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Success in the fight against childhood diarrhea

Rotavirus is the world’s most common cause of severe childhood diarrhea.  In the U.S. alone, rotavirus disease leads to around 70,000 hospitalizations, 3/4 million ER visits, and nearly half-a-million doctor office visits yearly.  But it rarely causes death.

The same is not true for the developing world.  Rotavirus disease is estimated to kill around a half-million children a year world wide.   Finding a way to mitigate this is an active public health concern, with the World Health Organization specifically recommending rotavirus vaccinations in areas where the virus has a significant public health impact.

Rotavirus causes a severe diarrheal illness. It is passed via a fecal-oral route, meaning that contaminated food, surfaces, and water can all be sources.   In developed countries like the US, rotavirus disease is unpleasant and inconvenient.  Since rotavirus spreads more readily in areas without access to clean water and medical care, it takes a greater toll in these areas, and children afflicted are at risk of death due to dehydration.  The US has seen a decline in rotavirus disease in the last few years, an effect that appears to be due to increased vaccination and a herd immunity effect.

Given the large number of pediatric rotavirus deaths in developing countries, the World Health Organization (WHO) has made vaccination a priority. Two articles in this week’s New England Journal of Medicine report on the progress of the fight against rotavirus.

The first article looked at the affect of the vaccine in  Africa.  It was a randomized, placebo-controlled trial of several thousand infants (the ethics of such trials in developing nations has been discussed at length elsewhere, including here).  It found a very significant reduction in severe diarrhea during the first year of life, with a vaccine-attributable reduction in severe rotavirus gastroenteritis of 5.0 cases per 100 infant-years.  This study did not specifically study mortality.

The next study specifically assessed mortality, but using an “ecologic assessment”.  The authors looked at deaths from diarrhea over a several year period which included a period before and after the regular use of rotavirus vaccine.  They found that:

Among infants who were 11 months of age or younger, diarrhea-related mortality fell from 61.5 deaths per 100,000 children at baseline to 36.0 per 100,000 children in 2008 (rate reduction, 41%; 95% CI, 36 to 47; P<0.001)

This type of study has certain limitations, but the seasonal peak of rotavirus deaths was found to be significantly blunted since the introduction of the vaccine.

The final piece in the Journal was a case series. It looked at three infants who appeared to have developed rotavirus infection from the vaccine itself.  The two available rotavirus vaccines are live attenuated viruses.  They should not cause disease under normal circumstances, and in these three cases, the circumstances were not normal.  All three children had severe combined immunodeficiency (SCID).   Immune diseases are a relative contraindication to vaccination. In the African experience, where HIV is endemic, children were vaccinated independent of HIV status and HIV rates were similar in all groups.  Despite this, there was still a reduction in severe diarrheal disease.

The two currently available rotavirus vaccines are not associated with intussusception as a previous vaccine was, and appear to be safe, effective at preventing severe diarrhea in small children, and effective at reducing deaths in small children.  These vaccines appear to be effective across geographic and economic regions, although the magnitude of the effect was greatest in hardest-hit areas.

This puts a very heavy  burden on those who would choose to fight the introduction of these vaccines.  Rotavirus vaccine appears to be a safe, effective measure for preventing one of the world’s most common causes of childhood mortality.

References

Madhi, S., Cunliffe, N., Steele, D., Witte, D., Kirsten, M., Louw, C., Ngwira, B., Victor, J., Gillard, P., Cheuvart, B., Han, H., & Neuzil, K. (2010). Effect of Human Rotavirus Vaccine on Severe Diarrhea in African Infants New England Journal of Medicine, 362 (4), 289-298 DOI: 10.1056/NEJMoa0904797

Richardson, V., Hernandez-Pichardo, J., Quintanar-Solares, M., Esparza-Aguilar, M., Johnson, B., Gomez-Altamirano, C., Parashar, U., & Patel, M. (2010). Effect of Rotavirus Vaccination on Death from Childhood Diarrhea in Mexico New England Journal of Medicine, 362 (4), 299-305 DOI: 10.1056/NEJMoa0905211

Patel, N., Hertel, P., Estes, M., de la Morena, M., Petru, A., Noroski, L., Revell, P., Hanson, I., Paul, M., Rosenblatt, H., & Abramson, S. (2010). Vaccine-Acquired Rotavirus in Infants with Severe Combined Immunodeficiency New England Journal of Medicine, 362 (4), 314-319 DOI: 10.1056/NEJMoa0904485

Posted in: Science and Medicine, Vaccines

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64 thoughts on “Success in the fight against childhood diarrhea

  1. Excellent evidence.

    I guess the question now is, how do we make sure as many kids as possible get these vaccines?

  2. Plonit says:

    Surely in very low mortality countries (i.e. where rotavirus is essentially a cost in productivity of parents caring for children with diarrhoea), one has to consider the cost of introducing a new vaccine and whether that money could be spent on something that would be more effective in reducing mortality and morbidity.

    As I understand it, that was the position of the UK Joint Committee on Vaccination and Immunisation last time they looked at this question. At somewhere an estimated £70 per person vaccinated for Rotarix and £75 per person vaccinated for RotaTeq, we are talking about £42-45million GBP per annum, if we pick one age group, and don’t attempt to ‘catch up’ any older age groups. Given that the estimated annual deaths involving rotavirus (no information on comorbidities) are 3-4, that’s getting on for more than £10million per life saved. With one eye to the fact that there are plenty of other, more cost-effective, calls on public health spending, I can understand why the JCVI didn’t recommend introducing the vaccine against rotavirus – though they might reconsider if the costs went down considerably.

    Obviously, if we include the ‘social cost’ of work days lost then the calculation looks different, but we don’t include those costs for decision-making about other areas of health spending.

    And for countries where infant mortality from rotavirus is commonplace, the introduction of the vaccine should be a no-brainer. It’s a different calculation in countries where mortality is extremely rare.

  3. Scott says:

    @Plonit:

    In the U.S. alone, rotavirus disease leads to around 70,000 hospitalizations, 3/4 million ER visits, and nearly half-a-million doctor office visits yearly.

    All of those cost money too – a lot of it. And 70K hospitalizations would seem to imply significant vaccine-preventable morbidity. The numbers aren’t directly comparable, of course, since these are US and yours are UK, but they certainly imply that there’s a lot more to consider than just deaths. Essentially, the proper monetary cost to the NHS is the cost of the vaccine minus the cost of all the foregone hospitalizations/ER visits/office visits.

    Quite possibly the JCVI did consider these factors, and I have insufficient data to conclude whether they’d change the conclusion anyway, but the reasoning recounted in your post is oversimplified.

  4. Plonit says:

    Sure, it’s oversimplified – a back of the envelope job. The study that the JCVI seem to base most of their health economics on is

    Jit M and Edmunds WJ (2007) Evaluating rotavirus vaccination in England and Wales. Part II. The potential cost-effectiveness of vaccination. Vaccine 25(20): 3971-9. This does include the various other costs you mention (hospitalizations, costs to primary care), and calculates that the cost of Rotarix is £61K per QALY gained and RotaTeq is £79K per QALY gained, if QALYs are your bag.

    Still not particularly cost-effective compared to many other services that a public health system might provide.

  5. Plonit says:

    Here’s the JCVI statement

    http://www.advisorybodies.doh.gov.uk/jcvi/JCVI_statement_rotavirus.pdf

    it links to their minutes, in which some of the more detailed discussions can be found.

  6. Zoe237 says:

    “All of those cost money too – a lot of it. And 70K hospitalizations would seem to imply significant vaccine-preventable morbidity. The numbers aren’t directly comparable, of course, since these are US and yours are UK, but they certainly imply that there’s a lot more to consider than just deaths. Essentially, the proper monetary cost to the NHS is the cost of the vaccine minus the cost of all the foregone hospitalizations/ER visits/office visits.”

    Is this long term morbidity? Are there any long term risks to rotavirus in the U.S.? Is it an oral vaccine?

    My son had rotavirus when he was 3, from preschool. He didn’t have to be hospitalized, but we did go to the doctor. I found it more annoying than dangerous, but that’s only my experience. My kids are too old to be vaccinated for rotavirus now, so I haven’t really researched it.

    I have heard about the huge death tolls from rotavirus in the third world though, so am glad that this is available and a huge lifesaver.

  7. Zoe237 says:

    Never mind, found the answers.

    Here is a cost analysis for the United States:

    CONCLUSIONS. Despite a higher burden of serious rotavirus disease than estimated previously, routine rotavirus vaccination would unlikely be cost-saving in the United States at present. Nonetheless, rotavirus vaccination may still be considered a cost-effective intervention.

    http://pediatrics.aappublications.org/cgi/content/abstract/119/4/684

  8. Plonit says:

    $197190 per life-year saved, hmmm.

    Who pays for vaccinations in the US? Is it the patient, or insurer, or government (from taxes) or….

  9. micheleinmichigan says:

    Plonit,
    it is “or…”

    In my (U.S.) state vaccines are often paid for by insurance, depending upon your plan, sometime not paid, sometimes the patient has a co-pay or administrative cost. The health departments, funded by states and federal funds, also offers free vaccinnation clinics and there is state insurance, that I believe would cover vaccines, for children whose parents meet certain income or disability criteria.

    I believe that parents can get all vaccines required for school attendance through the country health department for free (or low cost?). I’m not sure how convenient it is in regards to transportation, time off work.

    When I started typing I thought I could answer this post coherently, but it turns out our convoluted health system has made me incoherent. Hopefully someone else here can do a better job.

  10. JerryM says:

    A related talk was posted to TED.com today:

    http://on.ted.com/869J

    He talks about the fact that while there are good solutions to diarrhoea – saline/sugar stuff – people aren’t giving those things, because of the intuitive feeling that you don’t put water in a leeking cattle, so they decrease fluid intake. which is exactly the opposite of what you should do.

    It’s a very interesting talk, also for skeptic outreach purposes.

  11. EricG says:

    to add to micheleinmich…

    you can really get them just about anywhere. CVS (neighborhood drugstore) sells them for $10, im sure walmart does as well. kaiser (health care hmo) provides them included in the package. you can get them for “free” (govt) at various health clinic, school things, work things.

    there is pretty much an all out shotgun approach to getting the vax around

  12. wertys says:

    It sure is nice to know that rotavirus vaccine can help save lives where homeopathic ‘remedies’ cannot…..

  13. micheleinmichigan says:

    EricG said “you can really get them just about anywhere. CVS (neighborhood drugstore) sells them for $10″

    I think this is true for children in some States, not others’. I guess in Michigan you need a NP on staff (at a drugstore or other retail location?) to vaccinate younger kids. That knocks out a lot of the drug stores.

  14. micheleinmichigan says:

    EricG – I always assumed that the workplace flu shots were funded by employers – Was I giving them undue credit?

    JerryMon – I would think the decreased fluid intake would be caused by nausea with the virus. Is that not the case? Sorry will have to get back to your link.

  15. DanaUllman says:

    Actually…there IS evidence to show that individually chosen homeopathic medicines provide benefit to children with diarrhea.

    Three randomized double-blind and placebo controlled studies have verified the value of homeopathic medicines to treat acute diarrhea in children (Jacobs, et al., 1994; Jacobs, et al, 2000, Jacobs, et al. 2003) (2 of the 3 of these studies were published in conventional high impact journals). The combined results of these three studies using individually chosen homeopathic medicines and the metaanalysis of 242 children showed a highly significant result in the duration of childhood diarrhea (P=0.008).

    The study in 1994 was published in PEDIATRICS, and this study showed that children with a known pathogen responded better to homeopathic treatment than children with diarrhea without a known pathogen.

    Although individually chosen homeopathic medicines have been shown to be effective in above 3 trials, one study where children were given the SAME formula (without individualized treatment) show no significant benefits.

    This similar team of researchers conducted a double-blind, placebo-controlled study testing a homeopathic combination medicine in the treatment of 292 children in Honduras (Jacobs, et al, 2006). Tablets containing a combined preparation of the five common single homeopathic remedies used to treat diarrhea or placebo were administered by a parent after each unformed stool. Children were followed up daily for 7 days or until symptoms resolved, whichever occurred first. Time until resolution of symptoms, daily rate of unformed stools, and total number of unformed stools were compared between the two groups.

    There was no significant difference in the likelihood of resolution of diarrheal symptoms between the treatment and placebo groups (hazard ratio = 1.02, 95% confidence interval: 0.79-1.32), with a median time until resolution of 3 days for both groups.

    References:
    Jacobs, J, Guthrie, BL, Montes, GA, Jacobs, LE, Mickey-Colman, N, Wilson, AR, DiGiacomo, R, Homeopathic Combination Remedy in the Treatment of Acute Childhood Diarrhea in Honduras, Journal of Alternative and Complementary Medicine, Oct 2006, Vol. 12, No. 8 : 723 -732.

    Jacobs, J, Jimenez, LM, Gloyd, SS, “Treatment of Acute Childhood Diarrhea with Homeopathic Medicine: A Randomized Double-blind Controlled Study in Nicaragua,” Pediatrics, May, 1994,93,5:719-25.

    Jacobs, J, Jimenez, LM, Malthouse, S, et al., Homeopathic Treatment of Acute Childhood Diarrhea: Results from a Clinical Trial in Nepal, Journal of Alternative and Complementary Medicine, April 2000,6,2,:131-140.

    Jacobs, J, Jonas, WB, Jimenez-Perez, M, Crothers, D, Homeopathy for Childhood Diarrhea: Combined Results and Metaanalysis from Three Randomized, Controlled Clinical Trials, Pediatr Infect Dis J, 2003;22:229-34.

  16. David Gorski says:

    Dana, Dana, Dana, Dana.

    How often does it have to be repeated that those studies are crap?

    http://www.sciencebasedmedicine.org/?p=82
    http://www.sciencebasedmedicine.org/?p=495

    Really, you are like the Energizer Bunny of Woo. You just keep going and going and going and going, no matter how many times you’re shown not to have clue one what you’re talking about?

  17. Chris says:

    A while ago I was taking a class at the same university that has Jacobs. I was sent an email asking for my anonymous input on a new head of the School of Public Health. I sent them those two links, and said that her unethical research on children was unethical and was demeaning to the university and its School of Public Health.

  18. BillyJoe says:

    DanaUllman

    Moving right along now, nothing to see here :D

    In Australia, they are given at 2,4, and 6 months paid for by the Health Department.
    The vaccine, that is, not Dullman’s Dangerous Placebo Pill.
    So someone in the Health Dept thinks they are cost effective (either that or the drug company reps have twisted and arm or two)

  19. Zoe237 says:

    Here is a price list. At our local health department, people can get vaccines for about $5, income eligible. They also have started home visits I believe. For me, our health insurance pays about 60% and I pay the rest in copays at the doctor. I’ve never gotten a shot from a store- assuming that’s also health insurance or out of pocket. Government has paid for the H1N1 shot.

    There is a difference between the prices of vaccines for the CDC, and for the private sector, I’m assuming because of their government contract. Rotateq- $57/$69, and Rotarix- $83/$102.

    http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm

    These prices are much more expensive than for MMR, Dtap, Hib, maybe because the patents have not run out.

    I also read a few months ago in an associated press article that vaccines are now money makers, especially due to gardasil ($105/$130) and prevnar.

  20. EricG says:

    danaullman

    laughable. meta analysis of 242 children? “highly significant?” go back to school, thats what they bust on day one of stats.

    if im not mistaken, arent some of these epidemiological studies (in psych we routinely see norms on the order of THOUSANDS for a personality assessment, for instance) in the many…many…many of thousands of participants?

    effect size? give me 100 subjects and 100 fields of data and i’ll find something significant. perhaps *soooooo* significant that spss reports the p value at .000 *gasp*!

  21. Plonit says:

    Okay, so when you buy a vaccine below cost, someone else (government?) is paying the difference, right? And children are for “free” in lots of places. So, growing the list of recommended/required vaccines draws on the public purse, especially where they are newer/more expensive vaccines.

    And what I don’t understand is why, in a country where universal primary health care is felt not to be cost-effective, it would make sense to introduce a vaccine that research suggests costs $197190 per life-year saved. Just thinking about it from the point of view of being an opportunity cost

    Given that there are so many ways in which you can purchase your vaccines, how do you monitor vaccine coverage?

  22. emervents says:

    Vaccine coverage is monitored in Australia by the government. The doctor who gives the jab notifies them. Provided we keep our address current with the government we are also sent reminders.

    http://www.medicareaustralia.gov.au/public/services/acir/index.jsp

    As for rotavirus vaccine being part of the schedule? My daughter is a toddler and she’s never had it. Must be a very recent addition.

  23. stbloomfield says:

    Here’s my argument from emotion:
    My son spent a couple of days in the hospital when he was 10 months old due to rotavirus. They didn’t have a vaccine back then. If you’ve ever seen a 10 month old screaming from getting an IV then the cost of this becomes trivial.

    I hope with the recent announcement from the Gates that we get get this vaccine out there to more kids in poor countries.

  24. Plonit says:

    Australia has a universal public health system – and I would imagine most people would use it for the purpose of vaccination (just as in the UK, few people would go to BUPA or Harley Street for vaccinations covered on the NHS). So the issue of monitoring coverage in Australia would seem similar to in the UK.

    In the US, the complexity of purchasing and providers described upthread may make it more difficult to monitor coverage, but that’s just my ‘gut’ reaction.

  25. Zoe237 says:

    “In the US, the complexity of purchasing and providers described upthread may make it more difficult to monitor coverage, but that’s just my ‘gut’ reaction.”

    I don’t think so. There is an automated system in Michigan that all the different sources report to- it is a computerized database. YOu may also be able to “opt out” of the system. Not sure if there is a national database or not.

  26. Zoe237 says:

    Oh, and the only shots I’ve seen available at a pharmacy or senior center are flu shots. Which makes sense since most healthy adults don’t go to the doctor every year.

    Most commonly, you go to the doctor, if you have insurance, or the health department if you don’t. And yes, the government pays for vaccines for those who can’t afford them.

  27. Rotavirus may seem like more of an inconvenience than a life-threatener to many of us in the developed world, but it’s bloody miserable to have it. I’d gladly have gotten my son the shot just to spare him the misery. I’d gladly get it myself, for that matter!

  28. DanaUllman says:

    Cool…according to your logic now, PEDIATRICS cannot be trusted nor PEDIATRIC INFECTIOUS DISEASE JOURNAL…and the editorial boards of these journals are not nearly as informed as the anonymous people here. Let’s think about other creative ways to re-write history and medical science. Actually, THAT is what this blog is all about.

    As for EricG’s innane comment about having 100 possible “fields of data” that one can find some changes in any experiment? Ha! Yeah, don’t ya hate it when the primary and secondary measurements show benefits from homeopathy.

    The more accurate statement is that skeptics (who are really “denialists” and “hyperdenialists”) will find 100 reasons to deny the truth…while ignoring their own prejudices (how convenient).

  29. Chris says:

    Mr. Ullman, you are relying on the research of one person, and you failed to notice something different about her most recent effort (and this is the first time I have seen you actually included it!):
    Jacobs, J, Guthrie, BL, Montes, GA, Jacobs, LE, Mickey-Colman, N, Wilson, AR, DiGiacomo, R, Homeopathic Combination Remedy in the Treatment of Acute Childhood Diarrhea in Honduras, Journal of Alternative and Complementary Medicine, Oct 2006, Vol. 12, No. 8 : 723 -732

    Here are the conclusions (emphasis added by me):

    DISCUSSION: The homeopathic combination therapy tested in this study did not significantly reduce the duration or severity of acute diarrhea in Honduran children.

    I believe we should ignore her weasel words about needing more studies.

  30. Geekoid says:

    @Dana – we would only be denialist if we didn’t demand the same level of evidence for everything, regardless of are personal bias.
    the studies you mention are poorly done. Not because they are about homeopathy, but because they are poor studies.

    You are denying the evidence, and the fact the study is crap in order to back your bias. It’s time for you to slaughter sacred cows and look at the evidence and under stand what a good study is.

    IF Homeopathy worked, it would be a boon to society and be a good thing. Unfortunately wishing something to be true because it would improve society does not make it true.

  31. Adam_Y says:

    Let’s think about other creative ways to re-write history and medical science.

    Homeopathy defies the laws of physics. Repeat homeopathy defies the laws of physics. Once again homeopathy defies the laws of physics. And since it doesn’t take a psychic to tell what you will say next. Quantum mechanics is a part of physics. Quantum mechanics is a part of physics.

  32. icewings27 says:

    @Plonit
    I’m sure if your child was going to die from rotavirus you’d be willing to pay at least $197190 to save him, wouldn’t you? Would you? Hmmmm?

    I am all in favor of rational argument and cost effectiveness is certainly something to consider in all vaccination programs but seriously, can we have a little heart too? We’re talking about little children dying for cripes sake!

  33. Plonit says:

    I’m sure if your child was going to die from rotavirus you’d be willing to pay at least $197190 to save him, wouldn’t you? Would you? Hmmmm?

    +++++++++

    That’s not the purpose of the issues I’m trying to raise.

    The individual who wants to vaccinate doesn’t have to spend that much money – you pay the cost of the vaccine and its administration. It’s a form of “insurance” if you like.

    You’re wrong in the calculation – the cost is $197190 per *life year* (not even quality-adjusted!). Life expectancy in the US is 78 or thereabouts. So, the lifetime cost is more like $15million per life saved.

    In the real world, $15 million to save one life (or $197190 per *life year*) is $15million that you don’t have available to spend on other interventions that may be more cost-effective, and may save more lives. For instance, you could take money used for rotavirus vaccinations in a country where mortality from rotavirus is extremely rare and use it to pay for rotavirus vaccinations in a country where mortality from rotavirus is commonplace. In doing so, you would maximise the number of lives saved for the money spent. Not to do so this is irrational, unless you think the value of the life of one child in the US is worth several times that of a child in the developing world. Who’s the heartless bastard now?

    And even if you were to make some case for health care spending being contained within cohesive communities that all ‘pay in’ – it still makes sense to think about funding particular health care interventions in terms of cost-effectiveness, because it gives you a better sense of what you are NOT funding in order to pay for this intervention. From the point of view of what the community spends on health, though (either from their own pocket, or via the government), there is something to be said about making comparisons about the cost-effectiveness of treatments.

  34. respekt says:

    I really like how you posted references, I hope this is gonna be the norm in future articles

  35. Plonit says:

    Just for comparison:

    cost of rotavirus vaccine per (unadjusted for disability/quality) life year saved in the US = US$197190

    cost of rotavirus vaccine per discounted life year saved in Mexico = US$4,383

    Valencia-Mendoza A, Bertozzi SM, Gutierrez JP, Itzler R. Cost-effectiveness of introducing a rotavirus vaccine in developing countries: the case of Mexico.BMC Infect Dis. 8:103. 2008

  36. micheleinmichigan says:

    Zoe

    “I don’t think so. There is an automated system in Michigan that all the different sources report to- it is a computerized database.”

    Yes, I’m also in Michigan. I periodicely get statements from the county health department that My daughter is behind on a required vaccine* I am not sure if the pediatrician and health departments vaccine clinics send on information to the county health department or if it is only vaccine required providers like schools, daycares and camps who forward required records to the county. (phew)

    She is not behind on her vaccines. Her first vaccinations were given at an orphanage and we re-vaccinated due to a lack of immunity on the one titer we could test. So her records are hard to transcribe into a database system and often confuse administrators.

  37. micheleinmichigan says:

    p.s. – periodically

  38. Joe says:

    @ DanaUllman on 02 Feb 2010 at 11:11 am “Cool…according to your logic now, PEDIATRICS cannot be trusted nor PEDIATRIC INFECTIOUS DISEASE JOURNAL…and the editorial boards of these journals are not nearly as informed as the anonymous people here.”

    So many Straw Men, so few fire extinguishers. Nobody said what you indicate. Even the best journals inadvertently publish unreliable research. While there are CAM magazines with no credibility, nobody has invoked that with respect to the scientific journals that you named.

    Look at the citations provided by David Gorski. Publication, even in good journals, is just the first step acceptance, or rejection, by the scientific community.

  39. EricG says:

    @ danaullman

    “As for EricG’s innane comment about having 100 possible “fields of data” that one can find some changes in any experiment? Ha! Yeah, don’t ya hate it when the primary and secondary measurements show benefits from homeopathy.”

    great, so you come to conclusions riddled with Type I error, thanks for coming clean.

  40. DanaUllman says:

    @Chris

    You (and probably everyone else here) does not seem to know the difference between homeopathic medicines and homeopathic combination medicines.

    The fact of the matter is that three trials using individually chosen homeopathic medicines had a statistically significant effect, as compared with placebo. However, when children were given a homeopathic formula or a placebo, there was no difference.

    Only misinformed or hopelessly daft (or cruel) people would discourage more research on treating children for diarrhea, especially in the light of the fact that millions of kids die each year from dehydration brought on by diarrhea.

  41. Chris says:

    Did you miss the part where the rotavirus vaccines were working? And did you miss the part in Jacob’s studies that the kids did get re-hydration therapy?

    Oh, wait, you probably didn’t. You tend to automatically filter out information if it goes against your beliefs.

    Anyway, why not do some good animal models for homeopathy?

    I saw a video of Dr. Novella participating in a homeopathy debate. He wrote about in a couple of blog posts, the second one included a very testable claim:

    Dr. Saine’s presentation degenerated into a sales pitch for homeopathy that would make any sideshow barker proud. He assured us that homeopathy is more effective than standard medicine and can cure just about anything, magically free from any side effects. He even claims that homeopathy can cure rabies with 100% success. Rabies is almost 100% fatal, even with modern treatment, so this is quite an astounding claim.

    Here is a test you can do!

    Get some laboratory mice and separate them into three different groups. Infect all groups with rabies. Then treat one group with the standard protocol (basically give them a rabies vaccine!), the second group with homeopathy and do nothing with the third. And then report the findings.

    If homeopathy can cure rabies with 100% success… or even with something greater than 5% of the standard protocol group, then you might have something.

    Until then, you are just making unsubstantiated noise.

  42. Chris says:

    By the way, Mr. Ullman, it is usually better to prevent an illness than treat it. That is what a vaccine does.

    What evidence did Ms. Jacobs provide that her sugar pills prevented rotavirus diarrhea? Also, remember her most recent paper says that the homeopathy did not work.

  43. pmoran says:

    “The fact of the matter is that three trials using individually chosen homeopathic medicines had a statistically significant effect, as compared with placebo. ”

    This doesn’t really help, Dana. It simply enhances the implausibility of the claim supposedly being tested, if essentially identical pathological and aetiological processes require different treatment in different babies.

  44. BillyJoe says:

    Dana,

    “As for EricG’s innane comment about having 100 possible “fields of data” that one can find some changes in any experiment? Ha! Yeah, don’t ya hate it when the primary and secondary measurements show benefits from homeopathy.

    Eric,

    “great, so you come to conclusions riddled with Type I error, thanks for coming clean.”

    Okay, I’m going to risk being totally embarrassed:
    I am betting that Dana does not understand what Eric is saying.
    Prove me wrong, Dana.

  45. Peter Lipson says:

    I just can’t stop thinking of the irony of all that rotavirus-induced diarrhea succussing its way through the sewers, creating potent homeopathic rotavirus cures…

  46. Grinch says:

    Age of Autism show how much knowledge they lack actually lack:
    “Managing Editor’s Note: Kudos to The Wall Street Journal for sharing this information about a live virus vaccine infecting a once unacknowledged population, so that American parents and physicians can make informed decisions for their infants and patients. About the last line, that RotaVirus “…causes more than 500,000 deaths from dehydration among young children world-wide, mostly in countries were vaccination isn’t common.” Is it lack of vaccination or lack of clean water, proper nutrition and access to medical care that leads to these deaths?”

    http://www.ageofautism.com/2010/02/merck-rotateq-may-be-contraindicated-for-infants-with-scid.html

  47. Calli Arcale says:

    Grinch:

    All of the above, really. Rotavirus is very infectious, so it spreads quite well even when you have good sanitation, especially among people who are not good about hand-washing. That particularly includes small children, but also a distressing number of adults even in the US. So you’ll get it in any case. Most adults in the US are probably now immune to several strains due to childhood exposure. (Note: like many pathogens, rotavirus is not a single entity. There are many strains, and the vaccines cannot target all of them. It targets those which are most likely to cause serious harm — those which are common, virulent, and highly infectious.)

    So you stand a good chance of getting a rotavirus infection no matter what. But if you lack access to clean water, proper nutrition, and prompt medical care, your odds of *surviving* that infection go down considerably.

    A small child who develops severe dehydration due to rotavirus will probably survive in the US, because they can be hospitalized and given intravenous fluids with the right electrolyte balance. But hospitalization is really something you want to avoid. For one thing, if you wait just a little bit too long, it might be too late by the time you get there. For another, it’s expensive and uncomfortable and very stressful for a small child. (I was hospitalized at age 4 for meningitis. It was awful. The staff were great, but how do you tell a four-year-old that they can’t go home with their mommy and daddy and brother?) And lastly, you can pick up new infections. Hospitals do an excellent job, generally, with infection control, but the very nature of their business means the worst germs of all are in the building and *incubating*. So you might survive the rotavirus, but develop a MRSA infection. Better to avoid the whole thing.

    And the rotavirus vaccine isn’t even a shot. It’s oral, so it’s not so stressful on the kids.

  48. DanaUllman says:

    Preventing a disease is important, so Chris above suggests that you should not consider methods to treat disease. Ya gotta love it when people here say stupid things and are not corrected, but if anyone says anything about homeopathy, the hoards attack.

    Type 1 error is real, though it is a common excuse for people to claim when research results are different than another person’s worldview. How convenient…you can claim type 1 error anytime you don’t agree with results…and then, you try to claim that you’re “scientific based medicine.” It is hard to believe that you can believe this baloney.

    It is true that the Jacobs trials also gave ALL children oral rehydration therapy, but here (again) is where you folks lose all credibility (and don’t even seem to read the research…or understand simply research procedures): ALL children got ORT, and ALL children underwent the homeopathic interview process, but only HALF of the kids got the individually determined homeopathic medicine.

    Which kids got better? Let’s see which ones of you actually read the research.

  49. Scott says:

    It is true that the Jacobs trials also gave ALL children oral rehydration therapy, but here (again) is where you folks lose all credibility (and don’t even seem to read the research…or understand simply research procedures): ALL children got ORT, and ALL children underwent the homeopathic interview process, but only HALF of the kids got the individually determined homeopathic medicine.

    Pop quiz: Who can identify why this makes the results much LESS reliable and much MORE prone to be a statistical artifact?

  50. Scott says:

    Hmm, rethinking that phrasing a bit. “Statistical artifact” was not the best choice of words, so cut the question off after “reliable”.

  51. Calli Arcale says:

    Because it’s clearly not blinded, a common feature of every positive homeopathy study which I have read. The lack of a placebo is notable as well, but the lack of a blind should be expected to increase statistical errors.

    Dana Ullman says:

    Preventing a disease is important, so Chris above suggests that you should not consider methods to treat disease. Ya gotta love it when people here say stupid things and are not corrected, but if anyone says anything about homeopathy, the hoards attack.

    Actually, he was responding to your apparent stance that treatment is the only thing that matters; prevention appears to be unimportant to you. He was definitely not arguing that treatment is unimportant, merely that when it can be achieved, prevention is better for those concerned.

    I know I’d rather my children not get diarrhea at all, though I am glad there are good treatments when they do get it.

    Sidenote: in this thread, two philosophies for treating rotavirus have been suggested. One: supportive therapy (i.e. rehydration and nutrition while the body takes care of the healing itself). Two: homeopathy. It is interesting that here it is science-based medicine which is trusting in the body’s ability to heal itself, while homeopathy believes the body is not capable. Fortunately, the body *is* capable, so a homeopath treating rotavirus sees the patient recover and credits this to the homeopathy. I find this interesting because, although I did not see Mr Ullman make this claim in this thread, I have elsewhere seen homeopaths claim that homeopathy is all about helping the body heal itself.

    Mind you, while the supportive therapies are generally sufficient, it would be very cool if somebody came up with a drug that really did kill knock out rotavirus.

  52. EricG says:

    @ BillyJoe and Dana

    “Type 1 error is real, though it is a common excuse for people to claim when research results are different than another person’s worldview. How convenient…you can claim type 1 error anytime you don’t agree with results…and then, you try to claim that you’re “scientific based medicine.” It is hard to believe that you can believe this baloney. ”

    Looks like you were preliminarily right, BillyJoe.

    Allow me to demonstrate:

    “[insert any threat to a study] is real, though it is a common excuse for people to claim when research results are different than another person’s worldview. How convenient…you can claim [threat] anytime you don’t agree with results…and then, you try to claim that you’re “scientific based medicine.” It is hard to believe that you can believe this baloney. ”

    So, you still haven’t remotely addressed type 1 error (which I am beginning to think you don’t understand) and why controls to type 1 error typically lead to incongruent results. Nor have you demonstrated why you think its ok to lump hundreds of variables together and cry “halleluiah” when significance is reached.

    “…common excuse for people to claim when research results are different…”

    Really? How common? I’ve never seen it. Care to provide any reference as to when “people” have “commonly” employed this “excuse.” Actually, I would challenge you to find a single empirical critique that rests solely on the argument of “this study had too much Type I error, therefore, I reject it.” Type I error *is* real, and studies that ignore it are similarly ignored. Take stats.

    But this isn’t even the point, you said “showed a *highly* significant result” without mention of effect size. This is a *hallmark trait* of a study trying to oversell its findings. Perhaps they are trying to sell remedies on their personal websites…

    Do we additionally need to find out whether you know why an effect size is important and why “highly significant” is in folly?

  53. pmoran says:

    “– you can claim type 1 error anytime you don’t agree with results…and then, you try to claim that you’re “scientific based medicine.””

    It is still “science-based” because it takes into account all other relevant knowledge, including a deep understanding of the investigative processes involved.

    The finding of specific faults in the studies is a bonus, but not essential to the belief that homeopathy works, to the extent that it “works”, as placebo. .

  54. DanaUllman says:

    I love it! Calli Arcale asserts that the Jacobs studies were not placebo controlled. Wow…s/he just makes things up out of very thin air…and no one hear makes any effort to straight the record straight.

    Calli…please simply read my above posts…or better, read the abstracts of the studies…or better yet, read the studies…and in any case, please stop proving evidence based daftness of the people here who only seem to provide criticism of pro-homeopathy statements. Evidence based foolishness is a more apt description of this site.

    Not only does Calli Arcale prove him/herself to be without a clue…but also indicts others here as being deaf, dumb, and blind (even doubly blind) for not having the courage or the intelligence to provide correction.

  55. squirrelelite says:

    Dana,

    You said, “You (and probably everyone else here) does not seem to know the difference between homeopathic medicines and homeopathic combination medicines. ”

    So, I presume, you can tell the difference between homeopathic medicines and homeopathic combination medicines. If so, how do you tell the difference?
    Can you also tell the difference between either of these homeopathic medicines and a plain glass of water?

    And, if so, when do you plan to claim the JREF award for $1 million?

    Also, I notice that you have made several comments but have yet to mention Dr Gorski’s links to two previous SBM blogs, one of which you commented on in October 2008. However, in that blog you didn’t answer Dr Hall’s question:

    For your convenience, I repeat it here.

    “Dr. Ullman,

    Since you have joined the conversation, I wonder if you would care to comment on the statement from the world’s first professor of complementary medicine, Edzard Ernst, who used to practice homeopathy and used to take homeopathic remedies himself, that “With respect to homeopathy, the evidence points towards a bogus industry that offers patients nothing more than a fantasy.” He was certainly aware of Dr. Jacobs’ research and all the other published research when he made that statement

    The world awaits your answer.

  56. Chris says:

    Mr. Ullman, I noted that Jacobs also used conventional rehydration treatment in her regrettible homeopathy studies.

    How does that negate the rotavirus vaccine? In what way is vaccination a lesser solution to rotavirus diarrhea to treatment (by treatment I mean fluids with salts and sugar)?

    This is not cholera, where the vaccine is not that good, and treatment with fluids containing salts and sugars works. This is rotavirus.

    You did not seem to understand my statement, so I bolded an important word that you missed:

    What evidence did Ms. Jacobs provide that her sugar pills prevented rotavirus diarrhea? Also, remember her most recent paper says that the homeopathy did not work.

    Did you see the word?

    Do you understand there are different definitions for the words prevent and treat?

    How would your most vaulted sugar pills prevent rotavirus?

    (I also noticed you did not seem to notice or care about the way to prove Saine’s contention that homeopathy is better for rabies than conventional treatment. Why?)

  57. EricG says:

    Dr. Ullman

    since you have posted since my last point and not addressed it, while engaging my previous points to some degree, I can only assume you cannot pass basic rigor on interpreting statistics. it should be a snap for someone with a bit of background.

    These are very straight forward questions:

    how can you reconcile the overselling of effects by slipping in a known statistical no-no and failing to mention the key aspect (effect size)?

    what allows you to believe that any association arrived at is valid considering that you see fit to ignore type I error?

    while your at it, it would be nice to see you qualify “Type 1 error is real, though it is a common excuse for people to claim when research results are different than another person’s worldview” seeing that is a fairly large accusation. who does this? likewise, why is dismissing a study for its lack of rigor to control type I error a bad thing? (hint, you cannot simply gloss and assert about error to address this)

    Thanks!

  58. Calli Arcale says:

    DanaUllman:

    I love it! Calli Arcale asserts that the Jacobs studies were not placebo controlled. Wow…s/he just makes things up out of very thin air…and no one hear makes any effort to straight the record straight.

    Calli…please simply read my above posts…or better, read the abstracts of the studies…

    I have not yet had time to read the studies (and I prefer to go beyond abstracts, personally), so I am relying on what you said. You said that all of the children in the study received oral rehydration therapy, all of the children were interviewed for determination of individualized therapy, and then half of the children received the prescribed individualized therapy. But I do not see anything saying that the remaining half received any sort of a placebo.

    So it’s not a placebo controlled trial; it’s a comparison of ORT + homeopathy against ORT alone. Such trials are not always worthless (comparing a new therapy as an addition to standard therapy against standard therapy alone is in fact the ethically responsible choice when it comes to something as potentially lethal as severe diarrhea in small children). However, if the children not receiving homeopathy did not receive a placebo, then they and their parents would know which group they were in.

    My concern, ultimately, is that the study may not have been adequately blinded. I would be happy to be corrected, but you seem to think that is not your job, as you railed against the lack of others correcting me “hear” in the two posts between mine and yours. BTW, please note that my comment was held in moderation for a while; it is quite unfair for you to expect immediate response from other members. Of course, you have not taken your own advice. Correct me. I like to learn, so I do not mind.

  59. Chris says:

    Eric G, you referred to Ullman as “Dr. Ullman.” Um, no. Mr. Ullman is not a real medical professional, and only has a Masters in Public Health. He used to sign in as “Dana Ullman, MPH.”

    Mr. Ullman has been pathetically promoting homeopathy for years with papers he has misinterpreted, or literature he warps to his beliefs. Read a review of one of his latest books:
    http://www.quackometer.net/blog/2007/12/homeopathic-revolution-by-dana-ullman.html

    You can learn more about Mr. Ullman by checking out his contributions and subject bans at Wikepedia.

  60. Chris says:

    Take note that Mr. Ullman has been discussed here before:
    http://www.sciencebasedmedicine.org/?p=448

  61. EricG says:

    Chris,

    my mistake, I thought i had seen him referenced as “dr.” and thought that might be respectful.

    likewise, i’ve read his contributions and various rebuttals etc. and so on, so i’m reasonably aware of his standing on the board and from a sbm stance in general. i have not, and it might be interesting to, paroozed his offerings throughout the web otherwise. thanks for the link.

    While it probably pains the regular contributors to see him seriously engaged, I find no other recourse acceptable than to repeatedly and specifically bludgeon with reason…no matter how many times it has to be done. can we fairly assume that Mr. Ullman has no basic understanding in stats since he shyed away from a very simple challenge to his supposed knowledge base? I think so. Is knowledge of stats crucial to interpreting empirical data? Absolutely. Is this a good way to inform a casual reader that Mr. Ullman is not to be taken seriously (at least in whatever capacity he is engaged)? I think so.

  62. Chris says:

    If you have the patience to deal with Mr. Ullman, go for it. I usually tire after noting his absolutely misunderstanding what was said, and even what the “science” he is quoting actually says.

    I thought it was quite silly that he popped up on a posting about the success of a vaccine! It boggles the mind that he thinks that homeopathy treatment for diarrhea is equivalent to prevention with a vaccine!

    When I was in active lurking, I noticed that after being told several times the problems with his “evidence” he will bring it up a week later without changing or missing a beat. For amusement go to the Respectful Insolence blog listed in the list of blogs (where the Quackometer is also listed), and look up Dana Ullman. Especially where he brings up a Chest paper on homeopathy being used in the ICU, and cannot understand the obvious problems with the paper (the groups were not balanced, and just like Jacob’s study on 3rd-world year children with diarrhea, actually got standard treatment with the homeopathy!).

  63. EricG says:

    chris

    thanks for the input, i might have to check those out too.

    though i fancy myself no christopher hitchens, i have drawn a pretty clear line and “issued a challenge” that is actually quite simple. barring provision of a reasonable answer and account, I really have no further reason to engage him at all. ha, I suppose most here reach that conclusion at one point or another…

  64. BillyJoe says:

    Regarding Dana Ullman

    The Dullman, as is now affectionately known, has become a hit and run merchant. I think his browser has alerts for topics where he can cut and paste about homoeopathy. If he enters any discussion, he does so only superficially. It’s been quite a while since anyone’s been able to engage him in serious debate.

    The best ploy, I think, is not to ignore him, but to ask him a pointed question about the study he inevitably references. This requires him to do a bit of thinking (yeah, I know, that is the point! :D) and requires him to actually look at the details of the study he references (which he has not the intelligence to interpret correctly – that is also the point :D).
    That usually sends him running for cover.

    As a matter of interest, I am almost certain that he has not practised homoeopathy for at least a few decades. He ignores any questions along these lines. For example, he will not respond to requests about his practise location, and a internet search comes up empty.

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