Measles - NYC Health Special Edition

Recent Infections in Brooklyn and Queens

As of April 8, 2019, there have been 285 confirmed cases of measles in Brooklyn and Queens since October. Most of these cases have involved members of the Orthodox Jewish community.

The initial child with measles was unvaccinated and acquired measles on a visit to Israel, where a large outbreak of the disease is occurring. Since then, there have been additional people from Brooklyn and Queens who were unvaccinated and acquired measles while in Israel. People who did not travel were also infected in Brooklyn or Rockland County.

The neighborhoods that are affected include:

• Bensonhurst: 1 confirmed measles case (no additional cases since November 2018)
• Borough Park: 49 confirmed measles cases (no additional cases in the past week)
• Brighton Beach: 1 travel-related case
• Crown Heights: 1 (no additional cases in the past week)
• Midwood/Marine Park: 3 confirmed measles cases (no additional cases in the past week)
• Williamsburg: 228 confirmed measles cases (26 additional cases in the past week)
• Flushing: 2 confirmed cases (no additional cases in the past week)

Vaccination Requirement

On April 9, the Health Commissioner ordered (PDF) every adult and child who lives, works or resides in Williamsburg and has not received the measles-mumps-rubella (MMR) vaccine to be vaccinated. People who demonstrate they are immune from measles or should be medically exempt from this requirement will not need to get vaccinated.

If the Health Department identifies a person with measles or an unvaccinated child exposed to measles in Williamsburg, that individual or their parent or guardian could be fined $1,000.

Measles is a virus that causes fever and a rash. It is highly contagious and anyone who is not vaccinated against the virus can get it at any age.

Although measles is rare in the United States because of high vaccination rates, it is still common in other parts of the world. Measles is common in some countries in Europe, Asia, and Africa and is occasionally brought into the Unites States by unvaccinated travelers who return with measles infection.

Measles is spread through the air when an infected person sneezes or coughs. A person will start being contagious four days before a rash appears. They will stop being contagious four days after the rash appears.

The virus remains active and contagious on surfaces for up to two hours.

Symptoms

Symptoms usually appear 10 to 12 days after exposure to the virus. In some cases, symptoms may start as early as seven days or as late as 21 days.

 Early symptoms include:

• Fever
• Cough
• Runny nose
• Red, watery eyes

Three to five days after initial symptoms, a rash of red spots appears on the face that then spreads over the entire body.

Anyone can become infected with measles, but the virus is more severe in infants, pregnant women and people whose immune systems are weak. Complications of measles include:

• Diarrhea
• Ear infections
• Pneumonia (infection of the lungs)
• Encephalitis (swelling of the brain)
• Premature birth or low-birth-weight in pregnancy
• Death

Prevention

Vaccination is the best way to prevent measles. Anyone who has received two doses of a measles-containing vaccine is highly unlikely to get measles.

MMR Vaccine

A child should get a measles vaccine on or after their first birthday. The vaccine is combined with mumps and rubella vaccines into one vaccine called MMR (measles, mumps, rubella). A second dose of MMR vaccine is recommended before children enter school at 4 to 6 years of age. Infants ages 6 to 11 months should also receive MMR vaccine before travelling internationally.

Anyone born after January 1, 1957, who has not received two doses of a measles-containing vaccine, or who does not have a blood test proving that they are already immune to measles, should receive two doses of the MMR vaccine.

For information on where you or your child can get vaccinated, call 311.

Measles - NYC Health

Jim Jordan And Mark Meadows Warn Drug Companies Not To Cooperate With Congressional Investigation

Drug prices have soared and as Congress begins to investigate, Congressman Jim Jordan and Mark Meadows warn drug companies not to cooperate with a congressional investigation.

Congressional Hearings on Drug Pricing

L-Congressman Jordan R-Congressman Cummings (chair)

The House Oversight Committee is attempting to study how drug companies set prescription drug prices, but Republicans have warned the industry that it may be better for them not to cooperate. 

Republicans on the House Oversight Committee sent letters to a dozen CEOs of major drug companies warning that information they provide to the committee could be leaked to the public by Democratic chair Elijah Cummings in an effort to tank their stock prices.

Cummings requested information from 12 drug companies such as Pfizer Inc., Johnson & Johnson, and Novartis AG in January as part of a broad investigation into how the industry sets prescription drug prices.

“Rep. Jordan is on the absolute wrong side here,” Cummings said in a statement  “He would rather protect drug company ‘stock prices’ than the interests of the American people.”

Cummings seems to be bragging about an “astronomical” impact on drug company stocks. In the context of his statements before and after, he seems to be saying the “astronomical” impact is on taxpayer savings, which justify giving his committee more resources. A minute later he says: “Whatever you all give us, we will give it back in savings by rooting out fraud, waste, and abuse.”

There is no doubt that Pharma stock prices are going to be affected by cost containment measures. PBMs (pharmacy benefit managers) have had a paradoxical effect on drug prices. The PBMs interact with large health plans and hold a large market share of prescription drugs.  Patients most affected by rising drug prices are those without insurance coverage.

The Health 202: Pharmacy middlemen are under scrutiny for pushing up drug prices

The middlemen who negotiate the prices paid by consumers at the pharmacy counter — known as pharmacy benefit managers — face their own Senate grilling tomorrow over the role they play in making drugs more expensive in the United States than anywhere else. 

The story of U.S. drug costs is a hugely complicated one and its villain shifts depending on which part of the drug supply chain is telling the tale. When pharmaceutical executives had their turn at the Senate Finance Committee in February, they characterized the PBMs as the bad guys, complaining that these third-party negotiators don’t pass drug discounts along to consumers but pocket them instead. Yet here’s an important piece of context to keep in mind, one that PBMs are likely to share with senators tomorrow: It’s the pharmaceutical makers who pocket by far the largest share of gross revenue from drug sales. Two-thirds of U.S. spending on pharmaceutical drugs in 2016 were captured by drug companies, while just 4 percent were captured by PBMs.

None of this is new, as we depict another hearing from years ago

Senator Everett Dirksen drug price hearing (circa 1960)

Dirksen, center holding glasses

Republicans Jim Jordan And Mark Meadows Warn Drug Companies Not To Cooperate With Congressional Investigation: 

Medical Students Speak Out About 'Disregard for Science' in Abortion Legislation

Alexandra Bader, Robyn Hanna, and Grace Oliver

Comments in italics are those of Health Train Express

From an early age, we are taught to believe those in power make educated decisions that are democratic and moral. However, elected officials are asked to create laws relating to a vast array of subjects, an impossible task for even the most motivated and well-informed individuals. Recently, we have been confronted with the limits of their knowledge and how this limitation yields uninformed laws that will negatively affect our lives, our patients, and our future practice. We encourage fellow medical students and physicians to harness their expertise and social capital to prevent the indoctrination of policies that are not grounded in scientific fact.

Not only is this deeply concerning to us as future physicians, but also as female citizens. It is alarming to observe the easy passage of a bill concerning the life and bodies of women by a predominantly white male legislative body. Trust is a vital part of the doctor-patient relationship and built through the development of an understanding of each patient’s unique values, goals and priorities. Our role as physicians is to aid patients in achieving their best quality of life and health by educating them on various efficacious treatment options and facilitating the best treatment plan for them. We do not make their decisions for them, rather we walk with them on the path of their choosing. Our grievance with Arkansas’ SB149 is not solely that it lacks a foundation in scientific fact, it also hampers the doctor-patient relationship and the individual autonomy that patients are entitled to as human beings.

An example of this limitation in action is the abortion trigger law Arkansas SB149. Within less than a month, this perilous piece of legislation was signed into law, making abortion automatically illegal in the state of Arkansas if Roe v. Wade is overturned.

The disregard for science the legislators hold became obvious when we answered the representatives’ questions during my testimony at the Health and Public Services Committee for SB149. It was evident that 1) the senators had their minds made up prior to entering the room and, 2) many senators did not understand the topics being discussed in this bill. When we tried to clarify misunderstandings, we were repeatedly cut off. Fact and science had little bearing in their decision — it was more convenient to use vague language that represents their personal beliefs than, say, to understand the distinctions of an emergency contraceptive versus an actual abortifacient. Science and data do not serve as the foundation of their governance over reproductive health, but rather inflammatory oration.

As citizens, we give elected representatives great power to regulate many aspects of our lives without requiring them to have the knowledge needed to properly inform their decisions. It would be unfair to expect them to be experts in their own right on everything over which they have influence. Therefore, we assert that legislators have a moral obligation to their constituents to seek expert assistance to better understand concepts with which they are unfamiliar. It became abundantly clear during our testimony that the men voting on this item did not have sufficient understanding of the concepts mentioned in the bill’s text to be able to appropriately consider its consequences.

Unfortunately this is true of many decisions made by state, local and federal representatives. "Politically naive"  students are fodder for cynical experienced legislators who act not on scientific evidence but on popular local beliefs, myths, religious concerns and/or fixed, false beliefs. Failure to recognize some politicians vote to be re-elected. Students frequently do not recognize not all subscribe to the ideals of physicians or physicians to be. It will always be an uphill battle to make meaningful change.

We urge our healthcare colleagues to leverage their credibility and medical knowledge to help influence our society for the good of our patients and our field. Patient care extends beyond the exam room. Health is our lane; our expertise, experience, and voices are urgently needed.

Health Train Express is glad to have you aboard as future physician leaders

Reference: This post is from Doximity Op-ed, a physician social media website.

Medical Students Speak Out About 'Disregard for Science' in Abortion Legislation

Crisis at the Border, Volunteer Doctors Struggle To Provide Stopgap Care To Immigrants | Kaiser Health News

It wasn’t the rash covering Meliza’s feet and legs that worried Dr. José Manuel de la Rosa. What concerned him were the deep bruises beneath. They were a sign she could be experiencing something far more serious than an allergic reaction.

Besides the obvious, the doctor wonders "Has this child been immunized"? What other illnesses could the child have had, and what is he now carrying?

The doctor is also thinking about the possible hundreds of children who are not being vaccinated due to the false myth that vaccination causes autism.  Vaccination for mumps, measles, rubella, polio and other diseases we rarely encounter in the United States.

Exemptions Surge As Parents And Doctors Do ‘Hail Mary’Around Vaccine Laws

CDC recommendations and information about Vaccination

 In the absence of a coordinated federal response, nonprofit organizations across the 1,900-mile stretch have stepped in to provide food, shelter and medical care. Border cities like El Paso, San Diego and McAllen, Texas, are used to relying on local charities for some level of migrant care. But not in the massive numbers and sustained duration they’re seeing now. As the months drag on, the work is taking a financial and emotional toll. Nonprofit operators are drawing on donations, financial reserves and the generosity of medical volunteers to meet demand. Some worry this “new normal” is simply not sustainable.

Dr. José Manuel de la Rosa writes a prescription at a makeshift clinic in an old warehouse in El Paso.

Why the crisis and danger?  The number of California children granted medical exemptions from vaccinations has tripled in the past two years.

Recently there have been sporadic cases of a polio-like syndrome with paralysis from an entero-viral illness (diarrhea, stomach cramps). Many migrant children have diarrheal illnesses when they arrive and by the time they are interred in refugee camps with poor hygiene and crowded facilities they have become a breeding ground.  Measle has reappeared as well. 

The current immigration problem has largely been ignored as a public health crisis. Immigrants come from a totally different immune environment. When North America was repopulated by Europeans the native Americans were decimated by new diseases were incapable of fighting. Of course, at that time the biologic diversity between Europe and a New World was far greater than migrants from Central America. (or is it?)

The current state of vaccination law

What is being done to reverse this troubling trend?

On The Border, Volunteer Doctors Struggle To Provide Stopgap Care To Immigrants | Kaiser Health News: As recent arrivals are released from detention with severe medical problems ranging from diarrhea to gaping wounds, a makeshift health system of volunteers is overwhelmed. The work is taking a financial and emotional toll.

The Epidemic of Stem Cell Treatment:

Elite Hospitals Plunge Into Unproven Stem Cell Treatments

A possible public health issue is growing across many states.

Credible physicians and researchers are performing clinical trials in accordance with FDA guidelines for clinical trials.  This will require some years of trials for the FDA approves this therapy.

One such institution is the Mayo Clinic's Center for Regenerative Medicine, headed by Dr. Shane Shapiro, Assistant Professor of Orthopedic Surgery and Program Director for the Regenerative Medicine Therapeutic Suites. His research is guided by the Food and Drug Administration's Clinical Trials protocol.

There are other ongoing studies at the Cleveland Clinic, University of Miami, and other respected Hospitals.

Ongoing early studies of stem cells are ongoing and in most cases, the results are in peer-reviewed journals, but not yet ready for clinical use.

Most stem cell clinics post unproven benefits of stem cell injections. The online video seems to promise everything an arthritis patient could want.   The doctor says regenerative medicine can help heal chronic pain while avoiding surgery. Stem cells are not a medicine or a drug. It is a biologic pharmaceutical.

Anyone considering stem cell injection must use extreme caution, and find several reference sources...Usually, this would be a University Medical Center. Patient testimonials are fraught with errors.

Stem Cell information from National Institutes of Health
Where do Stem Cells come from?


Regenerative medicine (stem cell) research is rapidly evolving and some printed information may already be obsolete. The jump on the bandwagon desire to obtain the most recent "breakthroughs' are often premature and potentially dangerous.



Opinion/Commentary: Stem cell treatments for arthritic knees are unproven

Elite Hospitals Plunge Into Unproven Stem Cell Treatments | Kaiser Health News: Critics are concerned about the explosion in controversial stem cell procedures offered by clinics — and, increasingly, respected hospitals.

UC Davis alerted 200 people about March 17 measles exposure |

UC Davis Health said Wednesday they sent out roughly 200 letters to people who may have been exposed to the highly contagious measles virus March 17 in the emergency department at UCD Medical Center. A young girl taken care of there was diagnosed with the illness.

The letter from UC told recipients: “You will need to notify your primary health care provider(s) and your child’s provider(s) of this possible exposure to discuss your possible risk of infection, vaccination history, and other questions you may have.”

In its early stages, the measles virus is often mistaken for a respiratory illness, public health officials say, and that is particularly true during the flu season when so many people are showing up to emergency rooms and doctor’s offices with influenza. Measles typically starts with a mild or moderate fever; cough; runny nose; and red, watery eyes. The telltale symptom of the disease is a red rash that eventually covers most of the body, but it does not appear for several days after symptoms start.

If you have been exposed to measles or have been traveling abroad and return with flu-like symptoms, doctors recommend you call ahead to your medical provider and provide that information. That way, they said, the staff can make arrangements to bring you in through a more isolated route.

Measles was just about eliminated by vaccination. Recently unfounded concerns about increasing rates of autism caused anxiety among some parents. Scientific evidence disproved this popular idea. A groundswell of anti-vaxxers convinced some to stop vaccinating their children.  An entire political philosophy of freedom and rights caused many naive people to believe this fake news.

Most parents have never seen a case of measles, and that may also be true of some physicians.  Like Polio and Smallpox measles was of historical interest. 

A scanning electron microscope photo of measles virus

Rubella or German Measles is often confused with Rubeola (Measles).

German measles is dangerous for pregnant women, since it causes birth defects, hearing loss in their babies.  MMR vaccine is a combination vaccine for Mumps, Measles and Rubella.

Any disruption or decrease in the vaccination pool leads to sporadic outbreaks. The virus is highly contagious and spreads via the respiratory route.  One sneeze in a public space can cause a mini-epidemic.  People in the early stages of measles have no symptoms, and no rash.  Prevention by vaccination is critical, because there is no treatment for active disease, other than fluids, cooling and analgesics.

Infected individuals can have measles for up to five days before showing symptoms, but most people will start have symptoms within 12 days. However, they can transmit the virus for days before symptoms appear. They do so by coughing molecules into the air or into their hands, where they can be spread to others. Medical officials say that the virus aggressively attacks immune systems and that exposure to even a few droplets with the virus can make people sick.

The measles vaccine is a safe and effective way to prevent the illness, doctors say. California law requires students to be vaccinated before entering school, unless parents have a medical exemption for their children. Measles can cause deafness and death.

Without vaccines, measles can be costly to prevent and treat. That’s because children – and even some adults – with the disease often have to be hospitalized for care and because public health departments have to pull many staff members from other work to identify and isolate people exposed to the virus.

UC Davis alerted 200 people about March 17 measles exposure | The Sacramento Bee

Death By A Thousand Clicks: Where Electronic Health Records Went Wrong

Has electronic health record improved the quality of health care?  Physicians, nurses, and others say a resounding NO.

There is a multitude of reasons:

1. Poor interface design, difficult to use, non-intuitive
2. Decreased workflow, fewer patients served.
3. Maintenance costs.
4. Information overload.
5. EHR does not follow the normal clinic workflow requiring workarounds.
6. The electronic health record is designed more like an accounting system, presenting non-relevant information, overloading the user's ability to focus on important data.

FDA Guidance has published information relevant to the design of electronic health records, however, it is generic and poorly focused on the relevant issues, and contains no reference to the quality of the content or usability.

The term 'meaningful use' is an oxymoron because it does not pertain to it's use by users, physicians, hospitals and others.

Early financial incentives brought to market inadequate and poorly designed electronic health records. The federal incentives were designed to enforce compliance with the collection of data, outcome studies rather than the effectiveness of health care using electronic health records.

Raj Ratwani (standing) studies eye-tracking with Dr. Zach Hettinger to see how doctors interact with EHRs.

Analysis of EHR acquisition is misleading. It is largely driven by incentives and a 'jump on the bandwagon' mentality which is directly opposite of how providers adopt new treatments or technology. ie, a technology doomed to fail.

Office adoption of EHR

Hospital adoption of EHR

Why Thousands of Doctors Still Don't Use Electronic Records

Electronic Health Record vendors struggle also to account for errors due to electronic health records and have implemented measures for reporting critical errors using Maude. Even that is highly flawed. Looking at their web site one can see it too is an overwhelming overload of nonrelevant information designed to 'account' rather than report. What physician or hospital would or could use it?

Others have turned to social media to vent. Dr. Mark Friedberg, a health-policy researcher with the Rand Corp. who is also a practicing primary care physician, champions the Twitter hashtag ­#EHRbuglist to encourage fellow health care workers to air their pain points. And last month, a scathing Epic parody account cropped up on Twitter, earning more than 8,000 followers in its first five days. 

Death By A Thousand Clicks: Where Electronic Health Records Went WrongKaiser Health News: Death By 1,000 Clicks: Where Electronic Health Records Went Wrong

CalHealthCares loan repayment program now accepting applications

It is a new day.  Student loans are creating a situation where medical students and others are left with 100,000 of dollars which they must pay back. In some cases, it amounts to a mortgage requiring 15 years or more to pay.  While some of the arrangements allow for low payment, it may still be a problem which can affect the ability to purchase an automobile or obtain a mortgage to purchase a home.

Some professional or advanced degree programs can extend for four to eight years.

During the last ten years, student debt has soared., while debt for automobiles and credit card has decreased.

There are many loan forgiveness programs, including those for specific jobs, locations, public service positions, and others. Each state or locale has repayment programs, such as the California healthcare loan repayment program for physicians who agree for a set period to treat California's Medii-caid program. This dovetails well with the shortage of physicians willing to accept Medicaid payments due to low Medicaid reimbursements

The rate of college tuition and fees has accelerated beyond the increase of median family income.

In order to mitigate some of this effect, a cap is now in effect for loans

AARP explains the impact of student loan debt extending into the life of senior citizens

The number of people over 60 with outstanding student loans has quadrupled in recent years

The true cost of a student loan and it's payback period is far in excess of the loan amount.

AARP recomends several means of accommodating loan debt.

Consider loan consolidation

If you're currently in repayment and you have multiple student loans, you may get financial relief by consolidating your student loans into one smaller, more affordable payment.

This gives you some economic breathing room. However, the trade-off is that loan consolidation extends the life of your loans, so you pay more interest in the long run.

Depending on what type of student loans you have (private or federal), your options for consolidating your loans into a single loan will vary.

Sign up for flexible repayments

If you have federal student loans, Uncle Sam offers a variety of loan repayment options that take into account your income, family size and other factors.

The income-driven repayment plans now available include an income-based repayment (IBR) plan, income-contingent repayment (ICR) plan, Pay as Your Earn (PAYE) repayment plan and the Revised Pay as You Earn plan, better known as REPAYE. The latter plan caps your student loan repayments at a maximum of 10 percent of your income, depending on when you took out the loan.

Get a loan cancellation if you qualify

In 2015, more than half of the 114,000 older borrowers who were subjected to garnishment of their Social Security checks were receiving Social Security disability benefits rather than Social Security retirement income, the GAO found.

However, nearly one-third of older borrowers who had defaulted were ultimately able to get rid of their college debt by obtaining a total and permanent disability discharge, the GAO reported.

A disability discharge is a loan cancellation that's available to borrowers with a disability that is not expected to improve. If you qualify, your loans could be written off entirely, but you will have to provide annual documentation about your income to federal authorities.

Lynnette Khalfani-Cox, the Money Coach, is a personal finance expert, television and radio personality, and regular contributor to AARP.org. You can follow her on Twitter and on Facebook.

CalHealthCares loan repayment program now accepting applications: The program incentivizes physicians to provide care to Medi-Cal beneficiaries by repaying educational debt up to $300,000 in exchange for a five-year service obligation.

The community-focused family medicine clinic: A “new model” in Oregon

During a time of tremendous change in medicine and health care in which no one is very happy do your want to be swept along with the 'pied pipers" of Medicare, HMOs, Private Insurers and the rest of the lot. My answer is NO! and there are many successful physicians and their Happy Patients doing their own thing and spending much less to stay healthy.

How would you like an hour with your doctor?   Really? Is this a scam?

How can we do that? These are all reasonable questions.  Read on, let me explain.

by Pamela Wible, M.D.  The Ideal Medical Clinic

"Six months ago I embarked on a quest to develop a health care model that would truly serve our community. I had an epiphany that involving the community in the creation of the clinic would be integral to the success of the venture. In neighborhoods and community centers throughout the region, I facilitated public forum discussions on the “Ideal Medical Clinic.” All participants were encouraged to express their wildest dreams and most creative visions in roundtable discussions that were remarkably lively, providing fertile material for the birth of our true community-based medical practice. Just 1 month later, 90% of the community input was incorporated into a fully functioning solo “Family and Community Medicine Clinic.” Concurrent with my venture to create the ideal medical practice locally, the Future of Family Medicine (FFM) project has spearheaded a national campaign, a call to action for family physicians to create a new model of family medicine. After substantial research, the FFM project determined the characteristics of the “New Model” of family medicine: • a personal medical home • patient-centered care • whole person orientation • team approach • elimination of barriers to access • advanced information systems **"

If you want this type of medical care...engage and own it. Start your own Ideal Medical Clinic

Contact Dr. Pamela Wible

The Future of Family Medicine: A Collaborative Project of the Family Medicine Community

Physician Suicide Letters Answered Paperback – January 11, 2016

Pet Goats and Pap Smears

What do you really need?

Not much. The Chamber of Commerce, local business, City Council, One generous philanthropy.

BE BOLD, GO WHERE NO MAN HAS GONE BEFORE (except Dr Wible and a few hundred others. (probably thousands by now)

 

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