Month: March 2017

The Right Tool

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fullsizerender“I’ve got to use the right tool,” I thought to myself as I attempted to pound a nail into the wall with the bottom of my coffee cup. Kneeling on the exam room table, I was attempting to hang a picture on the wall before the clinic day began. I have all sorts of useful tools in my clinic – scalpels, special scissors and a multitude of precision instruments for surgical procedures and other medical care. But on that day I did not have a hammer for pounding in a nail to hang a picture. I smiled, and reflected on how comical I must look, awkwardly perched on the exam room table trying to put a nail in the wall with a coffee cup. I had opted for what was convenient but not what was appropriate. Without the right tool, I was not successful in getting my job done and was wasting valuable time. Hoping I was now a little wiser, I climbed off the exam table with the picture, walked back to my office, picked up my stethoscope, and began the clinic day seeing patients.

Using the right tool is critical. I was immediately reminded of this as my first patient – a 65 year old man – came in for a physical. As is the case for many Americans, the biggest threat to his health was the risk of having a heart attack or a stroke. He had several important risk factors for heart disease: he was overweight, had high cholesterol, high blood pressure, and was recently diagnosed with diabetes. He needed to lose weight, but weight loss was difficult for him. During the course of the visit we discussed his weight, and he shared with me that he was trying the “Ketosis Diet” to help him lose weight. He had read about this diet on the internet and purchased a book. He explained the diet was rich in cheese, bacon, and other meats. Apparently by avoiding all carbohydrates and eating mostly fat, one loses weight. The diet fit in nicely with his existing eating habits. After considering his diet, I cautioned that the types of foods he was eating were exactly the type of foods medical research recommends avoiding to prevent heart disease. I attempted to steer him towards the right tools – heart healthy foods and physical activity – for his job, the job of preventing a heart attack.

When it comes to preventing disease, individuals need to stop pounding nails with coffee cups. Pounding a nail requires the right tool: a hammer. When it comes to medicine, the hammer is science. Evidence based research – the scientific process – is the perfect tool for promoting health and has an excellent track record. Modern medicine has been successful at preventing and treating disease because of the scientific process. To make health decisions based on the latest internet popular opinion is using a coffee cup instead of a hammer to pound a nail.

Healthcare providers need the truth of science to guide them in making sound recommendations for both individual patients and for the population as a whole. Vaccines are a perfect example. Vaccine medicine is medical science at its best, in that it offers a clear example of scientific research that originates in the laboratory, and that is later applied to people and populations to prevent deadly infections. Every day, vaccines prevent diseases that could have been; every day, vaccines save lives. Thanks to science, Polio is almost eradicated from the globe and the Americas have been declared free of Measles. Meanwhile, looking forward into the future, Zika – a more recent threat – may well prove to be a short chapter in history books, as a number of promising Zika vaccines are currently undergoing clinical trials. Vaccine science is the right tool to prevent infectious disease.

The scientific process is critical not only for advancing medical care and vaccine science, but is vital to all realms of scientific research. Whether it is medicine, public health, or climate change, science is the best tool to understand our world. Science has a proven track record; it works. The alternative to using science is nothing more than a popularity contest of opinion. If we as a society choose to value proclamations devoid of facts over scientific research, we might as well equip all the carpenters in America with coffee cups. We need to choose the hammer and get the job done; science is the right tool to improve health, prevent disease, and has the potential to make the world a better place.

Medical Detectives Explore Mystery of Mumps Outbreaks

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The past year was a big year for the mumps virus. With 5,311 cases in 2016, the United States experienced the most mumps infections since 2006. The majority of the outbreaks occurred in the Midwest, however Washington State recorded 486 cases in the past 5 months. Mumps was a very common viral infection prior to the development of a vaccine in 1967, and for over the past 50 years has been well controlled. In attempting to understand the recent increased number of mumps infections, a rational explanation is that the affected individuals had not received all of their routine MMR (Measles, Mumps and Rubella) shots. However, the mumps infections have in fact occurred in populations where individuals have been up to date on their shots, having received the recommended two doses of MMR at around 1 and 4 years of age.  The question remains then, why has the mumps virus made such a commotion this past year?  Has the mumps vaccine become less effective? What does this mean for routine MMR vaccination in the United States? The recent rise in mumps cases has raised intriguing questions such as these for scientists to explore and attempt to answer.

 

A very refreshing aspect of the scientific process is that when events don’t quite make sense, scientists approach a problem by attempting to observe and note the facts, and then study the possibilities with objective research. With the recent increase in mumps infections, researchers are actively involved in the process of being “medical detectives.” They are looking at the data, evaluating possibilities, and figuring out how to test their ideas. While we do not yet know why the mumps outbreaks have occurred, there are clues that may offer insight into this mumps mystery.

 

The mumps infections have typically occurred in vaccinated populations, in which people have been living in high density environments, such as college campuses. This close proximity makes transmitting germs easier. Meanwhile, the mumps component of the MMR vaccine is good at preventing mumps infections, but not quite as good as the measles and rubella components. For example, the measles vaccine prevents measles infection with about a 98% success rate. Mumps “vaccine efficacy” is a little lower, at approximately 88%. This slightly lower vaccine efficacy can allow the infection to spread more readily. In addition, after a child receives the second MMR at age 4, the level of mumps protection declines gradually over time, which also increases the possibility of infection. All of these reasons – high density living situations, good but not great vaccine efficacy, and declining immunity over time – may have contributed to the mumps outbreaks.

 

However, perhaps some the most fascinating reasons why mumps has had a big year may have to do with the “big picture” perspective. Scientists know that some viruses naturally go through cycles over time, where infections increase at somewhat regular intervals. For example, before the advent of the rubella vaccine, rubella epidemics occurred every 7-8 years. It is possible that mumps may have a similar natural history, and perhaps this past year was time for a natural epidemic to occur. If this is the case, the vaccine could have blunted the spike of infections but not prevented it altogether. With this hypothesis in mind, it will be interesting to see if mumps naturally quiets down over the next couple years on its own accord.

 

In addition, measles and rubella have been completely eradicated from America, such that new cases in The United States are imported from travelers arriving from other countries. Mumps on the other hand has not been eradicated from America, and may be circulating within the country more than previously thought. It is known that approximately one third of mumps infections occur without symptoms, which in turn could enhance spread of the virus without our awareness, or “below the radar.” This phenomenon could have contributed to the increased number of infections. These are some of the thoughts scientists are considering, but they are only ideas at this time. Similarly, it may make sense for a third dose of MMR in the setting of a local outbreak; however, objective data is necessary before making this change.

 

Lastly, an interesting – and reassuring – observation from the recent mumps outbreaks is that while mumps infection occurred in several thousand people this past year, no complications of the infection have been seen. Before the vaccine was routinely used, mumps infection was associated with a 4% risk of hearing loss, 4% risk of pancreatitis, 30% risk of inflammation of the testes or ovaries, and resulted in approximately 5% of patients becoming hospitalized. This raises the question of whether those recently infected with mumps in fact had enough protection from the vaccine to prevent potentially serious complications. At this time we don’t know, but this is another hypothesis that scientists are exploring.

 

Medical epidemiologists are doing their fact checking in an attempt to understand the mumps outbreaks better. While science may sometimes be portrayed in the popular media as stodgy or lacking creativity, our current mumps mystery illuminates just how creative science can be with problem solving. Scientists have to “think outside the box” to figure out these problems, both in formulating possible explanations as well as determining how to use the scientific process to test their ideas. In addition, nothing is a given- no matter how good an idea it may seem – until it is supported by the evidence of high quality research. In fact, in science nothing is really ever permanently a “given” as science promotes an ongoing process of evaluating and reevaluating. However, the more research studies that come to the same conclusion, the more likely a concept may be true.

 

While there have been an increased number of mumps cases this past year throughout the country, and it is not entirely clear why, there are interesting observations – or clues – for researchers to explore. It will be exciting to see what our creative, problem solving medical scientists discover. In the meantime, be sure to encourage MMR childhood vaccination.  A profound consideration is that use of the MMR vaccine has reduced mumps infection by approximately 99% compared to the pre-vaccine era.