olivia-twenty-dahl

I swear that the evidence that I shall give, shall be the truth, the whole truth and nothing but the truth

The interwebs are not a court of law, that is for sure. The whole truth. Interesting idea. I have no idea how applicable Godel’s theorems are outside of mathematics, but from a practical point knowledge is always incomplete. There is too much to know and too little time and brain power to acquire perfect knowledge of a topic.

It is why medicine is a challenge. You have to synthesize all the available data, which is often incomplete. You have to decide what is quality information, what is not, and why, and how a given study or fact fits into the overall picture, on the continuous asymptotic journey towards unobtainable total knowledge. But you try for the whole truth, the good, the bad and the ugly.

Half-truths, partial stories, can be hard to challenge. In part because, well, they are half-true. They have an air of truthiness. It is perhaps much easier to counter an out-and-out lie. Well, maybe not. I’m thinking Wakefield here. I suspect that in having to admit that half-truths have some validity, it renders them more believable.

The world of pseudo-medicine, and pseudo-science, is filled with half-truths. I wonder when I read these half-truths whether the author is deliberately avoiding all the information, especially since the rest of the story often results in the weakening the impact of the half-truth. Paul Harvey could have had a field day with the anti-vaccine literature.

One of the greatest challenge facing young people today, is the large scale availability of half truth’s and manipulated facts
– Oche Otorkpa, The Unseen Terrorist

Influenza

Beware of the half-truth. You may have gotten hold of the wrong half.
– Author unknown

Take “Do Not Believe Everything You Read About Flu Deaths” from the October, 2014 Journal of Advanced Practice Nursing. As best I can tell this is a peer reviewed journal. You know, “peer“, as in “to appear partially or dimly.”

I imagine someone squinting over the top of their glasses at the manuscript, muttering, “that ‘peers to be a paper about influenza deaths. Let’s publish it.”

They start with:

Flu results in “about 250,000 to 500,000 yearly deaths” worldwide, Wikipedia tells us. “The typical estimate is 36,000 [deaths] a year in the United States…adding that “Those numbers are controversial because they are estimates.”

One would think that ‘advanced practice’ would include checking the facts from the original source with, oh, a google search.

That 36,000 number is an estimate and, an outdated estimate, from 1999. They seem not to have paid attention to more recent estimates from 2010 that used better models to estimate flu deaths. Why get all upset about the evil CDC using old, out dated statistics? The more recent estimates have influenza deaths varying from year to year:

During the past three decades, the estimated number of annual influenza-associated deaths from respiratory and circulatory causes ranged from a low of 3,349 to a high of 48,614 deaths.

So the 36,000 deaths is one of those half-truths, once the best, if flawed, estimate of influenza deaths but no longer.

Trying to determine how many deaths are due to influenza is tricky: there are direct deaths and indirect deaths from ‘flu, such as secondary bacterial pneumonia.

They ask:

But why are flu and pneumonia bundled together? Is the relationship so strong or unique to warrant characterizing them as a single cause of death?

Implying they are not. Again it depends. For H1N1 co-infections and deaths:

the incidence of influenza A H1N1 infection in CAP during the pandemic period was 19% (n, 667). We studied 128 patients; 42(33%) had bacterial co-infection. The most frequently isolated bacterial pathogens were Streptococcus pneumonia (26, 62%) and Pseudomonas aeruginosa (6, 14%). Predictors for bacterial co-infection were chronic obstructive pulmonary disease (COPD) and increase of platelets count. The hospital mortality was 9%.

Although in this study having a bacterial superinfection was not associated with increased death. In prior pandemics bacterial superinfections were perhaps a more important cause of death in influenza patients.

The majority of deaths in the 1918–1919 influenza pandemic likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory-tract bacteria. Less substantial data from the subsequent 1957 and 1968 pandemics are consistent with these findings.

The authors of the JAPN conclude:

The article’s answer is no. Most pneumonia deaths are unrelated to influenza.

But that is backwards. The question is, “how many influenza deaths are a result of a secondary bacterial pneumonia?” Sometimes it is, sometime it isn’t.

And there are the vascular events (heart attacks and strokes) and exacerbation of other cardio-pulmonary diseases , set off by influenza, that kills people.

Influenza kills those people as well. Arguing that they are not ‘flu deaths, as suggested, is akin to arguing that the only gun deaths you should count are in those pistol whipped to death. Otherwise they died of bullets, bleeding or major organ trauma, but not guns.

The final point of the essay is that the CDC played up the flu deaths to get people to take a vaccine they do not need. That is where the summation of multiple half-truths equals one complete falsehood, the intimation that the CDC is manipulating data for nefarious reasons.

That is one of the curiosities about the vaccine opponents and pseudo-medical providers. Somehow they just cannot wrap their heads around the fact that most time most people in reality-based medicine really, truly, are making recommendations because the preponderance of data suggests it is the right thing for people to do.

Then, as I finish this part of the essay, I discover it is actually a Huffington Post article published by the Journal of Advanced Practice Nursing with no attribution that I could find, as are other articles on the site. Go figure. I was always under the impression it was tacky to publish the copyrighted material of others without attribution, although I cannot log on to the site to see if permission etc. are behind the paywall as I am not a member.

I suppose the take home is Do Not Believe Everything You Read in Advanced Practice Nursing.

Measles

A half-truth is a whole lie.
– Yiddish proverb

There is no shortage of measles articles for some odd reason of late. Some contain TNTC examples of half-truths. For example, Roman Bystrianyk’s “Measles and measles vaccines: fourteen things to consider.”

He starts:

  1. Measles death rate had declined by almost 100% before the use of a measles vaccine.

That is wonderful. And half the story. How about measles cases? Cases of measles didn’t fall precipitously until after the vaccine became widespread. They never show that graph. Instead, they show a section of the graph, using a different scale on the y axis and a different time interval on the x axis to minimize the effects. Please. I know what website he visits. Look carefully at the graph. Cases went from about 450/100,000 to 300/100,000 from 1934 to 1962. After the vaccine? Locally acquired measles went to 0/100,000. And yes measles was declining before the vaccine. We went from 500,000 cases a year to 50 only after the vaccine was introduced. A 99.9% reduction in cases after the vaccines; sadly, the estimated decrease in mortality was 39%. Measles can still be fatal. Controlling infections is always multifactorial, from understanding the epidemiology to nutrition to quarantine.

For the rest of the world measles is still a scourge:

Worldwide, an estimated 20 million people get measles and 146,000 people die from the disease each year—that equals about 440 deaths every day or about 17 deaths every hour.

And about 1/1,000 cases died in the US until 1963, the year the vaccine was introduced:

During this year, the whole of New England (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut) had only 5 deaths attributed to measles.

Note the ‘only’. Only five deaths. Only 10 heartbroken parents, 20 heartbroken grandparents, plus brothers, sisters, aunts and uncles sobbing at the gravesite.

How many measles deaths in the last decade in the US when our vaccination rates were maximal? Zero. None. Zip. Zilch. Nil. Nada. No mother needed to hold their ‘only’ lifeless child in their arms because of measles. Roald Dahl’s daughter need not have died in 1962, a year before the vaccine:

Olivia, my eldest daughter, caught measles when she was seven years old. As the illness took its usual course I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of colored pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.

“Are you feeling all right?” I asked her.

“I feel all sleepy,” she said.

In an hour, she was unconscious. In twelve hours she was dead.

From his diary:

Got to hospital. Walked in. Two doctors advanced on me from waiting room. How is she? I’m afraid it’s too late. I went into her room. Sheet was over her. Doctor said to nurse go out. Leave him alone. I kissed her. She was warm. I went out. ‘She is warm.’ I said to doctors in hall, ‘Why is she so warm?’ ‘Of course,’ he said. I left.

That’s the whole truth of measles and what the vaccine prevents.

The rest of the article contains some historical curiosities (The 1963 measles vaccine caused a severe disease called atypical measles) and a recounting of some of the over exuberance of the measles vaccine programs that do not apply to the vaccine today.

Measles was supposed to be eradicated in 1967 and A single shot was said to provide lifelong immunity.

Somehow I get the impression that the measles vaccine should have emerged with perfect understanding. That, unfortunately, is not how the world works. They did the best they did with the tools they had and with those tools saved the lives of millions. Our understanding of measles and immunity has evolved and with it the safety and efficacy of the vaccine improved.

Bystrianyk notes:

Measles is not serious in well-nourished people.

But forgetting to mention that in the current outbreak about 15% of cases have been hospitalized.

But the author has issues with a consistent argument, first saying measles is no big deal, then he also argues that there is no such thing as measles: that doctors are misidentifying other illnesses with a fever and rash as measles. He seems surprised that in a communities with no measles (because of vaccinations) that illnesses that look like measles are due to other infections, then implies that doctors were misdiagnosing measles in the past as well.

Bystrianyk also suggests that:

Now, whereas natural measles exposure generally left the person with reliable lifelong immunity, measles vaccines leave the individual with waning immunity.

Probably not so. It is more likely that when disease runs rampant in a community adults are getting reinfected and immunity is boosted with each epidemic rather than a single natural infection giving perfect life time immunity:

However, when one examines the neutralizing-antibody levels before and after an epidemic of measles, one finds that the reinfection rate is high in those with low antibody levels. In one study, for instance, 50 per cent of the subjects with initial neutralizing-antibody levels of 1:2 to 1:8 become reinfected whereas those with levels of 1:16 or higher escaped.63 Almost all cases of reinfection are clinically inapparent. After live-virus vaccination, the antibody levels also tend to fall in persons living in isolated islands where measles has not been observed, suggesting the possibility that the persistence of antibody level after measles vaccination depends on reinfection and the “booster effect” produced by exposure to wild virus. Subacute sclerosing panencephalitis of Dawson represents another remarkable example of endogenous reinfection by measles virus…

Whether from disease or vaccine, often the only way to maintain high antibody levels and protection against an organism is to be re-exposed, either from natural disease or revaccination. I would rather get a booster vaccine as an adult than be boosted by recurrent disease epidemics. But that’s just me.

Measles is, technically, eradicable. Rinderpest probably jumped from cattle to humans to become measles. A couple of years ago rinderpest was eradicated from the planet, although I half expect us to return the favor and eventually have measles jump back into cattle.

To eradicate measles we will need more than half truths.

It’s not enough to be able to lie with a straight face; anybody with enough gall to raise on a busted flush can do that. The first way to lie artistically is to tell the truth — but not all of it.
Robert A. Heinlein, Time Enough for Love

 

 

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.

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