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Thursday, 29 November 2012

HIV success stories for World AIDS Day - and a bit of statistical slight of hand

Plenty of news on HIV these days.   That World AIDS day is December 1st might be just coincidental.

Leading the headlines is the report out of BC on the success of HAART in reducing population transmission Picard story on HIV fight. This is great news.   Perhaps a bit self-serving for the 'treatment as prevention' folks that are taking credit for the reduction.  The STOP HIV program, which inherently makes a lot of sense, was only implemented in 2008 and the data on which the research they are claiming success reflects the time period of 1995-2008 (up to start of STOP HIV).  The BC reduction in incidence began in about 2003 and has been consistent over most of the last 9 years.  

They also fail to acknowledge that Canada has started trending downwards since 2008. 

Read the full article at PLOS One Burden of HIV in Canada.   The conclusion is based on data from only three provinces who had innumerable other differences in their approach to addressing HIV and not just in access to HAART.  There are other correlations that might also explain the differences noted, including political stripes of the leadership.  So while non-treatment public health efforts across the country have likely been the major initiators of the downward trend, the use of treatment will be advantageous to sustaining the decrease.   One can see a very similar trend with tuberculosis rates prior to and following the discovery off streptomycin as one of the first effective anti-TB drugs.

A more balanced discussion of the Stop HIV approach can be found in a CMAJ editorial at CMAJ on HIV seek and treat 

In honour of World AIDS day, Health Evidence has produced a list of high quality evidence reviews of practices associated with control of HIV http://health-evidence.ca/saved_searches/run_search/1134  although some are very dated. 

Also in recognition of World AIDS day is the release of an international report The beginning of the end.  Notable as well on page 11 is the incidence of HIV globally has been decreasing since 2003 – the reasons internationally are different from the Canadian experience.  

US rates are more difficult to obtain, and perhaps reflective of less positive news as well.   A detailed analysis was published at US HIV statistics 2008-2011.  A real positive is the addition to the USPTF of universal screening for HIV USTPF draft HIV screening recommendation as a Grade A recommendation.

Tuesday, 27 November 2012

Hot public health topics: Gambling X 2, intimidation, privatization, HPV and influenza vaccine

While headline stories capture our attention, the follow-up of such stories often has a very different course and outcome.   Here are a few story updates.  

Gambling remains an emerging public health issue. DrPHealth October 2012 reviewed some of the more recent trends. Two stories of note that are worth updating.  First, that the Toronto Board of Health, on recommendation from Dr. David McKeown recommended against the expansion of gambling in the city.  Read the excellent background information at Board of health materials.  These resources will be beneficial for all public health workers going into the future and mandatory reading for students of public health.    

Regrettably the federal government House of Commons moved in the opposite direction by approving a bill that will open single sport betting in Canada.  That the sports industry and health professionals alike may object has raised the possibility that the bill will be defeated in the senate CTV coverage of sports betting issue.   There is no doubt that this form of gambling that is uniquely not permitted in Canada, is fuelled by illegal gaming operations.  

Just weeks after his inflaming comments about the Toronto Medical Officer of Health political intimidation of public health workers , Mayor Ford has become the centre of one of Canada’s largest political fiascos.  He has had the judiciary rule him in conflict and requiring him to vacate the mayorality seat.  Follow the story at CBC on Mayor Ford 

Toronto’s Shouldice Clinic was on the verge of sale to the private sector Shouldice clinic and privatization of health care.  The offer for purchase expired without approval or denial from the Minister of Health – effectively killing the transaction in a no context situation Shouldice clinic sale abandoned.

The Calgary dioceses has been the central point for controversy over the HPV vaccine for many years, refusing to permit vaccination of girls in their schools.  While Bishop Henry has not changed his position, the school board is reconsidering its position HPV vaccine and Calgary Board of Health.  There was a recent study released showing HPV transmission occurring amongst girls prior to sexual intercourse.
November 29th - apparently just last evening, the school board reversed its 4 year old decision and will permit HPV vaccination - story at Calgary Herald Story

As the influenza season rapidly approaches, and the first outbreaks are being reported from H3N2, another story out of Ontario that pharmacists will be given the scope of practice to immunize against influenza and prescribe tobacco reduction aids amongst other preventive measures.  Based on experience in a few other provinces, this is a positive move.  Ontario pharmacists gain right to immunize. 

Monday, 26 November 2012

Nut allergies and Nutty Reactions

Someone should start collecting stories of the reaction that parents have when their young child develops a rash after eating peanut butter, and the next thing they are advised they must carry an epinephrine autoinjector and that the condition is life-threatening.  It would be enough to freak out the best of parents.

A recent story related to the mother who wanted oak trees removed from the school yard because her child had developed a “nut allergy”.   Stories that we’ve heard include parents who insist on the right to inspect other students lunches, or on staying with the child in the classroom, appeals for children to have education assistants with them as health challenged students with severe disabilities do. And the topper is the Texas company that trains “nut sniffing” dogs, with parents appealing that the animal is required to protect their child’s wellbeing and therefore required to stay with the child in the classroom.

Some might consider the above a bit of an overreaction.   Were it our children though, we would likely be just as concerned.  The question is what is a reasonable level of concern?  and from a public health perspective, what should we support parents and schools in ensuring a risk reduced environment?

1-1½ % of students at school start will have a positive skin test to peanut extract.  Only half of these will display any clinical symptoms.  Moreover almost all peanut allergic reactions require an adequate volume of consumption, often at least a full kernel, before any manifestations are expected.   That most peanut allergies are treated as if any antigen exposure in the air will elicit a reaction is inappropriate.

The existence of a peanut allergy also does not mean allergies to other tree nuts (and peanuts are not even be classified as a nut by biologists but more a legume as they grow underground).  Even having skin test reactions to certain tree nuts does not mean an allergy or any reaction to all tree nuts.   So, to have a peanut reaction and associate this with acorn associated reactions is a huge misinformed leap.  Another common misperception is that milk allergies are manifest in a similar fashion, and rarely do milk products result in anaphylaxis, nor is there a need to modify the classroom environment to become “milk-aware” in an effort to reduce exposures. 

Schools have become much more “nut-aware”, resulting in overall school based exposure reductions by some 90%.  However even in classrooms with known interventions to eliminate peanut exposures, careful examination will usually reveal some peanut containing materials – and this has not resulted in life-threatening situations. 

As a great resource, Anaphylaxis Canada has developed a common sense and reasoned approach to food allergies of a variety of natures.  Anaphylaxis Canada .   In the end, it is about education, the environment, and emergency response.   Education of the parents, child and classmates, reducing exposure through making the environment nut aware, and lastly parents and the school being prepared for managing the very uncommon emergency situation.  

Wednesday, 21 November 2012

Oxycodone generic approval - a political mess with public health consequences

For those that follow the debate, back in the beginning of this year numerous provinces delisted oxycodone and severely decrease its access.   The debate at the time was the consequence of poorly prepared drug policy shifts on the large number of prescription drug addicted persons.  Oxycodone loosing public funding DrPHealth Feb 22, 2012.  Many of the predictions have materialized.    

In the subsequent months numerous stories ran that followed the impacts including the rise in heroin use  Calgary Sun article and the substantive costs associated with single oxycodone doses for persons wishing to maintain their addictions.   Limited value in managing the addiction has been documented but is a potential positive outcome. 

Now, in the weirdest of ironic moves.  The very government that started the domino of confusion and angst, has its left hand approving the generic form of oxycodone. 

Remember that one of the key switches that occurred was the maker of OxyCotin restructured the formulation in a harm reduction effort by utilizing slow release drug delivery mechanisms. 

So the basic dilemma  we have a drug that has been demonstrated as unsafe but has not been delicensed totally by Health Canada. Because it is not delisted, and the patent is expiring, Health Canada apparently does not have the power to preclude the licensing of the generic formulations.

It is not bureaucracy run amok – but a symptom of a system that was designed to preclude bureaucratic obstacles in the drug approval process.   That  Minister Aglukkaq would stand up and say that politicians can’t stop the process is an oxymoron – it is the politicians that set the process up so it would not be stoppable. 

As Andre Picard flags in his Globe and Mail piece, the oxycodone situation is unique and requires political leadership Andre Picard on oxycodone.  Regrettably, this federal government has consistently failed to show leadership on health issues – and this is another example of its causing a problem that the provinces will be expected to solve, and have to foot the bill for the associated costs.

Monday, 19 November 2012

International Day of the Child - is it a time to celebrate or one to grieve?

November 20th is the International Day of the Child.  It celebrates the 1989 signing of the UN Convention of  Rights of the Child Convention document.   The landmark document is an update of a 1959 which updated a 1924 declaration.  It is reassuring to note that children are high on the international list of priorities, but one has to ask how successful we are globally?  And how successful we are within Canada?

Several provinces have children’s advocates.  Arms length individual charged with watching out for the wellbeing of children.   A report from the BC representative for children and youth was just released that touches on a subject in the wake of the Amanda Todd tragic suicide.  Trauma, Turmoil and Tragedy is a report on youth suicide and self-harm. 

Notable were the consistent themes of risk for youth with tragic outcomes.
                      Lack of stable living arrangements – most notably, children in care being subject to multiple moves .
                      Domestic violence – a significant feature in the lives of more than half the youth.
                      Mental health issues – identified in nearly 70 per cent of the youth and compounded by a lack of clarity of services to address these issues .
                      Substance abuse – by family members as well as the youth themselves.
                      Learning disabilities and lack of attachment to school.
                      Significant romantic conflict in the 24-hour period leading to these incidents.

The report further flags the overrepresentation by Aboriginal persons and those that have been involved with social services.

Many youth suicide prevention programs have been based on preparing caregivers such as teachers to grapple with individuals displaying self-harm behaviours.  Assist (Living Works home page) is one of a number of programs available in Canada dependent upon training providers to work with youth at risk of self-harm.  Other programs attempt to build resilience in individuals to reduce thoughts of self-harm or improve confidence to seek help.  Regrettably after all these years and innumerable programs, there remain few evidence based programs that demonstrate a reduction in the outcome of self harm or suicide amongst youth.

The contribution of the BC representative helps flag why current programming is likely not as effective as hoped.  Many of the characteristics are individuals are pre-existing risks that are identifiable and deserve intervention long before the youth become distraught.  Active intervention for those with risk may be a rationale new approach to consider.  The list of possible risks is similar to what one finds for truancy, school drop-out, criminal behaviour, unplanned pregnancy and a host of other socially unacceptable behaviours that can be interpreted as cries for help.

So while we celebrate the International Day of the Child, let us reflect on the innumerable instances where we as a society are failing to provide for the future of our youth. 

Thursday, 15 November 2012

Rare events – a Public health case history of US fungal meningitis outbreak

When rare organisms cause disease, finding the problem should not be a challenge.

How many of those working in communicable disease have ever seen a case of Exserophilum rostratum meningitis (and meningitis of all causes is notifiable in most jurisdictions)?  In fact the Mayo Clinic reported only one case over 40 years of a skin infection in an immunocompromised person. So when a cluster happens, alarms will sound and the system jumps into overdrive. 

The public health question is why have there been 32 deaths and over 400 illnesses from such an oddity? 

The first case was reported September 21 out of Tennessee where the bulk of initial cases were noticed.  By October 1, eleven cases from a single pain management clinic had been identified.  It only took just over a week to focus attention on the implicated methylprednisolone product, and that most of the deaths occurred in persons who received epidural injections.  The product was recalled by October 3rd.  By October 5th, active trace back was encouraged for persons receiving the product and many of the cases are related to the active trace back despite cessation of infections.

So far, Michigan has had 50% more cases than Tennessee and therefore should have been able to identify a problem sooner.  Based on the state's reaction, a delay in obtaining notices and initiating trace back occurred. Perhaps a reflection of the lack of depth of the state public health service.  

Not that any more rigorous process would have prevented infections or saved lives.   No doubt, there will be the occasional case that could argue they were injected after the lots were recalled, but most cases did not develop symptoms until 1-4 weeks after injection. The retrospectoscope will likely find flaws in the notification system, in the surveillance system, in the recall and trace back processes and likely in microbiological laboratories.  The ultimate critical question being how did contaminated injectable drug product enter into consumer circulation? and what drug preparation processes were lacking before lot release?

We are fortunate the product was not distributed in Canada – or maybe just lucky on this one.  Pharmaceutical quality control requirements are similar between countries and product can readily cross the international border. 

It will make for a fascinating series of monographs and publications.  For those interested in following the outbreak, check out the CDC outbreak website .   A notable omission in the public information are the epi-curves relating date of injection and onset of symptoms.  With such an extensive trace back, one has to wonder when did the first cases occur? And who missed the first rare bird that might have protected others?    

Rare birds incite curiosity, provide an opportunity to test the system, are unlikely to recur in an identical fashion, and may or may not contribute to improving the system required for the common, mundane and potentially larger outbreak scenarios.

Tuesday, 13 November 2012

Peace as a prerequisite of Health

Each November we remember those fallen in wars. The date set in memory of the Armistice that laid down arms on just the Western Front in Europe during World War II.   With recent costly military missions in Afghanistan and Iraq, attention has rekindled back to celebrating the sacrifices of our military personnel.

What we often forget, is that over 70% of the victims of war are civilians – caught between the power struggles and philosophical debates over which they have no control and often no opinion.

2011 saw an increase to 37 armed conflicts, of which 6 had more than 1000 deaths and are classified as “wars”.  This represented an increase of six armed conflicts over 2010. Formal statistics are tracked by a Norwegian centre following wars http://www.prio.no/CSCW/ .  Wikipedia lists a dozen wars, five of which have stated since 2011 Wikipedia listing of global conflict 

The war in Afghanistan topping the list of 2011 fatalities.  Some 1.4 Million deaths have been directly attributed to the war since 2001.  An additional 4.2 Million deaths attributed to the impact of sanctions against the country in efforts to stop the civil strife. 

The Syrian uprising that has garnished the most media attention, has amassed some 50,000 deaths, approximately half of whom were civilians up to 2011.  An estimated 20,000 people have died so far in 2012 and likely will be the war with the greatest number of fatalities this year.   Some 1.5 Million people have been displaced, and another 30,000 have ‘disappeared’.  Consequences of war that are easily overlooked.

Closer to home, the US war on drugs has just over 1000 causalities a year.  The Mexican drug wars resulting in an estimated 19000 deaths in 2011 with some optimism this is reducing going through 2012. 
While we remember those that have fallen in service, let us also remember those that have been the innocent victims deprived of their choices to live.  

Thursday, 8 November 2012

Economists' view of improving the Canadian Health Care system - reflective of a public health agenda

Economists and accountants are not the solution to the health care system, but what they have to say is worth listening to.  Not the beancounting bureaucratic accountants justifying current programming, but the broad thinkers that look at the industry from above the minutiae of professional protection, labour benefits and crisis management.   So when the Conference Board of Canada’s economists come out with a five point plan to fix the system, it is at least worth reading, and probably worth listening to.  

Five priorities for fixing the Canada health care system  is the result of a summit held late October in Toronto that sets out a logical and well thought through plan that focuses on doable and rationale approaches to health care reform. It is not new material or widely divergent from many other studies of the health care system, just this is coming from people who care about how our money is spent.

The plan, simply put:

1.       Build the “gateway” into the health system, primary health care
2.       Invest in information technology
3.       Link professional compensation to outcomes
4.       Manage elderly in the community
5.       Improve Canadian wellbeing

What is missing is the long list of where our major health care cash flows. No mention of high tech medical interventions, drug development, improved facility infrastructure, more surgeries, reduced waiting times, or more health care workers.  The focus is on what helps the patient not the professional.

Granted the details are missing on how to get there and what investments are most logical, but at least it is a vision that is solidly founded and perhaps might shape health system development going forward.  And in a country where investment and economy are currently the key decision drivers of the political machines, such statements from the Conference Board of Canada should be referred to and referenced as health policy is being shaped. That the statements for the most part reflect many of the ideals of public health for the last few decades is a refreshing vote of confidence.  

Monday, 5 November 2012

The US election - what happened to the health care debate?

'tis the day before the great decision.
Romney or Obama are furiously skittering
Rounding up votes with hopes of four years of bliss.
Tallying the states and crunching their numbers.

Jobs are the issue, with stimulating the economy close behind
Training, education, and energy still on the plate.
Sandy is history and left her mark on millions.  
But where, oh where, has the health debate gone?

In a race for the finish line, what was to be one of the biggest election issues, seems to have silently fallen off the political banter.   The election that had such clear political lines at the start; Romney campaigning to eliminate Obama's tentative efforts at health care reform; Obama attacking hard to defend the cautious progress that has been achieved.

There are some groups that have tried to speak out and make the issues public.  With little doubt, the Republican machine is bolstered by some of the 17% administrative costs and profits that the US health care industry generates and are somewhat at risk.  Women's groups, public health, environmentalists and others have shouted into the fog about the implications of not supporting the Democratic caravan and Obamacare reforms, but voices are few, far between and rarely associated with the actual political parties.

The Canadian "universal health care system",  around which can be found a national culture, when tinkered with,  can be the cause of loosing voter confidence and loosing subsequent elections.  Rarely can a political party run a campaign based on even the slightest of adjustments save a promise of a new hospital or expansion of existing services. More of the same will bring the voters out. Reforming the system occurs quietly out of the eyes of the public.  

Has the health care curse hit below the border?   Have the two political machines discovered that discussing health care change means only one thing - loosing voters to the other guy?  In a race that on the day before the election is too close to call by even the sophisticated pollsters and number crunchers, any comments that might shift voters away could crash the train just before it comes into the station - too big a risk to take.

Thursday, 1 November 2012

Sandy - a disaster in evolution

As the fury of the storm named Sandy dissipates moving through Quebec towards the Atlantic, its toll is being tallied.  Two Canadian deaths have so far been attributed to the storm, some 70 in both the US and another 70 from its initial assault in the Caribbean.   It is a tragedy of immense proportions.  Many will be grieving loss of the life, homes, possessions and finances. 

Notable is that on the 4th day after it rammed into the Eastern seaboard are the stories that emergency supplies having been used up, hospitals evacuating as generators fail, some communities still cut off from contact, and millions of homes without power. Gas stations  are closing because fuel supplies are exhausted from running generators. Communications lost as cell phone infrastructure has not been restored.   It will take days yet to restore some of those services – highlighting that emergency preparedness should reinforce the need for at least one week of supplies before expecting sustained assistance and not just the 72 hours that is often quoted.

As is expected in disasters, the consequences have been broader than damage caused by the predicted winds and rain.  Notable is the extensive loss of homes from gas related fires and hazardous spills associated with rupture of containment vessels.  In the days ahead will come the stories of personal impact – both heartening, and those of devastation. 

In a disturbing way, two stories that are circulating reflect somewhat misplaced priorities.  Out of Atlantic City is the income lost from casinos that closed.  The second is that even as the New York city attempts to recover from the storm, and many of their transportation subways are flooded, that the scheduled marathon this weekend will proceed – in part because of the number of participants who are registered from other countries and parts of the US who are to travel into the city even through transportation systems are crippled. 

Emergency planners will speak about continuity and recovery phases and planning.  Perhaps the least well developed and yet most important phases of managing a disaster.  How to maintain essential services, and how to rebuild from the rubble.  Let us hope that the next few days demonstrate strong leadership by emergency management crews that keep people as the central focus of the recovery efforts. 

Lest we forget, Sandy’s impact is however only a fraction of the over 1800 deaths from Hurricane Katrina in 2005.