Pneumococcal Pneumonia: Myths and Facts

The bacteria Streptococcus pneumoniae is the cause of pneumococcal pneumonia, causing 1.6 million deaths globally each year.

That’s more lives than any other single bacteria.

Pneumonia-like illness is in the top 10 causes of death in Australia. More women (1,303), die annually than males (1,019). Fatalities in the 50-80 age group are rising “exponentially” each year.

In the previous post we debunked a concerted attack on the pneumococcal vaccine by antivaccine lobbyists Meryl Dorey and Greg Beattie aka Gregyl. Serendipitously Greg Beattie’s graph strongly reinforced the importance of vaccination in preventing pneumonia, for at-risk groups.

Reluctance to vaccinate is already one cause of preventable pneumococal pneumonia and death in over 65’s and high risk demographics. I’ll leave you to judge the degree of morality involved in fallaciously inflating this problem.

Whilst that was an attempt at misinformation – or “disinformation” to quote Dr. Brian Martin – intended to undermine public confidence, there are separate myths that also apply.

This video © The Australian Lung Foundation addresses the most common.

Busting Greg Beattie or Two heads are sillier than one

On July 2nd Greg Beattie and Meryl Dorey released a rambling attack on the pneumococcal vaccine.

Bizarrely it was headed “Media Release” and despite listing the contact details of both Greg and Meryl, the Aussie media know anti-health warriors when they see them. It sank without a trace almost immediately.

Still, a look at the context and contents reveal much about the tactics used by both Beattie and Dorey. It proclaimed;

A media release being issued by a self-proclaimed group of ‘experts’, including many with financial links to vaccine manufacturers, is calling for increased use of vaccines against pneumococcal bacteria as a way of preventing pneumonia.

Without letting on, it was actually in reference to this Australian Lung Foundation media release. They were falsely suggesting a campaign targetting “young Australians” for pneumococcal vaccination was under way. In fact, it is Pneumonia Awareness Week and little wonder they did not link to the many facts related to pneumococcal disease.

On July 3rd, Sky News quoted Professor Booy from the National Centre for Immunisation Research and Surveillance. He had elaborated on implications from a survey completed by GP patients. The survey reached a sample of 2,500 and looked closely at risk factors. Sky News reported:

A survey of 2,500 GP patients found about a quarter of those aged 15 to 64 had at least one risk factor for contracting pneumococcal diseases such as pneumonia and meningitis.

About two in three of those had not been vaccinated, according to research by the University of Sydney’s Family Medicine Research Centre. But most patients – nearly 80 per cent – aged 65 and over had a pneumococcal vaccination.

Risk factors included smoking, diabetes and chronic lung disease.

Okay. So, first off we have our most damning variable to be obfuscated by… (let’s call them Gregyl in the Hollywood fashion). What Gregyl had done was to report on these dynamics as if concerns related to low pnemococcal vaccination rates applied only to the mainstream population. In fact it was specifically related to risk factors which also include diabetes, heart disease, kidney disease and impaired immunity. Infants and the elderly are also deemed at higher risk.

The populations are referred to as “at-risk”. Reflecting this, the Sky News article was headed Vaccine rates low for at-risk pneumonia. To mock this Gregyl headed theirs Australians “at risk” from vaccination campaign (inverted comma’s theirs). In classic foot bullet style this indicates they knew very well there was no campaign targetting Aussies.

Having set the scene Gregyl can control the attack on the vaccine. They ask:

Will increased use of pneumococcal vaccines lead to declines in either the notification or mortality (death rates) from pneumococcal pneumonia?

This is certainly Beattie’s work as he favours irrelevant sources. He includes a 2008 letter from the WHO Bulletin, to answer his own question in the negative. Except he fails.

The letter is not looking at infection from pneumococcal bacteria or death rates from pneumococcal pneumonia following pneumococcal vaccination. It is arguing that the incidence of “clinical pneumonia” is not reduced by this vaccine. Pneumonia can arise from at least 8 strains of bacteria, 7 viruses and various fungi.

Worse, the letter deals with dynamics in developing nations. It is utterly and irrevocably deceptive to cite the dynamics of infectious disease in low income nations and apply them to a developed nation such as Australia. 50% of all cases of bacterial pneumonia globally, test positive for Streptococcus pneumoniae. It is the leading cause of CAP – Community-acquired pneumonia – in Australia.

To answer the question above – Yes most certainly.

As shameful as that was, Gregyl continue with:

Are those aged between 15 and 64 truly at greater risk of contracting or dying from pneumonia caused by pneumococcus as these ‘experts’ have stated?

The question is misleading as the issue at hand is at-risk, chronically ill patients. Beattie supplies an Australian Institute of Health and Welfare graph of pneumonia mortality per 100,000 citing age groups 0 – 14, 14 to 64 and 65 plus.

His aim is again to answer the question in the negative.

Predictably it shows a drop in pneumonia for the lower age groups from 1907 to 2006. It also shows a rise and fall for 65 plus from 1907 to 1967. It then tapers off reflecting the increased life expectancy and better health of older Aussies.

Of course, I should dismiss this graph out of hand as it covers all pneumonia cases. Yet it’s worth noting that a common misconception about pneumonia is that it’s a “really bad” cold or flu. In truth pneumonia strikes after infection with influenza or another disease that leaves one chronically ill or at-risk.

As more and more vaccines have been introduced, particularly pertussis, influenza, pneumovax, hepatitis B and follow up with boosters became common place, the health of Aussies has increased markedly. Thus the causes of pneumonia of all types have been less likely to exploit weakened immunity or chronic disease problems.

So in effect, Beattie’s graph actually reinforces the essential need for pneumococcal vaccination because it shows the power of vaccines in protecting at-risk Aussies from pneumonia.

Thanks to Beattie’s graph we have an answer backed by The Australian Institute of Health and Welfare. Yes, most certainly.

Next is:

What percentage of all cases of pneumonia are caused by pneumococcal bacteria?

Now it’s time to leave Kansas entirely Dorothy. Beattie links to the American Lung Association Pneumonia Fact Sheet, claiming that 14% of all cases of pneumonia are attributed by the ALA to pneumococcal bacteria. What Beattie has done is taken the male discharges (589,000) and female (643,000) from 2006. This total = 1,232,000 pneumonia discharges for 2006.

He then gets an August 2009 annual estimation of 175,000 cases to get his 14%. It goes without saying that his claim, “according to the ALA, blah, blah…” is a lie. There’s nothing wrong with making rough conclusions from different sources but Beattie had no reason to a.) falsely attest to an annual figure and b.) falsely attribute it to the American Lung Foundation.

Let’s check that paragraph:

Streptococcus pneumoniae or pneumococcal pneumonia is the most common cause of bacterial pneumonia acquired outside of hospitals. The bacteria can multiply and cause serious damage to healthy individual lungs, bloodstream (bacteremia), brain (meningitis) and other parts of the body, especially when the body’s defenses are weakened. It is estimated that 175,000 cases of pneumococcal pneumonia occur each year, with a fatality rate of 5-7%, or even much higher among the elderly

Now it’s time to address Gregyl’s focus on pneumonia. Remember, Gregyl is attacking pneumococcal vaccination. The trick so far has been has been to focus on pneumonia and ignore meningitis and septicaemia. This enabled Beattie to invent or ask the wrong questions.

The notion of streptoccocus pneumonia cases being minor compared to other types is nonsensical. As noted way above, of all bacterial pneumonia cases, Streptococcus pneumoniae bacterium is isolated 50% of the time. It is the leading cause of pneumonia acquired in the community. So for Joe Bloggs, it may as well be 100% of cases. We can see by the graph above that the greatest variable is age – not type.

So to answer this question – It makes no difference.

Beattie is almost cornered by his lies. Next up is:

Will use of the pneumococcal vaccine reduce the incidence of illness?

Astonishingly he then blurts out, with no references:

  • Most adults and children carry the bacteria without symptoms
  • The vaccine won’t stop us coming into contact with the bacteria
  • Levels of meningitis, septacaemia and pneumonia have not gone down
  • Death rates are increasing in the elderly since introduction

The disease is spread by droplets from person to person. The Department of Health and Ageing note:

Pneumococci can be isolated from the upper respiratory tract in children and, less frequently, adults, and can spread directly from the nasopharynx to the respiratory tract which may cause otitis media, sinusitis or pneumonia. Pneumococci are also able to enter the bloodstream to cause invasive disease which may manifest as meningitis, pneumonia, septicaemia…

What then about notifications and hospitalisations from pneumococcal disease? Are they rising?

Pneumococcal disease notifications and hospitalisations, Australia, 1998 to 2007

Absolutely not. No idea where these guys get data from but it certainly won’t back what they claim.

How are the most vulnerable, the young and old faring? What of Gregyl’s increased disease and death in the elderly?

Pneumococcal disease notification rates, Australia, 2002 to 2007, by age group and year of diagnosis

No. Not here. Even remembering that the elderly show reduced immune responses to vaccination.

So the answer is – Yes, it will control the illness.

Next we get:

Will vaccinating against 23 strains of pneumococcal bacteria provide true protection against pneumococcal pneumonia?

After telling us it lives in the upper respiratory tract Gregyl now admits there are 91 different strains, and the vaccine targets 23. This is a genuine query and results suggest the vaccine will protect against the strains, compared to notification.

Notification rates of IPD cases with serotypes contained in the 7-valent pneumococcal conjugate vaccine (7vPCV), versus notification rates for other non-7-valent serotypes, Australia, 2006–2007 compared with 2002–2004, by age group

The Immunization Action Coalition offer:

What causes pneumococcal disease?

Pneumococcal disease is caused by Streptococcus pneumoniae, a bacterium. There are more than 90 subtypes. Most subtypes can cause disease, but only a few produce the majority of invasive pneumococcal infections. The 10 most common subtypes cause 62% of invasive disease worldwide.

In a concerted effort to mislead, Gregyl claims that, “studies in multiple locations around the world” have shown bacterial vaccines to lead to serogroup replacement. They fail to cite one study. Then again use the WHO Bulletin letter on developing nations to argue the point. Finally they claim this has happened with pertussis leading to “potentially more dangerous strains of bacteria”.

As has been explained here countless times no “more dangerous” strain of pertussis has evolved. In fact the opposite is supported by data. Fatalities are less than 1997 and 2000, whilst hospitalisations are about the same. This is parallel to far more notifications. More so, Tom Sidwell has demolished the notion of pertussis bacteria evolving around the vaccine.

Lastly we get:

Is there any evidence at all that use of this vaccine has led to a decline in either incidence of or deaths from invasive pneumococcal disease?

It’s followed by the use of NNDSS total notification figures of invasive pneumococcal disease in Australia to argue that there has been no change. Whilst the graphs above show a definite change USA research also backs significant reduction in infant infection and a reduction in mortality for all other age groups.

Yet most offensive is that NNDSS notifications tell us nothing about vaccination status. Every notification might be unvaccinated or every one may be vaccinated. Yet you’re tricked as if 100% of Aussies actually have been vaccinated. Nothing suggests infection even originated in Australia? This is one of Dorey’s old tricks. The fact is that it is an unrelated data set dealing only with notifications.

So our final answer? Yes, there is an abundance of evidence.

All up this was an appalling and scurrilous attempt to both scare the public into believing a vaccination “campaign” was under way and use this to fallaciously attack a very successful vaccine. Along with rotavirus, pneumococccal vaccination is on rapid roll out in developing nations. A major reason for this is it’s outstanding success here.

Dorey and Beattie, or Gregyl if you prefer, have been caught out at every single turn in this so-called “media release”. Not only does other evidence refute these absurd claims, even the evidence they provided upholds the importance of this vaccine’s success.

To be fair there was another question about making an informed choice. Which is code for will parents be provided with more codswallop of this type. As it had all just vanished in a puff of smoke I could see no point in answering.

In conclusion, to Gregyl and particularly Greg Beattie I am grateful for the chance to answer Yes to all those questions.

No matter how distorted they were.

A Mother’s Choice, Fear and Confusion

In April and May 2009 channel Seven’s Sunday Night programme looked at the activities of The Australian Vaccination Network.

Following the first programme – A Mother’s Choice – the producers held a live audience forum entitled Fear and Confusion.

Both episodes are below, with a final credit scroll examining the activity of anti-vaccine GP, Giselle Cooke, which led to a NSW Medical Tribunal hearing.

Drug War tactics driving up HIV/AIDS

The Global Commission on Drug Policy recently released yet another report condemning illicit drug prohibition and the War on Drugs.

Entitled The War on Drugs and HIV/AIDS – how the criminalisation of drug use fuels the global pandemic the report lists 6 key dynamics behind the trend.

1.) Fear of arrest drives persons who use drugs underground, away from HIV testing and HIV prevention services and into high risk environments. 2.) Restrictions on provision of sterile syringes to drug users result in increased syringe sharing. 3.) Prohibitions or restrictions on opioid substitution therapy or other evidence based treatment result in untreated addiction and avoidable HIV risk behaviour. 4.) Conditions and lack of HIV prevention measures in prison lead to HIV outbreaks in incarcerated drug users. 5.) Disruptions of HIV antiretroviral therapy result in elevated HIV viral load and subsequent HIV transmission and increased antiretroviral resistance. 6.) Limited public funds are wasted on harmful and ineffective drug law enforcement efforts instead of being invested in proven HIV prevention strategies.

Let’s forget “drug war” and call this problem what it is. Treating drug use as a criminal offence. Now, just by raising that image we’re into different waters entirely. Pointing to problems with the criminal model immediately evokes suspicion of compulsory promotion of illicit drug use. We’re conditioned to assume if we don’t punish drug use, it will be everywhere and bring about a host of nasty outcomes.

Mostly, we’re well conditioned to associate drug use with crime and to see it as criminal. Stitched on to this is the pop culture image from which we draw stereotypes. My favourite is one I often refer to as Quinn Martin. Quinn Martin Productions brought us Streets Of San Francisco and a host of other unrealistic 1970’s TV Cop shows. If you wanted a crime – it was drug related. A bad guy or a weak willed loser? Toss in a druggie.

Of course, I’m not suggesting we imagine this. The reality is criminals are made from associating in criminal circles and from being incarcerated, regardless of the reason. How this fits in with the drug-crime punishment model was addressed recently by eminent Australians who authored the Australia 21 Report. They state:

The prohibition of illicit drugs is killing and criminalising our children, and we are all letting it happen

Rather than legalisation alone, that report discussed regulation, decriminalisation and de-penalisation. Far from being an open slather free ride these measures involve control, certain losses of freedom, the need to demonstrate responsibility and a major focus on rehabilitation back to a productive and useful lifestyle. What they don’t involve is the destruction of lives and sustaining criminal enterprise at huge cost to the community.

Yet in Australia we do very well managing HIV/AIDS in injection drug users [IDU]. 16 million use IV drugs globally. Almost 20% live with HIV. Fortunately, Australia managed to keep that level at 3%, and a significant number of that sample were at higher risk statistically from acquiring HIV from another high risk behaviour. This level remained stable for decades.

So the question does arise. Apart from acknowledging shocking human rights abuses, tragedy in many nations and an ongoing source of disease and corruption, what policy aspects need we mull over?

Since the Howard years Tough On Drugs initiative and emergence of groups like Drug Free Australia lobbying against expanded protective measures, the level of HIV in IDU jumped to 4%. It remains an exquisite example of how just a few years of delayed and abandoned Harm Reduction responses, increased punishment and disinformation about Harm Reduction efficacy has an immediately devastating impact on HIV control in Aussie IDU.

The fact that this collective undermining of Harm Minimisation occurred during a period when Harm Reduction services, research and supporting evidence expanded rapidly in Australia is testimony to how effective disinformation and intuitively themed attacks on evidence can actually be.

Still, as of April this year we remain extremely fortunate thanks to Harm Reduction:

HIV in IV Drug Users matched to Harm Reduction

The single greatest sabotage of Harm Reduction initiatives under the auspices of John Howard, was the suppression of a heroin on prescription trial in 1997. This had strong bipartisan support and the Federal Health Minister, four States and the ACT were excited about the decision to go ahead. Under instructions from then ANCD head Major Brian Watters – later to become a Board member of Drug Free Australia – Howard immediately vetoed the decision.

Exactly how many HIV cases, ruined lives and deaths this led to is impossible to estimate, and I would err toward a minimal estimate. Still, 15 years later we can assume the body pile is now somewhat impressive. In what is unique insight into how Howard in turn manipulated the zealots who tried to manipulate him, he never flinched on needle exchange.

To his credit he continued to fund over a thousand outlets across Australia, with some specialising in bulk dispensing, others in hard core risk management. Abandoning these programmes was insanity, despite conservative lobbyists being convinced he might do so. Yet to Howard, being seen to usher in heroin prescription – “free heroin” – as shock jocks called it was political suicide.

Despite strong support for our official policy of Harm Minimisation, which accommodated extreme spending against smuggling (Supply Reduction), this is how he presented his thoughts in 1998:

The policy of zero tolerance of drug taking in this country is a wholly credible policy and policy that ought to be pursued more vigorously by government and by people who are concerned about the problem.

Of all the lies he told, this remains one of my favourites. There was no such policy beyond words. He seemed to despise everyone equally. Which was essential for the politician he became. All that mattered to Howard was Howard, and securing votes. Manipulating drug workers, users, science advisers, policy experts and voters over what was a social crisis at the time was pure business.

British Columbia did introduce heroin on prescription in 2005. 5 years later the effects of the combined measures on HIV were compelling:

British Columbia: HIV infection matched to Harm Reduction initiatives

Similar success from heroin on prescription is found in every nation to usher in trials and programmes. Sadly, Australia was ready before the Howard years. We were in fact, world leaders. Now it’s a different story. We have one Medically Supervised Injecting Facility that ran as a successful trial for 11 years.

Seven of those 11 years were due to disinformation and sabotage from conservatives. In October 2010 the Kenaelly NSW State government passed a Drug Misuse and Trafficking Amendment bill to ensure the Centre became permanent. 11 years of moral panic was, at least legislatively, silenced.

Whilst actually attacking Harm Reduction initiatives, confusing methadone and buprenorphine with illicit drugs and muddling the lot in with AFL drug policy, Alan Jones delighted us with his wisdom on “Harm Minimisation”, in mid 2007 [MP3 here]. Obnoxious, offensive and completely ignorant of facts it is also somewhat representative of Aussie views today:

So today Australia has a long, long way to go before we do, if ever, fully recover from the rise of anti-drug conservatives under John Howard. They did far more damage than just raise HIV infection by 1% in injection drug users. Our fluency with progressive policy and public maturity has been undermined. Australia waits, on pause.

33 million people live with HIV today. Outside sub-Sahran Africa IV drug use accounts for 1/3 of new infections. For almost 15 years annual HIV infections have been falling on a global scale. Except for seven countries wherein HIV infections increased by about 25% primarily due to IV drug use.

The “drug war” is full on in Eastern Europe and Central Asia and unsurprisingly 5 of these 7 countries are in these boundaries. In the last decade people living with HIV in these areas has close to tripled. Russia has resisted Harm Reduction measures keeping methadone illegal and charging users for needle possession. As this demographic is actively abused by law enforcers the motivation to use needles based on access convenience and minimal time is heightened. The results are clear:

HIV infections – Russian Federation

Thailand has impressively cut HIV infection in workers in the famous tourist attracting sex industry from 40% in the mid 1990’s to around 5% today. This pulled male clientele infection rates down in parallel. At the same time fierce drug war tactics led to 2,500 “death squad” murders in 2003 and HIV is up to 1 in 2 IDU in some regions. A comparison of different demographics for HIV infection is compelling:

THAILAND: HIV infections per demographic

In a splendid example of stupidity the USA reinstated it’s 21 year ban on federal funding for needle exchange programmes only 2 years after ending it. A stark lesson for Australia, constantly under the assault of disinformation from anti-drug group Drug Free Australia, can be found on page 9 of the GCDP Report.

Recently in reviewing the history of Harm Reduction and HIV, I noted the stark difference between not just nations, but regions within nations favouring HR as a powerful controller of HIV spread. Similarly today it can be seen that in nations with extreme law enforcement, and regions within the USA with the most intense law enforcement that HIV levels are higher than those with low law enforcement.

For instance, a study of the 96 largest US metropolitan areas found that measures of anti-drug “legal repressiveness” were associated with higher HIV prevalence among injectors and concluded: “This may be because fear of arrest and/or punishment leads drug injectors to avoid using syringe exchanges, or to inject hurriedly or to inject in shooting galleries or other multiperson injection settings to escape detection.”

DFA fallaciously – and skillfully – report the exact opposite. Similarly DFA urge for dedicated Harm Prevention measures, described already on this blog as crude behaviour modification. Whether through blind or biblical force the aim is to do just that: force drug users to stop by changing behaviour. Forget the addiction and crush the symptom.

The easiest way to do this is control the environment. Enter compulsory detention. What DFA have called “compassionate detention”. The models they are considering are terrifying. Not only is HIV infection spread through these centres, they fail to offer any addiction treatment. Forced abstinence is associated with high fatality relapse.

Once infected with HIV criminal and punitive approaches act as a disincentive to testing and treatment. Requirements to be drug-free in order to receive treatment (as in Sweden) and denial of certain rights like child custody and employment correlate directly to higher HIV/AIDS fatalities. Confidentiality breaches and stigma impact frequently due to law enforcement regardless of country.

This leads to higher circulation of HIV in the community as treatment has been shown to reduce HIV transmitted via blood and body fluids. As such it is vital all demographics in all communities can be reached through treatment which ultimately leads to prevention.

Incarceration also increases HIV infection and Australia is heading toward a USA type model which has 25% of prisoners listed as HIV positive. Fortunately our initial lower levels in the IDU population will protect us significantly from such a nightmare. Unusually, prison needle exchange is resisted strongly. DFA play the key lobby role nationally and prison guard unions seem intent to deny evidence in favour of their health.

Australian prison guards profit enormously from selling syringes to prisoners. Secondary to money is the control of prison dynamics, control of prisoner behaviour and the essential control of these transactions in corruption entire. A syringe is power in the prison setting. The sooner we remove this tool from guards and protect prisoner health with clean exchanges, the better.

Resources spent on law enforcement are resources not spent on health initiatives generally, on a global scale. With drug crime and infection encouraged by the former and lessened by the latter, it is clear we face a major global challenge. Public health is the first principle of drug control.

Settings where HIV prevention measures have been curtailed as a result of economic concerns have been particularly vulnerable to increases in HIV risk among injection drug users. For instance, a greater than 10-fold increase in newly diagnosed HIV infections among injecting drug users has recently been reported from Greece during the first seven months of 2011.

Australia remains incredibly lucky and indeed most fortunate in this global picture. What cannot be ignored and what must be cautioned against is our slow morphing into a landing pad for USA styled conservative disasters. DFA is an arm of Drug Free America Foundation and act at their bidding. DFAF have their “division”, the Institute on Global Drug Policy who fund the Journal of Global Drug Policy and Practice.

This is no journal but a vehicle for lobbying against progressive drug policy primarily that which targets HIV control. All get together and play at the Swedish based World Federation Against Drugs which similarly is nothing like a “world federation”. What they strive for is patently out of this world.

As today’s most brilliant minds accept the evidence condemning prohibition, the global Drug Free Whomever groups seek to defend the UN Drug Conventions that originated in 1961.

Fortunate we may be, but complacent we cannot afford to become.