Measles came back with a vengeance in 2019, with cases quadrupling globally and 1,276 cases reported in the United States since the beginning of the year — the largest increase in 27 years.

Most of those cases worldwide were among people who weren't vaccinated against the preventable infection. Anti-vaccinations movements have gained ground in the industrialized nations while gaps of immunization coverage or lack of access to health care facilities plague Africa and developing nations around the globe.

But there's some good news in California. 

A new study by researchers at Stanford and the University of California, San Francisco shows the vaccination rate for measles is approaching 95% in nearly all counties of the Golden State. That auspicious number promotes herd immunity, protecting vulnerable unvaccinated people, such as newborns.

The co-authors of the study, which appears in PLOS Medicine, believe this hike in the state's vaccination rate is due to a contentious 2016 law that did away with the personal belief and religious exemptions following the 2014-2015 measles outbreak that began in Disneyland.

The new vaccine policy is associated with a 3% increase in statewide MMR (measles, mumps and rubella) vaccine coverage since the law was adopted, the researchers found, and a 2% decrease in non-medical religious and philosophical exemptions.

That jump may put the state above the critical 95% vaccinated point, which is needed for effective herd immunity against measles. "That would be very meaningful," said Stanford Health Policy's Eran Bendavid, MD, an associate professor of medicine and a co-author of the study.

The policy debates surrounding vaccine hesitancy in the United States have focused on vaccine exemptions, which provide an option for parents to waive current vaccination requirements for entry into school or daycare centers. Currently, 18 states allow nonmedical exemptions based on philosophical, personal or other beliefs.

"The factors driving vaccine hesitancy are complex and include misconceptions and misinformation about vaccine safety, low perceived risk of infectious disease, and lack of trust in health care providers," the authors write. 

The California experiment, however, could serve as an example to state legislatures and public health departments, as well as the federal government, the researchers say. 

"While we did see a small increase in medical exemptions, the much larger increase in MMR coverage suggests that the policy worked as expected," said Sindiso Nyathi, a graduate student in epidemiology, and one of the paper's first authors. "This is good news for states considering similar policies."

Sindiso said evaluating the efficacy of vaccine policies can be difficult due to lack of controls to use as comparisons, which limits the conclusions that can be drawn. To address that gap, their work used a hypothetical control group and estimated how many Californian children would have received the MMR vaccine if the law had not gone into effect. They then compared that to how many kids were vaccinated following the law's enactment in 2016.

The researchers also broke the data down by county. 

"Our county-level analysis found that greater increases in coverage were observed in counties with low coverage levels before the policy," Nyathi said. "This is good news, as it suggests that the policy was more effective in areas that had lower coverage. Similar policies may be an effective tool to bring vaccine coverage levels above herd immunity thresholds." 

While the researchers found the law work as intended, there was a small, 0.4% increase in the number of medical exemptions. 

Under the current California law, parents can request vaccination waivers for children whose medical condition might be impacted by the vaccine.

In September, Gov. Gavin Newsom signed into law another vaccination bill that will go into effect on Jan. 1. It will give the California Department of Public Health the power to revoke medical exemptions if it determines they are not medically sound. The department will also have the power to review exemptions from doctors who write more than five in one year.

After decades of inaction and stalemate, there are small but significant signs that the U.S. government may finally be ready to meet its legal commitment to manage and dispose of the more than 80,000 metric tons of used nuclear fuel at 74 operating and shut-down commercial nuclear reactors sites in 35 states across the country. The signs of progress include:

• Only a few weeks ago, the House Energy and Commerce Committee approved bipartisan legislation to authorize the storage of used fuel at an NRC-licensed interim storage facility and provide funding for the development of a long-term repository.
• Similar legislation has had hearings and is pending in the Senate, and less than a week after the House committee action Sen. John Barrasso (R-Wyo.) introduced a parallel bill to the House legislation and called on his colleagues for bipartisan support.
• A comparable bill passed the House in the previous Congress by a vote of 340-72.
• Congressional leadership on this issue includes Sens. Lamar Alexander (R-Tenn.) and Dianne Feinstein (D-Calif.) in the Senate, as well as highly motivated members in the House.
• The Trump administration’s last two budget proposals included funding for a spent fuel interim storage site, in addition to funding for Yucca Mountain. 
• Two private entities have filed license applications with the Nuclear Regulatory Commission (NRC) to construct and operate consolidated interim storage facilities, and the NRC is moving forward to process these applications.

These actions reflect an increasing recognition that the management and disposal of used nuclear fuel is an issue that need to be addressed, particularly if nuclear power is going to have a role in the reduction of greenhouse gas emissions.

Read the Rest at The Hill

Americans show much less tolerance for war crimes than they did during the war in Vietnam.

Read the Rest at Washington Post

In Aug. 2019, Bobby Chesney (from Strauss Center at the University of Texas at Austin) and Max Smeets (from ETH Zurich and also Stanford University’s Center for International Security and Cooperation (CISAC)) convened a workshop in Amsterdam focusing on military operations in the cyber domain, from a transatlantic perspective. The “Transatlantic Dialogue on Military Cyber Operations—Amsterdam” gathered experts from military, civilian, and academic institutions hailing from a range of countries, including the United States, United Kingdom, Germany, the Netherlands, Denmark, Estonia, and France.

Read the Rest at Lawfare Blog

The toll from gun violence at schools has only escalated in the 20 years since the jolting, horrific massacre at Columbine High.

By December 2019, at least 245 primary and secondary schools in the United States had experienced a shooting, killing 146 people and injuring 310, according to The Washington Post.

At least 245 primary and secondary schools in the United States have experienced a shooting — killing 146 people and injuring 310 — since the country's first mass school shooting at Columbine High School in April 1999.

Now, new Stanford-led research sounds an alarm to what was once a silent reckoning: the mental health impact to tens of thousands of surviving students who were attending schools where gunshots rang out.

A study has found that local exposure to fatal school shootings increased antidepressant use among youths.

Specifically, the average rate of antidepressant use among youths under age 20 rose by 21 percent in the local communities where fatal school shootings occurred, according to the study. And the rate increase – based on comparisons two years before the incident and two years after – persisted even in the third year out.

“There are articles that suggest school shootings are the new norm – they’re happening so frequently that we’re getting desensitized to them – and that maybe for the people who survive, they just go back to normal life because this is just life in America. But what our study shows is that does not appear to be the case,” said Maya Rossin-Slater, a core faculty member at Stanford Health Policy and faculty fellow at the Stanford Institute for Economic Policy Research (SIEPR). “There are real consequences on an important marker of mental health.”

The study is detailed in a working paper published Monday by the National Bureau of Economic Research. It was co-authored by Rossin-Slater, an assistant professor of health policy in the Stanford School of Medicine; Molly Schnell, a former postdoctoral fellow at SIEPR now an assistant professor at Northwestern University; Hannes Schwandt, an assistant professor at Northwestern and former visiting fellow at SIEPR; Sam Trejo, a Stanford doctoral candidate in economics and education; and Lindsey Uniat, a former predoctoral research fellow at SIEPR now a PhD student at Yale University.

Their collaborative research – accelerated by their simultaneous stints at SIEPR – is the largest study to date on the effects of school shootings on youth mental health.

The study comes as the issue of gun safety continues to stoke political wrangling and public debate. And the researchers say their findings suggest policymakers should take a wide lens to their decision-making process.

“When we think about the cost of school shootings, they’re often quantified in terms of the cost to the individuals who die or are injured, and their families,” Rossin-Slater noted. “Those costs are unfathomable and undeniable. But the reality is that there are many more students exposed to school shootings who survive. And the broad implication is to think about the cost not just to the direct victims but to those who are indirectly affected.”

A Driver for Antidepressant Use

More than 240,000 students have been exposed to school shootings in America since the mass shooting in Columbine in April 1999, according to The Washington Post  data used in the study. And the number of school shootings per year has been trending up since 2015.

Yet despite this “uniquely American phenomenon” – since 2009, over 50 times more school shootings have occurred in the U.S. than in Canada, Japan, Germany, Italy, France and the United Kingdom combined – little is known about the effects of such gun violence on the mental health of the nation’s youth, the study stated.

“We know that poor mental health in childhood can have negative consequences throughout life,” Schwandt said. “At the same time, children are known to show significant levels of resilience, so it really wasn’t clear what we would find as we started this project.”

The researchers examined 44 shootings at schools across the country between January 2008 and April 2013. They used a database that covered the near universe of prescriptions filled at U.S. retail pharmacies along with information on the address of the medical provider who prescribed each drug. They compared the antidepressant prescription rates of providers practicing in areas within a 5-mile radius of a school shooting to those practicing in areas 10-to-15 miles away, looking at two years prior and two to three years after the incident.

Of those 44 school shootings, 15 of them involved at least one death. The 44 shootings occurred in 10 states: Alabama, California, Connecticut, Florida, Nebraska, North Carolina, Ohio, South Carolina, Tennessee and Texas.

Researchers found a marked increase in the rate of antidepressant prescriptions for youths nearby, but only for the shootings that were fatal. They did not see a significant effect on prescriptions for youths exposed to non-fatal school shootings.

“The immediate impact on antidepressant use that we find, and its remarkable persistence over two, and even three years, certainly constitutes a stronger effect pattern than what we would have expected,” Schwandt said.

Meanwhile, adult antidepressant use did not appear to be significantly impacted by local exposure to school shootings.

Layers of Costs, More Unknowns

The researchers also analyzed whether the concentration of child mental health providers in areas affected by fatal school shootings made a difference in the antidepressant rates, and they drilled a further comparison between the prevalence of those who can prescribe drugs, such as psychiatrists and other medical doctors, and those who cannot prescribe drugs, such as psychologists and licensed social workers.

Increases in antidepressant rates were the same across areas with both high and low concentrations of prescribing doctors, the researchers found. But in areas with higher concentrations of non-prescribing mental health providers, the increases in antidepressant use were significantly smaller – indicating perhaps a greater reliance on non-pharmacological treatments or therapy for shooting-related trauma.

The researchers also found no evidence that the rise in antidepressant usage stemmed from mental health conditions that were previously undiagnosed prior to the shootings.

In totality, the researchers say the results in the study clearly pointed to an adverse impact from a fatal shooting on the mental health of youths in the local community. Furthermore, the results capture only a portion of the mental health consequences: Non-drug related treatments could have been undertaken as well.

“Increased incidence of poor mental health is at least part of the story,” Schnell said.

Though their analysis included only 44 schools and 15 fatal school shootings, Rossin-Slater noted how the trend of school shootings is growing. She believes the mental health impact found on the local communities they studied “can be generalizable to other communities’ experiences.”

That’s all the more reason why policymakers should consider the overall negative effects of school shootings, and how further research will be needed to gauge other societal consequences, the researchers said.

“Think of it as layers of costs,” Rossin-Slater said. And when it comes to evaluating gun violence at schools, “we think our numbers say, ‘Hey, these are costly things, and it’s costlier than we previously thought.’”

Using a dynamic microsimulation model, a research team, including APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston, shows that there are differentially positive health gains of smoking reduction among subgroups of smokers in South Korea, Singapore, and the United States.

Tobacco use is responsible for the death of approximately eight million people worldwide, estimates the World Health Organization, and countries are increasingly making tobacco control a priority. Indeed the relationship between smoking and the burden of chronic diseases such as cancer, lung disease, and heart disease, and, in turn, premature mortality, is well documented. Yet little is known about the health effects of smoking interventions among subgroups of smokers.

Do interventions targeted at heavy smokers relative to light smokers lead to disproportionately larger improvements in life expectancy and prevalence of chronic diseases? And how do these effects vary across populations? In today’s rapidly aging world, it is crucial to understand the potential health gains resulting from interventions to reduce smoking, a leading preventable risk factor for healthy aging.

That’s why a research team, including APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston as well as Stanford Health Policy faculty member Jay Bhattacharya, set out to examine the health effects of smoking reduction. To do so, the team simulated an elimination of smoking among subgroups of smokers in South Korea, Singapore, and the United States.

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The team’s findings, discussed in a new paper published by the journal Health Economics, show that smoking reduction can achieve significant improvements in lifetime health as measured by survival while also reducing the prevalence of major chronic diseases, though the effects are heterogeneous. Whereas interventions in both subgroups and in all three countries led to an increased life expectancy and decreased prevalence of chronic diseases, the life-extension benefits were greatest – 2.5 to 3.7 years – for those who would otherwise have been heavy smokers, compared with gains of 0.2 to 1.5 years among light smokers.

The team developed a dynamic microsimulation model to estimate the health gains of reducing smoking among heavy smokers and light smokers. Microsimulation models are powerful tools for assessing the value of health promotion: they model individual health trajectories while accounting for competing risks, thus providing valuable information about the impact of interventions and how they may interact with the changing demographics and socioeconomic profile of a population to determine future health. The team’s study applied microsimulation models tailored to the demographic and epidemiological context in the three countries, then compared the gains in survival and reduction in chronic disease prevalence from a given reduction in smoking and how these impacts vary depending on initial smoking intensity.

The team’s findings indicate that there are differentially positive health effects from smoking reduction. The life‐year gain among heavy smokers quitting well exceeds that of light smokers quitting in each country, but the magnitudes differ substantially: 11.2 times for South Korea, 6.8 times for Singapore, and 1.7 times for the United States. The lower life expectancy among Americans is related to the greater extent in which they suffer from risk factors, such as obesity, relative to the Asian counterparts in the study.

The findings illustrate how smoking interventions may have significant economic and social benefits, especially for life extension, that vary across countries. They are particularly important for aging societies that are concerned about the sustainability of their health insurance systems in the face of increasing burden of chronic disease.