Archive | Public Health

The current measles outbreak and the importance of vaccines

An unnecessary, completely avoidable outbreak of Measles in the United States.

First, the science.

Measles vaccination protects against measles.  The measles vaccine, and so many other vaccines, are some of the biggest successes in public health, leading to almost 100% decreases in the incidence of a wide range of fatal and disabling infectious disease.

Measles vaccinations

Measles cases in the United States, 1950-2001, CDC


Parental concerns

Some children have medical conditions that preclude vaccination (see CDC “Who Should Not Be Vaccinated”), but this is a small group. Some parents of healthy children believe (without any basis) that measles vaccines (and others) cause a range of negative health effects in children and, the current generation of parents born in the 1970’s, 80’s and 90’s, don’t remember how deadly infectious diseases can be. A third group of parents have religious beliefs opposed to vaccination.

The law

Most states require vaccinations before entry to the kingergarden, but may allow unvaccinated children to attend pre-school. Some states provide exemptions for religious or other objections (see the CDC database for state immunization laws).

 Current Measles vaccination behaviors

Because vaccinations have been so successful in eradication of infectious diseases, people have forgotten how terrifying and harmful the diseases were, and have focused their anxieties on the vaccines instead of the disease. This figure shows a downward trend in measles vaccine coverage in the United States, between 1980 and 2013, and the decline from initial high levels of 97 and 98% down to current levels of 91% is enough to affect herd immunity and allow the current outbreak of measles.

measles vaccinations

Measles vaccination rates in the US 1980-2013, WHO


The result – an unnecessary, completely avoidable outbreak of Measles in the United States

On the upside –

a vigorous discussion and flood of information reminding us all about the value of vaccines and the importance of vaccination, including a wide range of articles, stories and commentaries giving voice to the message.

Great overview in the The New York Times

Articles and cartoons in The New Yorker (not sure it is helpful to call people “idiots”), but an indication of the widespread involvement in the discussion.

Roald Dahl’s account of his 7 year old daughter’s death from measles.

Ebola – Is Public Health an Organized Sport, or Just a Pick-up Game?

The recent Ebola cases and fatality have triggered a collective process of finger pointing as we struggle to understand events and hold someone accountable.

Ebola Public Health

Hence, the television footage of health officials hauled off to Congress, accusatory headlines (“Alarming stumbles by the C.D.C.”) and appointment of czars. In the desire to pin the blame somewhere, notably the Centers for Disease Control and Prevention (CDC), we overlook the essential fact that in the United States public health responsibilities are fragmented among federal agencies, and decentralized throughout state and local government. The laws and regulations governing public health activities at federal, state and local levels is truly wonky terrain, but understanding these details is critical to being able to improve our response to public health emergencies. We need to know who actually has the authority to deal with specific public health functions and who should be held accountable (spoiler alert – it is not the Czar, nor the Secretary at DHHS, nor the Surgeon General, nor the Director of CDC). Often, it is a state health official, local health official or professional organization.

Let’s look at one of the most basic public health functions – disease surveillance and reporting. Reporting is the first step in preventing and controlling the spread of disease. We need to know about cases before we can take actions. One would think it would be mandatory. Not so. The US National Notifiable Diseases Surveillance System or NNDSS) is VOLUNTARY. The CDC role in this system is not voluntary, but is limited to receiving reports from states and publishing the data in an annual report.

Who decides which diseases are to be reported? “Public health officials at state health departments and CDC collaborate in determining which diseases should be nationally notifiable.” Do all states collect data on notifiable diseases? “States and jurisdictions are sovereign entities. Reportable conditions are determined by laws and regulations of each state and jurisdiction. It is possible that some conditions deemed nationally notifiable might not be reportable in certain states or jurisdictions.” This means that our national data and statistics on notifiable diseases are incomplete. Are states required to report notifiable diseases to the CDC? “Although disease reporting is mandated by legislation or regulation at the state and local levels, state reporting to CDC is voluntary”. This means that the state and local governments decide and mandate the data that are to be collected, not the CDC, not the federal government. The CDC works within this voluntary network to assemble and publish the best data it can.

The CDC is fundamentally an information organization. It conducts scientific investigations, analyzes laboratory samples, designs systems for collecting data, prepares and distributes information, publishes reports, and makes recommendations. It has relatively few powers. Authority to close down a restaurant? Local health departments. Authority to close a poultry plant? The US Department of Agriculture. Authority to recall a food item from the supermarket shelves? FDA, and, if it is a meat product, the US Department of Agriculture. What about the authorities to mandate that hospitals train their staff in safe procedures for treating Ebola, or mandate that hospitals maintain supplies of protective gear in the event of an Ebola case? I don’t know the answer to either of these questions, but I am betting that: a) it is different for each state, b) it may not exist in many states, c) the authority, if present, will reside in a hodge podge of state and local sanitation, labor, and health departments (protecting and training staff might be a labor issue as well as a health issue). While the CDC can recommend a certain level of preparedness, it does not have the powers to conduct audits or enforce recommendations. The level of preparedness at hospitals throughout the nation depends largely on decisions taken by hospital administrators to implement CDC recommendations, but there is no process in place to evaluate implementation or to correct inadequate implementation. Our only method of identifying non-adherence to recommendations is the occurrence of a major failure such as the one we have just seen at the hospital in Dallas.

The CDC prestige gives it some level of authority when making recommendations, but we shouldn’t confuse prestige with actual authority. CDC works effectively with states that value its input. In a foodborne outbreak, for example, states have the option of inviting the CDC to help it manage the outbreak – or not. When an outbreak is contained within state lines, the state health department is not required to call on the CDC, and not even required to report the outbreak – and some states don’t. As a result, the US has a calico pattern of statistics regarding foodborne outbreaks. States with strong food safety programs take a proactive approach to tracking down and identifying outbreaks, request CDC assistance with investigations, and report the outbreaks to the CDC; other states do just the opposite. Examine the CDC map that shows foodborne outbreaks by state. States with strong food safety programs have high rates of reported outbreaks! States with weak programs or no interest in reporting show few reported outbreaks. Take the example of Ohio, Indiana and Illinois, three bordering states that are fairly similar to each other. In 2012 Ohio and Illinois each reported 1.8 – 5.2 viral foodborne outbreaks per million (on the high end), but neighboring Indiana reported ZERO! Other states reporting zero viral foodborne outbreaks in 2012 include Mississippi, Missourri, Alabama, Arkansas, and West Virginia. The data reflect reporting behaviors rather than the information we need about occurrence of viral foodborne outbreaks.

Ebola public health

Food borne outbreaks, reported by state.

The pattern of fragmentation and decentralization is not limited to data reporting, but is repeated over and over throughout our health care system and public health infrastructure. Let’s not forget that the Supreme Court upheld the rights of states to opt out of the biggest national health initiative of the last 50 years, the Affordable Care Act Medicaid expansion. The rewards in public health are the rewards of doing interesting and important work. Every CDC employee (or ex-employee) that I have ever known works with amazing dedication and takes their responsibilities with the utmost seriousness. All see themselves as public servants, and I have never heard any of them complain about the lack of resources or any other aspect of their work. Blaming the CDC for our unpreparedness in the face of Ebola is probably the least productive thing we can do right now. Instead, we need to strengthen all the pieces of our decentralized public health network so that every American is protected in times of public health emergencies. Expecting an agency with relatively limited powers, such as the CDC, to be held accountable for failures in a decentralized network won’t get us where we want to be.

Top notch information about the Ebola virus

In the fast-moving events around the current Ebola epidemic, information has been essential. Fortunately, excellent communication and information resources are available. Here’s a quick cheat sheet to find quick and reliable Ebola information.

Begin with the Centers for Disease Control and Prevention, the government agency responsible for providing information on diseases to the public. Their Ebola information page covers Signs and Symptoms, Transmission, Risk of Exposure, Outbreaks, Prevention, Diagnosis, Treatment and specific issues Healthcare workers. There’s a chronological timeline, Clinical Guidances, and Communication Resources including factsheets, inforgraphics, Banners, Posters, Videos and more.

Ebola information - contact-tracing, from the CDC

CDC infographic on contact tracing.

The BBC website has plenty of good coverage, covering a lot of material simply and clearly. Their page includes a diagram of the virus and the infection process, a map showing where Ebola deaths have occurred and an interactive visual describing the different parts of the protective Ebola suit.

The leading medical journals provide a mix of resources that include editorials, discussions of ethics, and technical information about the status of research activities. These include The New England Journal of Medicine and JAMA, as well as the Lancet with its Ebola resource page, bringing an international perspective.

Visualizing Health

From the Robert Wood Johnson Foundation and the University of Michigan Center for Health Communications Research

We’re starting to see the fruits of all the excitement about data visualization and health, notably this thorough report from Visualizing Health, a project of the Robert Wood Johnson Foundation and the University of Michigan Center for Health Communications Research.

As they state,

In theory, data can help us make better decisions about our health. Should I take this pill? Will it help me more than it hurts me? How can I reduce my risk? And so on.

But for individuals, it’s not always easy to understand what the numbers are telling us. And for those communicating the information – doctors, hospitals, researchers, public health professionals — it’s not always clear what sort of presentation will make the most sense to the most people.

Their web site contains examples of tested visualizations, and what’s especially nice, they’ve done research assessing reactions from the general public. They’ve created a gallery of graphs, charts, and images, and they’ve done the hard work of evaluating them.


from Visualizing Health, one of their data visualizations

one of their data visualizations

Among the goodies, a “wizard” tool to help you learn more about a risk you want to communicate, and a sample risk calculator that shows off some of the best design concepts.

I like the way they’ve identified use cases:

  • Tradeoffs between medication or treatment options?
  • Relating biomarkers (such as BMI or cholesterol levels) to risk?
  • Health risk assessment output?
  • Population risks: disparities?
  • Population risks: emergent disease (“Should I worry about that measles outbreak?”)
  • Understanding multiple side effects?Understanding unique side effects?
  • Motivating a risk-reducing action?
  • Understanding tradeoffs that change over time over time?
  • Small risks, and understanding how to reduce small risks?
  • Explaining what “average years saved” means for an individual person?

I like the way they describe their methodology, using three tools to test their images (google consumer surveys, survey sampling international, and amazon mechanical turk). Transparency is always appreciated!

And, at the back of the report (why at the back?) a comic book style presentation on visualizing health in practice, using images to educate patients about diabetes.

about health literacy

about health literacy

Pediatric hospitalizations for mood disorders

Children get hospitalized for depression and bipolar disorders.

I wasn’t aware of how frequently this happens until I got my hands on some BIG DATA – the HCUP KID database of children’s hospitalizations. My colleagues and I analyzed hospitalizations in 2000, 2003 and 2006 and published our results in the journal, Child and Adolescent Psychiatry and Mental Health in 2011. For each of these years, we were able to look at records for over 2 million hospitalizations, and able to project these to the entire number of pediatric hospitalizations in the US in those years.

Some take home points

Percentages of hospitalizations where the principal diagnosis was a mental health diagnosis

  • In children age 15-17, 13.7 to 15.2% of hospitalizations had a mental health principal diagnosis
  • In children age 10-14, 15.0 to 15.6% of hospitalizations had a mental health principal diagnosis
  • In children age 5-9, 4.4 to 4.8% of hospitalizations had a mental health principal diagnosis accounted

The incidence of hospitalizations with mood disorders as the principal diagnosis compared to the entire population of children

12.1-13.0 out of every 10,000 children were hospitalized with mood disorders as the principal diagnosis in 2000-2006.


The incidence of hospitalizations for children with mood disorders increased with age – this figure uses data from 2006 to show the trend.

Children mood disorders by age

Region of the country

A surprising finding was the big differences between regions of the country. As an example, in 2006, the Western region experienced the lowest rates (10.2/10,000) while the Midwest had the highest rates (25.4/10,000). This figure shows the rates for 2000, 2003 and 2006.

children mood disorders by region of the US

Did you know?

Mood disorders including depression and bipolar disorders are a major cause of morbidity in childhood and adolescence, and hospitalizations for mood disorders are the leading diagnosis for all hospitalizations in general hospitals for children age 13 to 17.

Between 2000 and 2006, inflation-adjusted hospital charges increased from $10,600 to $16,300.