Romaine Riddle: Why the Toxic Outbreak Eludes Food Investigators

A major overhaul to safeguard the country’s produce is not yet in place, confounding attempts to shut down virulent strains or prevent them altogether.

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The E. Coli Outbreak Is Now the Largest to Span Multiple States Since 2006

At least 84 people have been infected so far, according to health officials, who traced the illnesses to romaine lettuce from southwestern Arizona.

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Global Health: Measles Cases in Europe Quadrupled in 2017

Vaccination rates across Europe are lower than in the United States. Various longstanding anti-vaccine movements persist there, and some conservative Protestant sects in Europe believe vaccination subverts God’s will.

Twenty years ago this month, a study of eight children published in The Lancet by Dr. Andrew J. Wakefield suggested that the measles-mumps-rubella vaccine triggered intestinal inflammation and autism. The journal later retracted the paper, and Dr. Wakefield lost his British medical license after it was revealed that he was a paid consultant for attorneys suing vaccine companies.

The controversy nonetheless triggered a wave of anti-vaccine hysteria. A 2016 survey of 67 countries led by the London School of Hygiene and Tropical Medicine found that skepticism about vaccine safety was highest in France. Skepticism was also high in Russia, Ukraine, Greece and Bosnia-Herzegovina.

The measles outbreaks have led some European countries to crack down. Laws were passed in France, Germany and Italy requiring that parents vaccinate their children or at least consult a doctor about doing so. Italy and Germany imposed fines of $600 to $3,000 for failing to comply.

The Centers for Disease Control and Prevention currently has Level 1 travel watches in effect for Americans thinking of visiting Britain, Greece, Italy, Romania, Serbia and Ukraine. Travelers under age 60 are advised to have two doses of measles vaccine before going. (Everyone born before 1957 is assumed to have had measles as a child and therefore to be immune.)

The United States eliminated measles transmission in 2000, but since then there have been sporadic outbreaks caused by infected travelers. In 2015, the “Disneyland outbreak” ultimately led to over 150 cases in seven states. Investigators believe it began with a single theme park visitor who infected 39 others.

As a result, California outlawed “personal belief” exemptions from vaccination requirements for schoolchildren, and vaccination rates shot up.

In the United States, measles causes pneumonia in about one of 20 cases. One to two cases of measles per 1,000 are fatal; some survivors are left blind or deaf. In countries where children are malnourished and health care is rare, the death rate is as high as 6 percent, the World Health Organization said.

Despite setbacks in Europe, measles vaccine has led to a huge drop in global deaths from the disease. In the 1980s, measles killed 2.6 million a year. In 2016, for the first time since records were kept, deaths fell below 100,000.

In the last two decades, philanthropic donors have paid for 5.5 billion doses for poor countries.

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The New Old Age: No Excuses, People: Get the New Shingles Vaccine

“This really looks to be a breakthrough in vaccinating older adults,” agreed Dr. Jeffrey Cohen, a physician and researcher at the National Institutes of Health.

What’s causing the enthusiasm: Shingrix, which the pharmaceutical firm GlaxoSmithKline intends to begin shipping this month. Large international trials have shown that the vaccine prevents more than 90 percent of shingles cases, even at older ages.

The currently available shingles vaccine, called Zostavax, only prevents about half of shingles cases in those over age 60 and has demonstrated far less effectiveness among elderly patients.

Yet those are the people most at risk for this blistering disease, with its often intense pain, its threat to vision and the associated nerve pain that sometimes last months, even years, after the initial rash fades.

Almost all older Americans harbor the varicella zoster virus that causes shingles; they acquired it with childhood chickenpox, whether they knew they had the disease or not.

The virus stays dormant until, for unknown reasons, it erupts decades later. The risk rises sharply after age 50.

Shingles is hardly a minor menace. “A million cases occur in the United States each and every year,” Dr. Schaffner said. “If you’re fortunate enough to reach your 80th birthday, you stand a one-in-three to one-in-two chance of shingles.”

Preventing the great majority of these cases — along with the risk of lingering and debilitating nerve pain, called postherpetic neuralgia — would represent a major advance in public health.

So while the old vaccine will remain on the market, the C.D.C. committee voted to make Shingrix the preferred vaccine and recommended it for all adults over age 50 — a group younger by a decade than those earlier encouraged to get Zostavax.

The committee also recommended Shingrix for adults who’ve previously gotten Zostavax, since a smaller study in people over age 65 demonstrated effectiveness and safety in those already vaccinated. The Food and Drug Administration approved Shingrix last month.

Once the C.D.C.’s director endorses the committee’s recommendations, and the agency publishes them, insurers — including Medicare and Medicaid — will start covering the vaccine.

“By early 2018, it should be broadly available to consumers in the U.S.,” said Dr. Thomas Breuer, chief medical officer of GSK Vaccines. (Canada has also approved Shingrix; it awaits approval in Australia, Japan and Europe.)

What makes the new vaccine so promising, especially for older adults?

* It provides better protection against shingles from the start. Though Zostavax, introduced in 2006, can reduce shingles cases by about half (and postherpetic neuralgia by two-thirds), that overall rate conceals big differences by age.

That vaccine’s effectiveness drops from 64 percent for people in their 60s to 38 percent among those over age 70, and falls still lower for people in their 80s.

But the new vaccine protects nearly as well in older groups as in the middle-aged. Shingrix racked up a 97 percent effectiveness rate in adults over age 50 and, in a separate study of people over age 70, prevented 90 percent of shingles in those 70 to well past age 80.

“In groups such as the elderly, who often don’t maintain vigorous responses to vaccines, this represents extremely strong disease protection,” said Dr. Kathleen Dooling, an epidemiologist at the C.D.C.

* Shingrix’s protection appears to last longer. Among seniors, the effectiveness of Zostavax wanes with disappointing speed. “After 11 years, the protection was close to zero,” Dr. Harpaz said.

Regulators don’t yet have 11 years of data on Shingrix, but in some samples, it remained effective for six years or longer, according to GSK. That should greatly reduce the incidence of postherpetic neuralgia, too, assuming the 42 million people in their 50s start getting vaccinated.

* The new vaccine may protect people with compromised immune systems.

A substantial number of older Americans have suppressed immunity because they’re undergoing chemotherapy or transplants, have H.I.V. or take steroids. For them, the previous vaccine was off-limits because it was made with a weakened live virus.

Yet immune suppression itself leaves the people vulnerable to shingles. Shingrix, a recombinant vaccine made from a glycoprotein and a combination of immunity boosters called adjuvants, doesn’t pose the same danger.

The C.D.C. committee held off on recommending Shingrix for the immunocompromised, because GSK is still running trials with these patients. But since the F.D.A. did not declare Shingrix contraindicated for them when approving it, they can get the vaccine once it’s available.

Public health advocates do foresee a couple of potential problems.

First, Shingrix requires two doses, administered at least two months apart. Prodding the older population to get a single shot has proved tough: barely 31 percent of those over age 60 have been vaccinated against shingles. How much harder will it be to persuade people to get two Shingrix injections?

Further, “it tends to be a bit of an ouch-y vaccine,” Dr. Schaffner cautioned.

In studies, most older recipients said they’d experienced pain, redness or swelling in their upper arms for a day or two after the shot, and 8.5 percent of those over age 70 deemed those symptoms uncomfortable enough to interfere with normal activities.

About half of those over age 70 reported more systemic side effects like fatigue, fever or aching joints, lasting one to two days. Physicians and pharmacists should prepare people for such reactions, Dr. Schaffner said.

“If people anticipate it, they’ll cope with it better. They’ll take a couple of Tylenol” — and not worry that something is seriously wrong.

They may feel pocketbook pain, too. Zostavax is the most expensive adult vaccine, and at $140 for each dose (plus the cost of administering the injection), Shingrix will be pricier still.

The 50- to 65-year-old cohort, many of whom have coverage under employee health plans, may not find that much of a barrier. At older ages, cost matters more.

Medicare will cover Shingrix under Part D (like its predecessor), not under Part B like the flu vaccine. That complicates reimbursement for those seeking vaccination in doctors’ offices, so Medicare patients will probably find it simpler to head for a pharmacy.

But not all Medicare recipients have Part D, and those that do could face co-payments.

Still, it’s no contest: The hazards of shingles and its complications dwarf any problems yet reported with Shingrix.

“Compared to shingles, a little arm pain for a day or so is a small price to pay,” Dr. Schaffner said. “If you know people who’ve had this illness, you’ll be first in line for this vaccine.”

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Rate of Autism Diagnoses Has Climbed, Study Finds

“One thing the data tells us with certainty: There are many children and families who need help,” Dr. Thomas R. Frieden, director of the C.D.C., said in a news conference on Thursday.

C.D.C. researchers did not meet any of the children they judged to have an autism spectrum disorder. The team made the decisions based on evaluations of the children, drawn from 14 states. The estimated rates in those states varied widely, from one in 210 children in Alabama to one in 47 in Utah.

“This is a fourfold difference,” Dr. Éric Fombonne, a psychiatrist at McGill University and Montreal Children’s Hospital, said in an e-mail. “It means that ascertainment is unequal across states. Thus, in the next surveys, as ascertainment will most likely improve where it is currently low, average rates are bound to increase. Is there, in addition to this, a real increase in incidence? It’s possible, but cannot be determined from the study design.”

Over all, boys were almost five times as likely as girls to get such a diagnosis — at a rate of one in 54, compared with one in 252 for girls.

The sharpest increases appeared among Hispanic and black children, who historically have been less likely to receive an autism spectrum diagnosis than white children.

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