insurance and women's health

Few people realize pregnancy is one of those pesky "preexisting conditions" we've heard so much about. But the push/pull between insurance companies and reproductive health does not stop there. My roommate Ella, a labor and delivery nurse in the Bronx, sent me this blog post which features a woman who was denied coverage due to a previous (completely unremarkable) Cesarean section, and told she could only eligible for coverage if she was willing to have her tubes tied.

just in case...

I have been told I have seemed anti-vaccine as I have blogged about the mandatory H1N1 and flu vaccines for health care workers (HCWs). I did pause over the notion that something like this could be mandatory for half a million people, many of whom explicitly stated they did not want it, for me the central issue was not rights, but efficacy. To me, if the two vaccines had been proven to be very effective in preventing transmission of the flu, it would be justified to require health care workers to get them. Similar logic has been applied to the MMR vaccine, which is mandatory for NYS HCWs, despite challenges in court. However, if the efficacy was low or even not well established, I thought requiring it would be wrong

The logic of the mandate was that HCWs who got the vaccine would be less likely to transmit flu to their patients than non-vaccinated HCWs because their immune systems would be better equipped to fight off the infection. I was unable to find any studies addressing this point explicitly. However, I did find an article in the September issue of the New England Journal of Medicine addressing the overall effectiveness of the flu vaccine. The article was especially interesting because the objection I have head most to the flu is, "how well does it work in young, healthy people?", and participants in this study were all between 18 and 49 years of age. In fact, the mean age of participants was 23.3 with a standard deviation of 7.4 years. That said, no one was excluded from the study on the basis of health unless they had a condition for which the flu vaccine was contraindicated.

The study's intention was to compare the efficacy of the inactivated virus vaccine to the live virus vaccine. The 1952 subjects, all eligible to receive either vaccine, were randomized into two groups. Within these groups, 5 out of every six people received a vaccine, the sixth received a placebo. INTERESTINGLY, each of the vaccines contained three strains of flu, two type As and one type B. One of the type As was H1N1. Subjects were told to follow up if they had a respiratory symptom (stuffy nose, cough) combined with a "constitutional symptom" (fever, malaise). If and when they did, the organism infecting them was cultured.

In the end, 119 participants came down with the flu. One had H1N1, and the others were infected with either the other A strain contained in the vaccine, H3N2, or a B strain that was not in the vaccine. The efficacy of the vaccine with inactive virus when compared to the efficacy of placebo was 73%, the efficacy of the active virus compared to placebo was 51%. Obviously, the inactive vaccine was the more effective of the two.

So there you have it. If you get the inactive flu vaccine, even if you're young and probably healthy, there's a significantly smaller chance you'll get the flu than if you don't. To what extent this translates to a diminished likelihood of transmitting it to someone else is still unclear, although the inference that it would lead to a significantly diminished transmissions is more plausible in light of this rate of efficacy. Frankly, the results were more dramatic than I anticipated, and while I'm still not sure I agree with mandating the flu shot, I am more sympathetic to the idea than I was before seeing these results.

can they make us? no, no they can't

On Friday, October 16, a judge temporarily blocked the mandate that all health care workers (HCWs) in NYS get both a seasonal flu and a swine flu vaccine before November 30 or face disciplinary action. The judge granted a "temporary restraining order", which I gather means the requirement was temporarily suspended. A further hearing was scheduled for October 30, when the health department would have had the chance to continue making its case.

However, it's doubtful that that hearing will ever take place, since on Thursday, October 22, Governor Paterson rescinded the mandate that all HCWs get the vaccine due to a more limited supply of the vaccine than anticipated. The CDC has thus far only been able to produce about 23% of the anticipated amount of H1N1 vaccine, and the state government has decided it's more important to vaccinate those at risk of becoming seriously ill from the disease (pregnant women, for example) than those at risk of transmitting the disease.

The requirement sparked controversy from the beginning, with health care workers protesting in front of the capitol building and lawsuits filed by three separate groups. Interestingly, each group represented a different demographic: one was nurses, one was public employees, and one was teachers.

more grocery stores in NYC

In late September, the New York City Planning Commission approved an incentive program to encourage more grocery stores to open their doors in underserved parts of NYC. The incentives include: allowing residential buildings to be 20,000 square feet larger than permitted now if they include a grocery store, forgoing the requirement that smaller grocery stores provide parking for their customers, and providing grocery stores in the targeted areas with "tax abatements". In order to be eligible, stores must devote a least one half of their square footage to food, and a certain percentage on top of that to perishables such as fresh produce, meat, and dairy. These areas targeted by this program include: northern Manhattan, central Brooklyn, south Bronx, and downtown Jamaica in Queens. (I kind of see why Staten Island people get so bitter sometimes...)

exam one done

Today was my first exam of this semester. It was in Diagnosis and Management II, from the lectures on GI, urinary, hepatitis of all ilks, and emergency preparedness. It went fine, with the usual mix of questions that range from obvious to esoteric. Of course, I want them to post the grades ASAP...

After this, I have few actual assignments ahead of me. This class has two more exams, and my other class requires one case presentation and one paper. However, the paper is our "capstone", intended to serve as a master's thesis, and has been in the works since early 2009. That's it. The vast majority of the work will be in clinical, where I have to see patients and present them to my preceptor. This semester's preceptor is a character, who prides herself on being "forceful" and having "a big mouth" but also seems like a very good clinician who cares a lot about her patients.

Because of the extra day of clinical (two per week instead of just one) this semester has been more challenging for most of us than previous semesters. This is especially true for those of us who are working. I've been keeping a mental tally of the weeks completed; my friend has made a paper chain with one link per remaining week, which she can tear off on Saturday nights. Her husband ruefully noted it was longer than he had been hoping. Another friend happily told me last night there were only 73 more days until December 23. Nice.

flu and H1N1 vaccine: can they make us?

A recent NYS mandate that all health care works get both a seasonal flu shot and an H1N1 vaccine has stirred some controversy. Hospital workers have objected to making the two shots a requirement for continued employment, saying that it's "anti-American" for medical treatment (or in this case, prophylaxis) be mandated. The state has countered that in the past when the vaccine was voluntary, only 40% of workers got it. I have nurse friends who are passionate about public health who have up until now declined to get the shot. They question its efficacy in young, non-immunocommpromised workers, and point out that the shot only contains the fews strains epidemiologists guess will be most prevalent this season, and thus is far from a sure thing.

I believe (and I may be wrong) that as a student working in health care, I am subject to the same mandate. I am certainly required to get both shots. A few weeks ago, my school notified all health care graduate students (nursing, medical, dental, and possibly the physical therapists) that we were required to get the seasonal flu shot ASAP and could not do our clinical rotations, mandatory as a part of the curriculum, without them. Those students who had student health insurance could get the shots at student health services; those who did not had to go elsewhere. I ended up going to an NYS Department of Health site to get mine. I am not sure what I will do when H1N1 comes out. Frankly, I felt that if they were going to require I get the shot, they should have at least offered me the convenience of paying for it at student health services, as they offer us the convenience of buying books at the campus bookstore.

Anyway, to the few people who read this blog, I would be interested to hear what you all think. Should it be mandatory for nurses, doctors, and everyone else, to get the flu shot by order of NYS?

long island hospital moves towards EMRs

North Shore Long Island Jewish Health System, a network of 13 hospitals, has announced its intention to digitize its record system. The hospital hopes the new system will provide both a competitive advantage for itself and improved care for patients, mostly by better integrating records kept across the system. The estimated cost: $400 million. NYC's government has historically been a leader in encouraging the adoption of EMRs, but most of that has been in small private practices, nothing on the scale of a network like this.