Friday, June 10, 2016

Pertussis: waning immunity and Tdap during pregnancy

I've written several posts on pertussis (whooping cough) and pertussis vaccines over the last four years. I started my position in communicable disease epidemiology at the Tacoma-Pierce County Health Department at the beginning of the 2012 Washington State pertussis epidemic. Pertussis is a issue that has demanded a lot of our time and attention ever since.
This is an article that I wrote for our Communicable Disease and Immunization Update newsletter:
Historically, pertussis was thought of as a childhood disease. We now recognize that immunity to pertussis, through immunization or natural infection, wanes over time, and that the effectiveness of acellular pertussis vaccines wanes much more quickly than immunity from whole-cell pertussis vaccines. A case-control study reviewing data from the 2012 pertussis epidemic in Washington State demonstrated that, for children who had received all acellular pertussis vaccines, vaccine effectiveness was 73.1% within one year, 54.9% between one and two years, and 24.2% between two and three years (Acosta et al., 2015). Two studies of data from the 2010 pertussis epidemic in California demonstrated that children who received one or more doses of whole-cell pertussis vaccine were less likely to have polymerase chain reaction (PCR)-confirmed pertussis than children who had received all acellular pertussis vaccines (Klein et al., 2013; Witt et al., 2013).
The age distribution of pertussis cases in Pierce County in 2012 was similar to that in California in 2014 (Winter et al., 2014), with fewer cases at the ages at which pertussis vaccine booster doses are scheduled and fewer cases and lower incidence of pertussis in people born before 1997 who would have received at least one dose of whole-cell pertussis vaccine as part of their primary series.
Infants too young to receive pertussis-containing vaccine are at highest risk for complications and death from pertussis. During the 2012 epidemic, the incidence of pertussis in Pierce County and Washington State was highest in children under one year of age. Of the 15 Pierce County residents hospitalized for pertussis in 2012, 12 (80%) were under one year of age and 11 of those were under 6 months of age, too young to have received 3 doses of DTaP.
In 2015, 5 Pierce County residents were hospitalized for pertussis, three of whom were infants less than 2 months of age. Two of the mothers of those babies did not receive the recommended dose of tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during pregnancy.
Case Series:
Case 1: Two-month-old girl with worsening cough admitted for observation with PCR-confirmed pertussis. Her mother received Tdap during pregnancy. While hospitalized, the infant had mild desaturations during coughing fits which quickly resolved without intervention. The baby was observed on the pediatric unit, not intensive care unit (ICU), and was discharged home on day three.
Case 2: One-month-old girl admitted with repeated episodes of desaturation and bradycardia. On the second day after admission, the baby was intubated and mechanically ventilated with sedation and chemical paralysis. She spent 8 days intubated, 11 days in the pediatric intensive care unit (PICU), and was discharged to home on day 15. Her mother did not receive Tdap during pregnancy.
Case 3: Three-week-old girl admitted after an episode of choking cough, apnea and cyanosis. Although the obstetric care provider recommended that her mother get a Tdap at the pharmacy, she did not receive one. The baby spent 3 weeks in PICU and was discharged four weeks after admission.
Although this sample is not representative, it is notable that the child whose mother received Tdap during pregnancy was not admitted to the PICU and had the shortest length of stay.
Antibody titers in adults who receive Tdap also wane. Healy et al. (2013) found that titers of pertussis-specific antibodies in cord blood from mothers who had received Tdap before or early in pregnancy were unlikely to provide adequate protection against infection for their newborn infants. In October 2012, the CDC's Advisory Committee on Immunization Practices (ACIP) recommended Tdap at 27 to 36 weeks of gestation with every pregnancy based on studies of paired maternal and cord blood from women who received Tdap during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives support the ACIP recommendation.
Two studies conducted in the U.K. evaluated the effectiveness of maternal Tdap at preventing pertussis in infants too young to receive DTaP. Vaccine effectiveness was 93% for infants born to women who received Tdap in the third trimester (Dabrera et al., 2015) and 90% for infants younger than 2 months whose mothers received Tdap at least 1 week before birth (Amirthalingam et al., 2014).
Although estimates since the 2012 recommendation have not yet been published, uptake of Tdap during pregnancy has been lower than optimal. As part of a pilot project, the Washington State Department of Health is currently collecting data on Tdap during pregnancy from hospitals in selected counties, including Pierce. Data are preliminary, but, in 2014, less than 50% of women who delivered at Pierce County hospitals had a dose of Tdap during the pregnancy that was recorded in the hospitals' electronic medical record. Administering Tdap during a prenatal visit is the most effective way to ensure that a pregnant woman receives the dose. CDC recommends that providers who do not stock vaccines in their offices make a "strong referral" for vaccination. Resources supporting immunizing pregnant women are found on the ACOG, CDC, and Tacoma-Pierce County Health Department websites.

Acosta, A. M., DeBolt, C., Tasslimi, A., Lewis, M., Stewart, L. K., Misgades, L. K., et al. (2015). Tdap vaccine effective in adolescents during the 2012 Washington State pertussis epidemic. Pediatrics, 135(6). doi:10.1542/peds.2014-3358.
American College of Nurse-Midwives. (2014). Position statement: immunization in pregnancy and p.ostpartum.
American College of Obstetrics and Gynecologists. (2013). ACOG Committee Opinion No. 566: Update of immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Obstetrics and Gynecology, 121(6). doi:10.1097/01.AOG.0000431054.33593.e3.
Amirthalingam, G., Andrews, N., Campbell, H., Ribeiro, S., Kara, E., Donegan, K., et al. (2014). Effectiveness of maternal pertussis vaccination in England: an observational study. Lancet, 384(9953). doi:10.1016/S0140-6736(14)60686-3.
Centers for Disease Control and Prevention. (2013). Updated recommendations for use of tetanus toxoid, reduced diphtheria, and acellular pertussis vaccine (Tdap) in pregnant women – Advisory Committee on Immunization Practices (ACIP), 2012. Morbidity and Mortality Weekly Report, 62(7), 131-135.
Dabrera, G., Amirthalingam, G., Andrews, N., Campbell, H., Ribeiro, S., Kara, E., et al. (2015). A case-control study to estimate the effectiveness of maternal pertussis vaccination in protecting newborn infants in England and Wales, 2012-2013. Clinical Infectious Diseases, 60(3). doi:10.1093/cid/ciu821.
Edwards, K. M. & Decker, M. D. (2013). Pertussis vaccines. In S. A. Plotkin, W. A. Orenstein, & P. A. Offit (Eds.) Vaccines (6th Ed.). [Electronic version]. Elsevier.
Healy, C. M., Rench, M. A., & Baker, C. J. (2013). Importance of timing of maternal combines tetanus, diphtheria, and acellular pertussis (Tdap) immunization and protection of young infants. Clinical Infectious Diseases, 56(4). doi:10.1093/cid/cis923.
Klein, N. P., Bartlett, J., Fireman, B., Rowhani-Rahbar, A. & Baxter, R. (2013). Comparative effectiveness of acellular versus whole-cell pertussis vaccines in teenagers. Pediatrics, 131(6). doi:10.1542/peds.2012-3836.
Winter, K., Harriman, K., Zipprich, J., Schechter, R., Talarico, J., Watt, J., et al. (2012). California pertussis epidemic, 2010. Journal of Pediatrics, 161(6). doi:10.1016/j.jpeds.2012.05.041.
Witt, M. A., Arias, L., Katz, P. H., Truong, E. T., & Witt, D. J. (2013). Reduced risk of pertussis among persons ever vaccinated with whole cell pertussis vaccine compared to recipients of acellular pertussis vaccines in a large US cohort. Clinical Infectious Diseases, 56(9). doi:10.1093/cid/cit046.

Tuesday, June 7, 2016

Bicycle helmets

We've had great weather here in the Pacific Northwest. I usually don't start riding my bicycle to work until late April or May, but this year I started riding in February. I few weeks ago I rode the first segment of the Olympic Discovery Trail and plan to ride the entire 130 miles from Port Townsend to La Push later this summer (Yes Twilight fans, that's vampire and werewolf country).

In April I took a longer route home from work through an area of the city where I had not ridden before. My front wheel got stuck in a railroad track and I had a hard fall. I picked myself up, got back on my bike, and rode home. It wasn't until I got home and took my helmet off that I realized that I must have hit my head during the fall because my helmet was cracked from one side to the other.

I didn't remember hitting my head and didn't think much of it at the time. I had a huge bruise on my left hip, an abrasion on my left arm, and the impact to my helmet was on the left side; all consistent with falling on my left side. What wasn't consistent was the abrasion on my right knee and that the most significant damage to my bike was to the rear derailleur, which is on the right side of my bike.

I went to work the next day, which was probably a mistake. It wasn't until I was recounting the accident to my coworkers that I realized that I didn't remember the accident. I remembered getting my front wheel stuck in the railroad track, and I remembered getting on my bike and riding away. I remembered being a little dazed at the time, but I knew where I was, how I got there, and how to get home. I don't know if I lost consciousness, but there was a man in a pickup who kept asking if I wanted him to call 9-1-1. At the time, I was unaware of how serious my accident had been. I left work early and went to an urgent care to get myself checked out.
A concussion is defined as injury to the brain caused by a hard blow or violent shaking, producing a sudden and temporary impairment of brain function, such as a brief loss of consciousness or disturbance of vision and equilibrium.

The characteristic loss of consciousness is believed to result from rotational forces exerted on the upper midbrain and thalamus, impairing the function of the reticular neurons. Headache, nausea, dizziness, irritability, and impaired ability to concentrate can persist for days after the event. Persistence of these symptoms for weeks is called postconcussion syndrome and can last from 1 month to a year.

Stippler, M. (2016). Craniocerebral trauma. In R. B. Daroff, J. Jankovic, J. C. Mazziotta, & S. L. Pomeroy (Eds.) Bradley's neurology in clinical practice, 7th Ed. [Electronic version]. Elsevier.

As a neuro nurse, I know that even a minor brain injury can cause profound disabilities. The realization that I had a concussion frightened me. I kept wondering if my difficulty concentrating and irritability were postconcussion syndrome or because I had difficulty sleeping. I kept wondering if I had difficulty sleeping because of postconcussion syndrome or because I had a huge, painful bruise on my hip. What's most frightening is thinking what might have happened if I had not been wearing a helmet.

Like a lot of you, I grew up riding a bike without wearing a helmet. We all turned out okay, didn't we? Not all of us. A lot more children died in bicycle accidents in the past than now.

CDC, 2015
There are several reasons fewer children die in bicycle accidents now. One possibility is that children ride bicycles less frequently than in the past. Bicycle helmets reduce the risks injuries and death from bicycle accidents (Attewell et al., 2001; Hooten & Murad, 2014; Persaud et al., 2014; Thompson et al., 1999) and helmet laws are also associated with decreases in deaths from bicycle accidents (Markowitz & Chatterji, 2015; Wesson et al., 2008).

Like any preventive measure, bicycle helmets do not completely eliminate the risk of injury and death. The fact that I can't remember my accident is evidence of that, but I doubt that I would have been able to return to work as soon as I did, if at all, had I not been wearing a helmet.

This is the first time I've been in a serious bicycle accident since I was a teenager. It's also the first time I've had a concussion. It has been a frightening experience. As parents, we want to protect our children from serious injuries. Brain injuries can cause lifelong neurological deficits. Getting Andrew to wear a helmet during our rides together was challenging at first, but I love him too much to let him ride without one. Now it's just part of the routine.

Children are more likely to wear a bicycle helmet if they ride with an adult who does and less likely to wear a helmet if they ride with other children who do not (Khambalia et al., 2005), so set a good example for them.


Please see these references for more information about bicycle safety and helmets:

I'd like to thank the staff at Tacoma Performance Bicycle for getting me back on the road so quickly after I damaged my bike. They repaired my bike and had me out of the store in less than 30 minutes. Of course, I bought a new helmet while I was in there.

American Academy of Pediatrics. (2001). Bicycle helmets. Pediatrics, 108(4), 1030-1032.
Attewell, R. G., Glase, K., & McFadden, M. (2001). Bicycle helmet efficacy: a meta-analysis. Accident Analysis and Prevention, 33(3), 345-352.
Centers for Disease Control and Prevention. (2015). Bicycle deaths associated with motor vehicle traffic – United States, 1975-2012. Morbidity and Mortality Weekly Report, 64(31), 837-841.
Hooten, K. G. & Murad, G. J. A. (2014). Helmet use and cervical spine injury: a review of motorcycle, moped, and bicycle accidents at a level 1 trauma center. Journal of Neurotrauma, 31(15), doi:10.1089/neu.2013.3253.
Khambalia, A., MacArthur, C., & Parkin, P. C. (2005). Peer and adult companion helmet use is associated with bicycle use by children. Pediatrics, 116(4), 939-942.
Markowitz, S. & Chatterji, P. (2015). Effects of bicycle helmet laws on children's injuries. Health Economics, 24(1), doi:10.1002/hec.2997.
Persaud, N., Coleman, E., Zwolakowski, D., Lauwers, B., & Cass, D. (2012). Nonuse of bicycle helmets and risk of fatal head injury: a proportional mortality, case-control study. CMAJ, 184(17), doi:10.1503/cmaj.120988.
Thompson, D. C., Rivara, F., & Thompson, R. (1999). Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews, 4, CD001855. doi:10.1002/14651858.CD001855.
Wesson, D. E., Stephens, D., Lam, K., Parsons, D., Spence, L., & Parkin, P. C. (2008). Trends in pediatric and adult bicycling deaths before and after passage of a bicycle helmet law. Pediatrics, 122(3), doi:10.1542/peds.2007-1776.


Thursday, December 31, 2015

Neuroscience nursing

Neuroscience: a branch of the life sciences that deals with the anatomy, physiology, biochemistry, or molecular biology of nerves and nervous tissue and especially with their relation to behavior and learning

Today is the last day that I can call myself a Certified Neuroscience Registered Nurse (CNRN), a credential I have held for 20 years. I can't renew my certification because I no longer work at the bedside and do not have the required number of hours of neuroscience nursing practice.

My interest in neurology and neurosurgery began when I was working as a nursing assistant in a long-term care facility. Many of the residents I worked with had neurological deficits from strokes and I was fascinated by the differences in deficits the residents had depending on what part of the brain had been affected.

After my first year of nursing school, I worked as a nursing technician in the rehabilitation unit at Harborview Medical Center in Seattle, the regional level I trauma center. Most of the patients I saw there had spinal cord injuries (paraplegia, quadriplegia, central cord syndrome, Brown-Séquard syndrome), but there were also patients with traumatic brain injuries and stroke.

After graduating from nursing school, I worked on the Neurology/Neurosurgery acute care floor at Harborview. It was there that I achieved neuroscience nursing certification. I spent most of my clinical career working in intensive care units (ICU), including neuro ICUs, in Philadelphia and Memphis.

"I hate neuro!"

I don't know how many times I've heard that from other nurses.

Neuro nursing is challenging. Patients with injury or damage to parts of the brain can be confused, their behavior can be unpredictable and even violent – and yes, although I've never been seriously injured, I have been assaulted by patients. People with neurological insults can have language deficits; they may not be able to speak or their speech may be nonsensical or difficult to understand. They may not understand what is said to them. There are also challenges in assessing neurological deficits. A subtle change in a neurological examination can signal an impending catastrophic event (e.g., transtentorial herniation).

Neuro nursing can be heartbreaking. Lives are shattered by neurological injuries and disease. Families struggle with changes in family roles and the loss of income from a person who can no longer work. A person's behavior can change so dramatically that it disrupts family dynamics. Both patients and families must learn to cope with neurological deficits. A person who was completely independent may become completely dependent on others. Imagine not being able to even scratch your own nose, much less feed yourself, dress yourself, or take yourself to the toilet. Often, the most productive members in a family or in society are those most likely to be injured. Men in their 20s are the demographic most likely to suffer a traumatic brain injury, men like my bother-in-law, Seth, who, more than a decade after his diffuse axonal injury, remains in a minimally conscious state (I met Holly, my wife, while I was taking care of Seth).

Neuro nurses have to learn to communicate with patients who cannot speak or understand spoken language. We have to anticipate the needs of someone who cannot communicate those needs to others. In collaboration with other health care professionals, neuro nurses teach patients and their families how to rebuild their lives and achieve the highest level of function and quality of life possible. We also have to anticipate our patient's frustration and anger. Sometimes, that frustration and anger is directed at us, so we have to learn to take care of ourselves. Sometimes, we hold the hand of a dying patient and comfort that person's family.

I love neuro!

One of the things I love about neuro nursing is that there is always something to learn; a rare neurological disorder or the name of an agnosia I had not seen before. I used to see a lot of gunshot wounds to the head. I spent many hours reading up on ballistics; what happens to a bullet when it penetrates the cranium and what happens to brain tissue when a bullet passes through it (you probably don't want to know).

Neuro was my first love in nursing. Even though I don't practice neuro nursing any longer, I suppose I'll always consider myself to be a neuro nurse. Working in Tanzania last year gave me an opportunity to step back into my role as a bedside neuro nurse. Since becoming a nurse in 1992, I've always looked for ways to challenge myself; to gain knowledge and learn new skills. Neuro nursing provided me with a wealth of opportunities to grow both professionally and as a person.

It's hard work. It can be physically, emotionally, and intellectually challenging. For me, the rewards were knowing that I made a difference in someone's life.

I thank my friend and mentor, Karen March, who was the Neuroscience Clinical Nurse Specialist at Harborview when I worked there, for nearly a quarter-century of guidance, support, and inspiration.

Karen at Haydom Lutheran Hospital in Tanzania
Karen, Holly, and me on one of the happiest days of my life

One last time,

Matthew Rollosson, RN, CNRN

Happy New Year!

Monday, November 9, 2015

Ebola one year later: an open letter to Robert J. Vickers

Dear Mr. Vickers,

One year ago today I arrived in Sierra Leone where I worked in the Maforki Ebola Treatment Centre in Port Loko. Saturday, November 7, 2015, Sierra Leone was declared Ebola-free. Two incubation periods have passed since the last case of Ebola virus disease (EVD) was diagnosed in that country.

Since returning to the U.S., I have given several presentations on EVD including a presentation to an ethics class at Pacific Lutheran University, a global health class at University of Washington, Tacoma, and, most recently, a presentation at the Washington State Public Health Association annual conference on the experiences of health workers returning to the U.S. after working in Ebola treatment facilities in West Africa. This is an image that I have included in some of those presentations:

On October 31, 2014, the Seattle Times published an opinion piece you wrote titled, Ebola aid workers can't be trusted. In it, you criticized Kaci Hickox and Craig Spencer, two health care providers who had worked in Ebola treatment facilities in West Africa. Craig Spencer is the only person to have developed EVD while being monitored for symptoms of the disease since the Centers for Disease Control and Prevention (CDC) published its guidelines for monitoring people with potential Ebola virus exposure. Dr. Spencer is also the only health worker to have developed EVD after returning to the U.S.

Kaci Hickox
Time Person of the Year 2014

Mr. Vickers, it had been established long before you wrote your article that ebolaviruses are not transmitted by asymptomatic people. It had also been established that at the onset of the "dry" stage of the disease, the stage at which Dr. Spencer presented himself for isolation and treatment, the amount of virus in the blood is usually too low to be detected by polymerase chain reaction (PCR). That is why EVD cannot be ruled out until 72 hours after the onset of symptoms. It is not until the "wet" stage of the disease, characterized by diarrhea and vomiting, that a person with EVD person becomes infectious. This is the reason the CDC has never recommended quarantining asymptomatic health workers who wore appropriate personal protective equipment (PPE) while caring for people with EVD.

Those of us who have worked in Ebola treatment facilities have watched people die from the disease. It is an ugly, painful death. We have also watched people recover from EVD and know that survival is dependent upon aggressive fluid and electrolyte replacement. It seems absurd to me that someone could think that those of us who have seen this disease would jeopardize our own probability of survival or the safety of those around us by ignoring or failing to disclose symptoms of the disease.

I find it ironic that you suggested a comparison between health workers, like me, and Gaëtan Dugas, who was erroneously identified as "patient zero" in the AIDS epidemic. Ironic, because a number of authors have compared the hysteria around Ebola and stigmatization of health workers to the hysteria around AIDS and stigmatization of people believed to be infected with HIV in the 1980s (See Davtyan et al., 2014 and Gonsalves & Staley, 2014). As the authors of Ethics and Ebola: public health planning and response wrote, “Similar to epidemics that have come before, the current Ebola epidemic reveals how social perceptions of infectious diseases can lead to unethical infringement of civil liberties and stigmatization of the ill, those who treat them, and those who otherwise come to be associated with them.”

I am fortunate that I returned to Washington State after working at Maforki. The Washington State Department of Health Guidance for local health jurisdictions regarding follow-up of asymptomatic persons with potential exposure to the Ebola virus is essentially the same as the CDC guidelines. By and large, there were no restrictions placed on my movements. I came home to my wife and son, I went to church where I was warmly received by the congregation that had prayed over me before I left, I went out to dinner with my family, and I spent a week playing with my little boy before I returned to work. If the weather had been warmer, I would have gone for a bike ride. If I had wanted to, I could have gone bowling.

Andrew, Halloween 2015
Many of my colleagues were not as fortunate. One of my colleagues in New York State wrote, “I was escorted out the main doors of the airport by two EMS, two National Guard, two Department of Health workers and two security guards. I felt like a criminal. I was then taken home in an ambulance with a National Guard escort." This was in full view of that person's neighbors. Several of my friends chose to spend three weeks in Europe rather than return to their home states to be unnecessarily quarantined. I have a friend who was harassed by her coworkers when she returned from Sierra Leone, another who was asked not to return to her apartment, and others who were told not to come to their families' holiday celebrations.

Kaci Hickox received a Diploma in Tropical Nursing from the London School of Tropical Medicine and Hygiene. I received a Master of Public Health and Tropical Medicine (MPH&TM) from the Tulane University School of Public Health and Tropical Medicine. Both schools are home to respected virologists who have studied ebolaviruses for decades. I also attended the CDC Safety Training Course for Healthcare Workers Going to West Africa in Response to the 2014 Ebola Outbreak before going to Sierra Leone. Those of us who donned PPE and worked with patients with EVD understand the risks and modes of transmission of ebolaviruses. Only a handful of U.S. health care personnel were infected and none of them transmitted the disease to anyone else.

Neither Kaci Hickox nor Craig Spencer placed the public at risk. The public's trust was betrayed by certain politicians and the media. I have singled you out, Mr. Vickers, not simply because my wife subscribes to the Seattle Times, but because I feel that your comments are representative of the most inflammatory and irresponsible statements I have heard from or read in the media regarding Ebola and the health workers who cared for people with the disease. There are, of course, others who bear greater responsibility for the shameful treatment that many of my colleagues received after sacrificing their time working to bring West African Ebola epidemic to a close. Perhaps worse than the abusive treatment of my colleagues, the stigmatization of health workers and threat of unnecessary quarantine may have dissuaded others from working in the Ebola response.


Matthew Rollosson, RN, MPH&TM

P.S. Couldn't you come up with a more contemporary cliché than Nurse Ratched? Kaci Hickox hadn't been born when the movie One Flew Over the Cuckoo's Nest was released.


I highly recommend reading Dr. Spencer's article in the New England Journal of Medicine (cited below). The following quote, taken from that article, eloquently describes what, I believe, many of us felt while caring for people with EVD:

"Every day, I looked forward to putting on the personal protective equipment and entering the treatment center. No matter how exhausted I felt when I woke up, an hour of profuse sweating in the suit and the satisfaction I got from treating ill patients washed away my fear and made me feel new again."


"Travelers from Sierra Leone entering the United States will continue to be funneled through one of five U.S. airports conducting enhanced entry screening (New York JFK, Washington-Dulles, Newark International, Chicago O’Hare, and Atlanta Hartsfield-Jackson). Travelers from Sierra Leone will continue to have their temperatures taken and answer questions about travel history and possible exposures to Ebola. Travelers will also provide their contact information so that the health department at their destination can connect with them, if needed. Under the modified entry screening, travelers from Sierra Leone with no enhanced risk factors will receive a version of the CARE kit that includes information about Ebola, a thermometer, and contact information for state and local health departments. Travelers will be encouraged to watch their health for 21 days after leaving Sierra Leone and to contact their local health departments if they develop symptoms consistent with Ebola.  Travelers from Sierra Leone will no longer need to be actively monitored by or be in daily contact with their health departments."

Two down, one to go!


Centers for Disease Control and Prevention. (2015). State and territorial Ebola screening, monitoring, and movement policy statements – United States, August 31, 2015. Morbidity and Mortality Weekly Report, 64(40), 1145-1146.

Davtyan, M., Brown, B., & Folayan, M. O. (2014). Addressing Ebola-related stigma: lessons learned from HIV/AIDS. Global Health Action, 7.

Gonsalves, G. & Staley, P. (2014). Panic, paranoia, and public health – the AIDS epidemic's lessons for Ebola. New England Journal of Medicine, 371(25), 2348-2349.

Infectious Diseases Society of America. (2014). IDSA statement on involuntary quarantine of healthcare workers returning from Ebola-affected countries.

Presidential Commission for the Study of Bioethical Issues. (2015). Ethics and Ebola: public health planning and response.

Spencer, C. (2015). Having and fighting Ebola – public health lessons from a clinician turned patient. New England Journal of Medicine, 372(12), 1089-1091.

Vickers, R. J. (October 31, 2014). Ebola aid workers can't be trusted. Seattle Times.

Sunday, August 23, 2015


I've taken a break from writing this blog. I have a couple of posts in the works, but I've put them on the back-burner while I enjoy the warm summer months.

I cut back my hours at work so I have a couple of days every month to take Andrew out and have daddy-and-son time together. Cutting back made a noticeable dent in my paycheck, but it's worth every penny! He and I have been taking a lot of bike rides together. The Scott Pierson Trail isn't as scenic as some of the other rides we take together, but it's not far from our house and we've been riding that trail a couple of times every week. We've gone out to Orting several times on our days out together to ride the Foothills Trail and, on the weekends, we ride the Five Mile Drive at Point Defiance Park (we go around the loop twice for a 10-mile ride).
Five Mile Drive: Andrew gets a nap, Holly gets a couple of toddler-free hours, and I get a work out; everyone wins!

Titlow Park

Titlow Park
Andrew loves going for rides with me, but he has the most fun running through wooded areas.

Snake Lake
Point Defiance Park
China Lake Park
This has been a good year for my pepper garden. This year I have all five of the domesticated species of chilies in my garden: Capsicum baccatum (aji yellow), C. chinense (habanero), C. frutescence (Tabasco), C. pubescens (rocoto), and several varieties of C. annuum (almapaprika, bell, and cayenne). I also have a couple of plants from seeds I brought back from Sierra Leone. I call them "Ebola peppers." I've been perusing a couple of Oaxacan cookbooks (The Food and Life of Oaxaca, Mexico and Oaxaca al Gusto) instead of reading references for this blog and planning what I'm going to grow next year.

Ebola peppers

Okra blossom
There have been a few disappointments this year. My tomatoes got hit with a bad fungus and, although the plants look great, I haven't seen a single pumpkin yet – I think the squirrels are eating them.

It's a lot of work, but Holly and I have created a pleasant space for our family to enjoy. So, please pardon me as I enjoy relaxing on this warm summer afternoon instead of writing about infectious diseases and vaccines.
Holly's piano studio