Mickey, Minnie, Measles

Sleeping Beauty’s Castle in Disneyland. Credit: Tuxyso / Wikimedia Commons

Sleeping Beauty’s Castle in Disneyland. Credit: Tuxyso / Wikimedia Commons

It’s a world of measles, a world of flu.
It’s a world of mumps and pertussis too.
It’s a world that we share,
but please stand over there.
It’s a small world after all.
— My new proposed lyrics for the ride It’s A Small World

In December I wrote that 2014 was a banner year for measles in the U.S.. Take a moment to read that post if you want a refresher on the symptoms and history of measles.

Well, gentle reader, if you were hoping that 2015 would be the year that humans make inroads against measles, I fear you’ll be disappointed. So far, it looks like 2015 will be a year in which unvaccinated people gather in large groups and get infected. We’ve had more measles cases in California in January than in all of last year.

As of Wednesday, the California Department of Public Health has counted 59 cases of measles in California this year. 42 of these cases, including 5 Disney employees, are associated with an initial exposure at the Disney amusement parks in Anaheim in December. It is known that subsequently some patients visited the parks in January while infectious.

Vaccination status is known for 34 of the 59 cases. 28 of the 34 were unvaccinated. Six were infants too young to be vaccinated. Health officials are still investigating multiple people who may have come into contact with known patients.

This outbreak has led the Department of Public Health to advise that unvaccinated people not visit crowded places with a large number of international visitors. That’s a reasonable start. Vaccinating everyone in line at It’s A Small World might be even better.

What to do if you don’t know if you’ve been vaccinated? If you were born before 1957 it’s safe to assume you’re immune, since virtually everyone in that generation was exposed to measles. Everyone else should have two doses of MMR. The first dose is usually given at 12 to 15 months of age, and the second at age 4 to 6.

If you’re not sure if you received both doses, your doctor can just give you another MMR dose, or she can check a blood test to see if you’re immune. When it comes to infectious diseases, wishing upon a star might not be enough.

Learn more:

Disneyland Measles Outbreak Hits 59 Cases And Counting (NPR)
Unvaccinated People Warned to Avoid Disneyland Resort (Wall Street Journal)
Measles advisory (California Department of Public Health)
Measles Makes a Comeback (my post in December)

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‘Tis the Flu Season

Graphic credit: CDC

Graphic credit: CDC

Ah, the joys of January 2! Bleary eyed employees return to work, holiday cards fill waste baskets, and everyone contracts influenza.

This year’s flu season has started earlier than expected and has already reached high numbers of flu cases in 36 states. California is not one of them, but that likely means we’re a couple of weeks behind the East Coast, not that we’ll be spared. In fact, this week I saw my first patient of the season who had a positive test for the flu, and Google Flu Trends suggests that the numbers of cases in Los Angeles just started to increase.

It’s too early to know whether this season will be worse than previous years. That largely depends on how soon the disease peaks and then declines. But this season has already caused more hospitalizations than usual and a large number of deaths. As of December 20, eighteen children have died of the flu.

Part of the reason for this season’s intensity is that the predominant virus strain circulating is H3N2, a strain that usually causes more hospitalization and deaths. To make matters worse, though this year’s vaccine includes the H3N2 strain, the virus has changed since the vaccine was made, making the vaccine an imperfect match for the circulating virus. Still, an imperfect match is better than none, and health officials still urge everyone over 6 months of age to get vaccinated. Remember, if you’re young and healthy getting the shot isn’t primarily about protecting yourself. It’s about making it less likely that you’ll transmit flu to a more vulnerable person that you come into contact with.

Please take a moment to review the Centers for Disease Control and Prevention’s (CDC) advice about what to do if you get the flu. It has a helpful summary of flu symptoms and treatment, as well as warning signs of severe illness. If you have a mild illness, please stay home. If you have severe illness or are at high risk of developing complications contact your doctor immediately. Antiviral medication works best if taken in the first 48 hours after the onset of symptoms. Let’s also all do our best to cover coughs and wash our hands frequently.

I wish you a happy and healthy year. Let’s hope this flu season peaks soon and that your first achievement of 2015 isn’t getting sick.

Learn more:

Severe Flu Cases on the Rise in U.S. (Wall Street Journal)
This season’s flu activity has reached the epidemic threshold, the CDC says (The Washington Post)
Teen’s death shows horror of flu epidemic (CNN)
Google Flu Trends for Los Angeles
The Flu: What to do if you get sick (CDC)
Weekly US Influenza Surveillance Report (CDC)

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Retrievable Stents Offer Improved Outcomes for Stroke Patients

A CT scan of the brain of a patient with a right middle cerebral artery stroke. Image credit: Lucien Monfils / Wikimedia

A CT scan of the brain of a patient with a right middle cerebral artery stroke.
Image credit: Lucien Monfils / Wikimedia

There are few illnesses as disabling as a stroke. A stroke is the cessation of blood flow to part of the brain. It can cause sudden difficulty speaking, difficulty moving a limb, facial drooping, or the loss of vision in a fragment of the field of view. In many stroke patients the loss of function never improves and the patients remain permanently disabled.

Before the 1980s there was no effective treatment for this devastating illness. Stroke patients were simply observed and given physical therapy. Some improved, and many didn’t. In the 1980s a blood clot dissolving medication called tissue plasminogen activator (tPA) began to be used for stroke patients with encouraging results.

tPA is given intravenously and has to be given within 4 hours of symptom onset. In patients with small clots who present to the emergency department in time, it can make a dramatic improvement in outcome. In the 1990s a large study proved that treating stroke patients with tPA is better than not. The main limitation of tPA was the narrow time window and its lack of effectiveness against large clots in large arteries.

By the late 1990s many large stroke centers were trying to improve on tPA. At UCLA, where I trained, stroke patients were treated by inserting a catheter in the clotted artery and delivering clot-dissolving medications directly to the clot. That became the standard of care at many centers, though there were never large studies to show that this was better than intravenous tPA.

More recently, various devices have been designed to remove blood clots from brain arteries. But again, there has never been evidence that these are more effective than intravenous tPA, until now.

A study performed in the Netherlands and published online this week in the New England Journal of Medicine (NEJM) attempted to determine the best treatment for stroke patients who have large clots in large arteries. These are the patients at greatest risk of serious permanent disability. The study randomized about 500 such patients into two groups. Patients in one group received usual care, which for the vast majority meant intravenous tPA. Patients in the second group received intravenous tPA and an attempt to remove the clot from the artery. In most of the patients this was done with a retrievable stent, a wire cage that is pushed through an artery, envelops the blood clot, and allows the stent and clot to be pulled out of the artery. This treatment can be performed as late as 6 hours after the onset of symptoms.

Ninety days later 33% of the patients in the group randomized to clot retrieval were functionally independent, compared to 19% of the patients in the group that only received tPA. That means for every 7 patients that receives clot retrieval in addition to tPA one additional person is functionally independent 3 months later.

Note that even though the patients in the clot retrieval group did better, even in that group two thirds of the patients were not functionally independent at 90 days. That means they needed assistance for their activities of daily living. That is a sobering reminder of the poor outcomes that await most patients with large clots in large arteries.

There was no difference in mortality or severe bleeding between groups. The group receiving clot retrieval did have an increased risk of another stroke within 90 days, but this risk was numerically smaller than the improved functional independence. This NEJM Quick Take Video summarizes the findings of the study.

So stroke is more treatable now than ever. But the time from the onset of symptoms to the initiation of therapy is still critical for a good outcome. So if you ever suddenly develop difficulty speaking, or can’t move a limb, or lose vision in a fragment of your field of view, call 911. Getting to an emergency room promptly can make the difference between getting 1970s care for your stroke and getting 2014 care.

Learn more:

For First Time, Treatment Helps Patients With Worst Kind of Stroke, Study Says (New York Times)
Stents Boost Stroke Recovery, Study Finds (Wall Street Journal)
Clot-grabbing devices offer better outcomes for stroke patients, study finds (Washington Post)
Video: MR CLEAN (NEJM Quick Take)
A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke (NEJM, subscription required)
Interventional Thrombectomy for Major Stroke — A Step in the Right Direction (NEJM editorial, subscription required)
The Stroke – Billy Squire (YouTube)

Tangential Miscellany

Happy Hanukkah, Merry Christmas, and a joyous and healthy 2015!

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Measles Makes a Comeback

The rash caused by measles. Credit: CDC/ Heinz F. Eichenwald, MD

The rash caused by measles.
Credit: CDC/ Heinz F. Eichenwald, MD

I haven’t written about measles in over two years, but unfortunately it’s in the news again.

Measles is a very contagious viral illness that causes a high fever, rash, cough, and a runny nose. Complications include pneumonia, brain inflammation and death. Prior to 1963 there were hundreds of thousands of measles cases in the US annually, causing hundreds of deaths. In 1963 the measles vaccine was introduced, leading to an immediate decrease of measles cases in this country.

In 2000 measles was declared eliminated from the US. That means that for at least 12 months there was no person-to-person transmission of measles in the US, and any cases in the US were acquired by travelers abroad. But since then, instead of progressive global elimination of measles, we’ve had several setbacks.

In 2012 I wrote that there were 222 cases of measles in 2011, the highest number since 1996. This year that number doesn’t seem so bad. From January to October 2014 there have been 603 cases in 22 states, including California. There were 20 outbreaks during that time, meaning episodes in which person-to-person transmission is occurring in the US. The majority of the cases were in unvaccinated people.

In January to April of this year there were 58 confirmed measles cases in California, including 22 in Orange County and 10 in Los Angeles County. Of them, the vast majority were linked to recent travel abroad. Most of the patients were either unvaccinated or had no vaccination documentation available.

The problem is that vaccination has been a victim of its own success. Before 1963 everyone knew lots of people who had measles, and everyone heard of some people who had terrible complications. The case for vaccination was obvious and universally understood. But with nearly universal vaccination, public understanding of the risk of measles has waned and increasing numbers of parents are choosing not to vaccinate their kids. Add to that a scurrilous and fraudulent campaign to link vaccines with autism (a link that has been debunked repeatedly) and you have the perfect milieu for reversing decades of life-saving progress.

These numbers have much to teach about how vaccines work and how they don’t work.

First, though most of this year’s measles cases were unvaccinated, a minority of the cases were people who had documented vaccinations. That means that vaccines, like any other preventive medicines, aren’t perfect. Some vaccinated people will not develop protective immunity and will remain susceptible. In addition, some kids can’t be vaccinated for medical reasons. That means that even in an ideal world in which everyone who can be vaccinated is vaccinated, a small fraction of the population remains susceptible to infection.

So how was transmission ever eliminated?

It’s the number of susceptible people, or rather their fraction of the population, that matters. Below some critical number, each susceptible person comes into contact with people who are all immune, making person-to-person transmission very unlikely. But above that critical threshold there are enough susceptible people to sustain a chain reaction of infection.

The scary conclusion is that I can’t be sure I’ve protected myself by being vaccinated. I’m protected when most people around me are vaccinated, and I contribute to their protection by being vaccinated myself. If parents’ refusal to vaccinate their kids only endangered them, we might only raise our eyebrows in disapproval. But their refusal endangers our kids too.

Learn more:

The Measles Outbreak Coming Near You (Wall Street Journal)
Wealthy L.A. Schools’ Vaccination Rates Are as Low as South Sudan’s (The Atlantic)
O.C. measles outbreak spurs officials to call for immunizations (Los Angeles Times)
Measles (Centers for Disease Control and Prevention)
Notes from the Field: Measles — California, January 1–April 18, 2014 (Morbidity and Mortality Weekly Report)

Some of my previous posts about measles:

Measles Cases in 2011 Highest in Fifteen Years (2012)
Study Linking Vaccines to Autism not Just Wrong, Intentionally Fraudulent (2011)
U.S. Measles Cases at Highest Numbers Since 2001 (2008)

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Thank You Very Much

Image credit: Jim/Wikimedia, Creative Commons license

Image credit: Jim/Wikimedia, Creative Commons license

Tomorrow I expect to sit with my extended family at my sister’s house and consume copious quantities of yummy food. After that, my and her kids will destroy her house in cute ways that will delight the grandparents. Good times.

That in itself is a reason for gratitude. Given the fact that most humans who have ever lived spent every winter nearly starving to death, the abundance of food and material comfort at our disposal is nothing short of miraculous. And the fact that we’re all healthy enough to get together to celebrate is a true blessing.

But I would be remiss if I headed off to celebrate without thanking you.

To my readers: I’m grateful for all your feedback, for pointing me to interesting stories, and for forwarding my posts on social media. It’s largely because of you that my posts have appeared on KevinMD, American College of Physicians Internist blog, The Jewish Journal, and other publications. I know my blogging has been very intermittent this year. Patient care will always come first, but I promise to keep trying to inform you.

To my patients: I’m so thankful to you for the trust you place in me. Some of you have had serious illnesses this year and it’s been an honor and a privilege to guide you through such trying times. It’s a blessing to simply make a living, but I have the double blessing of getting paid to do what I love. I owe that to all of you. And because so many of you mentioned me to your colleagues and loved ones, this year is my best so far. Thank you very much. I promise to do my best to keep you healthy.

As is my tradition, I hereby lift my patients’ dietary restrictions for one day. Of course, I can’t suspend the laws of biology. If you take your dietary indiscretion too far, I’ll probably hear about it from your local emergency department. I hope you are able to gather with loved ones and energetically attempt to enumerate your countless blessings.

Happy Thanksgiving!

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A Second Vaccine against Pneumonia Recommended for Seniors

Streptococcus pneumonia bacteria grown from a patient’s blood culture. Credit: CDC/Dr. Mike Miller

Streptococcus pneumonia bacteria grown from a patient’s blood culture.
Credit: CDC/Dr. Mike Miller

If you’re over 65, there’s a new vaccine you should know about.

But before I explain the vaccine, let me introduce you to the bacterium that the vaccine protects you from. The little blue ovals in the above picture are Streptococcus pneumoniae bacteria. You might have guessed by its name that S. pneumoniae is a leading cause of pneumonia, and you’d be right. Pneumonia is an infection of the lungs, usually manifested by fever, productive cough, and shortness of breath. Pneumonia can be caused by bacteria, viruses, and fungi, but S. pneumoniae is such a common cause of pneumonia that it’s nicknamed the pneumococcus – the coccus (little round bacterium) that causes pneumonia.

The Centers for Disease Control and Prevention (CDC) estimate that 900,000 people in the U.S. contract pneumococcal pneumonia every year, and tens of thousands of them die. Pneumonia is usually treated with antibiotics, but some strains of the pneumococcus have developed resistance to some drugs. If that wasn’t bad enough, S. pneumoniae can also cause bloodstream infections and meningitis, which are even more life-threatening than pneumonia.

Given the severity of pneumococcal illness in people over 65, prevention in this age group has been critical. For over 30 years a pneumococcal vaccine called Pneumovax 23 has been recommended for everyone 65 and over. (The generic name for Pneumovax 23 is PPSV23, 23-valent pneumococcal polysaccharide vaccine. You don’t need to know that for the test. I’m just mentioning it here because you’ll see that name in other articles. Oh, and there is no test.) Pneumovax 23 protects against 23 different strains of S. pneumoniae but the immune response it stimulates in patients is just meh. That’s good enough to protect against bloodstream infections and meningitis, so it still saves many lives, but the evidence that it prevents pneumonia isn’t very strong.

A newer vaccine against the pneumococcus appeared in 2010. It’s called Prevnar 13 (PCV13, 13-valent pneumococcal conjugate vaccine). It has been used since that time in vaccinating children. It only covers 13 strains of pneumococcus but it stimulates a much stronger immune response than Pneumovax 23. Interestingly, there is some evidence that immunizing children against the pneumococcus has led to fewer pneumococcal illnesses in older people since there are fewer sick kids around to infect them. This is another bit of evidence of a phenomenon called herd immunity – immunizing some members of a “herd” protects the rest of them just because there are fewer vulnerable members to transmit the disease.

Recently Prevnar has been tested in and approved for use in seniors. A recent study showed definitively that it helps protect from bloodstream infections, meningitis, and pneumonia caused by the pneumococcus. Last month the CDC recommended Prevnar in everyone 65 and older.

Because Pneumovax 23 covers more strains, seniors should now receive both vaccines, not just the new one, but because the two vaccines protect against some of the same strains, they can’t be given at the same time. Here’s the recommended timing.

  • People 65 and over who haven’t received either vaccine should first receive Prevnar 13 followed 6 to 12 months later by Pneumovax 23.
  • People 65 and over who have already received Pneumovax 23 since they turned 65 should receive Prevnar 13 at least a year after receiving Pneumovax 23.
  • People 65 and over who have already received Pneumovax 23 before turning 65 should receive Prevnar 13 at least a year after their most recent Pneumovax dose, and then should receive another dose of Pneumovax 6 to 12 months after the Prevnar but not earlier than 5 years after the last Pneumovax dose.

Got that? If not, this handy box illustrates the options nicely. The good news is that you can get the flu vaccine at the same time as either pneumococcal vaccine, so you’ve got that going for you, which is nice.

So if you’re 65 or older make sure that you get both Pneumovax and Prevnar in whichever order is appropriate for you. And if you’re younger, make sure your parents and aunts and uncles get the news. Because you don’t want the above picture to be the blood culture of someone you love.

Learn more:

Some Good News on Pneumonia (New York Times, The New Old Age blog)
New Advice for Vaccines to Stave Off Pneumonia (Wall Street Journal)
Pneumococcal Vaccination (Centers for Disease Control and Prevention)
Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP) (Morbidity and Mortality Weekly Report)

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Sorting Out the Different Flu Vaccines

A sailor receives a flu shot. Credit: US Navy

A sailor receives a flu shot. Credit: US Navy

The best way to avoid the flu is spending the months from fall until spring in a solitary bunker, communicating with other people only electronically. The second best way is getting the flu vaccine. The Centers for Disease Control and Prevention (CDC) recommends the flu vaccine for everyone over 6 months who doesn’t have a specific contraindication to it.

Because of the increasing number of different flu vaccines that are now available, this post highlights the three most commonly used flu vaccines, their indications and side effects.

Inactivated Standard-Dose Injectable Vaccine
This is the standard flu shot. It is approved for adults of any age and for children 6 months or older. It is recommended for pregnant women and for people with chronic illnesses, both of whom are at increased risk of serious complications from the flu. It is more effective in adults than the intranasal live-attenuated vaccine.

Side effects from the flu shot are very rare except for soreness and redness at the injection site. The vaccine contains no live virus, so the common misconception that the flu shot can cause flu-like symptoms is just that.

Intranasal Live-Attenuated Influenza Vaccine (FluMist)
This vaccine is a nasal spray. It is approved for healthy, non-pregnant people 2 to 49 years of age. It’s more effective than the inactivated vaccine in children 6 years old or younger. Because it contains a live virus, it should not be taken by pregnant women, patients with weakened immune systems, people with respiratory illnesses, or caregivers of severely immunocompromised patients.

FluMist can cause runny nose, nasal congestion, and sore throat.

Inactivated High-Dose Vaccine (Fluzone High-Dose)
Older people are at highest risk for complications for the flu, so they have potentially the most to benefit from vaccination. But ironically older people have immune systems that have the weakest responses to vaccines. For this reason, a vaccine with a higher dose was produced. Fluzone High-Dose has four times as much antigen from each flu strain as the regular vaccine. It’s basically just like getting four standard flu shots but in the same injected volume as one shot. It is slightly more effective in preventing flu than the standard vaccine. In a randomized trial trial 1.4% of older adults who received the high-dose vaccine later developed flu compared to 1.9% of those who received the standard-dose vaccine. That means that for every 200 older adults who take the high-dose vaccine instead of the standard-dose, one case of flu is prevented. Fluzone High-Dose vaccine is approved for adults 65 years and older. This group of people can also opt for the standard vaccine.

Fluzone High-Dose causes more injection-site reactions than the conventional vaccine but no increase in serious adverse effects.

The CDC influenza vaccination page has a lot more information about each vaccine and more specific contraindications.

So figure out which vaccine is right for you and get it. Our office only carries the inactivated standard-dose shot, but the others are available at many pharmacies. After protecting yourself you can come out of your bunker, or invite friends over. I’ll bring snacks.

Learn more:

Vaccination: Who Should Do It, Who Should Not and Who Should Take Precautions (Centers for Disease Control and Prevention)
Google Flu Trends for Los Angeles
Efficacy of High-Dose versus Standard-Dose Influenza Vaccine in Older Adults (New England Journal of Medicine, by subscription only)
Influenza Vaccine for 2014-2015 (The Medical Letter, by subscription only)

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Why Ebola is not a Major Threat in the US

Colorized electron micrograph of Ebola virus particle. Credit: CDC/Cynthia Goldsmith

Colorized electron micrograph of Ebola virus particle. Credit: CDC/Cynthia Goldsmith

I have written twice this year (links below) about the increasingly severe Ebola outbreak in West Africa. The news in West Africa is still mostly bad. Over 7,000 have become ill and over 3,300 have died. This is by far the worst Ebola outbreak ever.

This week marked another first, the first Ebola patient diagnosed in the US. This news is likely making many of my regular readers wonder “Should I freak out?” This is a reasonable question, and I will attempt to answer it. But first, let’s go over how this nasty microbe spreads.

Ebola is caused by a virus that is transmitted through contact with the bodily fluids of someone who is sick. It is not airborne; that is, it is not spread by respiratory droplets (coughing, sneezing). After being infected with the Ebola virus, a patient develops symptoms 2 to 21 days later. The patient is only contagious once symptoms appear, not before. Symptoms of Ebola include fever, headache, muscle aches, diarrhea and vomiting.

On Sept. 15 Thomas Eric Duncan, a man living in Liberia, was helping a neighbor who had become ill. (The neighbor later died.) On Sept. 19, while Mr. Duncan was feeling well, he boarded a plane and flew from Liberia through Brussels and Washington. He landed in Texas on Sept. 20 and visited family in Dallas. As is now standard practice for all passengers leaving Liberia, his temperature was checked before boarding his flight and was normal.

On Wednesday Sept. 24 Mr. Duncan began feeling ill. On Sept. 26 he presented to the Emergency Department at Texas Health Presbyterian Hospital. He told a nurse he had been in Liberia. The nurse used a checklist to screen for possible Ebola patients. Embarrassingly, that information didn’t get transmitted to the rest of the team caring for Mr. Duncan. He was evaluated and discharged with a prescription for antibiotics. Oops. Major, potentially consequential oops.

On Sept. 28 Mr. Duncan became more ill and was taken by ambulance to the same hospital. At that point, things unfolded as they should. He was quickly identified as a potential Ebola patient and isolated. On Sept. 30 tests confirmed that Thomas Eric Duncan is the first patient to be diagnosed with Ebola in the US. He remains hospitalized under isolation and is in serious condition.

Since then Centers for Disease Control (CDC) and state health officials have carefully tracked Mr. Duncan’s movements since he became ill. Remember, the disease is not transmissible until symptoms develop. So, as a CDC official said, there is “zero risk of transmission on the flight”. Four people at the Dallas apartment where he stayed are under quarantine and are being evaluated daily for symptoms. So far, all of them are still well. 12 to 18 people had direct contact with the patient and are also being followed by health officials but are not quarantined. A broader list of about 100 people who may have had very brief contact with Mr. Duncan was also interviewed by health officials to narrow the list to those who might have been exposed to Ebola and require monitoring.

So, dear reader, this is why you shouldn’t freak out. The conditions that have permitted Ebola to spread like wildfire in Africa simply don’t exist here.

What’s the worst that could (likely) happen? A few of the people under quarantine might get sick. That would be terrible. (Some of them are kids.) But the CDC would be on them like, um…, well, like health officials on an Ebola patient. They would be immediately hospitalized and isolated. It’s conceivable, but unlikely, that a couple of the 12 to 18 less-close contacts also become ill, but they would get the same treatment. The point is if Mr. Duncan infected anyone, those patients won’t have a chance to infect anyone else. That’s good workaday epidemic control and it’s one of the many things that African health officials don’t have the resources for.

There are a few other important differences between the conditions here and in Africa that bear on this outbreak. The first is that a very large number of the victims in Africa are healthcare workers. That’s because of the lack of even the most basic equipment for personnel protection, like latex gloves and disposable gowns. Another difference is that in Africa there is deep mistrust of public health officials and many families hide sick relatives and don’t seek care. In the US the response from the public is likely to be the opposite. If even three or four more patients are identified, the public is likely to overreact. Every fever, runny nose, or pessimistic thought in Dallas is likely to be reported to a physician. The problem will not be in quickly identifying all the Ebola cases. The problem will be that the healthcare system will be flooded with run of the mill flu symptoms. Don’t have a heart attack that day.

Traditional burial practices in Africa which involve direct contact with the deceased have also contributed to the spread of the disease, and obviously would not be allowed here.

So, spare a kind thought for Mr. Duncan. The Ebola case mortality in Africa is about 50%, but I hope with excellent care his chances are much better than that. I also hope that if any of his family fall ill they also recover.

West Africa will continue to require enormous resources to control the current outbreak. And infected people, despite the best screening methods, will continue to travel to the developed world and then learn that they are sick. But a few simple questions, some gloves and gowns, and meticulous tracking of contacts will always prevent a sustained outbreak here.

Learn more:

Five Things About Ebola in the U.S. (Wall Street Journal, a terrific brief summary of the facts)
Up to 100 possibly exposed to U.S. Ebola patient; four isolated (Reuters)
As Ebola confirmed in U.S., CDC vows: ‘We’re stopping it in its tracks’ (Washington Post)
Ebola Virus Disease (Centers for Disease Control and Prevention)

My previous posts about Ebola:

Ebola Outbreak in West Africa Worries Health Officials (April)
Largest Ebola Outbreak in History Continues to Spread (July)

Tangential Miscellany

Saturday is Yom Kippur so some of us are planning to fast. It’s also going to be very hot in Los Angeles, which means some of us are going to get dehydrated, faint, and end the day in the emergency department getting intravenous fluids. If you are planning to fast and you’re not-so-young, or if you take prescription medications, please ask your doctor if fasting is safe for you. Also ask which medications should be continued even if you’re fasting.

Have a safe Yom Kippur and a healthy and sweet 5775.

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All Ashkenazi Jewish Women Should be Tested for BRCA

A woman receives a mammogram. Image credit: National Cancer Institute / Wikimedia

A woman receives a mammogram. Image credit: National Cancer Institute / Wikimedia

Mutations in two genes called BRCA1 and BRCA2 greatly increase the risk of breast and ovarian cancer. Last year I wrote about Angelina Jolie’s discovery that she carries a harmful BRCA1 mutation and her decision to have preventive double mastectomy.

In the general population mutations in these genes are quite rare, but among Ashkenazi Jews these mutations are much more prevalent. One in 40 Ashkenazi Jews carries a mutation in BRCA1 or BRCA2. In the Ashkenazi population one in 9 cases of breast cancer and 2 in 5 cases of ovarian cancer involve mutations in a BRCA gene.

Identifying women with BRCA mutations who are at high risk of breast and ovarian cancer isn’t just an exercise in predicting trouble. Preventive action can be taken. As Angelina Jolie’s story teaches us, preventive surgery that removes the breasts and ovaries greatly decreases the risk. Mastectomy, of course, is difficult physically and psychologically. For some women at very high risk, intensive screening with mammograms and breast MRI offers some level of protection without resorting to surgery.

Thus far genetic testing for these mutations has only been recommended for Ashkenazi women with a strong family history of breast or ovarian cancer. That’s because BRCA mutation carriers with a family history of breast or ovarian cancer were the only group studied and found to have increased cancer risk.

But if the BRCA mutations themselves cause breast and ovarian cancer, why should family history matter? Why not test everyone who might have these mutations? The answer is that the risk of cancer in BRCA mutation carriers without a family history of cancer has never been measured. Without knowing that, it is possible that the mutation carriers who have a family history of cancer have an increased risk because of some other shared genes that have yet to be identified or because of some shared exposure to cancer-causing agents in the environment. That is, without knowing the risk of BRCA mutation carriers who do not have a family history of cancer, we can’t be sure if the BRCA mutations are the cause of increased risk, or simply a marker for some other cause that is yet unknown.

A study carried out in Israel and published this month in the Proceedings of the National Academy of Sciences sought to answer this question in an ingenious way. The study enrolled about 8,000 Israeli Ashkenazi men without a history of cancer and tested them for BRCA mutations. 175 of them were found to carry harmful BRCA mutations. The first degree female relatives of these 175 men (their mothers, sisters and daughters) were invited to undergo BRCA testing. This identified 211 female BRCA mutation carriers, many of whom had no family history of breast cancer. By studying the medical histories of the identified female mutation carriers, their risk of ovarian and breast cancer was calculated.

The results showed that a woman with a BRCA1 mutation has an 83% risk of developing breast or ovarian cancer by age 80. BRCA2 mutation carriers have a 76% risk of breast or ovarian cancer by age 80. These numbers are very similar to those from studies that only counted women with strong family histories of cancer. That means that a family history is not necessary to identify women who benefit from screening, and suggests that all Ashkenazi Jewish women should be tested for BRCA mutations.

National groups that evaluate scientific data and make testing recommendations like the American Cancer Society and the US Preventive Services Task Force haven’t had a chance to digest the news yet. They still recommend BRCA testing only for women with strong family histories of breast and ovarian cancer.

A medical geneticist I spoke with said that BRCA testing costs about $400 and is generally not covered by insurance. If you’d like to pursue testing, the first step is asking your doctor to refer you to a medical geneticist for pre-testing counseling.

Population screening for specific genetic diseases, like Tay-Sachs, has proven in the past to make enormous reductions in the societal burden of disease. Screening all Ashkenazi Jewish women for BRCA holds out the promise of similar gains against breast and ovarian cancer.

Learn more:

Study of Jewish Women Shows Link to Cancer Without Family History (New York Times)
Israeli research team: Screen all Ashkenazi-Jewish women for BRCA mutations (The Jerusalem Post)
Population-based screening for breast and ovarian cancer risk due to BRCA1 and BRCA2 (Proceedings of the National Academy of Sciences, abstract free, full article by subscription)
Understanding Angelina (My post from 2013 explaining the BRCA testing recommendations at that time)

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A Comparison of Low Carb and Low Fat Diets

Image credit: Wikimedia commons, public domainThe joys of September! Parents gleefully shove their reluctant children onto school buses, the palm trees in Los Angeles don’t change color, and everyone realizes that they gained 20 pounds during their summer vacation. It’s time to get serious again about losing weight.

But how should you eat to best help you shed the extra pounds? Many people are passionate about their favorite diet, but there is very little data comparing different diets to each other. Some swear by low carbohydrate diets (like Atkins), while others insist that low fat diets (like Weight Watchers and others) yield more weight loss and achieve healthier cholesterol numbers.

This week, a study published in Annals of Internal Medicine attempted to shed some light on this question. The study enrolled 148 men and women who were obese (BMI 30 to 45) but didn’t have diabetes or cardiovascular disease. The participants were randomized into two groups. One group was counseled to eat a low carbohydrate diet, with less than 40 grams of carbohydrates per day. The second group was counseled to eat a low fat diet, with less than 30% of total calories from fat, and less than 7% from saturated fat. Neither group was counseled about limiting total calories or about exercise. Both groups received ongoing periodic dietary counseling throughout the study.

The subjects were followed for a year and had periodic assessments of their weight, diet, cholesterol, blood pressure, and other blood tests measuring cardiovascular risks.

At the end of the study the group eating a low fat diet lost an average of 4 lbs. while the group eating a low carbohydrate diet lost an average of 12 lbs. Even more impressive was that the low-fat group lost lean body mass (muscle weight) and gained fat weight, while the low-carbohydrate group lost fat weight and gained muscle. This is especially surprising since average caloric intake and physical activity was similar between groups. One frequent criticism of low carbohydrate diets – that it results in an increase of LDL (bad cholesterol) – was dispelled. Total cholesterol and LDL levels remained similar between groups, but the low-carbohydrate group had bigger increases of HDL (good cholesterol).

This all suggests that a low carbohydrate diet leads to more weight loss than a low fat diet while improving body fat composition and some cholesterol measures. For those who are losing weight on a low carbohydrate diet but were worried that the excess fat intake was increasing their cardiovascular risk, this is good news.

Though the results were trumpeted as a major vindication for low carbohydrate diets, I interpret the results differently. Sure, the low carbohydrate group fared better than the low fat group, but what I find striking is how disappointingly modest the results in both groups were. The participants had a BMI of 30 to 45 which means that at minimum they were 35 lbs. overweight, some much more. An average weight loss of 12 lbs. is a laudable step in the right direction but is a small fraction of the weight that should be lost. Considering the fact that this weight loss took 12 months and that all longer term studies suggest that some of this lost weight will be regained, the results seem quite discouraging.

So I conclude from this study that any diet that helps you eat less and that you can maintain indefinitely will help you lose weight but that for meaningful weight loss you have to make a more radical change in your diet than the groups in this week’s study. If you feel full and not deprived on a low carbohydrate diet, then do it and stick to it. But you should probably have even less carbohydrates than 40 gm per day until you reach your target weight. This study at least reassures you that your cholesterol and body fat composition won’t get worse. If you do best with a low fat diet, consider a diet that is radically low in fat, like a plant-based vegan diet without processed foods. My patients who have stuck with either strategy have done well. This study is also a reminder that without exercise, changing what you eat will only achieve modest results. Frequent exercise can accelerate weight loss while maintaining muscle mass.

And for people who are over 100 lbs. overweight, especially those with diabetes, studies increasingly suggest that weight loss surgery has healthier outcomes than diet and exercise alone.

So let’s all make a plan and get started. Thanksgiving is just around the corner.

Learn more:

A Call for a Low-Carb Diet That Embraces Fat (New York Times)
Cutting Back On Carbs, Not Fat, May Lead To More Weight Loss (NPR)
Effects of Low-Carbohydrate and Low-Fat Diets: A Randomized Trial (Annals of Internal Medicine)

Some of my past posts on diet and weight loss:

Why Losing Weight Is So Hard
Startling Scientific Finding: Dieting Leads to Weight Loss
Scientifically Proven Weight Loss Method: Eat Less

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