Saying “Yes Thanks” to HIV Screening

English: The Red ribbon is a symbol for solida...
English: The Red ribbon is a symbol for solidarity with HIV-positive people and those living with AIDS. Français : Le Ruban rouge, symbole de la solidarité avec les personnes séro-positives. (Photo credit: Wikipedia)

In contrast to my rejection of (or questioning the real evidence in favor of) routine cancer screening practices in U.S. health care, I embrace the new HIV screening guidelines (due out later this month) from the U.S. Preventive Services Task Force (USPSTF). Their previous HIV screening guidelines, issued in 2005, only recommended HIV screening for adolescents and adults deemed to be at increased risk for HIV infection. The about-to-be released updated guidelines recommend that clinicians routinely screen all adolescents and adults ages 15-65 years and all pregnant women for HIV infection (as well as younger and older patients who are at risk for HIV infection).

They base their new recommendations on compelling evidence that earlier identification and treatment of HIV infection (before a person begins to have symptoms of disease) improves clinical outcomes for the individual, as well as significantly reduces the chance of transmission of HIV to other people. “The USPSTF concludes with high certainty that early detection and treatment of HIV transmission would result in substantial public health benefits in the United States.”

Since 2006, the CDC has recommended routine voluntary ‘opt-out’ HIV testing of adolescents and adults in the U.S. (opt-out meaning all patients be informed of routine testing and tested unless they decline). The CDC also recommended eliminating the pre-test counseling and the signed patient consent requirement for HIV testing, pointing out (correctly in my experience) that these act as barriers to HIV screening. The USPSTF clinical guidelines carry more weight with the passage of the 2010 Affordable Care Act that has a provision requiring all health insurers to cover all preventive services endorsed by these federal guidelines.

So today, on World AIDS Day, let’s remember the estimated 30 million people worldwide who have died of AIDS and the 60,000 people in the U.S. who have died of AIDS since the beginning of the epidemic. Let’s remember that HIV/AIDS continues to disproportionately affect people living in African countries, as well as African-American, Hispanic people and people living in the ‘Black Belt’ of Southern poverty in the U.S. because of social determinants of health. Let’s stop thinking of HIV/AIDS as something shameful/stigmatizing and a death sentence. Let’s “Work together for an AIDS-free generation.” Know your HIV status and encourage others to know theirs. This is a case in which we can steal the Komen Foundation‘s slogan “Early detection saves lives” and be telling the truth.

For a unique health-related holiday gift for yourself or for your loved ones (tongue and cheek), you can order the newly-FDA approved home rapid HIV test (Oraquick/uses a swab of fluid at gum line/takes 20-40mins) directly from Oraquick. It is delivered to your doorstep in an ‘unmarked brown box.’ You can also buy it (assuming you are at least 17 years old) from your local pharmacy. List price is $39.99 (exact same test only costs ~$17 in clinics/manufacturer says the increased price goes to pay for their 24/7 information hotline with bilingual English/Spanish representatives). In contrast, I’ve read estimates of the more sensitive HIV ‘blood tests’ available in clinics as costing on average $1.50).

Additional resources: Check out the website, and especially their link to CDC testing/treatment/supportive services (like mental health and substance abuse counseling, and housing). It has some cool downloadable apps for searching for HIV/AIDS related services in your area. If you don’t need to use it for yourself or your family, you can use it for patients you might work with. I’m glad to know I have 34 HIV testing sites within a 10 mile radius of my home.

Nurses and Anti-Vaccination

Last week I wrote about the current pertussis epidemic in my home state of Washington, coincidentally the state with the highest percentage of parents opting out of vaccinating their children for all of the usual vaccine-preventable diseases such as polio, tetanus, diptheria, pertussis and hepatitis B. I concluded by hoping that my own pertussis booster would protect me against a planeload of Washington State coughers I recently had the pleasure of sharing a red-eye with on our way to NYC. Since the average incubation time from exposure to pertussis to symptoms is 7-10 days (and can be as long as 21 days), I’m not yet breathing a non-congested sigh of relief. But I’m hopeful.

I am a critical health care consumer and I teach my students to be critical health care providers.  On a personal basis I don’t accept all health care screening and prevention guidelines without first examining the evidence and deciding for myself what is best for my own health. For instance, I tend to agree with the conclusions about mammography screening written about (beautifully) by Veneta Masson, a nurse practitioner and poet living in Washington, D.C. in her essay “Why I Don’t Get Mammograms” (Health Affairs/Narrative Matters October 2010). I have used naturopathic, acupuncture and other ‘alternative’ medicine modalities for illnesses that are beyond the abilities of allopathic mainstream medicine to treat. But for most vaccinations, I am a discerning early adopter. Having been threatened with an attack by rabid dogs in Northern Thailand, I have even gotten my rabies vaccine series. Doing street outreach has extra hazards in a country like Thailand. I did get the rabies vaccine series in Bangkok since they cost significantly less there—Bangkok is one of the main WHO rabies centers in the world. (Thailand, a Buddhist country opposed to euthanasia of animals—even rabid ones—has one of the highest rates of rabies in the world).

As a health care provider I consider it my professional duty to stay current on recommended vaccinations, including the annual flu vaccine. I have the option of receiving it at my work site (limited times/places so not very convenient) or at my doctor’s office, or—as I usually opt for—at my local Safeway pharmacy. My annual flu shot comes between shopping for groceries, is immediately covered in full by my health insurance, and is administered by a very friendly and knowledgeable pharmacist within about five minutes of registering for it. (I fully realize all of these lack of barriers/facilitators do not exist for everyone). I have read the evidence on risks and benefits of the annual flu vaccine and am convinced on the side of getting the shot. I listen respectfully to my nurse colleagues who opt out of the flu vaccine, but I am dismayed by how many opt out for anything other than religious or valid medical reasons. I haven’t tried to convince them to change their minds because I never saw that as my job. But if any of them happen to be reading this, I hope they will at least reconsider their decision.

The evidence is fairly overwhelming in favor of nurses and other health care workers getting an annual flu vaccine, in terms of reducing the risk of transmission to their patients as well as co-workers. The flu vaccine has proven to be safe and effective, and the flu vaccine ‘industry’ is not exactly a huge profit making one. Since 1981 the CDC has recommended that all health care workers get the flu vaccine on an annual basis. (A good review from a nursing perspective is Paula Sullivan’s “Influenza Vaccination in Healthcare Workers: Should It be Mandatory? OJIN/available on ANA’s website). Most hospitals have relied on voluntary participation of health care workers, sometimes accompanied by vigorous (and I would suspect costly) education campaigns. While rates of flu vaccine compliance are high for most physicians’ groups (with the notable and not surprising exception of surgeons), the rates of flu vaccine compliance among nurses remain much lower. Why the difference?

A recent article in the journal Vaccine “What Lies Behind the Low Rates of Vaccinations Among Nurses Who Treat Infants?

English: Avian flu vaccine development by Reve...
English: Avian flu vaccine development by Reverse Genetics technique. Basa Sunda: Ngembangkeun vaksin flu unggas maké téhnik reverse genetics. (Photo credit: Wikipedia)

” (O. Baron-Epel, et al, 30(21), 5-12-12) explored this question (in this case for pertussis vaccination). Researchers in the UK conducted a series of focus groups with 25 public health nurses working at several Mother and Child Healthcare Centers, about their understanding and beliefs on vaccination. Common themes that emerged from the focus groups included the usual barriers to vaccination: fear of side effects, and a lack of perception of personal risk or risk of harming patients. Other barriers included lack of trust in health care authorities (and of health information), strong value of personal autonomy (being able to refuse vaccination), lack of respect of nurses by hospital administrators, and the fact that they did not view themselves as role models for patients. The researchers concluded “There is the need to increase the nurse’s awareness of the unethical aspect of not being immunized and increase the perception of themselves as transmitters of disease.” (p 3154).

Cocooning and Epidemics

Pertussis bacteria (Bordetella pertussis)
Pertussis bacteria (Bordetella pertussis) (Photo credit: Sanofi Pasteur)

On the red eye this week from Seattle to NYC I was reminded of Washington State’s Whooping Cough (pertussis) epidemic. It was a full flight and at least ten people seated near me had deep hacking coughs the entire flight. It’s likely that at least a few of them had untreated pertussis and have now spread it to susceptible people. There were a few small infants on the flight and they are the most vulnerable to getting severe pertussis and dying of it. Adults with pertussis can have a cough that is so forceful it can cause them to vomit. A milder form of the cough can last for months. And pertussis is highly preventable with appropriate vaccination.

In Washington State we are in the midst of a pertussis epidemic. Mary Selecky, the Secretary of Health at the Washington State Department of Health, officially declared an epidemic on April 3, 2012, even though epidemiologic data indicate that pertussis cases exceeded the epidemic or outbreak threshold in late December, 2011. Declaring an epidemic allowed Governor Christine Gregoire to mobilize state emergency funds to provide more pertussis vaccinations to uninsured people in Washington State. It also allowed her to call on assistance from the federal government in the form of CDC investigators to monitor and advise intervention strategies.

According to the Washington State Department of Health website,  through the week of May 19th, a total of 1,738 cases of pertussis have been reported in Washington State for 2012, compared to 146 cases for the same time period in 2011. Since January 114 infants less than 12 months have been hospitalized with pertussis; 23 of those were under three months of age and presumably were the sickest and probably required the longest hospitalizations. No deaths have been reported from this year’s pertussis epidemic in the state.

Current US recommendations for vaccination against pertussis include the usual combination childhood vaccination series starting at two months of age, then a booster shot for adolescents ages 11-12 years. A more recent recommendation is for an additional booster shot for adults who are parents or caregivers of infants less than 12 months of age—the idea being that if the adults are vaccinated they are less likely to get pertussis and pass it on to susceptible infants in their care. Health care providers, especially the front-line staff of nurses, are included in this recommendation. This approach of targeting pertussis vaccination to the main caregivers of infants is called cocooning.

I’ve been monitoring the news coverage of Washington State’s pertussis epidemic. The Seattle Times published an article, “Whooping cough epidemic declared in Wash. State” (Donna Gordon Blankenship, 5-10-12). In her article, Ms. Blankenship emphasized the need for adults to get vaccinated as a way to protect infants, and quoted a CDC official calling this a “cocoon of protection.” She also quoted this same CDC official as stating that Washington State’s current pertussis epidemic has nothing to do with the anti-vaccination movement, and instead attributed it to better disease surveillance, the cyclical nature of pertussis infections, and an aging population with waning immunity as the vaccine wears off. That all made sense to me—except for the matter of it not being related to the antivaccination movement. How could it not be at least partially responsible for the current epidemic?

A New York Times article “Cutbacks hurt a state’s response to whooping cough” (Kirk Johnson, 5-12-12) emphasized Washington State’s budget crisis and recent cuts to the public health infrastructure as contributing factors to our states’ current pertussis epidemic. He pointed out that changes in the vaccine to make it have less side effects have also made it less effective over—immunity tends to wane faster. He included quotes from a school nurse (yeah school nurses!) in Skagit County, north of Seattle, which is the hardest hit county so far. He referenced the fact that Washington State has the highest percentage of parents who voluntarily exempted their children from vaccines out of fear of side effects or for philosophical reasons. Studies have shown that vaccine refusers tend to cluster, are often middle-class, college educated white people with antigovernment, anti-establishment views. They like living in the Eco-topia of Puget Sound.

A related topic I find fascinating is the seemingly rising trend of antivaccination sentiments among nurses—and the fact that an astonishingly low percentage of pediatric nurses get the booster vaccine for pertussis, despite CDC recommendations for them being part of the ‘cocooning’. I’ll deal with that issue in a follow-up post next week—unless I come down with pertussis thanks to my airplane seatmates. (I have had the pertussis booster so am counting on it working.)