Closing the loop on raw milk legislation

Earlier this year I blogged several times about raw milk and the movement advocating drinking it. One of those posts mentioned the Milk Freedom Act of 2014, a bill introduced by Rep. Thomas Massie of Kentucky, which, if passed, would have

Prohibit[ed] a federal department, agency, or court from taking any action that would prohibit, regulate, or otherwise restrict the interstate traffic of milk or a milk product that is unpasteurized and packaged for direct human consumption if such action is based solely upon a determination that because the milk or milk product is unpasteurized it is adulterated, misbranded, or otherwise in violation of federal law.

Just to circle back and check up on the status of the bill, it seems to have gone nowhere. The only echoes that came up in a quick Google search were comments attributed to Massie at a meeting called the "Food Freedom Fest" in September. The comments appear on a food rights and raw milk blog by David Gumpert:

U.S. Congressman Thomas Massie . . . was pessimistic about the chances of actually passing anything in the House of Representatives. Indeed, it isn’t even likely the legislation will get a hearing. “The dairy industry went apoplectic when we introduced the legislation,” he said. “My wife said she didn’t know the lactose industry was so intolerant.” . . . Massie told me after his talk that the best chance to get raw milk legislation through Congress and into law would be as part of some other appropriations bill guaranteed passage. Even that route is a long shot, he said, since not many appropriations bills are likely to get through in the coming year or so.

An alternate interpretation of these comments could be that a bill at odds with the basic tenants of food safety and that would place public health at risk if passed was opposed by corporations who have invested immensely in an infrastructure to deliver safe food. The only way that the bill might get passed is if it piggy backs onto a large appropriations bill, but that probably won't happen because the Congress isn't doing much these days anyway.

So, we can all rest well knowing that the Milk Freedom Act of 2014 will never see the light of day. Thank goodness for a Congress that perfected the art of doing little.

(image source: David Hartley)

An IGY for medicine

It's been an interesting first year of blogging, and I want to thank everyone for their helpful input and conversations. It's really been great.

The year 2015 will soon be upon us, bringing with it new opportunities for improving human health across a world fractured with poverty, strife, and war. Robert F Kennedy once said that

There are those that look at things the way they are, and ask why. I dream of things that never were, and ask why not.

This strikes me as an appropriate notion for healthcare and medical research. We should ask "why not?" and "what if?" much, much more often.

A little over 50 years ago an event unfolded that provided both hope for peace and a better understanding of our planet. Lasting for 18 months in 1957 and 1958, it was called the International Geophysical Year (IGY). The idea of an IGY is said to have originated in 1950, at a social gathering in James Van Allen's living room. Someone at the gathering opined that, with the recent development of tools like rockets, radar, and computers, a period of coordinated investigation could make a real impact on understanding the geosphere.

The IGY was thus an attempt to coordinate global research on, and measurements of, the earth, oceans, atmosphere, and sun. The accomplishments of the IGY were legion and included the discovery of the Van Allen radiation belts surrounding the earth; the launch of the first artificial satellites; the charting of ocean depths and ocean currents; and groundbreaking studies of the earth's magnetic field. The IGY required -- and successfully achieved -- international cooperation in a time of significant geopolitical tension. It provided a demonstration of what can be achieved when diverse peoples, who share common and coordinated goals, work together with cutting edge technologies.

Why couldn't we adapt the idea of the IGY and have a future International Biomedical Year, where nations apply tools such as supercomputing, machine learning, and genomic sequencing in a coordinated investigation of the ills plaguing human health? The idea would be to plan collaborative and complementary studies in order to accomplish agreed upon, viable steps toward solutions to important problems.

Admittedly, this is a pipe dream, but why not? What if the world's major government and non-government funding organizations closely coordinated their activities on a truly international, focused initiative? Maybe we could cure one or more cancers, or learn how to cut the incidence of heart disease, or finally understand Alzheimer's disease.

Let's try to ask "why not?" and "what if?" more often in 2015. And may you prosper and be well in the coming year.

(image source: Wikipedia)

Mumps on ice

The mumps vaccine was licensed in the US in 1967 and recommendations regarding use of the vaccine have varied since its introduction. As described in the CDC Manual for the Surveillance of Vaccine-Preventable Diseases, the Advisory Committee on Immunization Practices (ACIP)

made an official recommendation for one dose of mumps vaccine for all children at any age after 12 months in 1977. In 1989, children began receiving two doses of mumps vaccine because of the implementation of a two-dose measles vaccination policy using the combined measles, mumps, and rubella vaccine (MMR) vaccine. In 2006, a two-dose mumps vaccine policy was recommended for school-aged children, students at post high school educational institutions, healthcare personnel, and international travelers.

Mumps vaccine has had a profound impact on the annual incidence of mumps in the US. In 1968 more than 152,000 cases reported, while in 2003 only 231 cases were reported. Recently, however, the nation has witnessed a resurgence of the disease, and an apparently ongoing outbreak of mumps in the National Hockey League (NHL) illustrates how the mumps virus continues to circulate in the general population. The NHL outbreak has, so far, affected 15 players on five teams, and another three cases are suspected. A timeline of events surrounding the cases suggests the outbreak originated in October.

Doni Bloomfield wrote an article this week (which also contains "mumps on ice" in the title) that, in one vivid passage, illustrates potential infection pathways for mumps virus in professional hockey. Bloomfield quotes James Conway of the University of Wisconsin School of Medicine and Public Health:

You watch these guys taking a big hit up against the boards, there’s snot and boogers and all sorts of stuff flying around as the guy gets hit hard enough, so I don’t think it would surprise me at all that there’s some transmission just by stuff flying around during the games. It’s a sloppy, messy sport.

That's colorful imagery for sure, but in addition to how, it's important to ask why this and other recent outbreaks are occurring. Mumps is, after all, a vaccine preventable disease. 

It's possible that this group of players belongs to a demographic that has lower vaccine coverage, potentially due to parental reticence to vaccinate. However, at least one player is known to have had two doses of vaccine: one childhood dose, consistent with ACIP guidelines in the late 1980s, and another in preparation for foreign travel in February of 2014. Tara Haelle wrote an article recently on the mumps vaccine in which she quotes Paul Offit discussing the rate of waning immunity associated with this vaccine. Offit notes that

If you look at the three [MMR component] vaccines, measles and rubella induce larger memory in B and T cells . . . They have longer lasting immunity. Mumps is the weak sister of the three. You start to see vulnerability 10 years after the first dose and 10 years after the second dose.

Waning vaccine-associated immunity could thus play a role in this outbreak, and in potential future ones as well. Boosters have been used to compensate for waning immunity in past mumps outbreaks. Might a third dose of vaccine be appropriate for the general population at some point in the future?

(image source: CDC)

The epidemiology of Fearbola

In the mid-19th Century, a newspaper could reach several thousand people daily or weekly. By the mid-20th Century, TV and radio reached 10s to 100s of millions of people instantaneously and possessed a multinational reach. Today, with the Internet, and satellite TV and radio, it is possible to reach 100s of millions of people or more across the globe within minutes. This vast and practically instantaneous reach of technology feeds a seemingly insatiable, 24/7 appetite for news and information. What are the implications of this for fighting epidemics? 

We've seen some of the consequences in the Ebola outbreak this year. On the one hand, the ability of aid groups to spread information broadly has been helpful for raising awareness and bringing additional resources to bear on the epidemic. On the other hand, news headlines resulted in near-hysteria and much counterproductive behavior in the US and other developed nations. Examples were highlighted in a previous post, and many, many others have offered similar observations and commentary.

Perhaps the reactions observed in the US have been understandable, as many ingredients were present for an epidemic of sensationalism and fear: An active public imagination rooted in previous popular books and movies, a government that addressed the issue late and with almost Pollyannaish credibility at first, and a wealth of news outlets offering non-expert commentary while playing to the continuous news cycle.

The resulting epidemic of "Fearbola" should thus not be surprising. It is sobering, however, for it provides a warning for domestic public health agencies: Understand how to administer effective public health messages that are relevant and appealing to the constant clamor of CNN, Fox, and the like, or else risk being drowned out by noise and hype. What if this epidemic had been of a pathogen possessing a short serial interval and high virulence, transmissibility, and R₀? The medical system may or may not be prepared, but it seems clear that our risk communication strategies are not. Would the news coverage we saw during the Ebola hysteria in recent months have served the public well if this had been a bona fide threat to US public health?

It's important to understand how the epidemic of fear and hype came into being and propagated so well. I tend to think of messages as themselves being infectious. From that perspective, the ideas that resulted in the hysteria surely had R₀ > 1. For ideas related to "dread threats", such as virulent infections with no known cure, is this unavoidable given the high contact rate (e.g., frequency of checking for news and rumors combined with near-constant coverage), short serial internal (e.g., rush to post on social media), broad coverage, and rapid dissemination of modern communications?

If so, we must learn how to craft public health messaging strategies so that authoritative messages will out-compete hype and fear in our hyper-connected world. If we don't learn how to do so, we run the risk that important messages will be drowned out by high-incidence, fearful messages in future outbreaks of international public health importance.

(image source: David Hartley)