TIME Infectious Disease

Containing Ebola Is Extremely Labor Intensive, Former CDC Researcher Says

GUINEE-HEALTH-EBOLA
Members of the Red Cross provide information on Ebola to residents in Conakry, Guinea on April 11, 2014 at the start of the largest Ebola outbreak in history CELLOU BINANI—AFP/Getty Images

It's not about high-tech solutions but good old-fashioned legwork

Given the fact that the Centers for Disease Control and Prevention (CDC) is now urging Americans to avoid non-essential travel to Sierra Leone, Liberia and Guinea, which are battling the largest outbreak of Ebola in history, and the Peace Corps has pulled out its volunteers from the region, the key to bringing the epidemic under control will rest not with the highly trained scientists flown in from around the world, but with local volunteers.

In outbreaks like this, which has so far claimed more than 720 lives, the only way to control the spread of disease is by ensuring that anyone who is infected is isolated in a hospital, and that anyone they contacted are also monitored for symptoms. “The main way we have of controlling the outbreak is by preventing further spread of cases,” says Dr. Eileen Farnon, associate professor of medicine at Temple University School of Medicine. “You have to take people who are symptomatic out of the community so they don’t continue to spread disease.”

MORE: Here’s What You Need to Know Now About the Ebola Crisis

In 2007, Farnon, then at the CDC, traveled to the Democratic Republic of Congo and Uganda to help those nations battle smaller Ebola outbreaks. Farnon helped local health officials coordinate contact tracing, which involves asking every infected patient for a list of people they had contact with since they started experiencing symptoms, and then finding and monitoring those contacts for 21 days. “As you can imagine, the more infected patients there are, the number of contacts really grows exponentially,” she says.

The follow-up required an army of volunteers to visit the contacts daily during the incubation period, often taking their temperature and asking them about any unusual health symptoms. If people started showing signs of illness, the volunteers were responsible for contacting a hot line and arranging for them to come to a hospital for further testing and possibly isolation if they were infected.

MORE: Everything You Need to Know About the Deadly Ebola Virus Outbreak

Such contact tracing is also occurring now in West Africa, but it’s likely more challenging because of the denser and more fluid nature of the populations there, says Farnon. In the Democratic Republic of Congo and Uganda, the outbreaks occurred in remote regions and the contacts weren’t mobile and potentially infecting others in densely populated places like airports.

Farnon guesses that if contacts in the current outbreak mention that they are intending on traveling to another country, the health workers will likely discourage them from doing so, but that some, if they aren’t feeling sick, may still continue with their trip. That’s why national health officials need to coordinate screenings at border crossings to ensure that people who become ill are identified and cared for before they can spread the virus.

MORE: Infographic: Ebola By the Numbers

Farnon says there are social challenges as well. “People in the community will realize early on that patients who get admitted to the hospital, usually late in their infection, may die. And many start getting fearful about going to the hospital because they think it means they are going to die,” she says. While there are no treatments for Ebola infection, early care with proper hydration and nutrition can keep patients strong enough to overcome the virus. But even patients who survive are stigmatized because their neighbors think they are still contagious. Farnon says her groups provided a volunteer to accompany patients back to their homes to help them and their community to understand that they were no longer a threat.

The volunteers were the key to keeping the virus contained, says Farnon, and contact tracing, while labor intensive, was the key to managing the outbreaks in which Farnon was involved—and certainly essential to the west African situation as well. “The village health workers and volunteers are the primary means of getting messages to communities, because they have the relationships with the communities and the ability to mobilize others to help people look for the signs and symptoms of Ebola,” says Farnon.

“It’s a huge logistical undertaking,” she says—but it’s necessary.

TIME Infectious Disease

WHO Says All Men Who Have Sex With Men Should Take Antiretroviral Drugs

A nurse takes blood for a free HIV test, during an HIV/AIDS awareness rally on World AIDS Day in San Salvador
A nurse takes blood for a free HIV test during an HIV/AIDS awareness rally on World AIDS Day in San Salvador on December 1, 2011. Luis Galdamez—Reuters

Warns of 'exploding epidemics' of HIV among gay men

The World Health Organization has suggested for the first time that all men who have sex with men should take antiretroviral medicine, warning that HIV infection rates among gay men are exploding around the world.

In guidelines published Friday, it said that it “strongly recommends men who have sex with men consider taking antiretroviral medicines as an additional method of preventing HIV infection.” Similar guidelines were issued by the U.S. in May.

Gottfried Hirnschall, the head of WHO’s HIV department, says that infection rates among homosexual men are increasing again 33 years after the epidemic hit, partially because the infection doesn’t hold as much fear to a younger generation with access to drugs that enable users to live with AIDS.

“We are seeing exploding epidemics,” Hirnschall told reporters in Geneva.

Although HIV infection rates did drop by a third between 2001 and 2012, Hirnschall characterized progress as “uneven.”

[AFP]

TIME States

Alaska to Put Free Pregnancy Tests in Bar Restrooms

The program will help combat the state's high rate of fetal alcohol syndrome

The University of Alaska is leading a state-funded program to put free pregnancy tests in the bathrooms of 20 bars and restaurants across the state starting this December.

The two-year, $400,000 program is designed to combat Alaska’s rate of fetal alcohol syndrome, which is the highest of any state in the country, the Anchorage Daily News reports. Women of child-bearing age in Alaska are 20 percent more likely to binge drink in comparison to the national average.

“This is not a strategy for the chronic alcoholic who is drinking regardless of whatever message they see,” said Jody Allen Crowe, who founded a Minnesota organization that leads a similar program and is helping with the project. “This is really focused on the 50 percent of unexpected pregnancies, to find out they are pregnant as early as possible.”

Republican Senator Pete Kelly, who has said before that birth control is for women who “who don’t want to act responsibly,” first proposed the program.

[Anchorage Daily News]

TIME Environment

Carbon Regs Will Help Your Health More Than the Planet’s

EPA coal pollution
Carbon dioxide is the chief target of EPA regulations, but they'll also help curb conventional pollutants Photo by Robert Nickelsberg/Getty Images

Public health—through cleaner air—will benefit more from EPA carbon rules than climate change, and that's O.K.

When the White House rolled out the proposed Environmental Protection Agency (EPA) regulations on power-plant carbon emissions on June 2—regs that will reduce emissions 30% below 2005 levels—President Barack Obama attended a conference call with a number of public health groups, including the American Lung Association. Obama talked about the importance of treating carbon as a pollutant, of investments in energy efficiency that would cause electricity bills to shrink, of the momentum behind the move to a low-carbon economy.

But he spent much of his time talking about the health benefits that would come as the regulations cracked down on coal plant pollution:

“I got a letter from Dian Coleman, who is a mother of four. Her three kids have asthma. [...] She keeps her home free of dust that can trigger asthma attacks. Cigarettes aren’t allowed across the threshold of her home. But despite all that, she can’t control the pollution that contributes potentially to her kids’ illnesses, as well as threatening the planet. We’ve got to make sure that we’re doing something on behalf of Dian, and doing it in a way that allows us also to grow the economy and get at the forefront of our clean energy future.”

Carbon dioxide isn’t a pollutant—at least, not in the sense that breathing it in damages health. (If it were, trees would be a lot more dangerous.) CO2 does cause climate change, which in turn can directly threat health by increasing ozone levels, intensifying heat waves and floods and even worsening allergies, all of which the White House detailed in a new report out today. But Obama and his officials have been talking up a different sort of public health benefit that will come with the regulations: the reduction of dangerous, conventional pollutants like nitrous oxides, sulfur dioxide and simple soot. “Our role in this initiative is to protect public health and the environment,” EPA Administrator Gina McCarthy told me in an interview last week. “It’s key in this rule that when we lower carbon, we reduce traditional pollutants.”

The EPA says that the regulations will reduce those conventional pollutants by more than 25% over the lifetime of the rules as a co-benefit. That in turn will avoid up to 6,600 premature deaths, up to 150,000 asthma attacks in children and nearly 500,000 missed work or school days. That might just be the beginning—the more we learn about air pollution, the more dangerous it seems even at lower levels. A new study from the University of Rochester found that exposure to air pollution at a young age caused changes in the brains of mice, including an enlargement in the parts of the brain that is seen in humans with autism and schizophrenia. And air pollution is still a major problem in the U.S.—a recent report from the American Lung Association found that nearly 5 in 10 Americans live in places where the air can be dangerous to breathe.

There’s an added political value to the White House’s focus on the public health benefits of carbon regulations. Note the huge partisan gap on the issue in recent polls: climate change, unfortunately, remains an area where there is deep political division. But air quality and public health is something that Americans can get together on, at least somewhat, without the conversation turning into a debate over temperature trends and IPCC assessments. That could help these regulations, which are supported by a strong majority of Americans, overcome kneejerk Republican opposition. “You don’t need to have a debate over climate change,” says Jim Brainard, the Republican mayor of Carmel, Indiana and a member of the White House task force on climate change. “Who doesn’t want to breathe clean air?”

As I wrote last week, the EPA regulations by themselves will have only a small impact on total U.S. carbon emissions, and a negligible one globally. The hope is that these rules are just the beginning, that they will help prompt other countries to push their own carbon-cutting efforts further, and encourage businesses to find even better ways to accelerate the clean energy revolution. But countless Americans will breathe easier—literally—thanks in part to these rules. That’s reason enough to celebrate.

TIME States

Dengue Fever Infections in Florida Make Health Experts Wary of Mosquito-Borne Outbreak

Deadly disease on the rise in the Sunshine State

+ READ ARTICLE

After 42 Floridians came down with dangerous mosquito-borne diseases, state officials advised citizens on Wednesday to take steps to protect themselves against bug bites.

The Florida Department of Health announced 24 confirmed cases of dengue fever as of last week, and 18 confirmed cases of chikungunya, both viruses that do not have vaccines to prevent them and have not typically been found in North America, the CDC says.

All Floridians infected had traveled to the Caribbean or South America, and officials believe they may have contracted the diseases there, but epidemiologists worry that Florida mosquitos may be spreading the illnesses, which could lead to a potential outbreak, Reuters reports.

Dengue is a potentially fatal disease and both can cause long-term problems.

“The threat is greater than I’ve seen in my lifetime,” said Walter Tabachnick, director of the Florida Medical Entomological Laboratory in Vero Beach. “Sooner or later, our mosquitoes will pick it up and transmit it to us. That is the imminent threat,” he said.

[Reuters]

 

 

 

TIME cities

Washington D.C. Is The Fittest City In The U.S.

Lower death rates, ample parks and a healthy appetite for fruits and vegetables are just some of the factors that vaulted the nation's capital to the top of the list

Washington D.C. has topped a ranking of America’s 50 largest cities, arranged from fittest to flabbiest.

The new study, released on Wednesday by the American College of Sports Medicine, ranked the cities by two broad measures of public health: Personal health indicators such as prevalence of smoking and diabetes and the average city-dweller’s intake of fruits and vegetables, and environmental health, which included measures such as access to public parks, bike lanes and farmer’s markets. A panel of 26 health experts weighted the measures by importance, and voila, a health index was formed, allowing whole metropolises to size one another up like competitive weightlifters.

Washington D.C. topped the list, knocking Minneapolis-St. Paul’s off of its three-year winning streak (though the Twin cities came in a close second). Oklahoma City, Louisville, and Memphis rounded out the bottom of the list.

The authors stress that some of the rankings capture marginal differences between cities and that they all have areas of strength worth emulating and weaknesses worth addressing.

“We have issued the American Fitness Index each year since 2008 to help health advocates and community leader advocates improve the quality of life in their hometowns,” said Walter Thompson, chair of the AFI Advisory Board.

In other words, they’re all beautiful in their own way, and they all could use some work.

TIME

These Are The 5 Most Lethal States for Pedestrians

Fueled By Consumer Spending, Economy Grew At 3.2 Percent In 1st Quarter
A woman with shopping bags traverses a crosswalk near Columbus Circle April 30, 2010 in New York, New York. Chris Hondros—Getty Images

Read this, Floridians

A new study warns of a nationwide “epidemic” of pedestrian fatalities concentrated in states that aren’t exactly known for their bustling crosswalks.

Researchers at the National Complete Streets Coalition crunched the numbers on 47,025 pedestrian deaths over the last 10 years—a number that exceeds deaths from natural disasters sixteen times over, the study notes.

States with dense urban populations and heavy concentrations of walkers, including Washington D.C., New York and Massachusetts, skewed on the safe side of the study’s “Pedestrian Danger Index,” a measure of deaths relative to the number of people walking the streets.

The real danger zones are down south in the car-centric urban tracts of Florida, Alabama and Louisiana. In short, these states weren’t made for walking.

Untitled
Source: National Complete Streets Coalition

Orlando, Florida topped the list of most hazardous cities with 583 pedestrian deaths and a danger index four times above the national average. Tampa, Jacksonville and Miami came in 2nd, 3rd and 4th respectively among the most dangerous cities.

The study also found that elderly pedestrians accounted for one in five fatalities, suggesting that Florida’s urban planners should neither be singled out for blame nor let off the hook. And perhaps they should pay a visit to these 5 pedestrian-friendly states:

Florida and 5 States
Source: National Complete Streets Coalition

The study’s authors advocated for reductions in speed limits and clearer delimitations between car lanes, bike lanes and crosswalks to combat an “epidemic” of pedestrian deaths, averaging 5,000 a year.

“Not only is that number simply too high,” said Roger Millar, Director of the National Complete Streets Coalition, “but these deaths are easily prevented through policy, design, and practice.”

TIME public health

San Francisco Mulls Golden Gate Suicide Net After Record Number of Deaths

Suicide Barrier Could Be Installed On Golden Gate Bridge
A visitor looks over the railing on the Golden Gate Bridge on March 12, 2014 in San Francisco. Justin Sullivan—Getty Images

The city is expected in May to approve adding stainless steel nets that would hang 20 feet below the bridge and be invisible from most angles after a record 46 people leapt to their deaths last year. Another 118 were talked down by bridge staff or passers-by

San Francisco officials are poised to install the Golden Gate Bridge’s first suicide safety net after a record number of people died leaping off the world-famous bridge last year. Forty-six people jumped to their deaths in 2013, while 118 more were talked down.

The $66 million stainless-steel nets will hang 20 feet below the bridge and be invisible from most angles, The New York Times reports.

The Golden Gate Transportation District is expected to vote in favor of installing the suicide barrier as early as May. Other similarly iconic and dangerously tall structures, such as the Empire State Building and the Eiffel Tower, already have such barriers in place.

A families of the deceased group estimates more than 1,600 people have died jumping off the Golden Gate Bridge since construction finished in 1937.

[NYT]

TIME public health

Colorado Won’t Raise Legal Age to Buy Cigarettes

Cigarettes
Daniel Acker / Bloomberg / Getty Images

The state narrowly rejected a proposal to raise the legal age from 18 to 21. The move comes as cities and corporations across the U.S. are making cigarettes less accessible—or are being pressured to do so.

On Wednesday, a Colorado House committee voted 7-6 to kill a proposal that would have raised the minimum age for buying cigarettes to 21 across the Rocky Mountain State. The bipartisan bill, which had already passed one committee hurdle, would have made Colorado the first state to set the minimum at the same age for drinking—and, in that state at least, the legal purchase of marijuana. The current legal age for buying cigarettes in Colorado is 18.

There have been similar but less sweeping moves from state and local officials, all intended to curb cigarette use among young people. Four states — Alabama, Alaska, New Jersey and Utah — have pushed the minimum to 19. In November, then-Mayor Michael Bloomberg signed a bill raising the minimum for buying smokes in New York City to 21. Some counties in New York have since followed suit, and a dozen smaller towns in Massachusetts had raised the minimum age above 18 by the end of last year, many of them setting the bar at 21.

Debates about the issue often pit health advocates against business owners, who argue that such a ban could hurt their bottom lines and curtail the legal rights of citizens. But with major corporations like CVS pulling cigarettes off their shelves, sacrificing $1.5 billion to be more in step with public opinion, the tide seems to be turning against the capitalistic argument for permitting broad sales. After CVS’s announcement in February, nearly 30 state attorneys general called on five more giant corporations to also stop selling tobacco in stores that have pharmacies.

TIME public health

The Dangers of Hunting for Cancer

Why more screening is not always better

As a surgeon, I’m trained to crush cancer. For many years, every tumor I palpated and family I counseled drove me to hunt for cancer with vengeance, using every tool modern medicine has to offer. But recently, one patient reminded me that the quest to seek and destroy cancer can produce collateral damage.

The patient’s story began with a full-body CAT scan, a screening test used to detect tumors, which revealed a cyst on his pancreas. Some 3 percent of humans have these cysts and they are rarely problematic. Based on his cyst’s size and features, there was no clear answer as to what to do about it, but he was given options.

(MORE: Screening Cancer)

The patient tossed and turned every night, agonizing over stories of pancreas cancer tragedies, consumed by the dilemma of whether to risk surgery to remove the cyst or leave it alone. The conundrum strained his marriage and distracted him from his work.

Months before I met him, the patient underwent the surgery, which revealed that the cyst was of no threat to his health. The operation was supposed to cost $25,000 and eight weeks out of work. But the toll was much greater, including a debilitating surgical complication.

I thought: this is why he shouldn’t have had a CAT scan in the first place. Screening made him sick.

(MORE: What Now? 4 Takeaways From the Newest Mammogram Study)

New research is finding that some health screening efforts have gone too far. A recent study found that yearly mammograms do not prolong the lives of low-risk women between the ages of 40 and 59. Following 89,000 women for 25 years in a randomized controlled trial (the gold standard of science), the study is as methodologically impressive as they come. In fact, in research terms, the report has more scientific merit than any medical study of chemotherapy. As hard as it is for our pro-screening culture to believe, the data are clear. We are taxing far too many women not only with needless and sometimes humiliating x-rays, but also with unnecessary follow-up surgery.

The annual mammogram is not the only vintage medical recommendation under scrutiny recently. Another large study found that among low-risk adults, a daily aspirin — a recommendation hammered into me in medical school — kills as many people from bleeding as it saves from cardiac death. Doctors are also re-evaluating calls for regular prostate-specific antigen (PSA) tests and surgical colposcopies after “borderline” Pap smears because of the risks of chasing false positives and indolent disease.

The bad news is that the problem of unintentional harm is far bigger than many people suspect. The Office of the Inspector General for Health and Human Services reports that among Medicare patients alone, it contributes to 180,000 deaths annually. On a national level, unintentionally harming patients in the process of trying to improve their health now ranks as the number three cause of death in the U.S. — ironically just after cancer.

(MORE: Breast Cancer Screening Isn’t Going Away—At Least Not Yet)

In this era of rising medical prices, manifesting as higher deductibles and co-pays, cutting waste should be our top priority, especially when that waste pulls doctors away from the important work of caring for sick patients. A 2013 Institute of Medicine report concludes that Americans spend as much as one-third of our healthcare dollars on tests, medicines, procedures, and administrative burdens that do not improve health outcomes.

The patient I met also taught me about another negative outcome — one that does not show up in the national stats: emotional trauma from false alarms. The patient recounted feeling tormented by the idea that he might be harboring a “precancerous” time bomb. His distress arose not from cancer, but from medicine’s limited ability to interpret a normal variation of anatomy discovered by new technology.

The good news is that a grassroots movement within medicine is identifying unnecessary tests and procedures to educate doctors and the public about them. The American Board of Internal Medicine Foundation has been asking medical specialty associations to name the five most overdone tests and procedures within their specialty (choosingwisely.org.). The campaign has recently expanded and now includes 50 doctors associations.

Reducing over-diagnosis and over-treatment will require broadening medicine’s focus beyond hunting and killing disease to sound research and education on appropriate care. Medical training should also examine why our culture prefers CAT scans over physical exams, and pills over prevention.

Finally, we all must come to grips with the public’s expectation for more medicine. New research is capturing what individual patient stories, like that of my patient, have been trying to teach us: We have a quiet epidemic of unnecessary, costly, and sometime harmful medical care.

Dr. Marty Makary is a cancer surgeon at Johns Hopkins Hospital and associate professor of health policy at the Johns Hopkins Bloomberg School of Public Health.

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