COVID, toilet paper, and vaccines, OH MY!

The importance of illness prevention and management in vaccine preventable diseases and the relation to novel illnesses and legislation.

Chelsea M. Collins, BSN, RN, CEN, SANE-A
Johns Hopkins University, School of Nursing & School of Public Health
Social & Behavioral Foundations of Primary Care

Vaccination has been around for centuries with the first vaccination occurring in 1796. Most vaccine related adverse events are mild. According to the U.S. Department of Health and Human Services, for every 1 million doses of vaccines that were distributed, 1 individual was compensated. It’s important to note, not all compensation means that the vaccine caused injury. In the adult population, 50,000-90,000 vaccine preventable deaths occur each year. It is estimated that for every dollar spent on a vaccine, $6.30 in direct medical costs and up to $18.40 in indirect costs is saved.

Colorado has one of the lowest vaccination rates in the country. 95.1% of kindergartners nationally in the 2017-2018 school year were vaccinated for the diptheria, tetanus, and pertussis vaccine, while 94.3% had coverage for the MMR vaccine. In Colorado, this coverage was 88.7% for the same year. One case of measles costs approximately $140,000 for treatment, and the total cost to prevent the spread of measles is $266 million. Additionally, the US spends nearly $27 billion annually treating adults for vaccine preventable diseases. According to one study, 84% of Coloradans believe that vaccines should be required for children to attend public school.

Live interactive map of coronavirus-19

As of Monday, March 9, 2020, there are over 110,000 cases of coronavirus-19 internationally, with 3,994 deaths reported. Ongoing media storms and fear, toilet paper, water, and hand sanitizer are unable to be found in many stores. US stock market trading was halted on Monday, March 9, 2020 after falling 7% due to coronavirus fears. Masks in hospitals to protect health care employees are on short supply, with price gouging and ongoing purchasing of masks. Shortages of drugs in the US healthcare system are potential.

Legislation in the Colorado legislature like HB20-163, which seeks to close the gap in immunization coverage and protect vulnerable populations are paramount to spread preventable illnesses. HB20-1239, which has contingencies that already exist, HB20-1297 and SB20-084, not only prohibit effective management of preventable illnesses and increase costs to communities of those treatments. Fear of covid-19, which does not have a vaccine available in the immediate future, but ignoring vaccines available perpetuate compromising populations like immunocompromised individuals who are unable to be vaccinated,  children, and the elderly. Legislators, health care providers, schools, and community leaders must take a stand to ensure ongoing implications of preventable diseases are not drown out by panic and fear of novel diseases. By preventing the illnesses that we can, more efforts can be placed into the care and treatment of those novel illnesses that continuously present themselves.

Pushing Back Against Fetal Heart Beat Law

Elijah Nouvelage / Getty

On May 7, 2019 the Legislature of the state of GA signed into law HB 481, also known as the fetal heart beat law and the Living Infants Fairness and Equality (LIFE) Act. The passing of this law follows on the heals of other states like Mississippi, Kentucky, and Ohio. It also inspired lawmakers in South Carolina and Tennessee to push for similar measures.

What does the law state?:

The law which was suppose to be effective this year, on Jan 01, 2020, bans physicians in the state of GA from offering abortions at the 6th week of pregnancy. “Exceptions are made for cases where a person’s pregnancy is considered futile, during a medical emergency, pregnancy by rape or incest but only if they are 20 weeks pregnant and have filed a police report.” And gives the status of “a class of living, distinct persons” that deserve “full legal recognition” to non viable fertilized eggs, blastocysts, embryos, and fetuses.  Not only will the woman who tries to obtain an abortion be vulnerable to being prosecuted, but so will the doctor, nurse, and pharmacist who provides the services to end her pregnancy.

It is important to point out the in accuracy of the being used in the law and by the media discussing it. Even though it is called a heartbeat law, at six weeks an embryo does not have a heart beat or any cardiovascular system. 

An underlying motive: 

After Brett Kavanaugh took the oath of office to be a Supreme Court justice, conservative lawmakers believe that this is an opportunity to overturn Roe v. Wade, which recognizes a woman’s constitutional right to have an abortion. Due to the fact that the law passed in unconstitutional under Roe v. Wade and Planned Parenthood v. Casey, legislators hope that it will be brought up to the United States Supreme Court and that both laws will be overturned by the conservative majority.

What are the consequences?:

1. Unfortunately, at six weeks most people are not even aware they are pregnant given that it is 2 weeks after a missed period. This law will most likely prevent most people from getting a first term abortion.
2. Women in the state of Georgia are particularly vulnerable because they rely on a system ranked 49th out of the 50 states.(The US has one of the highest maternal mortality rates in the developed world.) This is significantly worse for Black women in GA, whose maternal death rate is twice that of white women in the state and 6 times the rate for white women, nationally. It has been acknowledged by The American College of Obstetricians and Gynecologists that racial bias “contributes to the to the disproportionate number of pregnancy-related deaths among minority women.”

A rock and a hard place:

Without access to abortion and being forced to rely on reproductive care where 60% of deaths are preventable puts women in a difficult situation to say the least. Not only that, but “Georgians face a critical shortage of reproductive health care providers, including obstetrician-gynecologists, and the rate at which Georgians, particularly Black Georgians, die from pregnancy-related causes is among the highest in the nation.” The Atlanta Journal Constitution stated that around 79 out of 159 counties in GA do not have an OBGYN.

Fighting the law:

Currently the ACLU, Planned Parenthood, and Sister Song filed a lawsuit against the law specifically calling out its affects on Black pregnant people. Sister Song have stated that, “Rather than working to end preventable deaths, and rather than honoring Georgians’ reproductive health care decisions, the Legislature has instead chosen to criminalize abortion from the earliest stages of pregnancy.” The ACLU is arguing that the law is violating a woman’s constitutional right to access abortion until about 24 weeks of pregnancy. If this law is not deemed unconstitutional or if it makes it way to the Supreme Court then women in GA and the US at large could not only face criminal charges for abortion, but risk death due to their lack of access to reproductive healthcare.

Universal No-Cost Contraception Coverage is the Answer.

Source: https://www.health.harvard.edu/blog/can-hormonal-birth-control-trigger-depression-2016101710514

Canada is known for its universal healthcare, but coverage is not as universal as one may think. Once a drug is prescribed, people’s wallets are at the mercy of their province or territories health insurance plan. In BC, the majority are covered by Fair PharmaCare, which is income dependent. Under this plan, a family with an annual income of $30,589 could end up paying $900 per year in deductibles and copayments. Resultingly, Canadians are reliant on a patchwork of public and private programs leaving many susceptible to falling through the cracks. In a recent Statistics Canada survey, 19% reported they did not have insurance that covered part or all of their prescription drugs. This is a significant barrier to receiving essential prescription medications, and contraception is no exception. 

Unintended pregnancy results in negative health outcomes for both mother and child, it can come with high personal cost, and it is a significant cost to our healthcare system. Even so, a 2016 study found that as many as 61% of Canadian women have had an unintended pregnancy. More than 25% of youth who do not want to be pregnant report that they do not use contraception at every act of intercourse. 

Cost remains a significant barrier to accessing reliable methods of birth control. Women should not be dependent upon a patchwork of health insurance plans for something that is recognized as a basic human right. Even if a person is able to avoid deductibles and copayments by accessing private insurance (which disproportionately covers the employed, high SES population, making this a social equity issue), youth are often covered under their parent’s plan and are forced to sacrifice privacy in order to access contraception. This makes youth uniquely susceptible to unintended pregnancy during a period when their life trajectory is arguably most sensitive to said pregnancy. While health insurance programs are designed to protect low SES populations, suboptimal coverage fails to protect families with incomes marginally above the threshold which would grants them 100% coverage, thus requiring them to pay deductibles which may be unattainable.

Options for Sexual Health, a social profit organization, is in support of universal no-cost coverage for contraception. They estimate that universal coverage would cost BC $52 million per annum and would result in savings of $95 million annually (saving on costs associated with abortion provision, perinatal care and delivery, as well as the cost of raising a child). Multiple professional organizations are in support of universal coverage, including the Society of Obstetricians and Gynecologists Canada, the Canadian Pediatric Society, and Canadian Medical Association, arguing that universal coverage is a cost-saving measure that would improve health outcomes and health equity. 

This is also a gender equity issue. People with uteruses disproportionately incur the costs associated with contraception which can cost $20 per month for the pill or nearly $400 for an IUD. Women often have to pay for most of the costs associated with unplanned pregnancy as well.

BC Premier John Horgan says that he is open to universal, publicly funded contraception, however, Adrian Dix, the Minister of Health, says the province is “looking at the PharmaCare system to make improvements”. As argued above, this is not good enough. This results in people falling through the cracks. In The Report on Budget 2020 Consultation, the Select Standing Committee on Finance and Government Services recommended to the Legislative Assembly that the provincial government “explore the provision of free contraception in a targeted and incremental manner”.  Nonetheless, despite thousands of letters and endorsements from various organizations, BC did not make access to contraception a priority in this year’s budget. 

This is a health equity issue, this is a gender equity issue, and universal no-cost contraception coverage is the answer. 

Community Health Worker models Can Save Medicaid Payers Millions. Here’s Why Pennsylvania Should Fund Them.

An IMPaCT worker listens to their client. From CHW Central

Dr. Shreya Kangovi is a bit of a celebrity at the University of Pennsylvania. In 2014, the pediatrician and health policy researcher and her team first published a JAMA study outlining their evidence-based model of Community Health Workers (CHWs), called Individualized Management for Patient-Centered Targets (IMPaCT). The IMPaCT model takes five common reasons for poor CHW model performance, such as “focus on a single disease” or “poor integration with healthcare systems” and builds their model in a strength-based way. The team has been optimizing and monitoring the project since. And in February 2020, Dr. Kangovi demonstrated in a Health Affairs paper that her model promises a return on investment of $2.41 for every dollar invested by Medicaid payers.

IMPaCT trains CHWs tightly integrated within a healthcare system, with direct access to patients’ primary care physicians and electronic health records. CHWs are selected for the job from behavior-based interviews that select “naturally incentivized helpers” from the same backgrounds and neighborhoods as the patients with whom they work. The CHWs use validated interviewing methods to really understand their patients’ life stories, and tend to form friendships with their patients, rather than cold and informal working relationships. Together with CHWs, patients set their own health goals, and the team works together to find a plan that helps them achieve their goals.

An IMPaCT Home Visit. From Penn Medicine

The programs are continuously monitored and evaluated- and they work. Further- they’re scaling up. In her 2020 paper, Dr. Kangovi describes that a pilot study in a UPenn Healthcare System serving 2,000 patients, a six-person CHW team saved Medicaid over $1.4 million within one year. These are some serious savings, and they generally come from reduced hospital admissions, and fewer inpatient and outpatient costs.

So who benefits? Well, those who pay for Medicaid. You. Pennsylvania’s Medicaid program, jointly funded by state and federal government taxes, spends about $27 billion across 2.9 million enrollees. Imagining IMPaCT teams scaling up across the state is a years-long endeavor, but it needs significant government investment. Historically, studies have proven that poor funding and infrastructure is the single biggest impediment to successful CHW outcomes- and this strategy has the potential to change the face of healthcare in America.

Fluorosis in northern Tanzania: testing, treatment, and education towards safer drinking water

Ground Water Contamination with Fluoride and Potential Fluoride Removal Technologies for East and Southern Africa, by Bernard Thole (2013)

In northern Tanzania, surface waters—including groundwater—contain high fluoride concentrations, in part because of volcanic activity, but also due to anthropogenic causes. Consumption of high fluoride concentrations (>1.5 mg/l) can lead to fluorosis, a condition where teeth become discolored from yellow to brown, and skeletal fluorosis, which causes weakness and bending of the bones due to long term consumption of high fluoride-containing water.

Health education strategies as well as testing and fluorosis mitigation strategies are needed to serve the population of northern Tanzania. Here, I propose a regional water testing and fluorosis mitigation program, coupled with health education strategies to combat misconceptions about the causes of fluorosis. To achieve these goals, efforts among existing stakeholders will need to be united and supplemented, where necessary.

Joining forces with existing stakeholders such as the Japan International Cooperation Agency (JICA), which has charted the geological regions with fluoride-rich groundwater, will be critical to success, as will the logistical support from Tanzania’s Ministry of Health.

Following in Philly’s Footsteps: Baltimore City’s Responsibility in Harm-Reduction

Despite being home to one of the leading medical and public health institutions in the world, Baltimore City also bears the distinction of having the highest overdose fatality rate of any city in the United States.  While the opioid epidemic has garnered significant media coverage in the past few years, this is not a new challenge for the city.  Rates of opioid overdoses have been consistently higher in Baltimore than the rest of the state and country for more than 20 years.  The city health department has already implemented several strategies for addressing this issue such as increased distribution and use of naloxone (an antidote medication proven to reverse most opioid related overdoses), expand access to wrap around addiction services, and education efforts to fight the stigma surrounding opioid use. These are all necessary steps in our efforts for harm-reduction, but there are more that can be taken.  One program that shows significant promise in the short-term is instituting supervised injection facilities (SIF).

Supervised injection facilities are locations that allow people to consume pre-obtained drugs while being supervised by a trained staff of medical professionals.  Their primary purpose is 3 fold: they provide sterile supplies (along with the disposal of dirty ones such as needles), an environment safe from judgement and law enforcement, and lifesaving overdose prevention.  To date, there have been exactly zero recorded deaths at any of the 100+ SIFs around the world.  Despite the promise they show for saving lives, many still argue against them on the grounds that they will make the surrounding areas less safe, and they are a waste of money.  However, both of these have been extensively disproven.  Not only is there no evidence for an increase in crime and/or drug use in the community, SIFs have actually been shown to be economically beneficial by decreasing healthcare expenditures caused by overdose and infections such as HIV and Hepatitis C. The following chart shows the cost-benefit analysis of an SIF in Baltimore city.

Source: https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0153-2

This is a call for support of safe injection facilities by the Baltimore City Health Department.  It is time that our city follows in the footsteps of 100 other cities around the world and the US in establishing SIFs.  Philadelphia is currently establishing their first, and we should be right on their heels.  People’s lives are on the line, and this cannot wait. 

Gaming disorder among youth in China – Let’s all help

With the high-speed internet access nowadays, online video gaming is becoming an increasingly popular hobby for youths in China. However, World Health Organization (WHO) included “gaming disorder” as a behavioral addiction in the latest edition of its International Classification of Diseases (ICD). Many adults have self-diagnosed themselves as severely sick according to WHO standard, but how about the minors? 

According to WHO, gaming disorder is defined as “impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.” 

Video game dependency can lead to physical problems, personal life problems, and academic or professional problems. China has already implemented some regulations to limit the number of new online games, restrict paying time and develop an age-restriction system in 2018 for poor eyesight youth. 

More so, China has imposed gaming curfew for minors in 2019, which “banned gamers under 18 from playing online between 22:00 and 08:00. They are also restricted to 90 minutes of gaming on weekdays and three hours on weekends and holidays.” Big gaming companies such as NetEase and Tencent are the pioneers in the industry who executed those rules. However, age limit for access and time duration allowed in online video games are not applied to every game. Youth can still find games that are not strictly following this policy or even off-line games to play. 

Chinese National Radio and Television Administration (CNRTA) is the department that gives permit to all kinds of media release in China including game. Requiring reliable age verification for every game to be released should be mandatory to reduce the youth health problems related to game addiction. 

Online gaming dependency affect people’s academic and professional life due to imbalance between school/work and entertainment. Ministry of Education of the People’s Republic of China and Communist Youth League of China have opportunities to organize activities to establish good values in youth, so they can make youth aware of the severity of game addiction and balance between academic life and entertainment.

Online gaming addiction could cause physical problems such as fatigue, physical pain, lack of sleep, etc. Mental health in youths in China has not been addressed enough that Ministry of Health of the People’s Republic of China should invest more studies in the relationship between youth health and gaming addiction.  

As a social cultural phenomenon, interventions at the level of policy is extremely important. Online gaming addiction is more than a personal behavior problem, social and the cultural environment in youth population has a greater impact. Chinese Internet Network Information Center should work together with all video game developers to build a reliable system to strict age and time limit for their service and inform the customers about potential risk of addiction. 

Measures to prevent abuse during the newborn period in Kagoshima Prefecture

According to WHO reports of child abuse, an estimated 1 billion children worldwide have been physically, sexually, or psychologically violent in the past year.  Many children in Japan also have been abused, and the number of reports of child abuse has increased in recent years, making it an important issue to be resolved in primary health care. 

In particular, the proportion of newborns and babies under one year old was high in the cases of death due to abuse, and according to the FY2018 report, of the 50 cases of abuse death, 53.8% were under the age of one year. Neonatal child abuse often leads to an unfortunate turning point, requiring early intervention.

http://www.orangeribbon.jp/about/child/data.php

Delivery facilities mainly report families at risk of abuse to health centers and automated consultation centres. Not all high-risk families are being adequately treated because of insufficient staff at health centers and child guidance centers.

The obstetrician and gynecologist are in charge of the delivery facility, and they are not accustomed to dealing with child abuse.The Japanese NGO “Japan Network for Prevention of Child Abuse and Neglect” exists, but they rarely intervene from the perinatal area.

So, we would like to establish a third-party organization for high-risk households during the period from discharge of the birthing facility to the growth of the newborn, and to establish guidelines for taking more appropriate measures.

The benefits of integrating and sharing information from delivery facilities and the NGO, health centers and child guidance centers are very important, and intervention here may be important in terms of the age at which deaths from child abuse occur more frequently.

However, there are issues such as the problem of the fund for establishment of facilities and the establishment of a cooperative system for each facility.

I am a neonatal physician working at Kagoshima City Hospital and have experienced several cases of abuse, so I would like to support abuse prevention measures. NICU is also in a position to provide information to public health centers and child counseling centers, and I would like to create a format for providing information and to be involved.

Complete Streets: For the Health of People and the Environment

Graphic created by Naadiya Hutchinson; Quote from the Baltimore Sun.

In 2016, the State of Massachusetts created a “Complete Streets Funding Program” that allowed for cities and municipalities that passed Complete Streets Legislation eligibility for funding of Complete Streets infrastructure projects. Senator Ed Markey of Massachusetts is now hoping to bring Complete Streets to the entire United States through the Complete Streets Act of 2019. The Complete Streets Act of 2019 would take 5% of all funding from highway infrastructure projects and designate it for construction for Complete Streets. The Complete Streets Act of 2019 would also set standards to ensure safe accommodation for all street users, including pedestrians and bicyclists. These types of criteria for roadways currently do not exist, as the priorities of infrastructure projects tend to favor the expansion of roads for drivers.

The Complete Streets Act of 2019 is supported by a wide variety of stakeholders from the National Complete Streets Coalition, including the American Public Health Association, Smart Growth America, the American Planning Association, LYFT, AARP and many more! Complete Streets intersects with a wide variety of missions and goals for organizations because the impacts of Complete Streets are far-reaching.

Example of Complete Streets Design: Courtesy of the Philadelphia City Planning Commission

Complete Streets decrease pedestrian and cyclist’s deaths by increasing road safety. With the nuanced designs of Complete Streets having designated bus lanes and prioritizing accessibility to people of all mobility statuses, Complete Streets incentivizes the use of public transportation. Through avenues of transportation becoming more available and convenient, Complete Streets increases public transit, biking, and walking, thus decreasing air pollution caused by single-occupancy cars. The pollution given off by vehicles is not only bad for our health but also contributes to the warming of our climate through the carbon dioxide given off in vehicle emissions.

Streets serve as a connection between the future we dream of and the future we create. Together as organizations and communities, we can create a future centered on the health of people and the health of our planet. Support the Complete Streets Act of 2019 today by becoming a partner of the National Complete Streets Coalition, or writing to your local congressional representative.

The worrisome increase in Dokha consumption among teenagers in the United Arab Emirates (Dubai) – it’s time to stop!

Dokha(which literally means “dizziness/headrush” in Arabic) is an alternative tobacco product smoked in the middle east, dating back to the 15^th century. The process is rather simple – fill the Dokha pipe with tobacco , inhale once and then enjoy the glorious nicotine head rush that lasts for a couple of seconds. Over the past 30 years , the popularity of Dokha has risen along with the prosperity and growth of the United Arab Emirates(UAE) – in particular, the state of Dubai – which is now considered the metropolitan hub the Middle East.

Courtesey of A. Razzaq(redrosedokha.com)

Unfortunately, several university based studies in the region concluded that approximately 30% of high school students smoke tobacco, and 60% of such smokers consume Dokha – which is very alarming! However it easy to see why most teenagers in Dubai smoke this product : it’s easy to use, it’s quick (and even stealthy), easily available(tobacco stores, grocery shops, gas stations) ,is associated with a rewarding “rush”(considered to be “cool” – see illustration below), and most importantly : shop keepers do not always ask for age verification . The fact that Dokha is also considered a historical and cultural paraphernalia, makes it seem more attractive than other tobacco products.

Regulations set forth by the UAE Health Ministry’s National Tobacco Control Program have been mostly focused on cigarettes, which paradoxically worsens the situation – as most teenagers will then revert to Dokha use. Although in 2018, the Tobacco Control Program announced a statement approving tighter regulation on Dokha sales and distribution, including labels with pictorial warning – this has not been implemented nationally. In fact, to date – there is no government led campaign focusing specifically on aiming to reduce Dokha consumption among adults and teenagers

As with most Tobacco products – Dokha use has been shown to increase the risk of Cardiovascular disease, and what’s worrisome is that in Dubai, Doctors are seeing cases of heart attacks in individuals younger than 40 years old – which is most likely related to the consumption of this nasty product at an early age.  As a pediatric cardiologist specialized in preventative medicine – this worries me, and I hope to one day, along with a team of supporters, find an effective method to reduce Dokha use amongst youngsters.

What my team and I suggest is to centralize the sales of Dokha. Dokha sales will be sold by one government funded /endorsed entity that will have several shops distributed within the UAE. Such a strategy can decrease the wide-spread availability of Dokha, enable tighter regulation and easier application of restrictions.

If we can limit the selling of this toxic tobacco substance to a few authorized locations this has the potential to significantly reduce sales and consumption by teenagers. This initiative will attract the support of several stakeholders: Emirates Cardiac Society, GEMS(Global Educational Management System) private schools(which have already taken the initiative to campaign against teenage tobacco consumption, teenage based anti-smoking campaign(Nahtam Social Responsibility). However such an initiative is not without obstacles – several run large private tobacco stores (Bin Khumery stores) that have been around for more than 30 years as well as traditional UAE nationals will be against this initiative. That said, we feel that the government will support our idea given the implications of Dokha on the health of the youth, and therefore the future health of the UAE.

Dokha is a dangerous tobacco product that has gained popularity among teenagers in Dubai, and if we do not act fast, the health of the youth is at stake. It’s time to stop!