Large Disparities Exist Even in State’s Healthiest County

Orange County children may be the healthiest in North Carolina, according to child-advocacy nonprofit NC Child. But a closer look at Orange County shows that the block you grow up on may matter more than your county.

Orange County is the wealthiest and most educated county in the state, and overall its children are the healthiest. Orange County Health Director Colleen Bridger says that’s not a coincidence.

“The more highly educated you are, the more likely you are to have a professional job that provides you with health insurance, time off to go to the doctor, time off to take your kids to the doctor and a living wage,” Bridger said.

But Orange County’s wealth and college degrees aren’t divided equally among all its residents. Census estimates show wide socioeconomic gaps between adjacent blocks.

“Even though Orange County in the aggregate is doing well, there are pockets of poverty and places where people are struggling that rivals any other place in the state,” Bridger  warned.

Bridger says the greatest health disparities within Orange County often come down to disparities in education. There are areas in the county where two-thirds of third-graders are reading below grade level. The county says it’s working to improve health outcomes by closing the education gap through a project called the Family Success Alliance. The program replicates an initiative out of Harlem in New York City.

“They’ve basically said ‘anything a child needs from before she or he is born to the time he or she has a job after they’ve graduated from college, we want to provide it.’ And so we want to replicate that here so that we are able to ensure that every child in Orange County can succeed, regardless of where they live,” Bridger said.

http://chapelboro.com/news/health/large-disparities-exist-even-in-states-healthiest-county/

Should I Get the Shingles Vaccine?

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Late the other night, I saw a TV commercial for Zostavax®, the vaccine for shingles. It opened with a picture of a man’s stomach emblazoned with large and grotesque pustules, allegedly from shingles. (The make-up crew for the commercial really outdid themselves.) Readers of Common Science® will know that I’ve never met a vaccine I didn’t like. So after being confronted with this man’s stomach, I wondered if I had been delinquent in getting my shingles vaccine and if I should hop in my car and head to the all-night vaccine clinic. Evaluating that question has turned out to be rather interesting and involves just the sort of multi-decade analyses and public health dilemmas that I enjoy writing about.

As usual, let’s start by reviewing the science. Both chicken pox and shingles are caused by the varicella zoster virus (VZV). You get chicken pox from your initial exposure to VZV. As I will explain below, shingles can arise decades later and, if it does, is from the same VZV infection that gave you the chicken pox in the first place. The symptoms of chicken pox are an itchy rash with blisters, fatigue, and often a low-grade fever. Chicken pox usually resolves in about a week. Children rarely experience complications, but getting chicken pox as an adult can result in neurologic damage or, in rare cases, death. Therefore, it has long been common practice for parents to intentionally spread chicken pox from child-to-child to protect them from getting a more serious case when they grow up.   Since chicken pox is very contagious and is spread by coughing, sneezing, and exposure to the rash, this process is nearly 100% effective.

Once you get chicken pox and recover, you are immune to new VZV infections. Let me provide some extra clarity on this point, as it will be important later. In a sense, recovery from chicken pox is not a full recovery. The rash goes away and you feel better, but some dormant virus remains in your body, more on that below. While your immune system generally can’t clear out this dormant virus, it can fend off any new VZV that it encounters. This is why you can only get chicken pox once.   Keep this dynamic in mind as we proceed.

I have fond memories of my own bout of chicken pox. My friend Mike got it first. Then my mom and my friend Todd’s mom brought us over to watch cartoons with Mike on the couch. Soon thereafter, my rash appeared and I got to miss a week of school, stay home and watch the Young and the Restless with my mom, and, as a result, learn all about betrayal, amnesia, and long-lost family members returning from the dead. Our mothers’ decision to expose us to chicken pox was a rational one, but it did open the pathway for us to get shingles decades later.

In most cases when you are infected with a virus and recover, the virus is completely eliminated from your body. As I mentioned above, with VZV, this is not the case. If you have had chicken pox like me, then you have dormant virus particles lurking about in nerve cells near your spinal cord. As you age, there is an increasing likelihood that the dormant VZV will reactivate and cause shingles. People who never had chicken pox cannot get shingles.

Shingles presents as a painful and irritating rash typically in a single stripe on one side of the body, which resolves in 2-4 weeks.   The rash from shingles sheds VZV virus particles in a similar manner to that from chicken pox. Therefore, if an adult or a child without immunity to VZV comes in contact with someone with shingles, then he or she is quite likely to be infected with VZV and get chicken pox. Twenty percent of people who get shingles develop neurologic pain that can be severe. Fortunately, 85% of these people report that the pain resolves within a year. But this still leaves 3% of people who get shingles with long-term symptoms.

The situation I have described above existed in the U.S. for many generations. Nearly all children got chicken pox, one third of whom developed shingles as adults, and a few of whom developed painful long-term neurologic pain. In addition, a relatively small number of adults got chicken pox. This equilibrium was disrupted in 1995 when the chicken pox vaccine was introduced in the United States. My recollection was that it was initially optional, but it is now a mandatory requirement for children to enter the school system. Like all vaccines, the chicken pox vaccine is not 100% effective. However, it seems to have created sufficient herd immunity such that chicken pox has been effectively eliminated as a childhood disease. My children are 14 and 16 years old and neither they nor any of their peers have had chicken pox to my knowledge. However, the introduction of the chicken pox vaccine has rather different implications for the children who get it and for the adults who had chicken pox when they were young.

If you get the chicken pox vaccine as a child and develop immunity to VZV, all is well. You will never get chicken pox and, consequently, you can’t get shingles. However, absent having a really expensive lab test done, you won’t really know if you have developed immunity. Therefore, if you get the vaccine but don’t respond, you may assume you are immune but then encounter the VZV virus, likely from exposure to someone with shingles, and develop a serious case of adult-onset chicken pox. This contrasts with actually getting chicken pox in which case you know you are now immune to new VZV infections.

This risk that non-responders to the vaccine will be exposed to someone with shingles will be elevated over the next couple of decades because cases of shingles are increasing. The reason for that is fascinating and requires a short discussion of the immune system to appreciate. First, let’s pick a virus – say, whooping cough. When you are born, you have no immunity to whooping cough. You can develop immunity either by being infected with the virus or by getting a vaccine for whooping cough. What developing immunity means is that your body “remembers” how to fend off that particular virus. If you are exposed to the whooping cough virus after having developed immunity, your body recognizes it and quickly gets rid of it. However, if too much time passes and your body is not confronted with the whooping cough virus, it may begin to forget how to fight it.   This forgetting process explains the need for getting boosters of some vaccines from time to time. Now let’s consider how this dynamic applies to VZV.

When you get chicken pox as a child you develop immunity to VZV. This immunity helps to keep the dormant virus particles which remain at bay for many decades. Exposure of adults to children with chicken pox provides an immunity boost by helping their immune systems to “remember” how to fend off VZV and thus helps to prevent their dormant VZV from reactivating. Since fewer and fewer children will have the chicken pox due to having received the vaccine, fewer adults will receive the immune-boosting effects of contact with them, and more of us will get shingles. Multiple studies have shown that this is already happening. Therefore, if you are an adult with dormant VZV in your nerve cells and find out that there is a child nearby with chicken pox, you should go visit them and watch some cartoons.

Given that you are unlikely to find a child with chicken pox you can consider getting the shingles vaccine, which was approved by the FDA in 2007. The shingles vaccine is a higher dosage version of the chicken pox vaccine, which is not surprising since they are both designed to combat VZV. For people aged 50 to 80, the vaccine reduces the incidence of shingles by 50%. For people over the age of 80, its effectiveness is somewhat reduced. Studies of the length of the effectiveness of the vaccine are ongoing, but current estimates are that it should remain active for seven years. Unlike the chicken pox vaccine, the shingles vaccine is optional, hence the late night commercials.

I find it interesting to contrast the deployment of the chicken pox and shingles vaccines in the United States with that in the United Kingdom. In the U.S. we deployed the chicken pox vaccine for children as soon as it was available, even though it was known that this would result in more cases of shingles for adults. The increased number of cases of shingles, in addition to being unpleasant for the sufferers, negatively impacts our economy due to an increase in both sick days and health care costs. In the U.K, they waited until both versions of the VZV vaccine were available, chicken pox and shingles, and are now deploying them in a coordinated fashion. They waited to make sure they could provide the shingles vaccine to their adults before removing the immune boosting effects of chicken pox-bearing children. Personally, I find the U.K.’s approach to be sort of inspiring. They were willing to allow their children to get chicken pox to help protect their elderly from shingles.

So, let’s return to the question from the beginning of this column. Should I go get the shingles vaccine? I’ve got VZV in my nerve cells, I turn 50 next January, and I have never encountered a child with chicken pox. Therefore, I am nearly certain that the answer is “yes,” and intend to ask my doctor about it during my next check-up. You should probably ask as well.

Have a comment or question? Use the interface below or send an email to commonscience@chapelboro.com. Think that this column includes important points that others should consider? Share this column on Facebook or Twitter. Want more Common Science? Follow me on Twitter on @Commonscience.

  • Zostavax® is a registered trademark of Merck, Sharpe, & Dohme corporation.
  • Common Science® is a registered trademark of Jeffrey B. Danner.
http://chapelboro.com/columns/common-science/should-i-get-the-shingles-vaccine/

UNC Study: Too Easy For Teens To Get E-cigarettes Online

A new UNC study shows just how easily teens can buy e-cigarettes online, in violation of state law.

“It took little effort for them to bypass the age verification practices of the vendors, because there was very little use of rigorous age verification,” says Dr. Rebecca Williams. “Only five orders were rejected due to age verification and we had an e- cigarette purchase success rate of 94 percent.”

Williams is a researcher at the UNC Lineberger Cancer Center. She recruited a group of teens to purchase e-cigarettes from 98 websites. A law passed in 2013 requires online sellers to verify age using a public records database, but the teens were able to type in false birth dates or lie about their ages.

“While seven of the vendors in the study claimed to use age verification techniques that would potentially comply with North Carolina law, only one of them actually did,” says Williams.

The e-cigarette industry is growing rapidly, yet remains largely unregulated. While proponents argue that they offer a healthier alternative to smoking tobacco, Williams says a growing body of research says otherwise.

“More and more research is coming in that shows that e-cigarettes are dangerous and in some ways maybe more dangerous than cigarettes. For example, there was a study that came out recently that showed that e-cigarettes can release five to ten times more formaldehyde than a typical cigarette does.”

Most troubling, she says e-cigarette use is on the rise among teens.

“The CDC has reported an annual doubling in the rate of teens reporting using e-cigarettes. Hundreds of thousands of teens annually are using e-cigarettes that never smoked cigarettes before.”

Williams calls for federal regulations that mandate age verification at the time of purchase and delivery.

“It’s important that we have federal regulations affecting these sales, and specifically, strictly enforced federal regulations, because without that, online e-cigarette vendors have little motivation to decrease their profits by spending the kind of time and money it takes to verify a customer’s age and reject underage buyers.”

You can read the full study in The Journal of the American Medical Association Pediatrics.

http://chapelboro.com/news/health/unc-study-too-easy-for-teens-to-get-e-cigarettes-online/

Is The Toilet The Greatest Public Health Invention Ever?

Last week’s column, Spinal Cord Miracle?, was an inspiring story about how scientific progress enabled a man whose spinal cord had been severed to walk again. This remarkable achievement came as a result of the expenditure of millions of dollars and decades of research. While writing that column, I was struck by the starkly contrasting circumstances of the billions of humans whose health is at serious risk due to lack of access to one of our cheapest and oldest technologies: the toilet.

Approximately 2.6 billion people – that’s 37% of us – do not have consistent access to a toilet. About half of that number have to resort to open defecation. This lack of access to sanitation facilities has very serious consequences. Human feces can contain a variety of pathogens, including bacteria, viruses, and parasites, which can cause serious disease and death. For example, every year approximately 1.5 million children per year die from diarrhea stemming from fecal-contaminated water or food, primarily in Africa and Asia.

The most well-known and feared of these diseases is cholera, which is caused by a bacterium called vibrio cholerae. Cholera sickens approximately 500 million people per year and kills more than 100,000. For a healthy adult to become infected with cholera, he or she needs to consume a dose of approximately 100 million vibrio cholerae bacteria. When the bacteria reach the acidic environment of the stomach, the vast majority die. However, some of the bacteria sense the danger and enter a semi-dormant state that helps them to survive and make their way into the intestines.

To continue their journey, the cholera bacteria must now work their way through a layer of mucus which protects the walls of the small intestine. When the cholera bacteria sense that they have become lodged in the mucus, they grow new flagella, hair-like tentacles used for locomotion, which allow them to worm their way through.

Once they make it through the mucus, they discard the flagella and attempt to colonize the lining of the small intestine. In a manner which parallels the process of humans spreading around the globe in the 16th century, this colonization process is a hard-fought war of attrition. In healthy adults, the beneficial bacteria which had been present in the intestine before the invasion will rapidly reproduce to crowd out the invading cholera in a process called competitive exclusion. In a successful competitive exclusion, the cholera will die off and the person will not become ill and will not pass on the disease to others.(1) Children, the elderly, and those already weakened by other illnesses are far less successful in the arena of competitive exclusion.

If cholera is successful in its colonization efforts, it then starts to secrete a toxin which causes irritation and inflammation of the intestinal wall. Inflamed intestinal walls absorb far less water than usual. Thus, the victim ends up with watery diarrhea, the vehicle by which others become infected, and can become severely dehydrated. Severe dehydration can to lead organ failure and, sometimes, death.

I laid out the steps of a cholera infection in order to illustrate how vibrio cholerae, because it has coevolved with humans over the millennia, has developed survival and reproductive strategies which are hyper-specific to its host, us. This hyper-specificity is common to many other pathogens which inhabit our gastrointestinal tracts and which are present in our feces. As a result, the feces of humans represent a far more significant health threat than the excreta of other animals which contain pathogens which are primarily adapted to them.(2) This explains why we avoid using human sewage for fertilizer.

For those of us privileged enough to live here in Chapel Hill, NC, we are protected from deadly pathogens by the sanitization measures employed by our water and sewer company, OWASA.(3) In places such as rural Tanzania, where systems like OWASA’s are not practical, a well-designed pit latrine can do the job. Communities which gain access to and adopt use of pit latrines instead of open defecation experience dramatic reductions in disease and death.

Given that we know that digging holes in the ground and putting a small shack on top will save lives at low cost, it’s tempting to go out into the world and build a few million latrines. And so we did. But when we did, we learned some important lessons. For example, between 1997 and 2000 the World Health Organization installed 1.6 million outhouses in rural India, home to approximately 600 million people who practiced open defecation. A follow-up survey conducted several years later showed that only 47% of them were still in use.

Results like the outhouse project in India helped to teach the international aid community that they needed to adapt their methods to include more community participation. They found that whether it was a well, a latrine, or any other new system, if they involved the community in its design and construction, the communities would use and maintain their new facilities over the long term. While low-tech projects like building toilets get less media attention than medical marvels like repaired spinal cords, they can help many, many more people. So the next time you consider how to allocate your charity dollars, consider groups which engage in community-based sanitation improvements. You will touch many lives.

Have a comment or question?  Use the interface below or send me an email to commonscience@chapelboro.com. Think that this column includes important points that others should consider? Share this column on Facebook or Twitter. Want more Common Science? Follow me on Twitter at @Commonscience.

1. In this allegory, the Americas are the small intestine, the Native Americans are the resident beneficial bacteria, and the Europeans are the cholera. When Europeans arrived in the Americas, pathogens such as smallpox and typhoid killed 80 to 90% of the native population, which was the primary driver in allowing their colonization to succeed. So one could say that the competitive exclusive efforts by the Native Americans failed.

2. To be clear, this is not to say that the feces of other animals present no threat to us, as they are the source of such pathogens as salmonella and E-coli. Animal feces such as cow manure can be sanitized prior to being used as fertilizer, through proper composting. If the temperature of the compost pile is >104°F, then the pathogens will either die or be deactivated. (At this point, please let it be known for the record that, with a tremendous show of restraint, I managed to not elaborate on why 104°F is the threshold and how it comes into play in other phenomena.)

3. Next time you see an OWASA employee, remember to say thanks.

http://chapelboro.com/columns/common-science/toilet-greatest-public-health-invention-ever/

As Use Rises, Public Health Officials Push For E-Cigarette Controls

As the popularity of e-cigarettes continues to grow, public health officials across the country and here at home are calling for more research and stricter regulation on their use.

“We really are in the Wild West of e-cigarettes because it has not been regulated at all by the FDA up to this point,” says Melva Fager Okun, Senior Adviser with Prevention Partners, a Chapel Hill-based non-profit focused on healthy workplaces and institutions.

Last week a trio of public health agencies released reports critical of the burgeoning e-cigarette industry. The Centers for Disease Control, World Health Organization and the American Heart Association issued calls for tighter controls on how the products are used, packaged and marketed.

E-cigarettes or personal vaporizers use atomizers to heat a liquid mixture of glycerin, propylene glycol and nicotine that users inhale. Often the mixture is artificially flavored, and Okun says it’s these flavors that have public health advocates especially worried.

“If you look at the over 7,000 flavors that these e-cigarettes come in, you can see they are definitely trying to appeal to youth,” says Okun. “They are candy flavors, they are cookie flavors and they are alcoholic beverage flavors.”

The use of e-cigarettes, called vaping, has skyrocketed in recent years to become a billion dollar industry.

Teens and young adults seem particularly drawn to vaping, as it is often marketed as safer than traditional tobacco. In North Carolina, use of e-cigarettes by teens has risen five-fold in the past two years.

Okun says much of the concern about e-cigarettes stems from evidence that they encourage traditional tobacco use as well. She cites a report from the CDC showing first time vapers were twice as likely to smoke tobacco within the year.

“I see it as a tremendous threat to the good progress that we had been making, and my great concern especially is that youth, who might not have even thought of picking up a cigarette, are now thinking about picking up e-cigarettes.”

The trend has gained ground locally as well. Okun says she’s seen an increase in retail shops selling vaporizers in Chapel Hill and Carrboro.

“I can hardly think of small shopping malls that now don’t have a designated tobacco and vapor product shop. I am very concerned.”

The federal Food and Drug Administration is considering extending its regulatory authority to include e-cigarettes. If that happens, the products will be subject to many of the same restrictions as traditional cigarettes.

In the meantime, organizations like schools, hospitals and businesses are trying to figure out how to regulate the use of e-cigarettes on their premises.

“In hospitals and patient rooms cigarettes have been long gone. Now people are pulling out e-cigarettes and staff is very confused,” says Okun. “It’s taking their time and effort now to address something they haven’t thought about in years, and they’re not sure what to do.”

Prevention Partners is hosting a free educational webinar on the topic of e-cigarettes on September 10. You can find out more here.

http://chapelboro.com/news/health/use-rises-public-health-officials-push-e-cigarette-controls/

NC’s Public Health Director Resigns

RALEIGH, N.C. (AP) – North Carolina’s public health director has resigned, 18 months after her appointment.

The secretary of the state’s Department of Health and Human Services announced she accepted Dr. Laura Gerald’s resignation Tuesday, effective immediately. Secretary Aldona Wos gave no reason for the resignation.

Gerald had two titles as state health director and director of the agency’s division of public health. Former Governor Beverly Perdue appointed her in January 2012, when the agency merged its division of public health and office of rural health and community care.

Wos informed division employees Tuesday evening.

Wos says Danny Staley will temporarily serve as the division’s acting director. His title has been deputy director.

Robin Cummings, director of the agency’s office of rural health and community care, will temporarily serve as acting state health director.

http://chapelboro.com/news/health/ap-ncs-public-health-director-resigns/

UNC Graduate Students Combat Worldwide Blindness

CHAPEL HILL- UNC’s academic year is over, but a pair of Tar Heel graduate students working toward a master’s degree in public health are still hard at work—and they’re preparing to join an effort to combat blindness around the globe.

One of the students, Casey McCormick of Charlotte, says she and fellow grad student Michael Wilson will be flying to Hanoi, Vietnam to work with a program known as Helen Keller International.

“We’re basically taking an already existing program that they’ve developed in a different province of Vietnam and moving it to an urban setting in Hanoi,” she says. “Then we’re kind of pairing that with a nutrition program because when you don’t eat properly, that has a big effect on your eyesight, and they’ve seen that with the younger generations in Vietnam.”

While in Hanoi, McCormick and Wilson will be helping to implement a program known as the ChildSight initiative into Hanoi’s schools. The program will provide free eye exams and glasses to needy children in Hanoi. The Western Asia-Pacific Region, including Vietnam, has the highest rate of far-sightedness in the world, with about 62 million cases.

McCormick says she decided to go on the trip because of its relevance to her chosen line of work.

“I’ve never experienced or been anywhere near Southeast Asia or taken any sort of classes about that region or culture, and I didn’t think it was appropriate to go forth with a global health degree without experiencing all parts of the globe,” she says.

And McCormick says having Wilson on the trip with her will make the trip even more of a learning experience.

“It’s definitely going to allow us to be more confident in the work we’re doing because we’ll have someone next to us who knows what we’re talking about and was in the same classes with us,” she says. “So, we’ll be able to bounce ideas off each other.”

McCormick and Wilson plan to leave for Vietnam on June 2.

http://chapelboro.com/news/unc/unc-graduate-students-combat-worldwide-blindness/