Spreading the spread…

… of waistlines.

The CDC usually releases its Mortality and Morbidity Weekly Report on Wednesdays to reporters, Thursdays to the rest of the world (it’s called an embargo).  But this week, the venerable MMWR went to the chattering classes early to talk about the rising tide of fat.

So, the pertinent graphic is this one:

The data come from something called the BRFSS – the Behavioral Risk Factor Surveillance System.  It’s data, glorious data, collected by phone from folks all over each of these states.  It’s about a 15-20 minute questionnaire about all things that folks do to preserve their health – or not.  It’s the same place where data about drinking and drug use come from, etc.

So, of course this data is subject to people lying.  Presumably, that means these estimates are a little lower than the actual numbers.  In North Carolina what also skews these numbers down is the fact that the BRFSS is collected by phone, i.e., land line.  If you live in a county like, say, Hertford without lots of land line service. As a result, none of those folks are being captured in the data.   And North Carolina is a state where lots of rural counties lack land phone lines – still (but that’s a different story).

Syphilis in North Carolina

Sat in today on communicable disease workshops happening at the Friday Center

One of the sessions was about the state’s current syphilis outbreak by the always entertaining Peter Leone .

And, yes, you’re not misreading that: NC currently has an outbreak of syphilis (PDF).  In 2008, there were 509 cases.  That number jumped to 937 in 2009, nearly double.  Leone says without prompt intervention, those numbers will go even higher. They’re trending that way for 2010.

Syphilis rates for select counties

Leone talks about the numbers of cases increasing in Mecklenburg, Forsyth, Wake and Wayne .  Other counties have cases, but the epidemic is concentrated in those counties. Leone who reminds us that ‘people don’t stay at home to have sex’ and that’s why the outbreak has been ongoing for a couple of years now, with nodes in places that tend to be located on interstate highways. Following that logic, Leone says Guilford County should have more cases than it does.  Numbers there have been remarkably low, with little variation in cases, but he notes that’s starting to change.

Mecklenburg has been climbing steadily, more than 174 cases in 2009 (up from 91 cases in 2008).  And as Leone has said, “as Mecklenburg goes, so goes the state.

What’s really sad is that in Forsyth, numbers had dropped to one case of primary syphilis (the infectious stage of the disease)  in 2003.  Only ONE case. But in the typical fashion, when public health professionals are successful, no disease happens, so the problem is over, right?

Wrong.

Nonetheless, numbers drop, presto, blammo, funding gets cut.  It’s the way of the world in public health – Forsyth’s syphilis prevention funding was cut in 2006.

Predictably, three years after the funds went away, cases had climbed to 46 in Forsyth, giving the county the highest rate in the state.

So, the big question is why.  Leone warns against making simple inferences from the numbers and coming up with simple solutions.  He says the increase of syphilis is a multifactorial issue, tied in with race, poverty, sexuality and education.

The short answer is that numbers are climbing most in the black MSM community (men who have sex with men).  There are now different ways for people to connect, and they’re doing just that.

“Folks can’t get STD online, but they can find one another and hook up that way,” says Leone.

And hook up, they do. And they hook up with friends, and friends of friends.  Leone says providers need to question folks about more than just whether or not they’re engaging in risky behavior, but to ask about their partners and friends, too. Just take a look at this diagram from a disease investigation.  All those circles represent folks who came up with syphilis.  Investigators asked about direct sexual contacts, but not friends, etc.  So, it looks as if some of those cases are pretty random…

Tracing sexual contacts in a syphilis outbreak

But, it’s not terribly surprising that people who have syphilis might end up knowing other people who might end up having syphilis. They engage in similar activities, perhaps have sex with one another… and when you start asking about social contacts, friends, etc, this is what you get.

Start asking about who knows who and this is what you get.

And it’s not just a problem for ‘them,’ i.e. those men who are having sex with men. To illustrate, he told a story about a woman who was in a ‘monogamous’ relationship for 14 years.  Well… at least she thought the relationship was monogamous, until she was diagnosed with HIV.

Leone urges routine HIV AND syphilis screening for anyone who comes into STD clinics across the state. They travel together.

And he says syphilis harbinger of more HIV cases out there that aren’t being caught, syphilis has a short transmission time, so people who come up with it are often an indicator of where HIV will end up moving.

Can we stop talking about Tuskegee yet?

Leone says he’s not seen as many co-infected cases of syphilis and HIV in black MSM, ever.

“Syphilis is an old disease, the reason we see it is because of societal issues, not behavior alone,” he says.  Leone notes some of the people coming up with the disease are teens.

“Is there something particular about a 15 year old MSM that he’s having lots of sex?” Leone asks. He says the reasons behind the behavior are wrapped up in lots of societal issues. For one thing there’s still a lot of distrust in the African American community of public health folks.  Talk about syphilis – um, remember.  Tuskegee was ALL about syphilis.  So it’s a sensitive topic.

“It’s about how we treat MSM, how we treat minorities, how we treat kids,” Leone says.  “If you’re a 15 year old who’s just figured out you’re gay, and you’re out of school for the summer and there’s no adult supervision, no recreational activities.   PLUS if you’re ostracized from your church… and community… and school because you’re gay, you relate by getting together with other kids like you.  You’re gonna have sex.”

Leone says we’ve spent years looking for a vaccine, a clean, silver bullet, but one hasn’t emerged.  What we haven’t done as a society is the same kind of work around homophobia, poverty, racism, etc.

So, for example, Leone says public health leaders should be talking about 100% graduation from high school as being effective for STD control.  And that’s not just about getting comprehensive sex ed or not. Leone notes knowledge doesn’t result in behavior change often.  So, while those young MSM who are engaging in risky behavior ARE the generation who didn’t have comprehensive sex ed, that’s not the only factor behind the risky behavior.

Even when we have done comprehensive sex ed, Leone says we’ve done sex ed the same way we’ve approached smoking – tell ’em to just stop having sex.

“But you’re not going to stop people from having sex. You’re just not,” Leone says.

Leone was followed by Connie Jones and Holly Watkins to talk about how state health officials are working with counties in a syphilis epidemic response team.  One small part of their effort is a series of public service announcements being aired on local channels.  Take a look:

They’re also heading out to clubs to do on site testing.

Keep your ears open.  I’m going to do a story on this!!

My 2¢ on Avandia

… well actually I’m borrowing them from a local diabetes expert.

Everyone and their editor is weighing in on Avandia, but I did want to get one thing into the conversation.

Yesterday, I phoned John Buse for a reaction. He runs the diabetes program at UNC who’s been head of the American Diabetes Association.  He was also famously smeared by GSK at one point during the Avandia wars.

He’s not a radical guy by any stretch of the imagination.  A political communicator, he chose words carefully when talking to me about Avandia before and after the decisions.  But he said something I think is telling… why would a doc prescribe it now?

…the real question I have is if the doctor prescribes Avandia for a patient, I’m not terribly worried about the patient, I’m a little worried about the patient, but it’s not like I am horrified that this is certainly going to harm the patient.  But I am much worried about the doctor, namely that bad things happen to patients with diabetes all the time.  They have among the highest rates of heart attack on earth.  If the patient has a heart attack, are those family members going to come after a doctor saying that FDA panel after FDA panel looked at this issue and decided it was a problem, and you decided to keep prescribing it?  You know, what were you thinking?

Again, I just don’t understand why people persist in prescribing the drug… (truck noise)

Why is it that some doctors persist in prescribing the drug? There is a fair consensus that there may be a safer alternative, not true that there is a safer alternative, but there is a possibility of a safer alternative.  What possible rationale is there for continuing to prescribe it except that you like the company you or that you like the shape of the tablet… I mean, I can’t think of a, of a clear rationale for prescribing rosiglitizone at this point.

(You can listen to the audio here, but he was on his cell phone, standing on a busy street and at one point, a truck passes and I ask him to repeat himself) John Buse on Why Prescribe Avandia?

During the Times liveblog yesterday, Gardiner Harris mentioned something about how two practicing physicians were among the panelists supporting continued use of Avandia. Harris posited this phenomenon as the difference between practitioners and academics.

Clinicians tend to analyze these questions based on what they would want at hand when treating the next patient who comes into their office, and they can often think of scenarios in which even a dangerous drug might be useful in those situations.

But academics, particularly those who spend time analyzing population level data, tend to point out that when drugs are sold broadly, small risks can lead to hundreds if not thousands of injuries. These experts have less confidence that doctors will always make the right decisions, so they tend to be far less accepting of safety problems.

It’s a classic argument, and one that rages continuously (remember, I’m an MPH, so by definition, an academic data hound). But cast this classic argument in legalistic Buse’s terms and you really don’t get a compelling reason to continue prescribing Avandia (rosiglitazone), except as a last-line drug for a patient who’s progress is refractory to other treatments.

Update:  Takeda, makers of Avandia’s big competitor, Actos, launched a direct-to-consumer ad campaign today.  H/T @aliciaault from EGMN

Berwick and ADAP

One of the things I read a lot this week was about how new CMS administrator Dr. Don Berwick wants to ‘ration’ care for Americans.

Actually, Berwick hasn’t said he wants to ration care, he’s made the statement that we as a country ration care all the time. The full quote, which comes from an interview done in 2009 is this:

Q: Critics of CER (Comparative Effectiveness Research) have said that it will lead to the rationing of healthcare.
A: We can make a sensible social decision and say, “Well, at this point, to have access to a particular additional benefit [new drug or medical intervention] is so expensive that our taxpayers have better use for those funds.” We make those decisions all the time. The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open. And right now, we are doing it blindly.

Working in nursing, I used to see rationing all the time – when I was told I could no longer see a patient because their insurer had said they ‘had enough’ visits, or when patients told me how they took their pills every other day in order to save money, or when insurers just plain denied treatment.  So, yeah, we don’t de jure ‘ration’ care as a society… it’s a de facto rationing, determined by your ability to pay.

Ironically, historically, Medicare has been one of the more generous payors, perhaps that’s why about a quarter of annual Medicare expenditures goes to services for people in their last year of life, 40% of that is on patients in their last month of life. This, even though research shows that providing primary care to Medicare patients reduces overall expenditures.

Then, this week, I saw this release from the US DHHS – that the fed has released an additional $25M for state ADAP programs.  Of course, I reported on it, because North Carolina has the longest waiting list (PDF) for poor AIDS patients to get access to drugs.

How is this not rationing of care…?

Speaking up for Aphasia

Several years ago, I was privileged to do a story about an aphasia program at WakeMed hospital. There, an inspired speech-language therapist named Maura Silverman was working with folks who have aphasia – an inability to communicate verbally that occurs frequently after stroke or head injury.

Aphasia is devastating. Few things are more elemental than the ability to say, ‘hello,’ ‘help,’ or ‘I love you.’ But for someone with aphasia, these words can be close to impossible to utter.

But Maura’s been blowing all the ‘conventional wisdom’ about aphasia out of the water – that recovery is a limited process, that what you regain at about 6 months is what you’ll remain with, etc.  Maura’s found a way to get aphasia victims ongoing therapy by having them meet in groups.  It reduces costs for them (especially because insurance stops paying for therapy after about 4-6 months), and allows people with aphasia to continue therapy for years… with continuous improvement.

The story is here and, if I can toot my horn, it won an award from the NC Associated Press for Best Health Story, 2007

Well good news… just received word that the aphasia program has gone independent, meaning more people can access it than just WakeMed patients. aphasiaproject.org

Maura also tells me there’s a fundraiser/ showing of the film Aphasia, The Movie next Thursday, June 10 at the Galaxy Cinema in Cary.  The film features Carl McIntyre, an actor who suffered a stroke and had aphasia as a result. The film premiered at UNC, and McIntyre does presentations for Speech-Language Pathology students.

Not MY kid…

File this one under ostrich-like behavior:

A researcher from North Carolina State University asked dozens of parents of all ethnicities and incomes about teens and potential sexual behavior.

The result: Many parents believe teens want to have sex – just not THEIR little angel!

Sociologist Sinikka Elliott interviewed about 50 parents from different ethnic groups, socioeconomic groups, etc.

She says parents described their kids as, “little, young and naive and don’t think of them as sexually desiring subjects… and by that I mean that they don’t think that their teens would necessarily choose to have sex of their own accord.  But they’re really concerned that they might be pushed into sex by their more sexual peers.”

The parents reported that it was the OTHER kids who would be more sexually aggressive – this was the case, even though several of the parents had kids who had become teen parents.

Elliott says teens are complicit in what their parents believe by telling them they’re not interested in sex.

Chalk another one up for comprehensive sex ed.  Elliott says it’s important that parents talk ‘frankly’ about sex to their kids even if the kids say they’re not ‘doing it.’

Just in case you want to hear the version that aired on WUNC.

Colorectal cancer screenings…

… who gets them and who doesn’t is the subject of new research out from a combined institute at UNC-Chapel Hill and the RTP-based research company RTI.

Talked to RTI’s Debra Holden who lead the study, and she says there are folks who tend not to get screened.  They’re:

-low income

-less educated

-have no insurance

-Asian

-Latino

-recent immigrants (less than 15 years in the US), and therefore unfamiliar with the US health care system

-have limited access to care, like in rural parts of NC

None of these is particularly surprising.

Now, there’s been a lot of chatter in the research about the cost effectiveness of tests like colonoscopies and sigmoidoscopies. The argument is that they get used more because they generate money for doctors and screening centers – they’re reimbursed well.

But Holden says there are older technologies that are waaaay cheaper, such at the stool guiac test (say GWEYE-ack).  It’s a little card that the doctor gives you, you bring it home, collect a sample of your own poop and then give it back to the doctor.

Collecting your own poop usually elicits an, “Ewwwww!” but I’d ask if its worse than a tube stuck up your butt…

The guiac test, a.k.a. the occult  blood test , works best if you do this three times – the test detects hidden (occult) blood. It costs less than a hundred dollars.  Research shows it’s good for screening, and the national guidelines (CDC, American Cancer Society, et al)  suggest this should be the first thing used, reserving sigmoidoscopies for once every 5 years and colonoscopies for once every 10 years.

However, Holden’s data show that rates of colonoscopy have increased over the past decade, while use of the other, cheaper-but-effective screening methods has stayed essentially flat.

Here’s how she put it:

“…there has been an awful lot of research done and studies published on different types of new tests, because our society tends to be enamored with new technologies, and so people always, if they talk about test, they want the newest, most innovative test that they can get even if it’s not necessarily proven that it would be the best option for them.

So there are a lot of research studies on that, and not so many on how you get people you to use the tests that we know work.  So we were saying that there needed to be a lot more research done because there are some strategies out there that have been proven to work, to increase people’s screening rates, but not very much research done on that.  So there needs to be more research done on that and less on these new high tech tests because we know we have some already that work.”

And that’s the straight poop…