I am not a fan of how newspapers use headlines to misrepresent stories to provke unwarranted fear, and heightened risk perception. Today, the Ottawa Citizen published two stories about seasonal and H1N1 vaccine. The first story, For Guillain-Barre survivors, flu shot stirs up unwelcome memories, emblazoned on the front page has all the elements of what is regrettably become the norm in newspaper headlines. Headlines are not under control of the journalist. The article was written by Sharon Kirkey.

Ottawa Citizen journalist Dan Gardner’s book, Risk: The Science and Politics of Fear discusses this journalistic approach to sensationalizing news called the Example Rule.

This rule is used to present rare occurrences as if they are common or lurking among us, misrepresenting true risk. Therefore, it was no great surprise to read the front-page headline of today’s Ottawa Citizen continuing this tradition. It outlines the history of a woman who develops a rare neurodegenerative disease called Guillain Barre Syndrome (GBS) and implies a link to the flu vaccine.

The medical content of the story accurately presented the risks of developing GBS, about 1-2 per 100, 000 people. There is some evidence that indicates that the flu vaccine may add an extra 1 per 1 million people. However, the headline clearly did not reflect this. It cites one Ontario study that the seasonal flu vaccine increases the relative risk of contracting GBS by 45 percent.

The absolute risk change of the 1 in a million increase was mentioned immediately following the 45 per cent claim. This former should have been the only statistic cited.

Relative risk is presented to emphasize dramatic change. It is used by media, pharmaceutical companies, food manufacturers, and the Natural Health industry among others to bolster their health claims.

Relative risk does not provide context for the change in risk and should not be included in health reporting. However, it is the number that will be cited by the reader when they discuss this issue with others, hence the problem of skewed risk perception.

The story ends with the woman who had GBS stating, “I made a promise to myself, that if I ever walk again, I will do whatever it takes to keep whatever doesn’t belong in my body out of it.” Although it is understood that traumatic experiences can influence one’s sense of risk, the statement is used to conjure up the idea that unnatural substances are implicated in the disease process and are to be avoided.

If that were the case, one could argue that we should avoid touching any manufactured product, walking down the street and being exposed to car exhaust’s polyaromatic hydrocarbons, and using chemical cleanser’s and agents among others. Exposure to some of these potentially harmful compounds is likely in the parts per million or billion as well. We do not routinely think about this because our sense of risk from these everyday products and activities is low.

News reporting should present information with context. The public should be treated with respect, which includes removing the fear mongering for the sake of selling newspapers, TV and radio shows and magazines. Globe and Mail health reporter Andre Picard has commented on this issue as well as Dr. Noni MacDoanald in an article written for the Canadian Medical Association Journal.

The second story written by Pauline Tam, Our best shot against swine flu?, deserves kudos to the reporter for excellent evidenced-based content and science writing.

Ms. Tam accurately represented the uncertainty that is inherent in medical research yet clearly emphasized the strength of evidence against many misperceptions about the flu vaccine.

She covered the issue about adjuvants or immune system boosters and reviewed how the adjuvant improves efficacy of the vaccine. The adjuvant, squalene, is produced by our liver and is found in many foods as natural oil.

One wonders why, given the focus by some groups on how natural products are better than synthetic, there is such controversy. It would make sense that the logic should remain consistent.

Ms. Tam also reviews the preservative thimerosal found in some multidose vaccines and cites evidence from numerous reputable sources regarding its safety profile.

What Ms. Tam accomplished it to foster critical analysis of health information and present it in context allowing the reader to make an informed decision and risk assessment. She shows medical research is always evolving and is not perfect (nor should it ever be if we are to continue to learn) and how it is a jigsaw puzzle of information pieces that are brought together to create the best picture to date about flu vaccine efficacy and indication for use.

Background:

The evidence-based website Up to Date cites this data:

Vaccination — Guillain-Barré syndrome has followed vaccinations, but this danger may be overstated.

Influenza vaccination — In the United States, an increased risk of GBS was associated with the swine influenza vaccine in 1976, although the severity of the risk has been controversial. Subsequently, no increased risk was observed up to 1991.

Individuals who received either the 1992-1993 or 1993-1994 influenza vaccinations were not at significantly increased risk for GBS, but combining the two seasons suggested that influenza vaccination resulted in approximately one additional case of GBS per million patients inoculated. This risk appears to be substantially less than the overall health risk posed by naturally occurring influenza.

The annual reporting rate of GBS following influenza vaccination in adults declined significantly from 1996-1997 through 2002-2003 in the US. Nevertheless, the long onset interval for post vaccination GBS compared with other post vaccination adverse events (median 13 days versus one day, respectively) is consistent with a possible causal association between GBS and influenza vaccine.

Other data are conflicting, but suggest that influenza vaccination is associated with a low or negligible risk of GBS. In a self-matched case control series from Ontario, Canada that identified 269 hospital admissions for GBS diagnosed within 42 weeks of receiving influenza vaccination, the estimated relative incidence of GBS during the primary risk interval (weeks two through seven after vaccination) compared with the control interval (weeks 20 through 43) was 1.45 (95% CI 1.05-1.99). However, a separate time-series analysis of 2173 hospitalized cases of GBS showed no statistically significant increase in hospitalizations for GBS after institution of the universal influenza vaccination program in 2000.

References:

Guillain-Barre syndrome following influenza vaccination.
Haber P; DeStefano F; Angulo FJ; Iskander J; Shadomy SV; Weintraub E; Chen RT
JAMA 2004 Nov 24;292(20):2478-81.

The Guillain-Barre syndrome.
Ropper AH
N Engl J Med 1992 Apr 23;326(17):1130-6

Guillain-Barre syndrome after influenza vaccination in adults: a population-based study.
Juurlink DN; Stukel TA; Kwong J; Kopp A; McGeer A; Upshur RE; Manuel DG; Moineddin R; Wilson K
Arch Intern Med. 2006 Nov 13;166(20):2217-21.

The Guillain-Barre syndrome and the 1992-1993 and 1993-1994 influenza vaccines.
Lasky T; Terracciano GJ; Magder L; Koski CL; Ballesteros M; Nash D; Clark S; Haber P; Stolley PD; Schonberger LB; Chen RT
N Engl J Med 1998 Dec 17;339(25):1797-802.

Related articles:

1. Safety data of the H1N1 vaccine
2. Why the headline “Healthy women at high risk of severe swine flu: study” is misleading
3. Trends in influenza vaccination in Canada, 1996/1997 to 2005

Originally published in The Ottawa Citizen February 14, 2005

Watching someone we love lose their sense of self has become an all-too-common occurrence in Canada and, indeed, in many parts of the world. Even as adults, our childhood image of our parents is firmly imprinted into our minds. The piece-by-piece loss of this image is painful to witness and frightening to the afflicted.

Although we associate dementia (the loss of intellectual capacity, gradual loss of memory, mood swings, changes in behaviour and inability to perform daily tasks) with the aged, Alzheimer’s disease, the most common form of dementia, occurs throughout adulthood.

How many Canadians suffer from Alzheimer’s? How do you recognize it? What have we learned about this disease? What treatments are available and what progress can we expect in the future?

The most common form of Alzheimer’s disease is Sporadic, involving 90 to 95 per cent of all cases. There is a rare genetically inherited form called Familial Autosomal Dominant that accounts for the remaining five to 10 per cent. Two-thirds of the 280,000 Canadians afflicted are women. One in four Canadians has a family member with the disease. Within the next 25 years, as baby boomers age, the number afflicted will increase to 750,000.

Today, $5.5 billion a year is spent providing nursing-home care, medications and community support services for people with dementia. Annual per person costs proportionally increase with disease severity: $9,541 for those with mild disease to $36,794 for those with severe disease.

We know the disease causes gradual unrelenting brain injury and damage. The brain is organized into different zones, each responsible for a specific function. For example, short-term memory loss, loss of vocabulary skill, and the inability to recognize familiar faces is associated with damage to the temporal lobe and hippocampus.

Despite these changes, people still appreciate, respond to and experience a full range of emotional responses.

Brain tissue becomes damaged because too much beta amyloid protein is secreted into the region. The carrier molecules that usually transport the protein away from the area are overwhelmed. As a result, plaques form and destroy the brain cells (neurons). In addition, twisting choking stringy material within living neurons (neurofibrillary tangles) destroy more of them.

Patients and their family and friends have difficulty pinpointing when the symptoms began because of the slow, progressive nature of the illness. Indeed, many of the treatments available work best in those with mild to moderate disease. An early diagnosis is essential to try to limit the speed of disease progression and improve quality of life.

Although there is no cure for Alzheimer’s disease, there are three cholinesterase inhibitor medications, donepezil (Aricept), rivastigmine (Exelon) and galantamine hydrobromide (Reminyl), available for people with mild to moderate disease that can help improve or slow the decline of cognitive tasks such as memory, language and orientation (knowing the date, time, and who you are). They can stabilize the person’s ability to cope with the responsibilities of daily life.

Notable in Alzheimer’s disease, many of the neurons that are destroyed produce acetylcholine, a neurotransmitter linked to learning and memory. When a neuron activates, it will communicate with the adjacent neuron by sending acetylcholine to it. The acetylcholine in turn will activate the next cell to keep the message going.

These cholinesterase inhibitor medications increase the amount of acetylcholine in the brain by blocking cholinesterase, the enzyme that breaks down acetylcholine, leading to an improvement of some symptoms.

Recently, mamantine (Ebixa), a different class of medication, was approved for use for people with moderate to severe disease.

Cessation of therapy results in symptom relapse after a few weeks. It requires about three months of therapy to see peak improvements. Over the next nine to 12 months, there is a slow return to the original starting point. Thereafter, the decline is slowed compared to those who do not take the medication.

New research is promising. A new drug called Alzhemed, currently in clinical trials, appears to prevent the formation of amyloid plaques and encourages the mopping-up of the beta amyloid before it reaches threatening levels.

Recently, an antibody vaccine against beta amyloid was injected into the brains of mice, and reduced plaque formation.

Although there is no known means to prevent Alzheimer’s disease, there are lifestyle measures that can reduce the rate of onset of the disease: exercise (walking has been shown to delay cognitive decline), smoking cessation, controlling high blood pressure and elevated cholesterol levels, moderate alcohol intake, and healthy eating habits.

Advances will continue as researchers gain more insight into the mechanism of the disease. This is happening now and offers hope to those suffering with this disease and to their families.

The Alzheimer Society of Canada website, www.alzheimer.ca, contains a plethora of information about the disease.

Related articles:

1. No evidence that Ginkgo Biloba prevents or slows cognitive decline
2. Verbal repetition as an early sign of dementia
3. The limitations of Alzheimer’s medications