Cholera, canals, and contagion: Rediscovering Dr Beck's report

Cholera remains a major global public health threat. A severe diarrheal illness, caused by toxigenic strains of Vibrio cholerae, cholera is endemic throughout much of the world,¹and causes sporadic outbreaks in regions with inadequate access to safe drinking water and sanitation.^2, 3 Even in the modern era, cholera can have a case-fatality rate in the range of 14 to 23 per cent.^4, 5 Cholera has pandemic potential: antigenic shifts in dominant V. cholerae strains are associated with the emergence of global epidemics with high case-fatality rates. The seventh known cholera pandemic started in 1961 and is still ongoing. The causative organism, V. cholera O1 biotype El Tor, has replaced the classical strain as the leading cause of endemic cholera worldwide.⁶ As events in Haiti in the autumn of 2010 have demonstrated, lack of universal access to clean water and sewage treatment in low-income countries means that this disease remains a major public health priority.^7, 8

While cholera continues to be a major source of mortality in low- and low-middle income countries, it may also threaten higher income countries via disease importation.^6, 9 Khan and colleagues have recently commented on continued importance of global ‘connectedness’ to disease emergence and spread, particularly given modern air travel.¹⁰A single person with the disease may spark a local epidemic in an area previously free of that pathogen. Travelers import cholera into Canada and the United States with some frequency (<12 cases per year between 1996 and 2007)¹¹ but the relative wealth of water- and sewage-treatment infrastructure in these countries appears to limit epidemic spread.¹²

Travel's role in diffusion of infectious diseases predates air travel. Indeed, the way infectious disease epidemics spread tells much about indirect connections between populations with little awareness of one another's existences. Fenn, for example, demonstrated that smallpox epidemics in the late eighteenth century showed a network of contacts spanning the American continent decades before Lewis and Clark's cross-continental expedition.¹³ Late nineteenth-century American disease control experts recognized the importance of travel and transit in the genesis of cholera epidemics. In their efforts to forestall or prevent cholera epidemics in US cities, they focused on Hamburg, then a major embarkation point for people crossing the Atlantic.¹⁴

Recognition by mainstream medical practitioners of the transmissibility of cholera emerged largely from John Snow's work on London cholera epidemics of the 1840s and 1850s,^15, 16, 17 and lagged behind the widespread popular belief that the disease was contagious.¹⁸ During the cholera epidemics of the early nineteenth century, physicians in Europe and North America disparaged fear of contagion as superstition. They admonished the public to attend to its ‘moral constitution’ to prevent disease. As Richardson notes, cholera was ‘hardly regarded as a biological entity but a means of retribution upon the morally suspect’¹⁹ –a product of the interaction between a corrupted atmosphere (a ‘miasma’) and exciting characteristics in the victim. Drunkenness, gluttony, sexual depravity, and any other form of ‘intemperance’, were held to increase vulnerability to cholera,^20, 21 as were both fear of cholera²² and lack of fear of cholera.²³

Economic liberalism, prevalent in professional classes, may have encouraged physicians to disparage the notion of cholera as contagious. Designating cholera as contagious would have, as a corollary, implied that disruption of trade and travel with via quarantine would be necessary to control the disease.^24, 25 State-directed disruption of individuals’ economic activities was unattractive to an emerging and increasingly independent-minded professional and merchant class.^24, 25

We discuss a document about the 1832 cholera epidemic, presenting geospatial data that imply cholera's contagiousness. These data might have allowed the report's author to intuit the transmissibility of cholera well in advance of Snow. And we explore the social context that led the report's author to disbelieve his own observations and favor a medical model inconsistent with his data.

Source: Journal of Public Health http://www.palgrave-journals.com/jphp/journal/v32/n3/full/jphp201120a.html

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A Practical, Up-to-Date Guide for Parents — Common Problems and Worries -- Part 2

By, Jeff Beaumont

Crossed Eyes

When awake and alert, your baby's eyes should look straight at you. One may turn in or out slightly when your baby is particularly tired, but both eyes should work together almost all of the time. If not, seek medical advice at your baby's next checkup. Don't be fooled by a wide nose which may make the eyes look as if they are turning in.

Very Frequent Urination

Most babies urinate nearly every hour until they are 2 or 3 months old, every 2 or 3 hours for the rest of the first year, and will sometimes urinate 2 or 3 times in a very short period. However, you should tell the doctor at the next checkup:

• If your young baby never seems to go more than one-half hour without urinating;
• If your older baby seldom goes more than an hour without urinating;
• If your baby strains hard to urinate; or
• If urine always comes out in a weak trickle or very fine tight stream.

Colds

Many babies have a slightly stuffy, rattly noise in their noses nearly all the time. This is not a cold; it just seems to be the way they are made. It will become less and less noisy and noticeable as your baby gets older and the air passages of the nose get larger. Your baby will also learn to clear the nose by sniffling. Don't use cold remedies for such a baby. You may be able to reduce the noise by sucking out the nose several times a day with a small rubber bulb called a nasal syringe.

Most babies will have 2 or 3 real colds in the first year and a perfectly normal baby may have 8 or 9. During colds, most babies become a little fussy and lose part of their normal appetite. Their noses run with clear watery material, which becomes thick and sticky in a few days. Their eyes may get red; they may cough and make a lot of noise when they breathe. They may have fever. The whole thing may last only 4 or 5 days or as long as 2 or 3 weeks, and a cough may take 4 or 5 weeks to disappear completely.

Neither you nor your doctor can do much about it except keep your baby as comfortable as possible. If your baby seems uncomfortable with aches and pains, give half a baby aspirin 3 or 4 times a day. Use the nasal syringe to clear the nose when stuffiness causes discomfort.

When You Should Worry—If your baby seems very weak and sick, has no energy to even cry loudly, nurses poorly, doesn't want over half of the usual bottle, doesn't wake up to be playful for even a short time—then you should seek medical care quickly.

How sick your baby acts tells much more about how serious the illness might be than anything else. If your baby has a high fever and a cough, but takes some of the bottle eagerly and wants to play, you don't have to worry. But if your baby is listless; weak; uninterested in attention, play or the bottle; you should get medical advice.

If your baby has labored breathing, you should get medical care promptly—day or night. Labored breathing means working so hard at breathing—getting the air in and out—that there is no energy left for anything else, even for nursing or for playing. Making a lot of noise breathing is not important, but having to work very hard to breathe is!

If your infant cries or moans as if in pain for several hours during a cold, you should get this checked by a doctor. If he or she is just fussy and goes to sleep after you give comfort and/or half a baby aspirin, you need not worry. But painful cries should not be ignored.

You will probably want to check with a doctor the first few times your baby has a bad cold, but you will soon learn what to expect with colds and how to treat them.

You really can't do much to prevent colds. Colds are most contagious—most easily passed from one person to another—during the few days before the signs of a cold appear. Once you have had a cold for a day or two, you are unlikely to give it to someone else. So keeping your baby away from people with signs of a cold will not help much.

Fever

Fever is the body's natural response to many infections. If your baby has a fever, there is something wrong. But how high the fever is doesn't tell you anything about how serious the sickness is. If an infant with a high fever is playful and cheerful, the sickness is not likely to be serious and you need not worry. A child with only a slight fever or no fever who appears to be sick and weak needs medical attention. Fever should warn you to watch carefully, but it doesn't tell you how sick your child may be.

Many babies will have a fever with every cold. Many have a fever for a day or two with no other signs of illness except tiredness and fussiness.

Most of the time an infant with a fever needs no special treatment. Give plenty to drink and take off any extra sweaters or blankets. If your baby seems uncomfortable or particularly jittery, give one-half a baby aspirin every 6 hours if your child is 3 to 8 months old. Give one-half a baby aspirin every 4 hours if your baby is 9 to 18 months old. Aspirin will reduce the fever, but fever itself does no harm. Use aspirin for pain and discomfort. Leave the fever untreated unless the baby seems uncomfortable.

If your child has a fever you can't explain for 4 or 5 days in a row, you should seek medical advice even if he or she doesn't seem very sick.

Vomiting

Your baby may vomit during a cold or fever—or have an illness which may have vomiting, or vomiting and diarrhea, as its only signs.

When your baby vomits, don't give anything to eat or drink for one hour. Then give one-half ounce of cold sweet juice, tea with sugar or soft drink. Repeat this half-ounce feeding every 10 or 15 minutes for an hour. Give 1-ounce feedings every 10 or 15 minutes for the next hour, and 2-ounce feedings as often as your baby wants them for the following hour. If there is no more vomiting, it is now safe to give small amounts of cereal, formula, crackers or toast. But don't give more than 2 ounces to drink at one time until there has been no vomiting for 6 hours.

If vomiting occurs after you start this routine, wait one hour and start again at the beginning with half-ounce feedings.

If your infant continues to vomit for more than one day or seems very sick and weak, you should get medical advice.

Care of a Sick Child

Don't worry if a sick child doesn't want to eat, but be sure to give plenty to drink. If there is a fever or diarrhea, your baby may be particularly thirsty. Give only the usual amount of milk and offer water, juice or soft drinks in between.

Let your baby decide how much exercise and sleep are needed. Babies who want to be up and playing can be allowed to do so. Babies who are sick enough to need extra rest will soon lie down and fall asleep by themselves. Better a happy child playing quietly than a child screaming in the crib because someone said, "Your baby's sick and should be kept in bed."

Try to keep your baby comfortable. This often means fewer blankets and clothes rather than more, especially for a child with a fever. There is nothing wrong with outdoor air or with automobile trips—provided your baby is comfortably dressed and allowed to rest when necessary.

Source: Health Guidance -- A Practical, Up-to-Date Guide for Parents — Common Problems and Worries

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A Practical, Up-to-Date Guide for Parents — Common Problems and Worries -- Part 1

By, Jeff Beaumont

Skin

Babies' skin just isn't as smooth and clear as the advertisements say it is. Almost every baby develops a fine pink or red rash whenever the skin is irritated by rubbing on bedclothes, by spitting up, or by very hot weather. Almost all of these fine pink rashes will go away promptly if the skin is bathed with clean water whenever it is dirty, and washed with mild soap once a day.

Many babies develop waxy scabs on the scalp and forehead, called "cradle cap" or "seborrhea." Daily scrubbing with mild soap and a wash cloth will usually keep this under control.

Small, red, blotchy "birthmarks" on the eyelids and back of the neck are so common that they are called "stork bites." They usually show up when the baby is between 1 and 4 weeks old. They go away by themselves after a year or so, and cause no trouble of any kind. There is nothing to do but wait.

Bright red raised "strawberry marks" are also quite common. They appear after one or two months, grow rapidly for a few months, stop growing and gradually disappear. Unless your baby has one that is particularly large or in a spot where it is constantly being irritated, it is best to let it go away by itself.

Large areas of pale blue discoloration, called "mongolianspots" are common, especially on the trunk of dark skinned infants. They become less obvious as the child grows older and have no importance.

Diaper Rash—Urine and bowel movements are irritating to the skin, especially when they stay in contact with the skin for a long time.

Prevent diaper rash by changing diapers frequently, by rinsing the diaper area with clean water at each diaper change, by rinsing diapers thoroughly after washing, and by applying a layer of zinc oxide paste (you can buy it at any drug store) to any irritated area.

If your baby gets a diaper rash in spite of this, you should:

• Leave off the plastic pants (or plastic covered disposable diapers) except when absolutely necessary. Using 2 or more cloth diapers at nap time and at night will make this less messy.
• Leave the diaper area completely uncovered for a few hours each day (nap time or early evening is most convenient); put a couple of diapers under the baby to prevent soiling.
• Apply a thin layer of zinc oxide paste to any irritated area after cleansing at each diaper change.

When to Worry—Any pimple or rash that gets bright red and enlarges, or that develops blisters or pus, may be the beginning of an infection that will need medical care. You can soak such a rash with a washcloth or towel wrung out in warm water, and keep it clean by washing with mild soap and water twice a day. If it gets worse, or if it doesn't get better in 24 to 48 hours, you should get medical advice.

Any rash that looks like bleeding or bruising in the skin should be seen by a doctor promptly (unless you know it really is a group of bruises).

Legs and Feet

Most babies' legs and feet don't look "normal" until the child has been walking for several years! The feet seem to turn in or out in the first year of life. By age 12 to 18 months the legs look bowed.

Almost all of these funny-looking feet and legs are perfectly normal and will gradually straighten out as babies run, play and climb. If you can move the foot easily into a "normal" looking position, and if the foot moves freely when the baby kicks and struggles, it is almost certainly a normal foot that developed a bend or twist while the baby was sitting on it during your pregnancy.

You won't cause bowed legs by pulling your baby into a standing position or letting your baby walk or stand "too early." Also, babies won't walk any sooner by being placed in a walker—which usually isn't much fun for babies anyway.

Umbilical Hernia—Swollen Navel

About one-fourth of all babies develop a swelling at the navel. This usually grows rapidly for several months, then grows with the baby for several months, then gets smaller and disappears. Large hernias may not go away until the child is 4 to 6 years old. The bulge often gets tight or tense when the baby cries or coughs.

Since these hernias almost always go away if they are left alone for long enough, there is no reason to have them repaired by surgery. They almost never cause any kind of trouble or pain. Occasionally a 4- to 6-year-old child may be embarrassed by a particularly large hernia, and it can be repaired at that time. By waiting, you will almost certainly save your baby an unpleasant and unnecessary operation.

Genitals

The boy's penis and scrotum and the girl's clitoris and labia are usually rather large at birth. They get slightly smaller over the next few weeks.

A girl may have a slight white creamy discharge from her vagina in the first few weeks, which is normal. It should become less and less and should not irritate the skin. Get medical advice if it becomes worse or if she develops a discharge after the first week or two. Any bulge or lump in a girl's genitals should be checked by a doctor.

One or both of a boy's testicles may seem particularly large, and be surrounded by a water sac or "hydrocele." Hydroceles are painless, cause no harm and go away without treatment, usually within a few months. Seek medical care for any swelling in the groin, and seek medical care immediately for any painful swelling in the groin or testicles.

If you want your boy circumcised, have it done while you are still in the hospital. It is not necessary, and it should almost never be done as a special operation once you and he have left the hospital (except for religious circumcisions).

A circumcision should heal completely within a week to 10 days. The tip of a circumcised boy's penis may become irritated by the diaper. Put a little vaseline or zinc oxide paste on the irritated area each time you change the diaper.

If your boy is not circumcised, don't try to pull the skin back over the tip of the penis. It will hurt and irritate. As he grows the skin will gradually loosen until it will pull back with ease (it sometimes takes as long as 3 or 4 years).

Sucking

Most babies get their thumbs and fingers in their mouths and suck on them. Many seem to find it especially enjoyable and do it often. It causes no harm and can be ignored.

Some parents don't like the looks of thumb and finger sucking and substitute a pacifier for the thumb. This also is fine and the pacifier can be thrown away toward the end of the first year. But don't substitute the pacifier for the attention, food or diaper changes that your baby wants and needs when he or she is crying! And don't use a bottle of formula or juice as a pacifier!

Source: Health Guidance -- A Practical, Up-to-Date Guide for Parents — Common Problems and Worries

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Despite 'Healthier' Options, Fast Food Is Still High in Calories

By, Laurel Avery

A trip to your local drive-through may present you with more options than you would have had a decade ago. Salads, oatmeal, fruit smoothies – at a glance it’s easy to think that fast food restaurants have upgraded their typical fries and burger fare. However, a closer examination reveals that despite the explosion of ‘healthy’ options, fast food still will not do your waistline any favors. Katherine W. Bauer of the Temple University Department of Public Health and Center for Obesity Research and Education led a study examining the calorie counts of offerings at eight popular fast food chains. The menu selections and average calorie counts of the last 14 years were tabulated and compared.

This study confirmed the ballooning of fast food menu choices. In 1997, the eight restaurants studied had a combined total of 679 menu items. By 2010 that number had leaped to 1036 items. Much of this increase is accounted for by ‘healthy’ options that include entree salads and sweetened teas. With the number of healthy options increasing, one would expect that the average calorie count would decrease. However, this is not the case. Bauer’s study found that there was very little noticeable change in the median number of calories in entrees and drinks. The average calorie count in side dishes did decrease from 264 to 219, likely because of limits on size and the addition of more side salads.

Steps to Take Now

Just because fast food menus are not getting much healthier yet does not mean you have to avoid the drive through completely. Instead, go in with as much knowledge as possible. If calorie counts are not plainly available on the menu board, ask for copies of the restaurant’s nutritional information. You can also find this information online.

Another common trap to avoid when eating fast food is consuming unnecessary calories. The average 20 ounce soda can have over 200 calories – calories that could be eliminated by switching to water. A slice of cheese can add 50 calories to a burger. A packet of salad dressing can have as many calories as the soda you just said no to, as well as a large portion of your daily fat allowance. While fast food restaurants may not be reducing their calorie counts, being an educated consumer will allow you to make choices that will improve your health.

Source: Health Guidance -- Despite 'Healthier' Options, Fast Food Is Still High in Calories

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Advanced policy options to regulate sugar-sweetened beverages to support public health

Consumption of sugar-sweetened beverages (SSBs) has increased worldwide. As public health studies expose the detrimental impact of SSBs, consumer protection and public health advocates have called for increased government control. A major focus has been on restricting marketing of SSBs to children, but many innovative policy options – legally defensible ways to regulate SSBs and support public health – are largely unexplored. We describe the public health, economic, and retail marketing research related to SSBs (including energy drinks). We review policy options available to governments, including mandatory factual disclosures, earmarked taxation, and regulating sales, including placement within retail and food service establishments, and schools. Our review describes recent international initiatives and classifies options available in the United States by jurisdiction (federal, state, and local) based on legal viability.

For centuries, water has been challenged by other beverages as the drink of choice. Tea and coffee were first, followed by the invention of soda water in the 1760s – the basis for cola beverages in the late 1800s.¹ Now beverages sweetened with cane sugar, corn syrup, and the derivatives of the two (collectively ‘sugar’)² are heavily consumed globally.³

As public health studies began to expose the detrimental impact of sugar-sweetened beverages (SSBs), consumer protection and public health advocates called for increased government control, often focusing on marketing.⁴ In 2010, the World Health Organization (WHO) proclaimed the marketing of unhealthy products to children an international issue, calling on Member States to act.⁴ But limiting SSB marketing to children is less feasible in the United States, where ‘commercial speech’ (or advertising) is protected by the First Amendment of the Constitution.

In the United States, commercial speech is amenable to regulation and can be restricted in certain circumstances, most notably in the school environment. A legal basis exists to argue that commercial speech directed at children is misleading and deceptive and thus, not protected by the First Amendment.⁵ Government restrictions, however, would likely provoke constitutional challenges from industry, resulting in complex litigation and unclear outcomes.

Government may consider alternative policy options to avoid such First Amendment challenges. The US Supreme Court has sanctioned the government's ability to protect and inform consumers by mandating the disclosure of factual information or regulating what US law refers to as conduct, which in this context refers to sales practices.⁶ We apply the Court's reasoning from other public health contexts (for example, tobacco) to SSBs. Our suggestions address information disparities and access issues in the retail environment. The options we consider may be attractive to other countries seeking to regulate SSBs without or in addition to marketing restrictions.

We describe the public health, economic, and retail marketing research about SSBs (including ‘energy drinks’, when applicable). Several policy options are available to address beverages of public health concern: requiring factual disclosures, earmarked taxation, and regulating the sale and location of such beverages within retail and food service establishments, and schools. We discuss legal viability.

Source: Journal of Public Health http://www.palgrave-journals.com/jphp/journal/v32/n1/full/jphp201041a.html

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Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes?

The issue of harm reduction has long been controversial in the public health practice of tobacco control. Health advocates have been reluctant to endorse a harm reduction approach out of fear that tobacco companies cannot be trusted to produce and market products that will reduce the risks associated with tobacco use. Recently, companies independent of the tobacco industry introduced electronic cigarettes, devices that deliver vaporized nicotine without combusting tobacco. We review the existing evidence on the safety and efficacy of electronic cigarettes. We then revisit the tobacco harm reduction debate, with a focus on these novel products. We conclude that electronic cigarettes show tremendous promise in the fight against tobacco-related morbidity and mortality. By dramatically expanding the potential for harm reduction strategies to achieve substantial health gains, they may fundamentally alter the tobacco harm reduction debate.

Harm reduction is a framework for public health policy that focuses on reducing the harmful consequences of recreational drug use without necessarily reducing or eliminating the use itself.¹ Whereas harm reduction policies have been widely adopted for illicit drug use (for example, needle exchange programs²) and alcohol use (for example, designated driver programs³), they have not found wide support in tobacco control. Many within the tobacco control community have embraced nicotine replacement therapy (NRT) and other pharmaceutical products, but these products are designed as cessation strategies rather than recreational alternatives. Recently, however, a new product that does not fit neatly into any previous category has entered the nicotine market: the electronic cigarette. Electronic cigarettes do not contain tobacco, but they are recreational nicotine devices and the user closely mimics the act of smoking. Thus, they are neither tobacco products nor cessation devices. The novel potential of electronic cigarettes warrants revisiting the harm reduction debate as it applies to these products.

In this article, we first explain what electronic cigarettes are and why they are difficult to categorize. Second, we examine the available evidence concerning the safety and efficacy of electronic cigarettes. Then, we review the most common arguments made against harm reduction in the tobacco control literature, followed by an analysis of each of these arguments in light of the recent emergence of electronic cigarettes. Finally, we identify conclusions from this analysis and their implications for the public health practice of tobacco control.

Source: Journal of Public Health 

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