Newsletter OCt 20

This is an electronic update for members and friends of the American Association of Public Health Physicians (AAPHP). We issue this from time to time, whenever several items of interest come to our attention.

Please send items of interest for the E-News -- and any other feedback -- to E-News editor Dave Cundiff, MD, MPH <cundiff@reachone.com>. Thanks!

The paucity of human HPAI H5N1 cases, and the apparent requirement of extensive direct contact for human-to-human HPAI H5N1 transmission, didn't stop the editors of The Lancet from opining that avian flu "is already looking like an inevitable influenza pandemic" and expressing alarm at the current level of scientific and organizational preparedness. The Lancet editorialists cite a leaked pandemic-preparedness draft as evidence that no single individual has been designated to coordinate U.S. government pandemic responses. The full Lancet editorial is available at http://www.thelancet.com/journals/lancet/article/PIIS0140673605675393/fulltext . Free registration is required. Readers may post comments in response to this article. As of this writing, no comments have been posted.

(Editor's Note: The opinions of influenza prognosticators seem to be much stronger than the science of influenza prediction. Top public health officials underestimated the 1918-1919 swine flu, but overreacted to the appearance of similar antigens in 1976. Regardless of caring, skill, and leadership, it may be almost impossible to avoid significant mistakes in such an uncertain environment. Public Health physicians with risk-communication skills, and an accurate understanding of scientific uncertainty, will be needed at all levels as the situation unfolds.)

2) Perspectives on Hurricane Katrina:

The 2005-10-13 issue of the New England Journal of Medicine includes a special section on Hurricane Katrina. This issue is on the Web at http://content.nejm.org/ until the next issue is published; then it will be in the archives at http://content.nejm.org/content/vol353/issue15/index.shtml .

Because of the public health importance of this content, the NEJM has made the Katrina-related articles available to non-subscribers -- in HTML or PDF format -- without charge.

Public Health physician Hilarie Cranmer, MD, MPH, from Boston, writes on "Volunteer Work -- Logistics First" ( http://content.nejm.org/cgi/reprint/353/15/1541.pdf ). Most, but not all, volunteering physicians came prepared to provide medical care in shelters the same way they do at home. Dr. Cranmer points out that conventional medical care is usually one of the least important needs in a refugee shelter. Higher priority must be given to public health needs such as "security and safety for the population, then water, sanitation, food, and shelter." In developing countries, measles vaccine for children is the next urgent task. Only then can the experienced disaster worker afford the luxury of arranging medical care. AAPHP's Webmaster Kim Buttery , MD, MPH -- who has led public health response to several hurricanes -- says Dr. Cranmer's article should be "required reading" for public health workers and students.

Public Health physicians P. Gregg Greenough, MD, MPH and Thomas D. Kirsch, MD, MPH give a complementary view in "Public Health Response -- Assessing Needs" ( http://content.nejm.org/cgi/reprint/353/15/1544.pdf ). Greenough and Kirsch speak briefly of the importance of safety and sanitation, then discuss epidemiologic and environmental surveillance and the importance of chronic disease care. While not discounting the priorities Dr. Cranmer articulates, Greenough and Kirsch note that epidemiologic surveillance and medical care are also life-saving. Many citizens, especially those of low income, depend on medical care. For many, the disruption of medical care can be lethal.

Other authors give technical information and personal anecdote about the hurricane and its aftermath.

The "Katrina" section is at the bottom of the current-issue web page at http://content.nejm.org/ , or in the left column of the archived web page at http://content.nejm.org/content/vol353/issue15/index.shtml .

3) BCG May Protect Against TB Infection:

Soysal et al, from Istanbul, Turkey, report on "Effect of BCG vaccination on risk of Mycobacterium tuberculosis infection in children with household tuberculosis contact: a prospective community-based study" in the 2005-10-15 issue of The Lancet .

The Turkish Ministry of Health recommends that all children receive Bacille Calmette-Guerin (BCG) vaccine at 2-3 months of age, and again at 6-7 years of age. It is currently estimated that 79% of children have been vaccinated in compliance with this recommendation.

The researchers studied Istanbul children with at least one household contact found to have active tuberculosis. They collected data on risk factors for tuberculosis transmission, including age, sex, school attendance status, socioeconomic status, paternal and maternal education, BCG vaccination status, number of index patients in household, drug resistance status of index patient, relationship of index patient to the child, and whether or not there was a smoker in the household.

Tuberculosis infection was assessed not only by tuberculin skin testing (TST), but by a recently developed enzyme-linked immunospot assay (ELISpot) that counts interferon-gamma producing T cells that respond to antigens only found in M. tuberculosis . The ELISpot test is thought to be a more sensitive and specific screen for latent tuberculosis infection. ELISpot is said to eliminate the biological effect of BCG vaccination as a confounder of traditional skin testing.

Univariate testing showed the risk of ELISpot positivity to be associated at p<.05 with number of index patients in the household; with the absence of a BCG scar; with increasing age; with mother's education; with the closeness of the index patient's biological relationship to the child; with school attendance; and with father's education. ELISpot positivity was associated at p-values between .05 and .10 with lower family income, index case drug resistance, and the presence of smoking in the home.

On univariate analysis, the odds ratio of ELISpot positivity associated with a BCG scar was 0.59. This suggested a protective effect of approximately 41%, if confounding variables were not a factor.

Multivariate analysis was performed. The child's age, a parent as index patient, the number of index patients per household, and the absence of a BCG scar remained significant on multivariate analysis. The odds ratios from multivariate analysis again suggested BCG to have a protective effect of approximately 40%.

The authors view the association of positive ELISpot with lack of a BCG scar as most likely representing a cause-and-effect phenomenon. Since not all BCG-vaccinated children develop scars, they concede that this protection may only be experienced by the more than 90 percent of vaccinated children who scar. They also concede that randomized trials may be needed, in order to eliminate the possibility that this apparent protection may be due to confounding variables.

The full article is available at http://www.thelancet.com/journals/lancet/article/PIIS0140673605675344/fulltext (free registration required).

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(Editor's Note: To me, the big news is that a randomized trial of BCG and primary infection is now possible due to the development of TB-specific blood tests.

This study may generate demands for widespread changes in tuberculosis vaccination policies. I don't think this observational study provides a very strong reason to change policy, because of confounding variables -- especially because adherence/compliance itself can be a causal and confounding variable. It is very plausible that people who follow their country's immunization recommendations against a particular disease, may comply more thoroughly with other preventive measures -- especially the measures that are directed against that same disease.

In a country such as the USA, where BCG is not routinely used, I would wait for stronger data -- especially a randomized trial -- before recommending BCG as a public health measure.)

4) AAPHP/ACPM Job Market Initiative Update:

Joel L. Nitzkin, MD, MPH, Chair of the AAPHP/ACPM Job Market Initiative, shared the following report for E-News readers:

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The Job Market Initiative (JMI) web page is now four years old. Over this period of time the web page has waxed and waned, depending mainly on available volunteer and staff support. Over the first year and a half, with limited volunteer support, the JMI started with 55 full page ads, then, with abstraction of ads from other journals and web sites, grew the number of ads posted at any point in time to about 200 per month. During this period, we received many compliments and thanks from both job seekers and employers for connecting people with jobs that they otherwise would not have known about. Then, in February of 2003, when anticipated additional staff support did not materialize from either physician volunteers or selected organizations, the abstraction of ads was temporarily discontinued. From then, through June of this year, the numbers of ads posted on the site at any point in time ranged from about 30 to 60.

Since then, we are now back to running 208 ads this last month. Hopefully, when anticipated additional staff and volunteer staff support come on line, we can consistently run over 300 job listings per month -- and perhaps begin again to receive the thank-you's that were so common during the first 18 months of the JMI -- then disappeared when we discontinued the abstraction process.

The primary goal of the JMI is not just to post ads -- but to actually increase the number and quality of jobs that express a preference or requirement for physicians with residency training or boards in preventive medicine. This will require an active program of outreach to actual and potential employers, and has yet to begin. If we can continue to build the JMI over the coming months to the point where we are consistently running at least 250 jobs per month, and securing about 1000 hits per month (about double the current number) -- we can then take steps to make the JMI web page financially self-sufficient without imposing fees for the posting of ads.

For more on the goals and process of the JMI, please see the policies and procedures memo noted on the bottom of the opening JMI web page on both http://www.aaphp.org and http://www.acpm.org .

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Today we welcomed new Job Market Initiative abstractors ROBERT S. RADER and ROSLYN JOHNSON, members of the ACPM staff. They will initially concentrate on Federal civilian jobs, which formerly were covered by Dr. Laura Fehrs.

This issue's Featured Job is CHIEF, PUBLIC HEALTH PROGRAMS at the University of Montana in Missoula. This position will start in mid-2006. The new Chief will coordinate faculty now in several other departments, and will recruit the founding faculty for a new Public Health academic unit. JMI's main page http://www.aaphp.org/JobMarket/PHP_positions.asp links to this position, via either "Full Page Ads" or "Listing of Jobs".

Volunteers are still needed -- please contact Dr. Nitzkin (address on the JMI Web site under "Job Market Initiative Plan") or the editor.

5) Member Update:

Thanks to Clarence R. (Reg) Allen, MD, MPH, JD and to Mariliz Suarez, MD. These public health physicians joined and/or renewed AAPHP membership since the last E-News.

AAPHP Trustee Peter D. Rumm, MD, MPH, Co-Director of the Drexel University Center for Public Health Readiness and Communication, addressed audiences in Britain and Lithuania in August 2005. Dr. Rumm spoke on "The National Advisory Committee on Children and Terrorism, and Current U.S. Changes in How Preparedness Is Evaluated." A copy of Dr. Rumm's slides is available at http://www.drexel.edu/pubhealth/html/preparedness.ppt .

AAPHP members: Please send news for "Member Update" to the E-News Editor. Thanks!

6) Bylaws Update - Resident and Medical Student Memberships:

The AAPHP bylaws posted from June 2005 until 2005-10-19 at http://www.aaphp.org/bylaws/bylaws2005.htm erroneously stated that AAPHP's resident and student dues would be permanently set at zero by our bylaws. Residents and medical students ARE eligible for free dues, but the basis for this decision was incorrectly stated.

Resident dues were set to zero for 2006-2007 by Board of Trustees action on 2005-08-01. Medical student dues were set to zero for 2006-2007 by Board of Trustees action on 2005-10-19. The posted bylaws have been corrected. We apologize for any confusion.

Please tell residents (in any specialty) and medical students about the opportunity to join AAPHP for the next two years without charge!

7) Acknowledgements:

Thanks to the publishers of the New England Journal of Medicine ( http://www.nejm.org ) to the publishers of The Lancet ( http://www.thelancet.com ), and to Drexel University for placing the above-mentioned articles on the Web without charge. Thanks also to AAPHP Webmaster Kim Buttery, MD, MPH, to the AAPHP/ACPM Job Market Initiative chair Joel L. Nitzkin, MD, MPH, DPA, and to AAPHP Trustee Peter D. Rumm, MD, MPH for sharing news for this issue.

Dave Cundiff, MD, MPH ( cundiff@reachone.com )

AAPHP Secretary and E-News Editor

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