The nurse depicted in this 2006 image was administering an intramuscular vaccination in the left shoulder muscle to a young girl. The nurse immobilized the girl’s arm by clutching it tightly, while the girl held up her sleeve in order to facilitate the procedure. CDC/ Judy Schmidt

Two deadly childhood illnesses are back in the news. The Centers for Disease Control (CDC) raised all sorts of flags over the number of measles cases in the United States last year. The number of pertussis cases, also called whooping cough, is also rising rapidly across the nation.

The CDC publishes the Morbidity and Mortality Weekly Report every week. In that report is the data from the National Notifiable Diseases Surveillance System. The latest report is for week 16, ending April 21, 2012.

Through week 16, the CDC has received 28 reports of measles case. For all of 2011, the number of cases was 222. There were seventeen outbreaks. The CDC held a press conference about the number, which was a spike from the historical median of sixty cases and four outbreaks. 200 of the measles cases were contracted overseas.

Measles (rubeola) is very contagious and is a serious respiratory illness. It is preventable through a series of immunizations. With 90 percent of the measles cases in 2011 having originated outside the United States, it is unclear what the reason is for the alarm. The Customs Service states that they have a program to prevent travelers with an illness from entering the country.

What was the legal status of the 200 patients who caught measles outside the U.S. but were diagnosed here?

Changing gears, the opponents to immunization place children at risk by avoiding necessary vaccinations. The same MMWR reports that the number of cases of pertussis, whooping cough, is up 29 percent over the same time last year. Eight of the top ten states in case counts allow parents to exempt children from immunizations based upon some sort of personal or philosophic objection. 59 percent of all the pertussis cases reported in 2012 originate in the 20 states that allow such objections.

Using the MMWR data, the highest number of cases of whooping cough reported in 2012 is from Wisconsin. They have reported 1,006 pertussis cases. Illustrative of the situation is a report from Fox 6 in Milwaukee. 30 students at the St. Matthias Catholic School in the Wisconsin city have whooping cough. The article quotes the school principal as saying that the cases are throughout the elementary and junior high grades.

Coming in second, with a declared pertussis epidemic, is Washington with 863 pertussis cases. Minnesota and Oklahoma are the only states reporting no cases in 2012. Here is a list of reported cases of whooping cough from the top ten states in 2012.

Only New York and Illinois do not allow a personal exemption. Also of note is the sharp drop in cases counts from New York to Pennsylvania.

Washington, on its Health Department website, reports more cases than the CDC, 1,008 pertussis cases. This is common and reflects reporting delays at the state or local level.

It is unclear why New York is reporting so many cases. In theory, without a religious or medical exemption, every student in New York ought to be immunized for pertussis. It is the law. The State Health Department has an office that audits public schools for their compliance with this issue and their record keeping on immunizations in general. Inquires to that office have not received a response.

Is it possible that some New York public schools schools do not comply with the law? The audits are not punitive and there is no punishment for not complying, so far as can be determined. It is a monumental record keeping task and schools can ill afford the loss of state revenues based on attendance. Barring large numbers of students would put one more financial strain on already tight budgets.

Look at any state or local website run by a public health authority and you will see information, glaring warnings, about the the dangers of West Nile virus. West Nile is an illness transmitted by mosquitoes that has been seen in humans in the United States for about 12 years. It’s an import, from overseas.

While searching for information about whooping cough, pertussis, case numbers on various sites I began to notice the “West Nile panic“. Lots of information about West Nile but far less about illnesses, serious illnesses with much larger case numbers.

Here are some case number examples from the CDC MMWR week 35 report for September 5, 2010.

In 2007, Michigan reported 392 cases of AIDS, 4,191 cases of Chickenpox, 292 cases of Whooping Cough and 17 of West Nile.

For that same year, New York State, including New York City, reported 3,984 cases of AIDS, did not report chickenpox and 22 cases of West Nile.

Massachusetts reported, for 2007, 602 new cases of HIV, 1,178 cases of Whooping Cough and six cases of West Nile.

Is the allocation of scarce public health resources to massive West Nile educational campaigns a wise choice? Looking at the case numbers for Chlamydia and Gonorrhea in the table suggest at least one place where educational dollars might be better used. The outbreaks of Whooping Cough and Mumps in 2009 and 2010 certainly could have been reduced with funding for more immunizations clinics.

Do public health agencies serve the interests of the taxpayers? Billions of dollars have been spent on illnesses such as SARS, bird flu, anthrax and smallpox, and are now being spent on West Nile. Is that protecting the public?

Map showing states with over 100 whooping cough cases. Click for a larger image.

It has been clear for some weeks now that the whooping cough outbreaks this year are geographically related. There appear to be two clusters, a Midwest one and one that includes California and a couple of bordering states.

Texas, with the second highest number of cases of whooping cough, does not seem to have infected its neighbors.

This map uses the data from the Centers for Disease Control (CDC) MMWR report for week 31, ending August 7, 2010.

The data is provisional for several reasons. Updated data from the various states for any given week will be included in the cumulative totals as received, but not reflected in the weekly case counts. In addition, in the cases of California and Massachusetts, the CDC has told us by e-mail that the states are not reporting all their cases every week. Both states are said to be overwhelmed with the numbers of cases to be reported and have chosen to fall behind in various ways.

Further information about whooping cough / pertussis can be found at this link.

The United States Centers for Disease Control (CDC) function as the national public health authority. Within the Centers is the Division of Vector Borne Infectious Diseases (DVBID). Its mission is to provide, at the national level, surveillance, research, diagnostic testing and assistance to state, local and foreign governments with regard to vector borne diseases. Those are illnesses carried by mosquitoes, ticks, fleas and other animals that can be transmitted to humans.

The budget for the DVBID in 2010 was $26.7 million. That line has been defunded in the Administration’s 2011 proposal, with $18.9 million added to the emerging infectious diseases area…

The American Society for Tropical Medicine and Hygiene (ASTMH) has called for restoration of the funding for DVBID. Edward T. Ryan, M.D., President of the ASTMH, spoke with me recently about this issue.

This is the division that works on dengue fever, malaria, Lyme disease, West Nile virus, spotted fever and all the other illnesses we get from bug bites.

More at Budget cuts at CDC threaten efforts on bug borne diseases

Whooping cough, or pertussis, continues to spread in many areas of the country. In other areas, the case counts are down dramatically from 2009. The best count, using both the data provided in the Centers for Disease Control (CDC) MMWR Week 27 report (as of July 10, 2010) and a press release from the California California Department of Public Health (CDPH), seems to be 7,174 cases in 2010, and 7,440 cases for 2009 through the same date.

The CDPH press release is cited for a reason. Just over half of all the cases of whooping cough in California have not been reported to the CDC. I have been following with the CDC on this issue and they forwarded to me this response from California, that had been forwarded to them:

We are counting cases that are coming from CDMS and from the raw file you are exporting. It is my understanding that only cases for which we’ve received a Case History Form are sent to CDC from CDMS. Many counties are extremely behind in submitting the form since they are overwhelmed with case investigation for the ongoing outbreak. We’ve been maintaining our in-state total to release to the media which we know doesn’t match up with what is being sent to CDC. Our total count of Pertussis cases reported Jan-June 2010 is 1,337.

The press released linked has increased that June 30 total to 1,496. Here is a graph illustrating the difference in reported numbers. Click on the graph for a larger image.

The inability of California to report its cases of whooping cough in a timely manner means that Federal public health officials cannot react in a timely manner to changes in the case counts. It should worry neighboring states, as well, since they, too, cannot know how severe the epidemic may be.

Here are the states, in decreasing order of 2010 pertussis cases, that make up 2/3 of all the cases of whooping cough in the United States.

The states in deep red are up at least 150% over 2009. The cases in salmon are up between 100% and 150% over last year. Despite their totals, Texas and Ohio are only up 8% over 2009. Arizona, however, is up 86% and upstate New York (everything outside New York City) is up 98% over 2009 at this time. Click on the graph for a larger image.

These nine states have seen 2/3 of the cases of pertussis. Only California is seeing a dramatic increase in case numbers, year over year. Upstate New York has gone to 190 cases in 2010 from 96 cases in 2009, for example. The public health authorities in California called it an epidemic, and the case number increase bears out that declaration.

While those states are seeing significant increases in cases of whooping cough for 2010 over last year, others have significant decreases. Here are the states with over 150 cases in 2009 and with reductions in cases year over year.

For more information about whooping cough:

Pertussis (Whooping Cough) – What You Need To Know from the CDC

Pertussis (Whooping Cough) from CDPH

The Army has been fighting malaria forever. Some of the greatest achievements in public health were made possible by U.S. Army doctors such as Walter Reed.

U.S. Navy Petty Officer 2nd Class Mathew Colson (middle) with APS West platform USS Gunston Hall observes as Senegalese Army Pvt. Cheikh Amanga (right) practices giving an intravenous catheter on Senegalese Army Pvt. Senghane Mbodj (left) during a tactical combat casualty care training course at the Ouakam Military Hospital for 26 members of the Senegalese Armed Forces as part of Africa Partnership Station West 2010 initiative. APS an international initiative developed by Naval Forces Europe - Africa, which aims to work cooperatively with U.S. and international partners to improve maritime safety and security in Africa.

Researchers at the Walter Reed Army Institute of Research here are discovering new ways to combat and prevent the spread of malaria.

“Every conflict the U.S. has been in we’ve been faced with malaria,” said Army Col. Christian Ockenhouse, director of the U.S. Military Malaria Vaccine Program, during an April 14 interview on the Pentagon Channel podcast “Armed with Science: Research and Applications for the Modern Military.

Malaria is a parasitic disease which infects red blood cells, Ockenhouse said. It’s transmitted through the bite of a female mosquito, goes to the liver to develop and emerges after five days into the bloodstream to cause the disease.

Most people believe malaria is a disease of the past, but it has not disappeared, he said. In sub-Saharan Africa, 3,000 children die every day from the disease, he noted, which also can target adults, including U.S. troops serving in Afghanistan, South America and Africa.

More information about malaria:

• Info 101: Malaria
• Malaria is not gone, just forgotten

In the military, malaria impacts readiness and missions, and measures are implemented to combat the disease, Ockenhouse said. Using insect repellant and camouflage face paint with repellent in it, wearing uniforms impregnated with insecticides and employing bed nets can help to prevent malaria.

One of the important measures to prevent the disease is taking anti-malaria pills. This pill regime is one of the most effective preventative methods, Ockenhouse said, but it has to be performed daily. “Often time soldiers forget or don’t take it if they don’t see any symptoms,” he said.

The researchers are working with the U.S. Food and Drug Administration in three areas to protect service members and children against malaria. First, they are developing a highly safe, highly effective vaccine. A second area is to develop better diagnostics, which would allow earlier detection and treatment of the malaria parasite in the blood. Third, they are developing new anti-malarial drugs to prevent infection and treat those that have it.

The researchers also are developing a medication for severe malaria. Ockenhouse spoke of an in-house program designed not only for early-stage research and development, but also to test new drugs against malaria in late-stage clinical trials intended for FDA approval.

The group also works overseas with laboratories located in Kenya, Thailand, Tanzania, Mali, South America and Peru.

“We are ambassadors in the countries where we work. We are there to lend assistance to their public health initiatives, which includes helping these countries test malaria vaccines, drugs and diagnostics and aiding in infrastructure and capacity development.”

The researchers also have assisted in the development of the world’s most advanced malaria vaccine that is being tested in 16,000 infants in 11 different countries. Preliminary studies indicate that use of the vaccine can reduce malaria by 50 percent. When licensed and made available the vaccine could save hundreds of thousands, if not millions, of children’s lives, Ockenhouse said.

“We are at the forefront of many endeavors in drugs and vaccines,” Ockenhouse said. “The DoD should be particularly proud that it is stepping up to the plate and leading the world’s efforts on this disease.”

DVIDS
Story by Christen McCluney

On Thursday, November 19, and Saturday, November 21, 2009, I spent about five hours each day working as a volunteer at a vaccination clinic run by the Monroe County Public Health Department (DPH). It was one of five each day held to vaccinate at risk groups for pandemic H1N1, the Swine Flu. I worked at the one held at the former Medley Center Mall in Irondequoit.

The DPH did a great job publicizing the clinics, with the cooperation of the local media. Attendance on Thursday was somewhat overwhelming, while that on Saturday was more even in flow.

The DPH contracted with private companies for the actual vaccine administration. DPH personnel and volunteers were used for crowd control.

The observations in this piece apply only to the location I worked at, unless otherwise stated.

The Mall is empty. That meant no heat either day, and somewhat uneven hallway lighting. It also meant sparse sanitary facilities, and the men’s room had been damaged by vandalism prior to the clinic. In fact, it was flooded on Saturday. The Irondequoit Kiwanis had coffee and donuts earlier on Thursday and through about 2 on Saturday. There were no other sources for food and drink in the Mall.

On Thursday, there were four to six people giving the vaccines at any one time. The private contractors made sure that they got all their breaks in. In the late afternoon there were some 400 people in line, and a four hour wait. I was told by DPH staff that the holdup was that the providers were having to answered questions. While that may have been the case, it was clear that there were far too few providers for the demand.

Just before 5 p.m. we were told to refuse entry to any additional patients, even though the clinic had been advertised as open until 8 p.m. Most people took the news with some grace, though several self-important individuals chose to create a problem.

I had begun work at 2:30. Throughout the afternoon it was obvious that the five clinics did not seem to be talking to each other. We were getting news from patients who had been turned away from other clinics and came to the Mall. We were not the first clinic to close its doors, as far as I can determine.

On Saturday, some changes had been made. There were now about eight to ten providers, and a separate line for people with children. We were given handouts to provide patients that would answer many of the common questions.

We closed at six on the dot. During the time I was working, there were no lines beyond the clinic area, and the only real wait was in the children’s line in the clinic, perhaps 15 minutes.

Both days, we took patients with movement or other issues straight to the clinic, about 50 yards from the Mall entrance, rather than ask them to make the much longer trek around to the clinic entrance. Even then, the distance was a little daunting for some.

Signage was poor. There were two manufactured signs, one that said “Clinic here” and another that gave the target groups for the clinic. The remaining signs were made on a computer, did not last well in the rain on Thursday and did not look at all professional.

We had no handouts on Thursday and ran out of the handouts on Saturday.

Far too many adults over 65 came. Whether they thought it was the seasonal flu vaccination or not, I do not know. The clinic was not intended for them and those doses could have gone to more at-risk populations. The only people turned away had valid medical reasons for the denial, such as an allergy to eggs or being ill with a fever.

On Thursday, the clinic closed before the hour advertised. There seemed to be no interest on the part of the DPH staff in continuing to give vaccinations while they had demand.

The Monroe County DPH has about 239 employees. It would seem logical that the department would be able to staff these clinics without volunteers from other county departments and from the public. In fact, other departments did have volunteers there, and those county employees will receive comp time for the hours that they worked past their normal quitting time.

Most of the public probably is not aware that clinics like this have been planned and discussed for years, as the potential for bioterrorism arose. A great deal of time and effort has been devoted to the problem of dispensing vaccinations to a large population in a short period of time. Sites have been selected, and plans made. I cannot determine if the clinic I participated in was the result of this planning. If so, a lot of people wasted their time in the last seven years.

Why was it necessary to use contractors to give the vaccinations? The DPH employs many people with the training and qualifications to give injections. They also have, in their plans for this eventuality, other groups of people they could have called upon, such as paramedics or hospital staffs.

Why were volunteers needed? The DPH had a couple hundred employees at work on Thursday who could have worked at a clinic. Those same employees could have been used on Saturday, as well. If it was all about overtime pay or union contracts, then just how would the clinics have worked if smallpox had been used in a terrorist attack as all of those folks planned for?

Thursday was cold and rainy. Saturday was cold. I kinda resent being cold and wet while DPH secretaries sat in warm offices and surfed the Web. If the department charged with preserving and protecting public health in Monroe County cannot generate an “all hands” response for a project like the Swine Flu vaccine clinics, I have to wonder just what they would do in a more serious situation.

The Irondequoit clinic vaccinated many, many people in the hours that I worked. In that respect, it achieved its goals. More clinics are being discussed for December.

For the future clinics to be successful, there must be:

• More communication among the sites
• Site locations suitable for large crowds, to include heat, lighting, bathrooms and refreshments
• More communication with the media, especially when it comes to closing sites early
• Professional signage – it can be reused
• a perception that the Monroe County Department of Public Health, as an organization, takes the matter seriously

Monroe County, NY, Department of Public Health list of positions

This, and my normal coverage of health issues, has brought to a head some thoughts on Public Health agencies and practices I have been mulling for some time.

In a series of posts, I will try to point out where we have gone wrong, what needs to be fixed and what is right with the system.

The Monroe County Department of Public Health has 239.5 FTE positions and its budget for the current year topped $68 million. That’s about 7.5% of the total county budget.

Every locality and level of government will have something similar. The states do, and so does the Federal Government. The duties of each public health agency will vary, and the funding provided the agencies to perform these duties will, as well.

As taxpayers and voters, we expect the national and state-wide Public Health agencies to address problems that reach beyond our neighborhood. The agencies at the city, town or county level are supposed to be focused on public health issues in our local communities.

The practice of Public Health has some great victories in its history. Malaria, typhus and yellow fever were driven from large parts of the planet. Smallpox was made extinct in the wild. Polio was largely defeated and nearly rendered extinct.

But, now, the men and women in the Public Health business face a different set of challenges. New and deadly illnesses compete with old ones that are making a comeback due to societal changes. Public Health is seen by many as more than just disease prevention, and issues such as gun violence and obesity are added to the agenda.

The direction for government-supplied Public Health services in this country is unclear. The current Swine Flu pandemic represents, in microcosm, all of the good and the bad that is modern Public Health. Stay tuned for more in this series.