Vaccines just aren't as easy to discover as they used to be

Edward Jenner had it easy. Swab some cowpox in 1796, scratch the nastiness into the arm of a little kid (see below), and, PRESTO, instant immortality. 

Vaccine success after vaccine success followed. Measles, mumps, rubella, polio... one after another global scourge quaked before the mighty pipettes of vaccine researchers.

I admit, the stalwarts who discovered those vaccines did more than transfer cow-pus to an un-consented minor research subject prior to doing a victory lap around the farm. Rather, they earned their laurels by working hard, and by being brilliant.

But ease wrought hubris, and as deadly viral menaces fell in succession, you could forgive one noted twentieth century sage, US Surgeon General William Stewart (pictured below), for saying, "It’s time to close the books on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease."

Whoops!

These early triumphs gave way to a long, hard slog. Vaccines against HIV, tuberculosis, herpes, staphylococci, and hepatitis C, among others, have proven far more elusive. Amid small successes, and spectacular failures, we have discovered an uncomfortable fact: we don't really know what makes a good vaccine tick. 

This week I was glad to contribute both heat and noise to the mix. In an op-ed in the Health Affairs blog, I write about the dangers of dogmatism and the lessons learned on the road to a new HIV vaccine. And, we also published preclinical data this week on a new scalable version of our tuberculosis vaccine. Data from our Phase 1 trial of the same vaccine should come out soon!

Who knows if all this will lead to glory. Probably not! Either way, it's been a pleasure to try. 

Lessons learned from a beatbox heart

Jimmy’s mother cries in the corner. She holds her hands up and open, the way you might receive a baby.  Or, the way you indicate helplessness when your baby is now addicted to heroin and shivering in a hospital bed.

Jimmy’s heart is failing.  Antibiotics alone will fail him.  Soon a surgeon will open Jimmy’s chest, cut out his heart valve, and sew in a new one.  I say this as gently as I can.

Standing with a medical student beside me, I try to teach about the physical exam. About compassion. About how to respond when a young man who hasn't opened his eyes for minutes suddenly does, and says something frightening. 

Check out my new essay at ReflectMedEd for more.

World AIDS Day 2016

As World AIDS Day approaches on Thursday, there is so much to be thankful for, and so much work yet undone.

People with HIV on effective treatment live as long as those without HIV, and almost never transmit HIV to their seronegative partners. Pre-exposure prophylaxis (PrEP) is safe and it works, and through it and other means of prevention we are slowing the epidemic, bit by bit. This fall a new vaccine aiming to build on the RV144 success story began testing in South Africa.

Despite those massive successes, 2 million more people are newly infected with HIV every year. Less than half of the world's HIV-positive population can access HIV therapy. In the United States, only 30 percent of people with HIV achieve the goal of full virological suppression on medications. A substantial fraction of people living with HIV don't know they are infected, and stigma is still a problem for people with HIV.

HIV is the defining health threat of our day. We have made real progress, but we cannot be complacent. It was a honor to discuss these issues and more for NHPR's Exchange radio show.

Wait for it

At 94, my patient V. was funny and flirtatious.  Her French accent made even the name of her life-threatening fungal infection sound poetic.

“DEE-seminated HEESTO-plasmo-sees,” she said, “Oaf the skin.”

I smiled.

I also admitted her to the hospital because our treatments were not working.  

What I did next, though, surprised both of us. To read more, check out my new article at the great blog Reflective MedEd.

Pervasive HPV myths that keep us from preventing cancer

Human papillomavirus causes hundreds of thousands of cases of cancer each year, yet the uptake of safe vaccines to prevent those cancers has been mindbogglingly slow.

I was glad to be quoted in a Reader's Digest story called "10 Myths About HPV That Could Seriously Damage Your Health."

Opioid contracts can backfire on patients

The US Senate recently passed legislation designed to address the nation’s opioid addiction epidemic, and President Obama is expected to sign it into law. Among other things, the bill promotes the use of opioid contracts. These are written agreements between doctors and patients about the conditions for prescribing opioids long term for chronic pain.

This is great news. It could also harm patients. My patient, Cindy was a perfect example.

To hear what happened, read my new article at The Boston Globe's new publication STAT.

Giving patients what they want, even if the doctor doesn't have the time

Doctors struggle to find the time to have in-depth conversations with their patients. Patients, in turn, don't share their end-of-life preferences with their doctors, which leaves them vulnerable to getting more aggressive care than they want. It also wastes a huge amount of money. 

In my new article, I confess a time I contributed to this problem, and point to a really exciting new solution. Harvard researchers, conducting a huge study across the state of Hawaii, have now proven a new way patients can get their wishes respected even if their doctor doesn't have as much time as they want. Online videos about end of life decisions. The videos are outstanding, and proven to work. Plus - bonus! - they saved the system money. 

It's win-win. Check it out!

Will legislators defuse the ticking time bomb of dirty needle use?

For years, Indiana had slowly dismantled its public health system, and needle exchange programs lacked both funding and legal safeguards. Then an HIV outbreak exploded into public view, and Republican Governor Mike Pence had to do some fancy footwork to undo the damage done. He allowed needle exchange programs to operate and provided some long overdue prevention funding. In the meantime, dozens of young Indianans were infected with hepatitis C and HIV. It was a sad case of politics overturning science and common sense.

Now, New Hampshire and other states are in the same boat: politically-minded legislators bloviate about punitive anti-drug stances while the opiate epidemic rages. Complications of injection drug use are on the rise, and it's only a matter of time before a new HIV outbreak comes to town. Needle exchange programs, proven over and again to prevent infections and thus to save lives, languish in the legal shadows.

Fortunately, new legislation is being considered to change help catch New Hampshire up to the 21st Century, and maybe save some lives in the process. I was proud to be quoted here about this overdue change.

Swipe right to connect young people to HIV testing

Midway through her sophomore year of high school, my patient told her parents that she had missed two periods and was worried she might be pregnant.

Stunned to learn that she was sexually active, her parents took her to the pediatrician, who had another surprise: She wasn’t pregnant but she did have H.I.V.

To learn more - including how my patient could have been protected from late H.I.V. diagnosis by a cool mobile app - check out my new post up at The New York Times. Many thanks to support from Dartmouth Public Voices Fellowship, a chapter of the Op-ed Project.

Will this new diagnostic test help us prevent antibiotic misuse?

Clinicians seeing a miserable patient with the sniffles or a cough commonly face a challenging choice: give them antibiotics on the off chance they help, or educate a patient who feels gross why those antibiotics won't work. More of than not, clinicians take the easy way out and reach for the prescription pad. 

The problem of course is that this leads to millions of unnecessary antibiotic prescriptions every year. It's one major driver of epidemic antibiotic resistance, and also why the epidemiology of the antibiotic-associated infection C diff is worse than ever. 

This problem doesn't persist because clinicians are stupid or uncaring. Rather, it is their best intentions that lead them astray. Faced with a concrete potential benefit for the patient in front of them versus an abstract risk down the road, often times clinicians choose that concrete potential benefit over a hard-to-imagine intangible risk like antibiotic resistance or future C diff. Even if the risks FAR outweigh any potential benefits.

A point-of-care test that could tell both docs and patients that those symptoms are definitively from a virus could really change that whole dynamic. And, it could save us from a lot of antibiotic misuse.

A new study out today brings us closer to that reality. Researchers out of Duke found gene expression combinations that were nearly unique to viral vs bacterial vs non-infectious illnesses. To learn more, check out this new post by Eric Boodman in STATnews. I was proud to be quoted in it. See also this very thoughtful post by the ever- excellent Judy Stone at Forbes.

This is not the first test to try to tell bacterial and viral respiratory infections apart. Other similar tests have tried the same thing, and seemed promising at the outset but ultimately flamed out. Take procalcitonin testing, for instance. The reason so many tests have failed before is that the promising diagnostic data found in early studies conducted amid artificially distinct clinical populations and implausibly controlled lab circumstances looked much worse once applied to the messy real world of clinical medicine. That's the next hurdle this new technology has to surmount: to show convenient quick utility in real patients in the real world.

I have my fingers crossed that this new technology will be better!