Tuesday, January 8, 2013

Public Health Poetry

The flu vaccine cannot give you the flu, I tell him.
It's dead virus, there's nothing alive about it.
It can't make you sick.  That's a myth.

But if we bury it in the grassy knoll of your shoulder,
an inch under the stratum corneum, as sanctioned by your signature
in a white-coated ceremony presided over by my medical assistant
and then mark the grave with a temporary non-stick headstone,

the trivalent spirit of that vaccine
has a 70 to 90 percent chance of warding off the Evil One,
and that's the God's honest truth.

"Myth Dispelled" by Adam Possner, from JAMA, December 5, 2012.
© American Medical Association, 2012.

Friday, January 4, 2013

Why Flu Spread So Fast In Those Schools

On December 10, 2012 the Health Department got a report from Shelly Millis, Superintendent of the Montebella Schools, that 180 children and teens were out sick with flu-like symptoms.  Some had tested positive for influenza types A and B. Our Medical Director, Dr. Robert Graham recommended that the schools close to halt the further spread of the illness. (This was a recommendation to the Superintendent who made the decision herself.  It was not a case of the Health Department ordering the school to close.)

Ten days later, on December 20th the same thing happened at Central Montcalm schools. With 259 students  out, Superintendent Kristi Teall made the decision to send everyone home. Coincidentally this was the same week some schools were dealing with gun rumors in the wake of Sandy Hook shootings.

Why did the flu spread so fast in these schools?  We used data from the Michigan Immunization Registry to examine the influenza immunization status of the students in the Montebella Schools.  Only 22 percent of the elementary age students had up-to-date flu shots, and only 4 percent of the middle and high school age students did. Four percent!

With so few students protected against the flu, it’s no wonder things got out of hand so fast.  Very few students had any level of immunity so the virus spread easily.  We are used to thinking of the decision to get a flu shot as an individual choice.  But getting a shot is a much about protecting others as it is about protecting ourselves. Everyone’s lives in those two schools were disrupted because they didn’t have “herd immunity”.

This is discouraging. The Health Department used to give thousands of flu shots every year, but now it is down to around 1,000 per year and falling fast. Now that so many pharmacies give flu shots, we hope people are going there to get their shots, but maybe that is not working as well as we hope it will.

By the way, the flu is here in earnest. In the graph below from the CDC, the red line is the percentage of people showing up at emergency rooms with flu-like symptoms. It is headed up fast meaning an early, and probably pretty intense flu season.

It’s not too late to get a flu shot. If you get one tomorrow it will kick in in about two weeks. But the flu season should last at least 10 more weeks so it should be worth it.

Thursday, January 3, 2013

We Don't Do That Anymore: Disappearing Public Health Programs

The federal government funds many programs intended to support local public health services including testing and treatment for diseases like HIV, other STIs, tuberculosis and lead poisoning; disease outbreak investigation; family planning and many more. It may come as a surprise, but the truth is that many local health departments do not offer many of these programs, leaving residents of those communities without access to needed health services.

At the Mid-Michigan District Health Department a good example of this comes from the Breast and Cervical Cancer Control Program (BCCCP).  Breast cancer remains one of the most common cancers diagnosed in women. Most forms of breast and cervical cancer are highly treatable if detected early enough.  But low-income, uninsured women are not able to afford to be screened, resulting in cancers progressing to late stages before being detected and thus higher death rates.  In 1990 Congress created the Breast and Cervical Cancer Control Program (BCCCP) providing money to States to help low-income, uninsured women gain access to breast and cervical cancer screening and diagnostic services. These services include—
  • Clinical breast examinations.
  • Mammograms.
  • Pap tests.
  • Pelvic examinations.
  • Diagnostic testing if results are abnormal.
  • Referrals to treatment.
And yet MMDHD is only able to offer these services in two of the counties we serve, Clinton and Gratiot, because of the intervention of local hospitals. We do not offer these services at all in Montcalm County (Although the Montcalm Area Health Center does).

The dilemma the State faces is that the funding for the program only enables it to offer BCCCP in full form to coordinating agencies in a couple of dozen communities across the state.  The coordinating agencies’ budgets include staffing to manage the program and arrange for follow up care if it is required.  If you are not one of the coordinating agencies you can participate in BCCCP but the only funding you get is a per-client payment that does not cover your costs.

In 2010, running an unsustainable deficit, we had to eliminate our BCCCP program. Before I go any further I need to say that it is a well-established fact in health research that distance to care is inversely related to outcomes. We see this both in rural areas, and in urban neighborhoods that have few providers.  So the fact that Mid-Michigan women would have to get to Grand Rapids, Lansing or Saginaw for screening meant that some would not be able to do so, with the inevitable result that more would have untreatable cancers.

Amazingly, when they heard the program was being eliminated, Sparrow Clinton Hospital and MidMichigan Medical Center-Gratiot stepped in and provided funding to the tune of several thousand dollars each.  Each year nearly a hundred and fifty women get screened and get follow up care if required, because of these generous partners.  Unfortunately, not all low-income rural and urban communities have a provider in a position to be their benefactor.

My last word is about true prevention. Remember, most cervical cancers can be prevented by the HPV vaccine. It is important for boys and men, as well as girls and women to get the vaccine so they do not spread HPV to their partners.  That’s a much better idea than an expensive screening program.