Category: Health

The recent return of polio has hit like something of an epidemiological thunderclap. It was in 1979 that polio was officially declared eradicated in the U.S.—an early step in a multi-generational effort to wipe out the disease around the world. On July 21, however, the New York State Department of Health announced a case of polio in an unvaccinated man in Rockland County, and since then, circulating poliovirus has been found in wastewater there and in neighboring Orange County, as well as in New York City. In London, the virus was also found in wastewater in February, and in Jerusalem, a case of the disease turned up that same month.

The three cases, though seemingly isolated, point to a troubling trend—one that goes against more than three decades of progress in eradicating the disease. In 1988, polio was endemic in 125 countries and led to the death or paralysis of 350,000 people—mostly children—each year, according to the World Health Organization (WHO). But thanks to a massive vaccination push by the WHO, Rotary International, UNICEF, the U.S. Centers for Disease Control and Prevention (CDC), and more, polio is now endemic in just two countries—Afghanistan and Pakistan—which have seen only 18 cases between them so far this year.

Polio, however, is creeping back, and health officials are now on the alert for what Raul Andino-Pavlovsky, a professor of microbiology and immunology at the University of California, San Francisco, calls a “silent epidemic” of the disease around the world. “This is just the tip of the iceberg,” he warns.

Adds Yvonne Maldonado, a professor of global health and infectious disease at Stanford University School of Medicine, “The case we saw [in New York] was unusual but a red flag that we need to be on the lookout for potential outbreaks. We do run the risk of developing more cases of paralytic disease.”

The bad news is that polio is stalking us anew. The good news is that just in the past year, a new vaccine has been added to the arsenal of existing polio vaccines—one that, properly deployed, could halt a new global outbreak of polio before it can get started. No matter what, the reappearance of the disease has raised a host of challenges—all of which need to be met if we’re to keep polio contained.

What’s behind the current outbreak?

Multiple factors have played a role in the return of polio—not the least of which is complacency, especially in the U.S. and other developed countries. When a majority of people alive have never encountered a case of a given disease, it’s easy to put it out of mind. “People don’t remember polio, they don’t see it,” says Ian Lipkin, professor of epidemiology at Columbia University’s Mailman School of Public Health. “There’s something about our species that just allows us to forget about the importance of these things.”

That can lead to a slow erosion in vaccine compliance—something that the numbers bear out in the U.S. Nationwide, 92.6% of children are fully vaccinated against polio by age 2, according to the CDC. Broadly speaking, that’s an encouraging figure, but vaccination rates vary state to state and even county to county. In Oklahoma, for example, polio vaccination rates are just 79.5%, and in South Carolina, the figure is 80.3%. In the Rockland County zip code where the case of polio turned up in June, the vaccination rate stands at an alarmingly low 37.3%.

The COVID-19 pandemic has also played a role in the return of the disease. “During the COVID era, families didn’t see their doctors or pediatricians as frequently as they normally would,” says Dr. William Schaffner, professor of infectious diseases at Vanderbilt University School of Medicine in Nashville, Tenn. “That has resulted in children falling behind in their routine vaccination schedules.”

According to Maldonado, the fall-off has been minimal, with just a 1% decline in polio vaccination rates among children since the pandemic began. But when it comes to infectious diseases, even a single percent can matter a lot. “It translates to tens of thousands of kids who aren’t completely vaccinated,” Maldonado says, “and those children are at risk for diseases that really shouldn’t exist in well-resourced countries.”

Read More: Polio Is Back. Here’s How to Keep Yourself Safe

The vaccine paradox

The irony of polio’s comeback is that the very vaccination campaign the CDC estimates has prevented 16 million cases of paralysis and 1.5 million deaths since 1988 is also partly responsible for the new resurgence. There are two kinds of polio vaccines. The first, known as the inactivated polio vaccine (IPV)—administered by injection—uses a killed virus to familiarize the body with the disease and prime it to recognize and attack a live virus if it ever encounters it. The other, known as the oral polio vaccine (OPV)—administered by mouth—uses an attenuated, or weakened, virus that can do the same job of priming the immune system, without actually causing the disease. The advantage of the OPV is that it’s easier and cheaper to administer, which is why it’s used in global eradication campaigns. The big disadvantage is that on rare occasions, the weakened vaccine can revert to its virulent strain. That can potentially lead to the disease in the person who received the vaccine, and even if it doesn’t, the reinvigorated virus is shed in feces, entering wastewater and potentially infecting other people. For that reason, the U.S. switched to the IPV exclusively in 2000—even though cases of viral reversion were exceedingly rare.

“The crude estimate was one in 3 million doses of oral vaccine administered would lead to a case of polio in the U.S. before 2000,” Schaffner says. “It’s rare, but it’s not inconsequential.”

Indeed it’s not. Genetic sequencing revealed that the virus that caused the recent cases in New York and Jerusalem and was found in wastewater in London was so-called circulating vaccine-derived poliovirus (cVDPV). So far this year, cVDPV has led to 535 other cases of polio in 18 other countries, according to the Global Polio Eradication Initiative (GPEI).

But the IPV has its problems too—in addition to its comparative difficulty of administration. The OPV, since it’s taken orally, establishes what’s known as gut immunity. Assuming the person who receives the vaccine is not among the unlucky few in whom the virus reverts to its virulent form, there is no viral replication in the intestinal system and thus no virus shed in the feces. The IPV protects the recipient from ever contracting polio, but does not prevent intestinal replication and spread if that person ever picks up a cVDPV.

Andino-Pavlovsky believes that sampling wastewater in any part of the world where the IPV is used would likely turn up some circulating vaccine-derived poliovirus that IPV recipients contracted, replicated, and shed, endangering unvaccinated people. “In Europe, in America, in Australia—every place where people are using the inactivated vaccine—it is likely,” he says.

A new vaccine

Even with the drawbacks to both vaccines, getting vaccinated is obviously better than not getting vaccinated, since all vaccine recipients are protected against contracting symptomatic polio. But the OPV and IPV do exist in a state of tension, with one producing vaccine-derived virus and the other contributing to its spread. For that reason, the WHO and other global health organizations call for an eventual switchover to the IPV exclusively—a move that would mean there would be no vaccine-derived virus to be picked up and shed at all.

“We need to stop giving the live virus so it stops circulating,” says Maldonado.

That, however, is not practical at the moment—not while there are still millions of babies and children who need vaccines in the developing world, where the IPV remains too pricey and skilled vaccinators who can administer injections are in far shorter supply than field workers who require little special training to administer drops to the mouth. As a stopgap, the WHO, the Bill and Melinda Gates Foundation, and the U.K.’s National Institute for Biological Standards and Control have come together to develop a new oral vaccine that is far more stable than previous versions, reducing the likelihood of the attenuated virus used in the drops ever reverting to its virulent state.

Andino-Pavlovsky, who was part of the team that designed the vaccine, explains that it works by targeting the spot on the viral genome that is responsible for reversion to virulence. In existing OPVs, that part of the genome needs to go through just a single mutation to go from being harmless to dangerous.

“What we basically did was modify this sequence,” he says, “so a single point mutation cannot cause reversion; a virus now has to go through four or five different changes before acquiring a more virulent phenotype. Basically, it’s a numbers game.” As Andino-Pavlovsky earlier described it to the journal Nature, “It’s like putting the virus in an evolutionary cage.”

The vaccine that contains that caged virus went into use in March 2021 and so far, 450 million doses have been administered in 22 countries. “The new vaccine is as effective as the previous one in generating immunity,” says Andino-Pavlovsky, “[and is] able to stop the silent epidemic.”

The goal, ultimately, is to drive polio over the cliff to extinction—as smallpox was in 1980—with a slow phase-out of all OPV, universal use of IPV, and the eradication of any form of poliovirus circulating anywhere in the world. The current return of the disease is a reminder that that job is not nearly done. Until it is, an old scourge will haunt us anew.

Correction: The original version of this story misstated the introduction date and distribution of the new polio vaccine. Rollout of the vaccine began in March 2021, not the end of 2021; and 450 million doses have been administered in 22 countries, not 180 million doses in 13 countries.

Write to Jeffrey Kluger at [email protected].

How long does a work break need to be to make you feel better?

Not very long at all, according to a new research review on “micro-breaks,” which the authors defined as a break of 10 minutes or less. The findings were published on Aug. 31 in the journal PLOS ONE. People who took breaks experienced statistically significant boosts in their wellbeing—making them feel more vigorous and less fatigued. The results, based on a review of 22 previously published studies that included 2,335 participants, indicate that those who took micro-breaks had about 60% better odds of feeling energetic, according to Patricia Albulescu and Coralia Sulea, co-authors of the study and researchers at the West University of Timisoara in Romania.

The research was less conclusive on whether micro-breaks improve work performance, however. The benefits varied from study to study and across different kinds of tasks, and ultimately the effect wasn’t statistically significant, although the researchers found that there was improvement as the breaks got longer.

However, there’s robust evidence that for your average worker with a sedentary job, little breaks can have a big impact, says John P. Trougakos, professor of organizational behavior and HR management in the department of management at University of Toronto-Scarborough, and an expert on breaks. (He was not involved in the new review.) By combining both short and long breaks into the work day, workers will feel better and produce better quality work.

Here’s what to know about micro-breaks, and how they can improve your work day.

Why micro-breaks are important

Trougakos argues that the studies in the new review miss an important factor: fatigue tends to worsen over time. Since the experiments in the 22 studies were constrained by time, it wasn’t possible to measure the ways in which being tired at work can create a vicious performance cycle.

“The more fatigued you get, the more effort you have to put in to keep performing. So you actually are expending more and more effort and doing it less and less efficiently,” says Trougakos. “Short breaks, whether it’s a 10-minute break, a 5-minute break, standing up and stretching, you’re kind of giving the person a chance to stop the depletion cycle, but also re-energize themselves a little bit.”

Overall, Trougakos says, while there hasn’t been much research on micro-breaks and performance, science suggests that short breaks are important. That includes studies with an ergonomics angle, which have found that resting your eyes and stretching is necessary to avoid eye strain and skeletal fatigue—discomforts that can distract and drain workers. Not taking sufficient breaks can also negatively affect workers’ sleep quality and life outside of work, and gradually lead them to feel burned out. Studies suggest highly productive employees tend to work in relatively short spurts, with long breaks—according to one study published by a productivity tracker company, spending 52 minutes working for every 17 minutes of break. “The idea is: you don’t work more to be more productive; you work smarter to be more productive,” Trougakos says.

The ideal breaks

The breaks you need might depend on what you’re doing; for instance, activities you enjoy might drain you less than a task you hate or that causes you a lot of stress. As a general rule, however, Trougakos recommends spending about 90 minutes working, followed by a 15- or 20-minute break. Over the course of that working period, you’d also be taking micro-breaks. Trougakos suggests a short stretch break every 20 or 30 minutes, as well as a break to “get away from the task” somewhere in the middle of those 90 minutes.

But what is the best way to rest during these short breaks? While there’s evidence that some things are good for everyone, like stretching, relaxing, or light to moderate physical activity (think: taking a walk), Trougakos says, the best break depends on an individual’s preferences. For instance, an extrovert might choose to grab a coffee with their work friends, while an introvert might duck outside with a book. The key, he says, is that you have control over what you do during your break.

To be sure, Trougakos admits that some managers and companies will be nervous about permitting their employees to take so many breaks. Flexibility is key—employees have different needs for breaks, which might vary depending on the task or even from day to day. However, in many cases, Trougakos argues that the shift to hybrid schedules and working from home has given organizations and workers a novel opportunity: to branch out and find new ways to work to maximize productivity. While permitting break flexibility might feel counterintuitive to companies, it actually fits with what most employers value: to “get people to be fully productive, but also be healthy and have a balanced life,” Trougakos says.

Contact us at [email protected].

In two votes, each 13-1, the immunization committee of the U.S. Centers for Disease Control and Prevention (CDC) recommended that Americans receive an Omicron-specific booster dose of the COVID-19 vaccine. Following a day-long discussion of the available data on Sept. 1, the panel recommended boosters from two manufacturers—Pfizer-BioNTech and Moderna, both of whom make mRNA-based vaccines; the new booster made by Pfizer-BioNTech is for people 12 years and older, and the Moderna shot is for adults 18 years and older. The group also advised that people wait until at least two months after their previous dose before getting one of the two new booster shots. Within hours of the vote, CDC director Dr. Rochelle Walensky accepted the committee’s advice to recommend the new booster.

The Omicron boosters can “help restore protection that has waned since previous vaccination and were designed to provide broader protection against newer variants,” she said in a statement announcing her decision. “This recommendation followed a comprehensive scientific evaluation and robust scientific discussion. If you are eligible, there is no bad time to get your COVID-19 booster and I strongly encourage you to receive it.”

The CDC’s guidance comes a day after the U.S. Food and Drug Administration (FDA) authorized the Omicron-specific shots by both companies.

The booster is the first to target a variant of the SARS-CoV-2 virus. All vaccines that have been approved by the FDA and recommended by the CDC until this point, as well as booster doses that the agencies have authorized, targeted the original virus that emerged in 2019. The latest Omicron booster targets the BA.4 and BA.5 subvariants of the virus, which now account for nearly all new infections of COVID-19 in the U.S.

The Omicron BA.4/5 booster represents a dramatic change in the way health officials are hoping to protect the public. Rather than recommending booster doses every few months, as they’ve been advising since the vaccines became available in late 2020, they are now hoping to shift to an immunization schedule that mimics that for influenza, with an annual shot. The newly authorized Omicron booster will replace existing boosters of the original COVID-19 vaccine. All people 12 years or older will be eligible to get one, regardless of how many previous booster doses they have received so far.

In recommending the booster shot, the CDC’s panel of independent vaccine experts acknowledged that while they have authorized boosters before, this one is different in a number of ways. Not only is it the first to target a variant of the virus, it’s also the first to contain genetic material against two versions of the virus—the original, or ancestral strain, and Omicron BA.4 and BA.5, in a so-called bivalent vaccine. In the case of both Pfizer-BioNTech’s and Moderna’s booster, the dose is the same as the previous boosters that have been authorized, but split between the original and Omicron BA.4/5 strains.

Perhaps most concerning for the committee members, the boosters from both companies have not been tested yet in people, which means that there is no direct evidence that the shots will actually protect people from getting seriously sick with COVID-19. Both Pfizer-BioNTech and Moderna developed Omicron boosters after an FDA panel of experts met in June and requested that the vaccine manufacturers target the BA.4 and BA.5 subvariants. The companies had developed a booster that combined the original strain and an earlier version of Omicron, BA.1, and showed that it helped boost virus-fighting antibody levels against Omicron. But given that BA.4 and BA.5 quickly overtook BA.1 in causing infections, the FDA requested a bivalent vaccine including BA.4 and BA.5. Both companies submitted data to the FDA in August from animal studies showing that their boosters raised antibody levels in mice.

FDA and CDC scientists stress that the animal data is sufficient to recommend the newest booster, given the totality of evidence supporting the safety and effectiveness of previous versions of the vaccines so far. They point to the real-world data involving millions of people who have been vaccinated and boosted up to two times with the original vaccine, as well as data on the bivalent BA.1 booster that never made it to market. Dr. Doran Fink, deputy clinical director of the division of vaccines and related products applications at FDA, opened the discussion by telling the members that, “FDA in its authorization considered the totality of evidence, which consisted primarily of an extrapolation approach based on data from clinical trials with similar bivalent vaccine formulations consisting of the original and Omicron BA.1 sub lineage component, as well as extensive experience with the use of the original monovalent vaccine both as a primary series and as boosters. Additionally, FDA considered supportive data from some animal studies that provided additional reassurance about our extrapolation approach.”

That’s a different approach than that taken by U.K. and Canadian health authorities, who decided to authorize the bivalent booster made by Moderna against the BA.1 subvariant.

That leaves some public health experts in the U.S. concerned about recommending the Omicron BA.4/BA.5 booster. Dr. Pablo Sanchez, professor of pediatrics at Ohio State University and the lone dissenter in voting against recommending the new Omicron booster, said: “I feel we really need human data. It’s a new vaccine, a new platform, and there is a lot of vaccine hesitancy already, so we need human data. I really feel this is premature and wish we had seen that human data.”

Sanchez, however, acknowledged that he would still probably get the booster, since he was convinced by the FDA’s argument that the available evidence, even if it’s indirect, suggests the new shot is both safe and potentially effective. There’s also the fact that every year, the annual flu shot is approved without data demonstrating effectiveness against the latest influenza strains circulating, making the immunization a bit of a gamble, albeit a calculated one. “I would remind the committee that every year, we recommend influenza vaccines based on new strains without clinical studies being done,” said Dr. Melinda Wharton, from the CDC’s National Center for Immunization and Respiratory Diseases and executive secretary of the CDC commmittee. “In a lot of ways, this is analogous to that.”

In favor of recommending a change in the booster, CDC researchers documented that people immunized with the original vaccine and boosters have waning, and in some cases very little, protection from getting infected with the Omicron BA./BA.5 subvariant. While the original vaccines and boosters are protecting people from getting sick enough to need hospitalization, even that protection appears to be diminishing, as more fully immunized people are getting moderately ill after getting infected with BA.4/BA.5. Modeling presented by CDC scientists also showed that if health authorities were to wait another few months, until November, for human studies to be complete on the BA.4/5 booster, about 137,000 more people would be hospitalized and nearly 10,000 people would die of COVID-19.

That’s the reason behind the government’s push to authorize the new booster, but it’s not clear if the public will follow health officials’ advice and rush to get boosted—especially in an environment in which people are weary of repeated boosters and increasingly skeptical of their effectiveness. As more people become infected with the highly transmissible Omicron BA.4/5 variant, they believe that their immunity from having been sick trumps the need to get boosted. And some health officials aren’t convinced that BA.4/5 booster provides that much additional protection from disease compared to the original vaccine, which becomes even more questionable when it comes to people who have been immunized and boosted, and who have recently been infected with Omicron BA.4/5, as many Americans have recently. Dr. Paul Offit, a professor at Children’s Hospital of Philadelphia and a member of the FDA’s vaccine expert committee, does not feel there is enough data to support recommending the new booster, and likely won’t line up for this shot. “The authorization and recommendation by the CDC doesn’t change the data, which is uncomfortably scant,” he tells TIME. “We still have no human data on this vaccine. I don’t plan to get this vaccine, mostly because I don’t think I need it. I have had three previous doses and one mild natural infection.”

Some of the data presented to the CDC committee members addressed this question of how much incremental benefit most people, who are vaccinated and boosted, will get from the Omicron-specific booster. While it makes biological sense to match the booster shot to the circulating virus, which is currently the Omicron BA.4/5 subvariant, the studies haven’t been completed yet. The early data in animals are encouraging, suggesting that boosting with the Omicron-specific shot may help people build broader immunity to not just the original strain but also to multiple variants, including Alpha, Beta, Delta, and Omicron, but mouse data can’t substitute for human trials.

Both companies are conducting human studies and expect to have that information in a few months, but in the meantime, people will have to make their own decisions about how comfortable they are with getting the newest booster dose. “I think this is a big step forward toward simplification,” Wharton told the committee. “I hope we are moving toward something that is simpler and will not require such frequent changes going forward. Clearly we are not there yet, but I think this is a big step forward.”

The U.S. government has already purchased 170 million doses of the Omicron BA.4/5 booster from the two manufacturers, and Pfizer-BioNTech has already shipped 100,000 doses to 62 sites that arrived on Sept. 1. After the Labor Day weekend, the company expects to deliver 3 million doses to more than 3,000 sites. Moderna is manufacturing 66 million doses to meet the government’s order, but has not reported how many have been shipped so far.

Contact us at [email protected].

During the past 60 years, experts have documented a steep rise in the incidence of both ulcerative colitis and Crohn’s disease—the two medical conditions that make up most cases of inflammatory bowel disease (IBD). For decades, this rise was confined to North America, Western Europe, and other industrialized nations. While there’s some evidence that the rise in IBD has slowed down or even plateaued in those places, IBD is becoming increasingly common in newly industrialized countries in Asia and other parts of the world.

There’s no question that genetic factors play a part in a person’s risk for inflammatory bowel disease—and especially for Crohn’s disease. But the increases in IBD incidence and the disease’s pronounced geographical patterns strongly suggest that environmental factors are also at play. “Following World War II, we’ve seen a rapid rise in IBD incidence throughout the developed world,” says Dr. Gilaad Kaplan, a professor and gastroenterologist at the University of Calgary in Canada. “Something about a Western lifestyle seems to be allowing this disease to flourish.” What is that something? That’s the unsolved mystery.

There are several theories—or rather, suspects. Researchers have found associations between IBD and air pollution, food additives, early-life antibiotic exposures, and other environmental variables. Kaplan says that several of these risk factors, not just one, likely underpin the increases in IBD. And they all have one thing in common: the gut microbiome. “Most people feel that what’s driving the inflammatory response we’re seeing, where the body’s immune system attacks the bowels, lies in the intestinal microbiome,” he says.

Your gastrointestinal tract is populated by billions of ­microorganisms that are critical to the health and functioning of your gut. These bacteria help digest the foods you eat, and the metabolites they produce help regulate your immune system. Kaplan says that a robust and diverse microbiome is a hallmark of a healthy GI tract, while anything that disrupts or imbalances the microbiome is associated with GI dysfunction, including IBD. “A lot of the environmental risk factors that have been studied widely are now being looked at through the lens of the microbiome,” he says. This new perspective is yielding important insights, including some related to the treatment of IBD.

Here you’ll find a rundown of the environmental risk factors that researchers have linked to IBD, as well as expert guidance on limiting those risks.

Air pollution and IBD

For a first-of-its-kind study published in 2010, researchers examined the association between ambient air pollution and the incidence of IBD. They found that young people who had grown up around high concentrations of nitrogen dioxide were more than twice as likely as other kids to develop Crohn’s disease.

Since that groundbreaking study, more work has linked air pollution to higher rates of IBD. “We’ve found that early-life exposures to both nitrogen dioxide and ozone are associated with increased risks,” says Eric Lavigne, a senior epidemiologist at Health Canada (the Canadian government’s equivalent of the U.S. Department of Health and Human Services).

Both of these pollutants are associated with automobile traffic. Fuel-­burning cars and trucks emit nitrogen dioxide in their exhaust. When that nitrogen dioxide mixes with heat and sunlight, it undergoes a chemical reaction that produces ozone. “In areas where there’s a lot of traffic, we might see elevated levels of this combination,” Lavigne says. “Living in close proximity to those areas may be a risk factor for IBD.”

How could air pollution affect gut health? Research has shown that after breathing in pollutants, the lungs may actually push these out into the throat so that they’re swallowed. This process is known as mucociliary clearance. Once in the gut, Lavigne says, these pollutants may cause damage to the gut’s microbiota in ways that promote inflammation.

Based on his and others’ work, he says that air pollution exposures during childhood—not in utero or in adulthood—seem to pose the greatest IBD risks. Keeping away from heavily trafficked roads, especially on hot sunny days, is one way to avoid these risks. “Levels of these pollutants are highest within 50 meters”—about 160 feet—“of busy roads,” he says.

Lavigne has also looked at the effect of parks and other urban green spaces on air-­pollution risks. His research found that kids who grew up near green spaces were at reduced risk for IBD. “Particles in the air may get trapped by the leaves from trees, and so having more trees and greener environments might actually create a buffer that reduces people’s exposures,” he explains.

Read More: The Connection Between IBD and Aging

Food choices and dietary exposures

The stuff you swallow can affect the composition of your micro­biome, and therefore your gut health. And researchers have identified a number of diet-­related variables that appear to play a role in IBD risk.

Some of the strongest work involves the very first foods a newborn ingests. “Breastfeeding seems to be very important,” Kaplan says. Research has shown that kids who are breast-fed, as opposed to formulafed, are more than 25% less likely to develop IBD. “As an infant, when you have breast milk, there seem to be tangible benefits that support the development of a robust and diverse microbiome,” he explains.

Beyond infancy, there’s evidence that consuming sugary beverages—especially soft drinks—increases a person’s risks for ulcerative colitis. The more soda someone consumes, the more their risk goes up. On the other hand, eating vegetables is associated with lower rates of ulcerative colitis, while eating whole fruits or other fiber-rich foods seems to reduce a person’s risks for Crohn’s disease.

“There’s also some really interesting research on preservatives that prolong a food’s shelf life,” Kaplan says. A 2021 study in the journal BMJ found that higher intakes of ultra-­processed foods—soft drinks, but also salty snack foods, processed meats, and other packaged goods—were associated with a steep rise in IBD. Compared with people who ate less than one serving of these foods per day, those who ate five or more servings were at nearly double the risk of IBD.

“Things like emulsifiers and additives and heavily processed food particles could actually lead to alterations to the microbiome that may be associated with risk for IBD,” Kaplan says. “Choosing whole foods and staying away from things that are processed or packaged may reduce your risks.”

Read More: How to Maintain Your Social Life When You Have IBD

Early-life hygiene and antibiotics

Antibiotics can save lives when someone has a bacterial infection. But these medicines kill indiscriminately—meaning they take out good bacteria as well as bad. And there’s evidence that when taken early in life while a child’s micro­biome is still forming, anti­biotics may cause imbalances that promote IBD.

“Antibiotics can alter the composition of the human gut micro­biota by decreasing taxonomic richness and diversity,” wrote the authors of a 2019 research review in the journal Gastro­enterology. They cited work linking early-life use of broad-­spectrum antibiotics—basically anything but penicillin—to a more than 50% increase in IBD risk.

“If you have a bacterial infection, you need antibiotics,” Kaplan says. But too often, these drugs are prescribed when they’re not really needed—for example, when a child has a respiratory-­tract infection that would likely resolve on its own without anti­biotics. Doctors are increasingly aware of the risks posed by antibiotic overuse. But parents still need to be wary, he says.

Meanwhile, while hygiene is usually considered a good thing—and not just a good thing but a safety measure that has saved countless lives—there’s strong evidence that being too clean, especially during infancy and childhood, may actually weaken the gut micro­biome. The “hygiene hypothesis,” as it’s called, argues that kids who interact with siblings, farm animals, pets, dirt, and other sources of germs tend to have healthier and more resilient gut microbial ecosystems, and research has linked all of these factors to lower rates of IBD (as well as allergies and autoimmune diseases).

“Early-life exposure [to germs] has an important programming role on the microbiome and immune system,” says Dr. ­Emeran Mayer, founding director of the Microbiome Center at the University of California, Los Angeles. The theory is that when the developing microbiome encounters germs and bacteria, this exposure trains its sensitivity and reactivity in ways that lower a person’s risks for IBD. And so raising kids in squeaky-­clean environments and apart from other children, animals, or sources of germs could imperil their gut health as well as their immune competency. (Some experts have even speculated that COVID-19 safety measures, like the heavy use of hand sanitizers, may inadvertently lead to an increase in IBD among young people.)

A complicated puzzle

While researchers have made a lot of progress in the study of IBD’s environmental risk factors, they say the relationship between a person’s gut health and these variables is immensely complicated. “Someone’s risks may be completely different when in utero or in childhood or in adulthood,” Kaplan points out. He offers cigarette smoking as an example. It may be that smoking during adolescence, more so than in adulthood, is a greater risk factor for gut disorders. Or vice versa. A person’s risk may also depend on the amount they smoke, as well as on their genetic predisposition for GI disease. “There are so many variables that create so much heterogeneity,” he says. “Saying that this is a risk factor and this is not is very difficult to do.”

With that caveat in mind, Kaplan says there are steps every­one can take to reduce their IBD risks. “These are often things that promote healthy living in general,” he says. “Eating more whole foods, getting regular physical activity, and trying to reduce stress in your life are all on the checklist I go through with patients.” For those who live in parts of the country where sunlight is sparse, he says that taking a ­vitamin D supplement may be helpful. “If you look at people who have IBD, you often see a vitamin D deficiency,” he explains. This may just be a by-product of the condition—not its cause. Still, he says that taking a 1,000-IU daily supplement is a low-risk bulwark against gut issues that may be related to a deficiency.

Read More: Fecal Transplants: a New Treatment for IBD

The role of external factors like diet, drugs, and pollution in IBD is complex. But medical science is making big strides in considering the impacts of environmental factors. “It’s pretty revolutionary the way the field has opened up,” Mayer says.

Contact us at [email protected].

Sometimes numbers tell a story, but sometimes they obscure one. According to the latest figures from the National Cancer Institute, the death rate for people diagnosed with bladder cancer has hardly budged during the past 30 years. But experts who treat the disease tell a different and more hopeful tale—and they credit a surge in clinical trials for much of it. “In just the last five or six years, there has been quite a bit of work looking at new therapies for patients with bladder cancer, and we’re seeing unprecedented responses with some of these new drugs,” says Dr. Stephen A. Boorjian, professor and chair of the department of urology at Mayo Clinic in Rochester, Minn.

Some of the greatest advancements in bladder cancer treatment have involved a class of drugs called immune checkpoint inhibitors. They shift a person’s immune system activity in ways that help it fight cancer cells. “These have been paradigm-changing,” Boorjian says. “The way we treat bladder cancer is different than it was just five years ago.”

Others in his field tell a similar story. For people with both metastatic and nonmetastatic bladder cancers, the past half-decade has witnessed the introduction of dozens of promising new treatments. Some have been revolutionary, whereas others have led to incremental but important improvements in care. In every case, these advancements have depended on clinical trials and the people who take part in them.

“Clinical trials are how we got here,” says Dr. Guru Sonpavde, director of the bladder cancer program at Dana-Farber Cancer Institute and associate professor of medicine at Harvard Medical School in Boston. “All the new drugs we have coming out that have changed the outcomes for patients with bladder cancer—all of this has come from clinical trials.”

Clinical trials are carefully designed research studies, conducted in a medical setting, that help experts identify new or better ways to prevent, diagnose, or treat a disease. “Participating in a trial is often the only way to get access to new and promising drugs, or to therapeutic alternatives that may be better than standard of care,” Sonpavde explains.

Although pretty much every type of cancer is the subject of ongoing research, he says bladder cancer may be one of the hottest areas for clinical-trial work. Part of that is because of the prevalence of the cancer; bladder cancer is the sixth most common cancer in the U.S., with more than 80,000 new cases being diagnosed annually. But another factor is that, until recently, decades had passed without major breakthroughs in bladder cancer treatment. “We had some chemotherapies, but this was a cancer where we hadn’t seen many advances until about five years ago,” Sonpavde says.

Like Boorjian, he highlights the game-changing effect that immune checkpoint inhibitors have had on the treatment of bladder cancer. This and other advancements have led to an explosion in new research—and with it, a need for more people to participate in clinical trials.

Unfortunately, this need is not being met. “There are so many drugs and therapies being explored in this space that in some cases there hasn’t been enough patient participation to validate study results,” says Dr. Ashish Kamat, an endowed professor of urologic oncology and director of bladder cancer research at MD Anderson Cancer Center in Houston. “To obtain reliable results, trials need lots of patients, and until we have greater participation it’s going to be hard to move the needle as much as we’d like.”

How to find clinical trials

Part of the problem, Kamat says, is that a lot of people with bladder cancer may not be aware that they are eligible to take part in a clinical trial. Cancer doctors—especially those not affiliated with major research institutions—often fail to bring up these opportunities with their patients. “I’ve given educational talks to patient groups, and people have come up to me and said they had no idea this option existed,” he says. “In some cases they’ve ended up coming to Houston and participating.”

He recommends that patients broach the topic themselves; simply asking your doctor if clinical trials are worth exploring could be enough to get the ball rolling. Also, websites like ClinicalTrials.gov, which is maintained by the U.S. National Library of Medicine, provide up-to-date information about current research trials. You can easily search for clinical trials that are actively recruiting participants in your home state or city. Meanwhile, most major health systems and research institutions maintain their own patient-facing sites featuring clinical-trial information. For example, MD Anderson, Dana-Farber, and Mayo Clinic provide these online resources.

Not everyone with bladder cancer will be a good candidate for a clinical trial. For some, the current standard of care may provide the most effective treatment for the disease. “For a patient that has low-grade bladder cancer, a resection”—that is, surgical removal of the tumor—“has a very high cure rate,” Kamat says. “For this -patient, it may not be advisable to participate [in a trial] because the standard of care is so effective.”

On the other hand, the prognosis for those with metastatic bladder cancer—that is, a cancer that has spread to other parts of the body—may make the prospect of a trial more appealing. “Unfortunately for patients in this space, existing therapies aren’t providing durable long-term survival,” he says. Clinical trials may provide their best opportunity to beat the averages. They may also provide alternatives to invasive procedures. Kamat says that among those with non-muscle-invasive bladder cancer—a group that makes up about 75% to 80% of new bladder cancer -patients—some don’t respond well to the current drugs. These patients normally must have their bladders surgically removed. “This is a life-changing invasive procedure, and clinical trials may provide another option,” he says. Of course, every case is different and needs to be evaluated by a patient’s physician.

Some may be hesitant to sign up for what is essentially an experiment. But clinical trials are tightly regulated to ensure that those who participate are not exposed to undue risks. Dana-Farber’s Sonpavde says clinical trials are always built on a foundation of prior work that suggests the intervention—that is, the new treatment or other thing being studied—is at the very least not excessively risky compared with the current standard of care, and that there is evidence it may be beneficial. “Once a trial happens, you already have basic research showing the intervention is promising,” he says. There is always some element of risk. But with this risk comes the potential reward of gaining access to new and better cancer care, he says.

Read More: The Latest Breakthroughs That Could Help Bladder Cancer Patients

What it’s like to participate in a clinical trial

Let’s say you and your care team have identified a clinical trial that could be a good fit. You’ll next meet with someone affiliated with the trial who will make sure that you understand exactly what the experiment entails. You’ll get a thorough explanation of the study’s design, as well as any potential risks or drawbacks.

If you decide you want to proceed—that is, if you give your informed consent—you’ll likely undergo some type of screening process to ensure you meet the trial’s criteria. It may involve additional testing—scans, biopsies, blood tests—as well as an examination of your medical records. “Sometimes we start doing these evaluations and something comes out that renders the patient ineligible,” Sonpavde says. For example, the genetic makeup of your cancer may ultimately not fit the study guidelines, or you may be taking medications that would interfere with the treatment. But if screening goes well, you will likely begin the study soon—usually within one to three weeks.

It’s important to highlight that, in many clinical trials, some people do not get the new drug or novel treatment. In other words, they’re part of a “control” group that will help the study team assess whether the new intervention provides a benefit. “Generally, the trial will be comparing the new treatment to the standard-of-care treatment,” Sonpavde explains. In other words, even if you don’t get the new treatment, you’ll generally be no worse off than if you hadn’t enrolled.

Another benefit of participating in clinical research is that in some cases—whether you’re getting the new intervention or the control intervention—the cost of your treatment will be covered by the trial. Outside of a clinical-trial setting, some cutting-edge drugs would cost thousands of dollars—or they may not be accessible at all.

On the other hand, clinical trials usually will not cover the cost of lodging or transportation for those who participate. This can be a major barrier for those who don’t live in cities or near research institutions. Also, participants are typically not compensated.

Read More: Changing Cancer Care, So Patients No Longer Feel Like a Number

What’s happening now

Almost every facet of bladder cancer is now the focus of clinical research. But several areas are the subject of particularly intense interest.

Boorjian says novel treatments for non-muscle-invasive bladder cancer are one of the most active areas of research. He recently led a trial that looked at something called adenoviral vector therapy. “This involves instilling the novel medication into the bladder to stimulate the immune system to attack the bladder cancer,” he says. His trial found promising results, and his group is now recruiting participants for some related trials. Meanwhile, Boorjian says a lot of current research is looking at new and improved ways to deliver effective treatments. For example, some trials are examining time-released delivery mechanisms for drugs, which may offer advantages over standard intravenous injections. “We’re looking at better ways to administer medications to minimize the risk of toxicity,” he says.

Another hot area of bladder cancer research is focusing on personalized therapies for metastatic cancers. These precision medicines can be directed at specific targets identified on tumors. Boorjian mentions some new classes of therapies that are designed to target specific genetic mutations within a person’s cancer cells. “We’re starting to target therapies to those tumors, and this is another move-the-field-forward change,” he says.

Changing the story

The National Cancer Institute estimates that this year alone, more than 80,000 people will be newly diagnosed with bladder cancer. More than 17,000 people with bladder cancer right now will not live to see 2023. Improving these figures will depend on clinical trials and the people who participate in them.

“The only way we make further advances is for patients to take part in this work,” Sonpavde says. Again, not everyone will be a good fit, and participating in a trial may present some risks. But you lose very little—and stand to gain a lot—by exploring your options with your care team.

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Climate change has caused more intense wildfires, heat waves, floods and hurricanes, lengthened allergy seasons and inflicted other forms of tangible harm. But an oft-overlooked consequence — one that warrants urgent attention and creative problem-solving — is worsening mental health.

The COVID pandemic has been a time of enormous suffering. According to the World Health Organization, the prevalence of depression and anxiety increased 25% globally during the first year of the pandemic. We are bruised and vulnerable, struggling to right ourselves after a tumultuous two and a half years.

But the daily reminders of global warming, including extreme heat, water rationing and parched landscapes, are threatening to worsen the situation, and we don’t have medications or vaccines to save us.

Climate change has direct effects on mood

Heat itself is associated with mental illness. Mood disorders, anxiety and aggressive behavior have been linked to higher temperatures. A 2019 study published by the National Bureau of Economic Research, found that violent crime in Los Angeles increased by 5.7% on days when temperatures rose above 85 F compared to cooler days.

Authors of a 2018 study in the journal Nature predicted warmer temperatures could lead to as many as 40,000 additional suicides in the U.S. and Mexico by 2050.

“There is a direct link, and mental health and psychosocial well-being will decline as climate change pressures increase,” said Kerry Wangen, a psychiatrist in private practice in Southern California.

People who face climate-related natural disasters frequently struggle with mental health problems. Hurricanes and wildfires lead to deaths and property destruction in the short-term. But they also contribute to depression, anxiety, post-traumatic stress disorder and suicidal thoughts.

Droughts can disrupt food and water supplies and lead to loss of livelihood, which can push families and whole communities into poverty, a risk factor for mental illness. According to a Washington Post analysis, more than 40% of Americans live in a county that experienced an extreme weather event in 2021.

Climate change also leads to the displacement of populations, as parts of the globe become uninhabitable due to sea-level rise, drought and other weather events. The result is more conflict and stress, both of which increase the odds of mental health problems.

Grappling with pervasive fears

The existential fear of climate change is a more pervasive concern, even if it is more subtle and less disabling than mental illnesses triggered by acute events. Fear of global warming leaves many of us feeling hopeless and powerless, dreading what is to come and sensing it is inevitable.

“Although I’ve never had a patient present primarily for climate-related anxiety, it’s common to discover that it’s there alongside other social and societal fears,” said Daniel Hochman, an Austin-based psychiatrist.

A 2020 poll by the American Psychiatric Association found that 67% of Americans are somewhat or extremely anxious about the effects of climate change, and 55% are worried about its impact on their mental health.

According to Hochman, climate anxiety — also referred to as “climate distress,” “climate grief” or “eco-anxiety”— can manifest as dysthymia, in which people are sad for the state of the world, and contribute to generalized anxiety disorder major depressive disorder, panic disorder and insomnia.

For children and young adults, aware that they have the most to lose, the climate crisis is a common source of distress. In a global survey, published in The Lancet in December, nearly 60% of the 16- to 25-year-old respondents reported they were “very” or “extremely” worried about climate change. An additional 25% admitted feeling “moderately” worried. Over 45% said climate change has a negative impact on their daily lives.

What you can do about it

During this summer of record-breaking heat, efforts to combat climate change have seen failure and triumph. On June 30, the U.S. Supreme Court undercut the Environmental Protection Agency’s ability to regulate carbon emissions. Last week, however, Congress passed legislation that will provide nearly $400 billion in tax credits for clean-energy projects to slow global warming.

As we move to address the palpable effects of climate change, we’d do well to follow the WHO’s recommendations to include mental-health and psychosocial support. We also need to boost funding for mental health and climate-change mitigation.

Bob Doppelt, coordinator of the International Transformational Resilience Coalition and author of the forthcoming book Preventing and Healing Climate Traumas: A Guide to Building Resilience and Hope in Communities, laments the inadequacies of our “crisis- and illness-focused” mental health, social service and disaster-response systems.

To address the “climate mega-emergency,” he calls for a public health approach to prevent and heal trauma and is working on federal legislation to support community mental health and resilience.

For those, like me, who often stare at the weather forecast with a sense of doom, Wangen recommends channeling our concern into positive change. Here are a few ideas:

1) Get involved locally

“Find ways to do something, however small, to make an impact locally and/or on a bigger scale,” Wangen said. Increase stress-reduction practices, such as meditation and prayer, and focus “on the present day to keep perspective in the here and now where change can be made, and life can be lived.”

2) Focus on small signs of progress

Doppelt encourages people to “get engaged in an existing neighborhood or community-based coalition or join with friends and colleagues to form a new one that strengthens the entire population’s capacity for mental wellness and transformational resilience for accumulating adversities.” Small signs of progress, he said, help create a sense of hope.

3) Join the conversation

Other innovative strategies for addressing personal eco-anxiety include attending a Climate Café, which encourages climate conversations and political engagement. The Good Grief Network is another option that seeks to build resilience and encourages meaningful action.

4) Keep things in perspective

Hochman also reminds us to get some perspective. Compared to 30 years ago, extreme poverty and famine are lower, he points out. Prior to the pandemic, life expectancy hit an all-time high. Energy and clean water are more accessible.

“Despite climate change, this is by far the safest and best time to live,” he said.

This story was produced by Public Health Watch.

Lisa Doggett, an Austin physician and senior medical director of HGS AxisPoint Health, is a columnist for Public Health Watch, a nonprofit investigative news organization. The views expressed in her column do not necessarily reflect the official policy or position of HGS AxisPoint Health or Public Health Watch.