New York State Health Department Investigators Conclude Outbreak Of Tic Disorders Is Mass Psychogenic Illness

In a new report issued at the end of January, the New Your State Department of Health and its collaborating co-investigator organizations found no environmental or infectious etiologies for the mystery illness affecting 12 cases of tic-like behaviors at LeRoy High School in upstate New York near Buffalo.

The investigators now consider the outbreak to be conversion disorder, a disease category characterized by physical symptoms without an identified cause other than psychological stress. Three of the twelve students had illness associated with tic symptoms before they attended the high school (three new students with possible tic symptoms were reported during the investigation and are currently under review).

The details of the cases provided the investigators with clues. Cases ranged in age from 13-19 years and all were female. Onset of the symptoms was in the latter half of 2011 between May and December. The cases are in different grade levels and no common in-school or after school activities were identified, though four participated in soccer and two in cheerleading. No temporal relationship between vaccination with HPV vaccine and symptom onset was apparent. Significant life stressors were identified in 11 of the cases.

In interpreting the results, investigators determined that the occurrence of symptoms only in female students, the lack of faculty/staff involvement, and the range of time of symptom onset were not consistent with an environmental or infectious etiology.

Because of publicity surrounding a hypothesis put forth by the advocate Erin Broncovich about a chemical spill resulting from a train derailment, investigators checked out that area and found no cause for concern. Another diagnosis ruled out was Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococci (PANDAS) because none of the cases met the five PANDAS criteria.

Working with NIH, the state health department has offered all of the patients a no-cost specialized medical consultation to continue their care.

Emily The Epidemiologist Now Playing On “The Bachelor”

The Epidemiology Monitor always considers unusual situations involving epidemiologists to be newsworthy items for our readers including such situations as the one at PepsiCo where a senior epidemiologist is employed as described in our February print issue. However, one of the most unexpected situations to come to our attention this month is the one involving a University of North Carolina epidemiologist who is currently one of the contestants on the Bachelor, a popular US “reality” TV show in which young women compete to be selected by an eligible male bachelor. We investigated to learn more about the woman who is only known on the show as Emily the epidemiologist. Here is what we have learned so far from our online sleuthing.

Emily is Emily O’Brien a former psychology major at Duke University and currently a PhD student at the UNC School of Public Health who published a paper last year on whether hospital arrival day is a factor on the outcome of stroke patients. Other reports are that she named  East of Eden as her favorite book, she likes to dance, is the smartest contestant, and she is not afraid to speak out about people who exhibit what she considers unacceptable behavior. For example, she does not like skinflints on dates!

Harvard’s New Epidemiology Chair Speaks Out On Her New Job, Public Health, And Epidemiology

Michelle Williams, the new chair of the Harvard Department of Epidemiology last summer was recently interviewed for a Harvard news publication about her plans for the Department and her thoughts about the field. Here are some excerpts from the interview.

“I want to still be very much involved in the first-person moment of teaching and bringing people along. Students are freethinking, freewheeling. They’re fearless. And that helps my science. I think we all benefit from them more than we would admit.”

“The fact that in public health , our mission is to discover and to translate those discoveries into ways that change the world and alleviate or prevent suffering is a pretty amazing thing.”

“It is important for epidemiologists to continue to lead the change in documenting the adverse health outcomes of Westernized diets and sedentary lifestyles, even in low-income countries.”

“Health disparities is a huge issue here in the United States, but disparities in global health get your attention really quickly.”

An estimated 34 million people are now living with HIV, an increase of 17% over the last decade, according to UNAIDS. Why? The number of persons dying from AIDS in 2010 has fallen to 1.8 million from a peak of 2.2 million in the mid-2000’s, and an estimated 2.5 million deaths have been averted in middle to low income countries since 1995 due to the introduction of antiretroviral therapy.

There were 2.7 million new infections in 2010. This was 15% less than in 2001 and 21% below the number of new infections at the peak of the epidemic in 1997. About 1.2 million of the persons living with HIV are in the USA.

There appears to be added momentum to World AIDS Day on December 1 this year because the tools to halt AIDS are now in hand. According to UNAIDS, “We are on the verge of a significant breakthrough in the AIDS response. The vision of a world with zero new HIV infections, zero discrimination, and zero AIDS-related deaths has captured the imagination…Just a few years ago, talking about ending the AIDS epidemic in the near term seemed impossible, but science, political support, and community responses are starting to deliver clear and tangible results.

The Canadian Task Force on Preventive Health Care now recommends against routinely screening for breast cancer for women aged 40-49, but does recommend screening every 2-3 years for women 50-69 and 70-74 (Canadian Medical Association Journal, November 22, 2011) The estimated number needed to screen (NNS) to prevent one death from breast cancer in the youngest age group is 2108 for screening conducted once every 2-3 years for about 11 years. According to the recommendations, preventing this one death would also result in about 690 women having a false positive mammogram, leading to additional testing and to an estimated 75 women having an unnecessary biopsy. Estimates of overdiagnosis of breast cancer were not available for this age group but in women 39 years and older, the group estimates 5 women will have an unnecessary lumpectomy or mastectomy for every 1000 women screened. The Task Force judgment is that “this ratio of potential benefit to harm does not justify routine screening in women 40-49 years of age". The Task Force acknowledged that women who place a higher value on a small reduction in mortality and are less concerned about undesirable consequences are likely to choose screening.

Pregnant Women With 2009 H1N1 Infection Have Much Poorer Pregnancy Outcomes

A cohort of 256 hospitalized pregnant women with confirmed H1N1 infection in late 2009 and early 2010 and 1220 pregnant woman controls were followed-up by researchers at Oxford University to ascertain pregnancy outcomes. Results reported in BMJ showed that perinatal mortality among infected women was 39 per 1,000 live births versus 7 in controls, mostly due to an increase in stillbirths among the cases. These findings reinforce those which call for vaccination of pregnant women, not only for the sake of the mother, but also for the sake of the fetus.   

Public Broadcasting System Examines The Health Effects Of Income Inequality By Talking With Epidemiologists

Because of the Occupy Wall Street movement, everyone’s awareness of income inequality has been heightened recently. Also, a new report from the nonpartisan Congressional Budget Office shows just how bad the situation has become in the United States with the wealthiest segment experiencing triple digit increases (275%) in income compared to more meager increases ranging from 18-75% in other income classes. An interview with British epidemiologists Michael Marmot and Richard Wilkinson by the Public Broadcasting Service helps to understand the health consequences of these disparities. Below are excerpts from the interview in late September.

Wilkinson: Societies with bigger income differences between rich and poor do worse on a whole range of measures. They have worse health. They have more violence. They have more drug problems. Standards of child well-being are worse.

Wilkinson: Perhaps two or three times the mental illness as the more equal countries. Because, in a more unequal society, there is more status competition. We judge each other more by status, and we feel more judged.

Marmot: Health and disease are the good and bad effects of where you are in the hierarchy, mediated by the effects of chronic stress.

Wilkinson: Money becomes more important because it says what your’re worth. So people in more unequal societies work longer hours, much longer hours, are more likely to get into debt. They save less of their income.

Wilkinson: We sometimes say, if you want to live the American dream, you should move to Finland or Denmark, which have much higher social mobility.

Forbes Article Questions Scientific Soundness of IARC Conclusion On Cell Phones

A recent provocative article in Forbes online magazine entitled “Behind the World Health Organization’s ‘Cancerous’ Pronouncement on Cell Phones’ has called into question the scientific soundness of the recent IARC report which called radiation frequency from cell phones a “possible carcinogen”. The reason for the critique by Geoffrey Kabat, a cancer epidemiologist at Albert Einstein and author of “Hyping Health Risks: Environmental Hazards in Daily Life and the Science of Epidemiology”, is his conclusion and that of other epidemiologists that the bulk of the evidence shows no increased risk.

If so, how could the committee conclude that cell phones are a possible carcinogen? Kabat’s view is that non-science related factors such as the inclusion of a Swedish investigator on the committee--a vocal promoter of his finding that phone use is associated with an increased risk of glioma--gave excessive weight to this limited evidence considered potentially very flawed by some epidemiologists familiar with the study.

Another explanation is contained in the remarks of a committee member who told Kabat that the IARC “wanted to send a message” that we still have limited information about the possible effects of cell phones, particularly among children, and that a clean bill of health for cell phones is premature. That seems hard to argue with from a public health perspective.

Actually, Kabat’s objection appears not to be with the IARC’s conclusion, since indeed the data on cell phone risk are still limited and monitoring has not been carried out long enough to be fully convinced about the safety, but with the IARC’s terminology. He calls the term “possible carcinogen” as it applies to cell phones an “ambiguous label” and “unfortunate” because it means one thing to scientists working for IARC and something different to the general public. Thus, it seems the IARC report is problemmatic more from a communication than a scientific perspective.

Kabat warns that the label chosen—possible carcinogen-- is likely to be misused in the future to make it seem that we have more of a risk than the evidence justifies. He reminds readers that we need to rely on scientists to use clear language to tell us what things are worth worrying about.

To read the Forbes article, visit:
 http://www.forbes.com/sites/realspin/2011/08/23/world-health-organization-cancerous-cell-phones/
 

Times Reports Death of Bruce Dan Who Helped Link Tampons and Toxic Shock Syndrome

Bruce Dan, a medical television personality, who helped link tampons and toxic shock syndrome while working as an EIS Officer at the CDC, died in Baltimore on September 6 at age 64, according to a recent obituary in the NY Times. The obituary details the history of the investigations in 1980 which found that a large group of cases occurred in menstruating women using tampons. One brand of tampons, Rely, carried a higher risk because its lubricant increased the level of toxins in the bacterium. According to the Times, Rely was removed from the market and other brands were redesigned to help prevent bacterial growth. In 1981, Dan and others received the Langmuir Prize for epidemic investigation and a US Public Health Service Commendation Medal. To read the full obituary, visit the Times online at:

http://www.nytimes.com/2011/09/11/health/research/11dan.html

What Is A Computational Epidemiologist?

The recent article in Science Times described above referred to an assistant professor of pediatrics at Harvard as a leader among self-described “computational epidemiologists”. Since the term was unfamiliar to us and we are always on the lookout for new applications of epidemiology, we made an inquiry. Wikipedia has a short three sentence definition as “a multi-disciplinary field utilizing techniques from computer science, mathematics, geographic information science, and public health to develop tools and models to aid epidemiologists in their study of the spread of diseases. It differs from bioinformatics in that it is centered more around studying how diseases spread, and not the actual disease itself.”

Another unfamiliar term in the article was “crowdsourced epidemiology”. According to Wikipedia, crowdsourcing is “the act of outsourcing tasks, traditionally performed by an employee or contractor to an undefined, large group of people or community (a "crowd"), through an open call.” In epidemiology, one application of this is the mobile application Outbreaks Near Me which has been downloaded by thousands of persons and through which persons have reported outbreaks. Questions arise as to whether or not this type outbreak detection has any advantages over the more traditional approaches because the reporters may not be representative and can skew the information. This limitation applies to many other potential uses of  “public science”.

“When you can measure what you are speaking about, and express it in numbers, you know something about it. But when you cannot, your knowledge is of a meager and unsatisfactory kind.” This quote attributed to Lord Kelvin seems to have been taken to heart by Columbia University epidemiologist Sandro Galea and colleagues. They surveyed the literature between 1980 and 2007 to identify studies with estimates about the link between social factors and adult all-cause mortality, calculated summary relative risk estimates, obtained population level estimates of the prevalence of each factor, and calculated the population attributable fraction for each factor. They found that approximately 245K deaths in 2000 attributable to low education, 176K to racial segregation, 162K to low social support, 133K to individual level poverty, 119K to income inequality, and 39K to area level poverty.

Galea was quoted in the NY Times saying “If you say that 193,000 deaths are due to heart attack, then heart attack matters. If you say 300,000 deaths are due to obesity, then obesity matters. Well, if 291,000 deaths are due to poverty and income inequality, then those things matter too.” In their paper, Galea and colleagues conclude that “these findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations.”  Co-authors in the AJPH June issue were Melissa Tracy, Katherine Hoggatt, Charles DiMaggio, and Adam Karpati.

The outbreak of shiga-toxin producing E.coli (STEC) in May and June 2011 in Europe has now totaled 265 cases with Hemolytic Uremic Syndrome (HUS) and 3151 non-HUS cases and there have been 42 deaths, all but one in Germany. A report from the European Food Safety Authority in early July implicated a particular lot of fenugreek seeds imported from Egypt in December 2009 [http://www.efsa.europa.eu/en/supporting/doc/176e.pdf].

Several seed types (alfalfa, fenugreek, lentils, adzuki beans, and radish) were suspected in Germany, however, a separate cluster of cases occurring in France in June 2011 gave investigators an important clue. While three types of sprouting seeds were implicated in France (fenugreek, mustard, and rocket), only fenugreek seeds were common to both outbreaks. They became the focus of the investigation and were traced back to Egypt. Results from the microbiological tests carried out on seeds have been negative, possibly due to the limitations of the tests used or the sampling plan used to select the seeds for testing.

The hypothesis is that the fenugreek seeds became contaminated with STEC 0104:H4, the implicated agent, at some point prior to leaving the Egyptian importer. According to the report, this reflects a production or distribution process which allowed contamination of fecal material of human or animal origin, possibly at the farm level but still not established.