The last one came out years ago and he moved on, you think to yourself as a chill runs down your spine. You know there is no way he would dust that old concept off after all this time. Then why the sudden and overwhelming sense of dread? Why the cold sweat?
Trust your instincts.
Through a combination of dark magic and poor time management skills, it has been resurrected. In fact, it’s shambling towards you at this very moment. It’s right around the corner, just out of frame. Can you hear it now? Can you smell the rot?
Screaming won’t help. There is no escape. Just accept your fate and keep reading.
That’s right. Here we are today with another collection of odds and ends from both within and beyond the world of science-based medicine, where despite our best efforts there exist alternative realities in the darkness of shadows yet to be illuminated by science and reason. Behold…a miscellany of medical malarkey is upon you!
The Ohio Measles Outbreaks
Last month, I discussed a measles outbreak in central Ohio:
Since late October, more than 70 children have been diagnosed with measles and 26 of them have been sick enough to require hospitalizations. Remember, despite it’s often bland portrayal in sitcoms and cartoons of the past, something that has been wielded as an anti-vaccine talking point, measles is a terrible illness that historically put 25% of infected kids in the hospital and killed 1-2 per 1000.
37% of the infected children in the current Ohio outbreak have been hospitalized so far, which underscores the fact that we don’t have effective treatments. There is no modern medical anti-viral triumph that cures this disease. There is supportive care and correcting vitamin A deficiency, which has been linked to increased risk of death. The modern medical triumph was the vaccine.
As of a week ago, this total has risen to 85 children with 8 additional hospitalizations. 40% of the involved children were sick enough to be put in the hospital, which continues to outpace historical percentages. There hasn’t been a death associated with this outbreak, but as I’ve discussed in the past that doesn’t mean that these kids aren’t at risk of serious or even deadly complications in the future.
While this outbreak has largely involved the unvaccinated, 24 of the cases were in children who were too young to have gotten their first dose. This is important to point out because one (of many) garbage talking point spouted by those proselytizing anti-vaccine beliefs is that the vaccinated shouldn’t care about people who refuse immunizations if they believe they work. This is obviously wrong because it ignores the need for herd immunity to protect those who cannot receive immunizations or who remain unprotected despite their immunizations, since no vaccine is 100% effective.
The last case of measles diagnosed in Ohio was on December 24th, which is promising. If they remain measles free through the first week of February, the outbreak will be officially over per CDC guidelines. Hopefully there will be a silver lining of increased vaccine rates among the hesitant in response. Of course, I would rather people respond to education and guidance from trusted medical professionals in the future rather than the acute fear of an impending infection.
Vaccine Rates Continue to Drop in U.S. Kindergartners
As reported last week, the official vaccine uptake numbers from 2021-2022 are in and the decrease seen in 2020-2021 continued:
Overall, those receiving state-required vaccinations declined to about 93% last year, down from 94% in the previous school year and 95% in the 2019-2020 school year, according to the CDC report.
The specific vaccines included in the CDC data were the MMR vaccine (93.5%), DTaP (diptheria, tetanus, pertussis, 93.1%), polio vaccine (93.5%), and varicella (chickenpox) vaccine (92.8%). I imagine for many folks 93% seems like a pretty good number, and it would be for Mrs. Peebles’ Biology II class. Unfortunately, for highly infectious diseases like measles we really need to be a bit closer to 100% in order to maintain herd immunity and protect vulnerable people, particularly those who are at high risk of severe disease.
When it comes to vaccine rates, there is significant variation between and within states, largely because of because of the three Ps of healthcare disparity: politics, poverty, and prejudice. Sticking with measles, for example, New York was a clear winner with an MMR vaccination rate of 98%. Great job, you coastal liberal elites. Rhode Island came in second with just over 97%. Let’s all raise a coffee milk toast to all those anti-virus Ocean Staters.
On the other end of the data are states like Alaska (78%), Wisconsin (82.6%), and Georgia (83%). Overall, only 13 of the 49 (what’s your deal, Montana?) states included in the data met the CDC goal of 95% of eligible kindergartners having received both doses of the MMR vaccine. So is most states, and almost certainly even in parts of the others, there are communities that are fully primed for a major outbreak of this horrible disease.
Because of limitations in how this data was collected, the numbers could be even worse in reality. For example, it didn’t catch home schooled kids. This data doesn’t tell us why the numbers have continued to slip, but I doubt anyone would deny the complex and multifactorial nature of the problem. When it comes to reversing the trend, the CDC recommends rigorous enforcement of school vaccine requirements, school-based vaccine clinics, school nurse follow-up with undervaccinated students, and reminder/recall systems.
A Costly New Sickle Cell Cure
It’s hard to imagine a more heart wrenching malady than sickle cell disease, a group of inherited genetic disorders that alter the shape of red blood cells and can cause a wide variety of health problems. This can include anemia, because the abnormal red blood cells have shorter life spans, but more infamously can result in severe pain throughout the body, strokes, an increased risk of severe bacterial infections, and a lifespan often shortened by decades. In addition to the physical manifestations, there are also significant psychological and social difficulties faced by patients with these conditions.
Because it mostly affects black people in the United States, there is a history of extreme disparity in the recognition, research, and response to sickle cell disease. I wrote and then erased several attempts to encapsulate this issue, but they all felt inadequate. I know the problems. I’ve seen the repercussions time and time again. Hell, as a white man who grew up in the South, and then practiced medicine down there for the first decade of my career, I know that there were times when I contributed to it.
I’ve learned so much in recent years by truly listening to people’s lived experiences, accepting that implicit bias saturates medicine, and, most importantly, recognizing my part in it. Patients with sickle cell disease have dealt with the worst of this bias in medicine. This NEJM “Perspective” from 2020, written by actual experts in the care of these patients, does a much better job of explaining it than I ever could:
Medicine is a mirror for the racial injustice in our society; it is a field riddled with racial disparities in everything from research funding to patient care to life expectancy.1-3 There may be no population of patients whose health care and outcomes are more affected by racism than those with sickle cell disease (SCD). Patients with SCD are too often marginalized and dismissed while seeking medical care when their bodies hurt and they cannot breathe. As medical leaders around the United States issue statements denouncing racial injustice and calling for us to “dismantle racism at every level,”4 we must ensure that these pledges translate into durable improvements for patients with SCD.
Today, I can happily report that there are some significant improvements for patients with sickle cell disease right around the corner:
This year, Jackson and other people with sickle cell may have the option of finally living without the damage it causes. Two drug companies are seeking approval from the Food and Drug Administration for gene therapies that may provide what amounts to a cure. But the decision to take the medication — should it become available — is not so simple, it turns out.
This potential but very promising cure has, in clinical trials, halted the process that leads to the many varied complications of sickle cell disease. The red blood cells produced in the bone marrow do not become misshapen. In addition to prevention of the severe pain caused by the condition, these treatments could save billions of dollars in medical costs if all patients who might benefit gain access to them. Sadly, but not unexpectedly, many of them won’t.
First off, the expense will be a huge problem as the modified virus used to deliver the gene therapy will run upwards of a million dollars per treatment. Insurance might cover that, because the average lifetime cost of treating sickle cell disease is almost twice that. But there are other factors that would add to the cost in dollars or even lives:
Treatment starts with intense chemotherapy in a hospital to wipe the bone marrow clean, leaving space for genetically modified red blood cells that result from the treatment. Patients then spend about a month in the hospital waiting for the modified cells to grow. After they are discharged, the patients are immunocompromised for about six months while their immune systems recover.
Insurers are likely to pay for the part of the treatment that involves using a disabled virus to deliver the therapy. But whether they will pay for most of the chemotherapy, hospitalization and other costs is uncertain. Patients worry about bills from hospitals and doctors. Even if it is mostly covered, co-payments can be an issue.
In addition to the overall cost of these new therapies potentially preventing patients from accessing them, many won’t be able to for medical reasons. Bone marrow transplant is already an existing and potentially curative intervention for sickle cell disease, but it has been limited because few patients have a matched donor available. It is also only indicated for patients with severe disease, in particular recurrent strokes, meaning that many don’t qualify despite having significant and frequent disruptions in their quality of life, multiple hospitalizations, severe pain, and shorter lives. And when they do qualify, bone marrow transplant has significant potential risk and about 5% die because of complications.
The process that allows these new gene therapies to work, the ablation of a patient’s bone marrow in order to start with a clean slate, is the same as with bone marrow transplant. Similarly they will be at risk of life threatening infections for months. Though the issue of finding a matched donor would no longer be a concern, I imagine that the criteria for deciding who qualifies for gene therapy would be the same. Finally, many older patients will be too medically fragile to even consider taking the risk of ablative chemotherapy.
Oh, and this:
And, independent of the cost, how easy will it be for patients and family members who assist them to take off a month or more for the treatment, often traveling to distant cities with medical centers that can administer the treatment?
And finally…I can’t even with this crap
Acupuncture for sepsis. Maybe so, according to a systematic review and meta-analysis that was published last May in Acupuncture in Medicine:
The available evidence showed that combination of acupuncture and routine therapy may have benefit for sepsis compared with use of routine therapy only. Due to the low degree of certainty regarding its effects, further research is required.
I suspect that the routine therapy was doing most of the heavy lifting in those cases, but perhaps I’m just biased. I should keep an open mind. Although, there has been a long and sordid history of people thinking things work for sepsis, sometimes for years, that end up being useless or even harmful. Xigris, I’m looking in your direction. And you aren’t off the hook either, vitamin C. But maybe the little needles are the ticket. Maybe they just need to be electrified.
See you next time!