MPH Master pieces

British citizen dies of rabies

By an awful coincidence, it was reported today that a British patient who contracted rabies while on holiday in Morocco has died of the disease. I don't want to make any big thing out of a tragedy but it does confirm that you have to be prepared for rare events. 

Rabies

Rabies is almost unknown in the UK but that doesn't mean it can't happen. This is the latest guidance. More detail than you need unless dealing with an incident but it's one of those things which is worth skimming now so that when you do need it, you remember it exists

Cardiac screening of footballers

The death of any young person is a tragedy. When that death occurs suddenly on a football pitch, in plain view of millions of viewers, the tragedy soon becomes a call for action - why was this elite athlete not given a proper medical? How could they have missed a lethal cardiac problem?

The Football Association rose to the challenge and here are the results. It's an impressive piece of research carried out over 20 years. The conclusion, alas, is that screening is most of the sudden cardiac deaths would not have been prevented by screening. Whether it's worth doing anyway is another question. The report doesn't seem to indicate any harms, and given this programme is run for professional footballers it isn't taking resources away from other more effective healthcare programmes. What do you think?

Typhoid

Typhoid update: the balance has changed between treatment (used to be good) and vaccine (used to be useless) for typhoid: see here for the latest thinking. 

Folate

Well! It seems from a news story that the British government is about to introduce folate fortification of foodstuffs. 

The story starts in the 1970s when Smithells, studying neural tube defect, found that mothers of children with NTD had low folate levels. Wald then ran a classic trial which showed convincingly that folate supplements reduced the risk of a second affected pregnancy in a woman who had already given birth to an affected child. It's known that the neural tube forms and closes very early in gestation, and certainly before the mother will realise that she is pregnant - hence any folate supplementation has to be done pre-pregnancy. That pretty much rules out supplements as a population strategy to reduce NTD, except perhaps n the USA where taking all sorts of vitamins and supplements is remarkably common. Hence the idea of putting folate into an ordinary foodstuff - flour. There is a precedent from the success of putting iodine into salt to eliminate goitre and endemic cretinism 

But folate in flour has its opponents. Some people object to anything they dub mass medication; and the folate will of course do no good to any male, or to any female too young or too old for pregnancy. Not only won't do any good, but it may just possible do harm: giving folate to someone who has a deficiency of vitamin B12 (e.g. old people with very poor diets) can precipitate sub acute combined degeneration of the spinal cord. Furthermore, NTD seems to be on the way out anyway - the incidence of NTD has been dropping since the 1970s, presumably due to overall improvements in the availability of salad and green vegetables. (Note that to study NTD incidence accurately you need to add abortions to the birth prevalence - birth prevalence of NTD is particularly high in Northern Ireland because abortion remains illegal there.)

However, as blogged here 10 years ago (this is an ongoing saga) many jurisdictions already fortify flour with folate, and the result seems to be the good without the harm. 

Of course whether a government consumed by Brexit is capable of doing anything about anything remains to be seen. 

 

Policy approaches to diet related disease

This short piece could almost serve as a model answer in an exam on 'policy approaches to diet related disease'. Essential reading therefore for this blog's target readership!

Suicide trend

Welcome news from the Office for National Statistics: suicide is on the decline. ONS always sticks to the facts, so no suggestions as to why, but three possibilities come to mind:

• better treatment
• access to the means of suicide is becoming more difficult
• something else

I haven't put 'everyone is happier' as a fourth possibility because mental illness and feelings of wellbeing are not opposites - they sit on different continuums. 

The 'better treatment' argument is an interesting one. Remember that every serious mental illness (e.g. bipolar disorder, schizophrenia) increases the risk of suicide - not just depressive disorder. It's a slight worry that we are now seeing a backlash against anti-depressive drugs. Certainly they are over-prescribed; but also they are very effective when indicated - baby and bathwater dudes!

Restricting access to the means of suicide probably helps. The initial evidence came from a dramatic reduction in suicide when the gas supply in England changed from coal gas (lethal) to North Sea (not): people did not switch to an alternate means and the overall rate reduced. Currently there is a focus on barriers at jump bridges and action at railway stations. 

It used to be true that medicine was a high risk occupation for suicide - again probably a question of access: doctors know how to kill themselves and eavready access to an array of drugs. But now the opposite is true - doctors have a particularly low rate. Difficult to think why the change has occurred. 

Lastly you should read the note on how suicide is defined in official statistics. 

Contaminated blood

A public inquiry is under way to investigate the disaster that befell people with haemophilia. But sometimes when you don't even know the virus exists. A paper written in 2012 said this:

'There are 219 virus species that are known to be able to infect humans. The first of these to be discovered was yellow fever virus in 1901, and three to four new species are still being found every year.'

Really the only way forward is to remember that all treatments carry risks, and the benefit conferred by the treatment must be worth having. 

Here is the latest annual report from NHS Blood & Transplant on infections. 

Medicaid expansion and infant mortality

More evidence that free health care is worth protecting. Under Obama's Affordable Care Act, there was an option to increase Medicaid coverage, to include for example contraception, and pregnancy and maternity care. Thirty one states agreed this option; the other 19 declined, thus creating a natural experiment. Infant mortality went up (albeit slightly) in the 19 that declined, and went down in the other 31. The difference was greatest for African Americans.

Of course this is observational data, and the states which declined the expansion were an interesting group, politically and socially.  

Screening women for AAA

To a surgeon faced with the devastating effects of late-stage disease - an enormous cancer, or a ruptured aneurysm - the answer seems straightforward: screen epos to catch the disease early when surgical cure is safe, simple and possible. It doesn't take long in public health to realise that life is, alas, more complicated than that.

Here is an excellent discussion based on the question of screening women for abdominal aortic aneurysm. Even elective surgery on small aneurysms is major surgery, and some women will die during the operation:

'Apart from concerns about cost-effectiveness, there are ethical dilemmas associated with the use of AAA screening. That the health-care system causes the death of healthy citizens by inviting them to an intervention that they have not asked for is ethically problematic. It is not as simple as a matter of net benefit in terms of mortality because it is not clear that a death saved by screening equals out a death caused by screening—such strict utilitarianism is hardly acceptable.'

One issue not mentioned is question of gender-specific screening programmes. There is an obvious biological rationale for gender specific screening for breast cancer (but remember that men also get breast cancer) but in this case gender is really just a marker - men have traditionally smoked more than women and smoking confers an increased risk of AAA. Screening men is a way of picking off a high risk group. Logically, and given that smoking habit should now be recorded in all GP practices, the target for screening should be defined by smoking status not gender.