolks almost as bad as smoking.  Misrepresentation? Possibly.  Certainly a spin on the questionable facts. 

The damage is done, just google “egg yolks as bad as smoking”.  Newspapers across the globe have picked up the coverage of the press release and are running with the story without the scientific community having any opportunity to pull in the reins.  Like the benefits of oat bran, vaccines and autism or a hundred other scientific myths – this one has become entrenched as an urban reality before its time, and the mythbusters will take years to establish its credibility or not as media retractions are as rare as hen’s teeth.   By then, we will have genetically modified chickens producing yolkless, or at least cholesterol reducing yolked eggs and an industry that can propagate the myth for its own benefit. 

Marginal science compounded by the new wave of high tech communications to support researchers in getting higher scores on referencing and citing for performance assessments.  The question, will this be used to penalize appropriately both the researcher and the communications people?  It would be a progressive day if there was a public statement on how this story was not what it was cracked up to be.   

Thursday, 16 August 2012

Intimate partner violence (Spousal abuse) - for such a prevalent problem, why do we know so little?

How time flies!   This is the 200th posting for DrPHealth.  There just seems to be an endless supply of public health issues to comment on.  Thanks for your continuing support, and please forward the link to your friends and colleagues and follow on Twitter @DrPHealth.  

Speaking out on tough issues like spousal abuse is the first step to reducing the problem. Raise your voice by sharing information widely 

Over the past five years,  just over 1 Million Canadians are victims of intimate partner violence (IPV).  Roughly half of these are still within the relationship in which the violence occurred.  IPV affects both genders equally, however females tend to be more physically and sexually victimized, and more likely to leave the abusive relationship.  

In a January 2011 report, Statistics Canada released an updated fairly comprehensive report on Family Violence that includes a significant chapter on IPV  Stats Can Family Violence report.  It is a subreport of the General Social Survey undertaken every 5 years with the last cycle in 2009.  The Family Violence report provides some trending suggesting that rates of IPV decreased between 1999 and 2004, but remained constant through the 2009 cycle. 

Other points of note about current partner violence is it is more likely to occur in younger age groups, common-law relationships (versus legal marriage), and relationships involving previously married persons.   The correlation with socioeconomic status is not clear.  Reporting is more prevalent in lower income situations, but there is not a gradient associated with education of either the victim or the perpetrator. 
Only a fraction of incidents are reported to the police, and less still result in definitive action to prevent recurrence.  Incidence of violence represent only about a third of partner abuse, with some 17% of the Canadian population reporting some form of abuse, the majority being emotional in nature. 

On any given day nearly 5000 women are in one of the almost 600 shelters across the country.  Even among shelter residents, only 40% had reported the abuse to the police. 

A recent Cochrane evidence review prompted a Health-Evidence summary statement on interventions to prevent intimate partner abuse  Health evidence summary statement on IPA .  It is disappointing that many of the promising practices of providing brief or intensive support  have not stood the test of effectiveness under trial conditions or still require better study.  Only intensive advocacy in shelters demonstrating reduced physical violence outcomes in the 1-2 year time frame, and possibly brief advocacy in the emergency department on using safety behaviours have sufficient evidence to warrant inclusion in current programming.  
The US Preventative Task Force reviewed screening recommendations for IPV in July this year and concluded as well that there is some evidence that screening followed by intervention has value, but that there are major gaps in the evidence to develop definitive conclusions.  US Prevention Task Force IPV screening 

For such a prevalent and disconcerting health and social problem, while our knowledge is increasing, we should be just as concerned about of lack of understanding about why IPV persists, how to prevent it, and how to manage it with the least consequence to victims and children who are caught in the wake of the relationship dysfunction.  

Tuesday, 14 August 2012

Canada’s physicians speaking out on determinants of health

This week is the annual general meeting of the Canadian Medical Association. To the credit of the CMA, the sessions can be accessed on line and behoove a level of transparency that many governmental entities should emulate http://www.cma.ca/ 

Admittedly some public health folks get very frustrated with individual members of the the medical profession.

Conversely, their voice carries considerable weight in corridors throughout Canada.  They have a strong track record on some public health issues related to child health and environmental health pieces.  

Two pieces in the preamble to the meetings that are worth noting for public health professionals.  A strong statement on acknowledging the linkage between health and wealth, and that the gap is increasing  increasing CMA announcement with link to report   also in CBC story on health and wealth  . The full report provides reasonable detail on inequities as they relate to perceived health, healthy behaviours, health care access and a special focus of the impact of the economic downturn on health. 

The second item of note is the incoming statement of the sixth female president of the 145 year old CMA, and first openly gay president.  A strong advocate for marginalized populations, Dr. Anna Reid’s tenure should be one of particular interest, and hopefully will stir the pot in what has been described as a “grey haired male clique”.  Globe and mail story on CMA president

While the CMA remains interested in health, in opening comments to the CMA conference, Minister Aglukkaq appears to be continuing to convey the Harper governments abandonment of responsibility, both morally and fiscally, to Canada's cultural commitment to universal healthcare.   http://o.canada.com/2012/08/13/base-health-care-debate-on-fact-leona-aglukkaq-tells-canadian-medical-association/

The support and influence of the CMA should not be underestimated, and strategically involvement of the medical profession is a wise choice in advocating for public health improving activities. A statement not supporting an initiative is very difficult to overcome.  The CMA searchable policy database provides access to resolutions, position papers and government briefs.   A quick search on determinants of health displayed 24 policy issues.  

While there may at times be differences in vision of what a future health care system might look like, the CMA and physician community align closely with other public health organizations in the direction of their policy. 

Update:  August 22 - As sent in by a friend, the Globe and Mail carried another worthy posting about the changing of the culture at CMA, worth the read as well.  G and M August 20

One laughable exception to the changing mentality is a comment from a provincial chapter president in speaking to a public health audience – “we do population health, one patient at a time”. This from the same person who recently was noted to be billing close to 3/4 Million per year, and when challenged on live radio replied by saying "I do work 24/7".   Well, perhaps not all the medical profession gets it, fortunately the collective wisdom of the physician community usually prevails.  

Monday, 13 August 2012

An emerging outbreak of H3N2v swine influenza - what is the threat assessment?

The lay literature has touched on the threat of swine and the potential for influenza  Time August 10th.  In the background the machinations of the public health are starting to turn. With an epicentre in the Indiana –Ohio region of the US, some 153 cases have been identified in the past month compared with 13 in the previous year.   We have had enough false alerts that perhaps we should all be desensitized and just ignore the warning signs.

What makes this strain interesting, novel and perhaps disconcerting?  It is a swine based variant and normally not highly transmissible to humans, however this strain appears to have picked up the pandemic strain M gene which facilitates human transmission.

Admittedly that over half the cases appear to have been related to interactions with swine, and many to participation and attendance at farm fairs where pigs intermingle and humans enjoy their antics.  The other half likely represent first generation transmission between humans. Sustained human transmission has not yet been noted. 

The good news to date, is the severity of illness appears consistent with seasonal influenza, however the morbidity data to date are scarce.  The bad news is that current seasonal trivalent vaccines do not appear to confer much immunity (~15%). 

If you are looking for more information, follow the CDC Atlanta sites, there are multiple links that change frequently so take the time to check in regularly to find out what is changing CDC H3N2v information page .  Updated information tends to be posted as well to the MMWR MMWR home, and check in on ProMED where there are already 69 postings on this topic as of August 11.  ProMed home  

If one digs a bit deeper you will find that some of the current work has a Canadian flavour.  The influenza collaboration between BC including BCCDC, Quebec including INSPQ, and the National Microbiology Laboratory in Winnipeg is a tour de force of international experts and have already released several relevant papers on the H3N2v  J of Inf Diseases   Eurosurveillance

As with avian H5N1 that has been circulating since about 2000, and currently surging in Cambodia and Indonesia  WHO updates on H5N1, the US based H3N2v increase in activity is deserving of close observation.  H3N2v is not worth losing sleep over yet, but do expect more attention given it is just south of the border and has the expertise, resources and attention of the CDC.  It is also an excellent example of tracking and response to an emerging pathogen where little is known at the onset

Thursday, 9 August 2012

Dental public health - an unsung group of Canadian heroes

A news item out of Quebec is one of the few positive stories recently for the somewhat marginalized dental public health community Dental coverage extended to age 16.  Even DrPHealth can be accussed of not providing adequate attention to what is one of the great Canadian public health stories – the huge success in ensuring healthier mouths throughout life through proper hygiene, fluoride, nutrition and care.  While the controversies around fluoride surface frequently DRPHealth on fluoridation , the ongoing successes of dental public health are not sufficiently celebrated.

Do check out the Canadian Dental Public Heath Officer’s report at Canada CPDO report   Quietly hidden in the number that the average number of teeth effected by decay in Canadian children is 2.5, is that amongst the previous generations these numbers were four or more times higher.  It is this reduction which is the unsung public health success.  

Most public health entities retain some vestige of oral health prevention services which often require constant self-justification.  The Canadian Association of Public Health Dentistry is a national professional group for all public health dental professionals.  On their website is a link to a variety of dental public health reports in Canada CAPHD site for links  including the 2012 Ontario CMHO annual report which focused on dental public health however the link is broken and is provided here Ontario CMOH report 2012 .

Collectively, all public health workers need to express gratitude to the dental community for their work, and support for the key areas that need ongoing emphasis, namely:
  • ·         Universal access to dental coverage and preventative care for children across Canada
  • ·         Reducing the current burden of dental ill-health carried by Aboriginal populations
  • ·         Improving oral health services for street oriented populations and those economically challenged
  • ·         Improving oral health services for aging persons.

To this should be added a refined strategy to make widespread the utilization of preventative measures such as water fluoridation, childhood varnishes, and targeted childhood sealants.  

Be sure to send a smile to your dental health co-workers.  Their phenomenal Canadian success is buried in the history books. Their ongoing challenge to be acknowledged, appreciated and supported by the rest of the public health community.  

Today, lets celebrate Quebec's good fortune in once again demonstrating a commitment to both the public's health and to children.  

Wednesday, 8 August 2012

Northern Gateway pipeline, can the current Canadian assessment process support Prime Minister’s comments?

The Enbridge northern pipeline proposal has more than its share of detractors on our west coast.  Certainly the debate was taken up an added notch by Prime Minister Harper in a speech that suggests that the decision will be based on science, not politics.

Fair – that was what the original intent of an environmental impact assessment  (EIA) process was to be, a way of ensuring project benefits exceed risks. 

Here lies a triple misdirection. 

First is the belief that the existing standard EIA process is objective and comprehensive.  Harper’s comments speak to the “economic costs and risks” and that projects are evaluated “on an independent basis scientifically”.  While some economists may suggest that the discipline is a science, it was not the intent of the original EIA process which informed decision processes. Nor was the EIA process ever structured to be the only component of project evaluation.

Second, the project comes months after the Harper government “streamlined” the EIA process, which has raised considerable concern about the independence and objectivity of the process EIA process DrPHealth April 2012.  The question raised previously was what will happen to the human health component of an already flawed EIA process? 

One has to wonder about the timing of the Enbridge proposal, which came first, the proposal or the changes to the EIA process.  If the EIA changes were actually independent, then the Enbridge proposal must be seen as opportunistic . 

The third flaw, is the ultimate approval process for the project rests within Cabinet, a closed door, highly politically based location where transparency and objectivity is parked in favour of testing the political acceptability of any decision.

 The objectivity of the EIA process will be tested by its ability to incorporate health sciences and social sciences in addition to environmental impacts.  The test of the Harper government will be how this information is balanced on the “economic costs and risks” which remains enshrouded in political values and tested behind the closed doors of Cabinet.  As for holding Harper and the government accountable for its actions, that is a duty of the democracy. http://www.cbc.ca/news/canada/british-columbia/story/2012/08/07/pol-gateway-tuesday-harper-bc.html   

Thursday, 2 August 2012

Ebola – a term that sends shivers in everyone’s mind

Uganda is suffering from another Ebola outbreak.  Its fourth since 2000. 

For those that are not familiar with PROMED, you can find postings and listing on the outbreak at ProMED Ebola recent posting .   ProMED is an open source system that permits timely reporting on any disease activity from local to national jurisdictions.  A useful and essential tool in monitoring global disease spread.  About ProMED.  

Ebola was first recognized in Sudan in 1976.  It has surfaced in a number of central African countries stretching from Uganda to the Ivory Coast.  Four distinct subtypes of the virus  have been located.  No natural host has yet been identified, although suspicion remains with fruit bats.  Initial human illness tending to occur through infected monkey meat consumption.  Several occupationally related cases have been related to necropsy of monkeys and to care of infected persons.

The prototypical view of North American or European workers entering an African village wearing space suit type biocontainment units fuels the international fear associated with the illness. 

The dramatic characteristic of the illness being the high mortality rate, predominately due to hemorrhagic fever compounded by limited medical intervention.  Mortality rates of greater than 50% are typical.  The most recent Ugandan outbreaks are suggestive of a less virulent strain with only 20-25% mortality.  While person to person occurs, sustained transmission has not been the norm when good hygienic precautions are put into place.

In total some 2270 persons have been infected, 1625 deaths with a combined mortality of just over 70%.  Ebola has surfaced on about two dozen occasions over the last 35 years, seven of those outbreaks effected more than 100 persons, nine others between 10 and 100. 

The current outbreak has infected 20 patients as of the ProMED posting, with 14 deaths.   Based on the reports, WHO, CDC, and Ugandan Ministry of Health are actively involved in containing the situation.  A simplified science blog posting linked with National Geographic provides a good overview National geographic science blog on Ebola

Ebola may not been the most critical current zoonotic threat, but it does stimulate a fear reaction that is a reminder of the hidden threats that lie waiting in animal species.  As a comparsion, H5N1 (avian influenza) has infected 607 persons total with a 58% fatality rate, SARS (possibly also bats) affected about 8000 people with a 9% fatality rate; rabies (several species including bats) may top zoonotic list with an estimated 55,000 deaths annually and a case fatality of greater than 97%.