Mandatory Measles Vaccination in New York City - Reflections on a Bold Experiment
The article we suggest to read this week is "Mandatory Measles Vaccination in New York City - Reflections on a Bold Experiment", published on The New England Journal of Medicine in July 2019.
Though a vaccine has been available for more than 50 years, measles has recently reemerged as a public health threat in the United States. Outbreaks have arisen where vaccination rates have waned, and local governments have responded, through encouragement to vaccination given by officials and religious leaders, quarantining people exposed to the virus, free visits, meetings with community leaders, barring unvaccinated students from all schools and from public spaces designed for more than 10 people, and fines and jail time for disobedience.
New York City and Rockland County have seen the most cases. On April 9, its health commissioner ordered that, within 48 hours, anyone more than 6 months old who lived, worked, or attended school within four Brooklyn ZIP Codes, unless immune or medically exempt, “shall be vaccinated against measles.” The city first threatened civil and criminal repercussions but eventually settled on a $1,000 fine. Reactions were mixed.
Notably, mandatory vaccination is not forcible vaccination. But the city’s “shall be vaccinated” language appears to leave the latter option open, and the health commissioner said it could be considered on a “case-by-case basis.”
For competent adults, forcible vaccination should represent an unconstitutional intrusion on liberty. Forced vaccination of children may be different: vaccination offers near-certain protection from illness, and some scholars argue that vaccination is a human right.
The author reported many open questions on this topic, concluding that unless New York City clarifies its order or the issue arrives in federal court soon, physicians may wish to consider their response to a directive to forcibly vaccinate a child.
The author presented her own opinion about the matter: vaccination should be reserved for extraordinary cases, in which the risk of death or disability is overwhelming, after less intrusive options have been exhausted.
By May 29, New York City had issued 123 civil summonses for noncompliance with
its order. Between October 2018 and March 26, 2019, when its state of emergency began, the county tallied 16,958 MMR vaccinations. Over the next 9 weeks, it added 4624. But Rockland did not order vaccination.
To reset vaccination norms, state legislatures could lower the age of consent, eliminate nonmedical exemptions to school-entry vaccination laws, and fund research on combating vaccine disinformation.
The author concluded warning that force does not educate, develop trust, or protect human dignity, and it will never be an antidote to fear.
Full artile is available here: https://www.nejm.org/doi/full/10.1056/NEJMp1905941
AUTHOR: Julie D. Cantor
Advanced glycation end products (AGE) and receptor for AGE (RAGE) in patients with active tuberculosis
This week we suggest to read an article titled "Advanced glycation end products (AGE) and receptor for AGE (RAGE) in patients with active tuberculosis, and their relationship between food intake and nutritional status", published on the US National Library of Medicine- National Institutes of Health website.
Tuberculosis (TB), caused by Mycobacterium tuberculosis complex, is a major public health problem worldwide, especially in low- and middle-income countries. It is estimated that one-third of the world’s population is infected with Mycobacterium tuberculosis, and 8 million develop the active form of the disease each year, resulting in 2 million deaths per year. Brazil is in 18th place among the 22 countries responsible for 80% of TB cases globally.
The pathogenesis of the consumptive syndrome, which is long recognized as a characteristic of TB, is largely unknown. The proinflammatory cytokines are the initial candidates as agents causing the metabolic alterations. In addition, cell-mediated immunity and innate immune responses play an important role.
The receptor for advanced glycation end products (RAGE), a pattern-recognition receptor that binds multiple ligands, is expressed in normal lungs and is upregulated during inflammation and infection. AGEs are a heterogeneous group of irreversible products resulting from nonenzymatic glycation between reducing sugars and free amino groups of proteins, nucleic acids, or lipid; carboxymethyl lysine (CML) is the predominant AGE in human plasma, which is over synthesized in conditions of inflammation and lung damage. The interaction between AGEs and RAGE on the plasma membrane causes inflammation, oxidative stress, and apoptosis in lung cells.
Studies investigating the relationship between food intake, nutritional status, AGE and RAGE levels and TB, are mostly with animal models.
The authors reported the results of a prospective case-control (1:1), pilot study, conducted in a general, tertiary care, university-affiliated hospital (Hospital de Clı´nicas de Porto Alegre–HCPA), from June 2017 to June 2018, evaluating AGEs and RAGE levels in adult patients with active TB and healthy controls, and investigating the relationship between food intake and nutritional status with AGEs and RAGE levels.
35 TB patients and 35 controls were enrolled. Demographic data, presence of cough, fever, night sweating, hemoptysis, sputum production, weight loss, dyspnea, chest pain, smoking status, alcohol consumption, drug use, presence of comorbidities, results of the main diagnostic tests, outcome of hospitalization were recorded. Blood sample was collected after an overnight fast.
The authors found that sRAGE levels were higher in TB patients than in controls (p = 0.046). In contrast, only among cases that were current smokers, lower sRAGE levels were associated with weight loss and mortality (p = 0.006). Body Mass Index (BMI) was significantly lower in cases than in controls (p < 0.0001). Also, undernutrition was more frequent in cases than in controls. However, there was no significant correlation between those parameters and CML or sRAGE levels. There was no statistically significant difference in CML levels between cases and controls.
The authors concluded highlighting that, although some limitations (it was a single center study, the higher prevalence of HIV among cases could have been a confounding factor, the US common diets used could be different from the Brailian diet), this was the first study, which generates a hypothesis on the role of CML/RAGE in TB patients and not in animal models.
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AUTHORS: Andrades M, Coutinho SE, de Almeida EGC, Holler SR, Silva DR, Silva LF, Skupien EC, Lazzari TK, Zampieri LR.