San Francisco Medical Society Blog

SFDPH Health Advisory: Human Infections with Avian Influenza A: H7N9

Tue, 07 May 2013 11:31:06 GMT

May 1, 2013 (Revised from April 12, 2013)

The U.S. Centers for Disease Control & Prevention (CDC) has updated its interim guidance:

Antiviral Treatment: Due to the potential severity of illness associated with Avian Influenza A:H7N9 virus infection, CDC now recommends that all confirmed, probable, and suspect cases of Avian Influenza A:H7N9, including outpatients with uncomplicated illness, be treated with neuraminidase inhibitors as early as possible, without waiting for laboratory confirmation of influenza before initiating treatment.

Infection Control Guidance has been updated; Droplet precautions are no longer recommended but Standard, Contact and Airborne precautions should be implemented by health care personnel; suggestions are provided for clinics unable to fully implement Airborne Precautions.

Case Definitions: A definition for Suspect cases (Cases Under investigation) has been added, defining Suspect as patients with influenza-like illness (ILI1) with:

Recent contact (within ≤ 10 days of illness onset) with a confirmed or probable case of infection with Avian Influenza A:H7N9 virus; or
Recent travel (within ≤ 10 days of illness onset) to a country where human cases of Avian Influenza A:H7N9 virus have been recently detected or where Avian Influenza A:H7N9 viruses are known to be circulating in animals. (As of 4/29/13, those countries are China and Taiwan).

Actions Requested of Clinicians

IMPLEMENT Standard, Contact and Airborne Precautions2, including eye protection and respirators, for health care personnel caring for patients meeting criteria for a Suspect case of Avian influenza A:H7N9. Place a surgical mask on the patient to reduce spread of respiratory secretions and have the patient avoid public settings (e.g., public transportation). Aerosol-generating procedures should be performed only if they are medically necessary and cannot be postponed.
REPORT suspected Avian influenza A:H7N9 in patients who meet the criteria described in the case definition for case under investigation (CUI). Call the SFDPH Communicable Disease Control Unit at (415) 554-2830; after hours, weekends and holidays press “1” and “1” again to page the on call physician.
COLLECT specimens for testing and, after obtaining approval from SFDPH Communicable Disease Control, send specimens to SFDPH Public Health Laboratory per instructions below.
TREAT empirically with neuraminidase influenza antiviral medications (oral oseltamivir or inhaled zanamivir) as soon as possible, without waiting for laboratory confirmation in all patients who meet the case definition for case under investigation, including outpatients with uncomplicated illness.
CONSULT an infectious disease specialist and/or the CDC webpage3 for updated information

Click here to view the SFDPH health advisory on Avian Influenza A: H7N9.

For more information about health alerts, advisories, and updates from the San Francisco Department of Public Health, please visit http://www.sfcdcp.org/healthalerts.html.

Health Policy Report: Medical Policy-Making 2012

Mon, 08 Apr 2013 15:32:41 GMT

The 2012 SFMS delegation to the California Medical Association’s (CMA) annual House of Delegates meeting took a wide range of proposed resolutions for consideration by the statewide gathering. Each resolution, some with modification, moved important health care issues forward in the areas of health care delivery, health care mandates, and pharmaceutical industry issues, including medication disposal and insurance coverage.

Our roster of policy proposals this year, with outcomes, included:

Tracking Prescriptions to Curtail Medication Abuse (Rokeach, Loring, Turner): CMA supports the development of a fully functional, Web-based prescription drug monitoring program (PDMP), whether it be an improved CURES (Controlled Substances Review and Evaluation System) program or a new one that should be fully funded, including through a fee-per-prescription paid by manufacturers and suppliers of drugs monitored.

Reducing Overutilization: Physician Leadership (Denys, Fung, Eng): CMA supports physician-led, evidence-based efforts to improve appropriate use of medical services and will educate physicians, hospitals, health care leaders, and patients about the need for physician-led, evidence-based efforts to improve appropriate use of medical services. This resolution originally referred to the “Choosing Wisely” effort that will be the topic of the January/February 2013 edition of San Francisco Medicine.

"Pay for Delay" Practices on Generic Medications (Susens): CMA will ask AMA to support federal legislation that makes tactics delaying conversion of medications to generic status, also known as “pay for delay,” illegal in the United States. As noted in a recent NEJM piece, that might already be the case!

Increasing Utilization of POLST Orders (Newman, Schickedanz, Lopato): CMA encourages physicians to become educated about all aspects of the POLST form and to integrate discussions about, and use, POLST in all appropriate instances where medical services are provided to patients at the end of life. Surprisingly to many, this was perhaps the most hotly debated resolution of the year, as our original allowed for nurse practitioners to fill out POLST forms for physician confirmation, as is done in some other states.

Medical Mandates for Insurance Coverage and Medi-Cal (Chan): CMA supports the principle that mandated coverage for private insurers should also apply to publicly financed entities, when appropriate; and will advocate that the state legislature must budget for the increased cost to Medi-Cal and enrollees of the California Health Benefit Exchange when passing mandated coverage.

Promoting Quality and Transparency in Graduate Medical Education (Schickedanz): CMA supports efforts to urgently address the anticipated imbalance between the number of medical school graduates and available residency training positions; and greater transparency at all levels in the calculation, distribution, and tracking of graduate medical education (GME) funding; and will petition the Centers for Medicare and Medicaid Services to address perceived disparities in the distribution of GME funding.

Cell Phone Use in Cars (Udovic-Constant, Fouras): CMA will support public education efforts regarding the dangers of distracted driving, particularly activities that take drivers’ eyes off the road, and will ask the AMA to do likewise. Our original was more forceful, asking for more severe penalties and even bans.

There was much more, with something of interest to every specialty, practice setting, and personality.

Click here to view the full list of the new policies adopted at the 2012 CMA House of Delegates.

Interested in submitting a resolution or suggesting a resolution idea for 2013 HOD? Please contact SFMS at membership@sfms.org.

Most California Voters Support Soda Tax To Boost Students' Health According to Poll

Fri, 15 Feb 2013 11:20:16 GMT

68% of voters said they would support a tax on sugar-sweetened beverages if the revenue boosted school nutrition and physical activity programs, according to a new Field Poll.

The poll—conducted on behalf of the California Endowment—surveyed 1,184 registered California voters by telephone in October 2012.

According to the poll, 75% of respondents said that regularly drinking sugar-sweetened sodas increases the chance of individuals becoming overweight, while 42% said the same for sugar-sweetened energy drinks, and 26% said the same for sugar-sweetened sports drinks.

The SFMS and CMA have been strong advocates on combating child obesity. CMA took a policy position in support of the ban after its House of Delegates approved the resolution submitted by SFMS members Shannon Udovic-Constant, Arti Desai, and Adam Shickedanz introduced the resolution “Marketing of Unhealthy Food and Beverages to Children” at the 2011 HOD.

Additionally, CMA sponsored AB 1746, which would ban the sale of sugary sports drinks on middle and high school campuses throughout California. They are currently prohibited on elementary school campuses. Existing education code bans the sale of sodas in schools; this legislation would expand that to include sugary drinks.

Click here to read the original SFMS/CMA press release about AB 1746.

Source: California Healthline, February 15, 2013.

Boston Declares Health Emergency Amid U.S. Flu Outbreak; Resources for Health Care Providers

Thu, 10 Jan 2013 11:40:55 GMT

The country is in the grip of three emerging flu or flulike epidemics: an early start to the annual flu season with an unusually aggressive virus, a surge in a new type of norovirus, and the worst whooping cough outbreak in 60 years. And these are all developing amid the normal winter highs for the many viruses that cause symptoms on the “colds and flu” spectrum.

Google’s national flu trend maps, which track flu-related searches, are almost solid red (for “intense activity”) and the Centers for Disease Control and Prevention’s weekly FluView maps, which track confirmed cases, are nearly solid brown (for “widespread activity”).

With flu cases in this city up tenfold from last year, the mayor of Boston declared a public health emergency on Wednesday as authorities around the United States scrambled to cope with a rising number of patients.

Health authorities say a virulent strain this year has caused the number of flu cases to surge earlier than usual. Hospitals around the country have scrambled to find additional space to treat the ill, and some have had to turn people away.

The U.S. Centers for Disease Control and Prevention (CDC) reported that the proportion of people visiting their doctors for flu-like illnesses has doubled in the past four weeks.

Encouraging vaccinations is one of the most effective steps in combating what looks to be a serious strain of the flu, said Dr. William Hanage, an associate professor of epidemiology at the Harvard School of Public Health.

The flu season typically picks up in December, builds to a peak in January or February and fades away by late March or early April.

Flu Information for Health Care Providers

San Francisco Department of Public Health Health Officer order regarding mandatory influenza vaccination or masking for health care professionals during flu season
Flu information from the SFDPH Communicable Disease Control and Prevention, including vaccination guide and health alerts
American Public Health Association's report on early start of flu season, December 4, 2012.
CDC Report of 2012-2013 Influenza Season Week 52 Ending December 29, 2012.

Meningitis Outbreak Fuels Calls For More Oversight

Wed, 10 Oct 2012 10:04:40 GMT

The Centers for Disease Control and Prevention reported that eight people have died and 105 people in nine states have been sickened by a type of fungal meningitis they were exposed to when they received tainted spinal steroid injections.

According to The Wall Street Journal, as many as 13,000 patients may have been exposed to fungal meningitis from tainted spinal steroid injections. Some lawmakers called for bringing certain specialized pharmacies under greater regulatory scrutiny. The oversight of compounding pharmacies, which create customized versions of medicines, is gaining greater attention as the death and illness tolls in the outbreak continue to rise.

Source: Kaiser Health News

Brown Signs Legislation Requiring Signatures To Opt Out of Vaccination

Mon, 01 Oct 2012 15:30:50 GMT

On Sunday, Gov. Jerry Brown signed legislation into law that requires parents who exclude their children from immunization requirements to submit a signed statement that they received information about risks and benefits of immunization.

Details of Law

AB 2109—proposed by Assembly member Richard Pan (D-Sacramento)—requires a signed statement by the parent and by a health care provider.

The law will take effect in January 2014.

Brown said that he will direct the Department of Health to provide an option to avoid having to obtain a health care provider’s signature for people choosing not to vaccinate their child because of religious beliefs.

Comments

Brown noted that AB 2109 does not eliminate parents' current right to exclude their children from vaccinations but attempts to ensure that they have important health information in making that choice.

“This bill is about explaining the value of vaccinations—both the benefits and risks—for an individual child and the community,” Brown wrote in a signing message for AB 2109. He added that the information “will be valuable even if a parent chooses not to vaccinate.”

Pan, a pediatrician, said, “AB 2109 utilizes the expertise of California’s 150,000 licensed health care practitioners to inform parents about the safety and efficacy of vaccines, answering specific questions they may have.”

Opponents say the law is a form of government coercion that requires parents to overcome bureaucratic hurdles before exercising their legal right to opt out of vaccinations. They also argue that parents could incur cost in obtaining a health care provider's signature.

Source: Sacramento Bee, September 30, 2012.

Mandatory Influenza Vaccination or Masking of Health Care Workers During Flu Season

Fri, 21 Sep 2012 15:02:41 GMT

The San Francisco Department of Health has issued a Health Officer order mandating that all hospitals, skilled nursing, and other long term care facilities in the City and County of San Francisco require their health care workers (HCWs) to receive an annual influenza vaccination or, if they decline, to wear a mask in patient care areas during this flu season.

Influenza infection accounts for 36,000 excess deaths in the U.S. each year; 90% of which are people over the age of 65. HCWs are both at risk for influenza and can transmit the virus to their patients. The goal is to increase influenza vaccination rates of HCWs, reduce employee absenteeism during the flu season, and reduce HCW to patient transmission of influenza.

The influenza season is defined as December 15 to March 31.

Click here for more information and a copy of the Health Officer order.

Bad Bugs, From Farm to Us: Curtailing Antibiotic Overuse in Agriculture

Tue, 04 Sep 2012 09:57:09 GMT

By Steve Heilig, MPH; Philip R. Lee, MD; and Lester Breslow, MD

Editor’s Note: With ever-increasing microbial resistance to our ever-challenged arsenal of antibiotics, clearly we need to do everything possible to stay ahead in the Darwinian race between bacterial pathogens and humanity. One intervention, increasingly indicated by research and supported by many reputable health organizations, is to decrease the massive prophylactic and growth-promoting use of antibiotics in the production of food, primarily meat.

Ten years ago, the SFMS brought policy to the CMA and then to the AMA urging more careful and curtailed use of antibiotics in food production. We also hosted a daylong invitational conference on this topic, cochaired by two living legends of public health, Phil Lee, MD (a longtime SFMS member, UCSF chancellor emeritus, Stanford medical professor, and former United States Assistant Secretary of Health), and Lester Breslow, MD (dean emeritus of the UCLA School of Public Health, former California state health director, and past-president of the American Public Health Association), along with then-SFMS President George Susens, MD. This meeting resulted in a new network of advocates working to preserve antibiotics, as well as an editorial in the Western Journal of Medicine (then edited by SFMS member Linda Clever, MD). This piece, reprinted below, has become one of the most-cited articles on this topic, no doubt due to the stature of Lee and Breslow. Breslow died in April of this year at age 97, prompting extensive tributes, from the New York Times to many professional forums. Breslow said he saw himself as “a political activist for disadvantaged people”—which, with respect to microbes, could include anybody. This reprint is offered as one more thanks—and, sadly, it remains all too relevant.

Click here for the list of references used in this article.

Antibiotics are arguably the single most important and widely used medical intervention of our era.

Almost every medical specialty uses antibiotic therapy at some point. These drugs have prevented incalculable suffering and death and are perhaps still the closest medications we have to a “magic bullet.”

Of course, bad bugs can bite back, and bacterial adaptation and resistance were reported soon after antibiotics were first used. The struggle to stay one step ahead of pathogens has been widely described and debated. Correcting the overuse of antibiotics in human medicine has gradually become a priority, with slow but heartening progress being gained in this Darwinian race. Still, the rise of multidrug resistance and the ready transfer of resistant traits among pathogens require heightened action if we are to prevent increasing outbreaks of infections that become more difficult, or even impossible, to treat.

One essential course of action is to minimize any and all causes and reservoirs of antibiotic resistance. Besides medical use in humans, there is the troubling issue of use in agriculture, specifically in livestock production. Antibiotics have long been routinely used not only for the treatment of infections but also as a means of getting animals to market faster by growth promotion. Controversies about these practices have resulted in numerous reports, dating back decades, urging more caution or outright bans on the practice. The World Health Organization and other leading medical and public health bodies have advised that animals not be dosed with antibiotics used in humans—to little avail here in the United States to date, even though our own Food and Drug Administration took this position as far back as 1972.¹

Still, many longtime observers of the issue were surprised—or even shocked—to learn the true extent of antibiotic use on farms; estimates are that upward of 70 percent of all antibiotics manufactured are used in agricultural settings.² Although the exact percentages are uncertain, agricultural antibiotic use is apparently more substantial than previously thought. And the type of use is worrisome because it involves continual, subtherapeutic doses that would seem to provide ideal environments for the selection of resistant pathogens.

The introduction of new molecular epidemiologic tools has heightened the worry because these tools have been used to show that resistant bacteria originating on farms are finding their way into humans.^3-10 The extent of this epidemiologic “spillover” to date is uncertain—assertions of the extent of bacterial resistance arising from farms vary widely—and this needs to be a higher research priority. But there is no question that the phenomenon does exist.

Recognizing this risk, the American Medical Association’s House of Delegates adopted a policy that “nontherapeutic use of antimicrobials in animals that are also used in humans should be terminated or phased out based on scientifically sound risk assessments.”¹¹ Reaction from the pharmaceutical industry, in the guise of a trade association of manufacturers of animal drugs, was swift. The Animal Health Institute erroneously claimed “The assertion that there is increasing evidence that resistance developed in animals is spreading to humans is not true,” and it went on to oppose any further restriction on agricultural use.¹²

As a case study of such profit-motivated opposition, Bayer Corporation vigorously contested the FDA’s proposal to withdraw a widely used class of antimicrobial, fluoroquinolones, from agricultural use. These medications are used to combat some of the same bacterial pathogens that are treated with the same drugs in human medicine. Hence, there is a high risk of resistant strains finding their way from animals to humans.¹³ Abbot Laboratories, the other major manufacturer of fluoroquinolones, showed admirable scientific judgment and corporate responsibility in agreeing to the FDA’s request. Unfortunately, judging from the Animal Health Institute’s response to the AMA, we fear the drug industry’s reactions may more closely mirror Bayer’s shortsighted approach. But notably, even some forward-thinking agricultural leaders are now questioning the wisdom of such stonewalling.¹⁴

Admittedly, we tend to give more credibility to those who do not have any financial interest in the status quo. Leading experts unequivocally state that our current practices of feeding antibiotics to animals go against “a strong scientific consensus that it is a bad idea” and that the long stalemate on this issue constitutes a “struggle between strong science and bad politics.”¹⁵ The intentional obfuscation of the issue by those with profit in mind is an uncomfortable reminder of the long and ongoing battle to regulate the tobacco industry, with similar dismaying exercises in political and public relations lobbying and even scandal.¹⁶ As with tobacco control, science and health concerns should take precedence over profit in regulating the overuse of antibiotics in the production of meat and other agricultural products.

Antibiotics do have a place on farms, but the benefits of their use can likely be preserved while minimizing harm. We need to learn more about the extent of risk, but the delay tactic of allowing current practices to continue while “more research” is conducted is unacceptable. Enough is already known to justify a more cautious, preventive approach.¹⁷ Other nations are ahead of the United States in this regard and have banned routine agricultural use, with demonstrable benefit in reduced bacterial resistance.¹⁸

We call on the FDA or legislators to, in the coming year, ban the nontherapeutic agricultural use of antibiotics. This ban should be lifted only if it is scientifically proved, in unbiased studies, that this use does not contribute to bacterial resistance in humans. Producers of agricultural antibiotics should be required to submit data on the specific antibiotics used, in sufficient detail to track usage and resistance trends. Finally, individual and business consumers of meat should begin to demand that the meat they purchase be grown without the routine use of antibiotics.

The need to preserve the efficacy and supply of our antibiotic tools becomes even more crucial. It is time for our government to act in the public interest on this important issue.

Click here for information on the growing campaign surrounding this issue, including the AMA-endorsed Preservation of Antibiotics for Medical Treatment Act (PAMTA, H.R. 965/S. 1211).

For a recent update on how Denmark is leading on this issue, see Pig out: If farmers do not rein in the use of antibiotics for livestock, people will be severely affected. Nature 486, 440. 28 June 2012.

Originally published: West J Med. 2002 January; 176(1):9–11.

References

1. World Health Organization. WHO acts to safeguard vital treatments for the future. WHO/39 September 11, 2001. www.who.int/inf-pr-2001/en/pr2001-39.html.
2. Mellon M, Fondriest S, Union of Concerned Scientists. Hogging it: Estimates of animal abuse in livestock. UCS Nucleus. 2001; 23:1-3.
3. Witte W. Medical consequences of antibiotic use in agriculture. Science. 1998; 279:996-997.
4. Ferber D. Superbugs on the hoof? Science. 2000; 288:792-794.
5. Alliance for the Prudent Use of Antibiotics, Tufts University. Annotated Ecology References. www.healthsci.tufts.edu/apua/Ecology/EcoFaq.html.
6. van den Bogaard AE, London N, Driessen C, Stobberingh EE. Antibiotic resistance of faecal Escherichia coli in poultry, poultry farmers and poultry slaughterers. J Antimicrob Chemother. 2001; 47:763-771.
7. Van Looveren M, Daube G, De Zutter L et al. Antimicrobial susceptibilities of Campylobacter strains isolated from food animals in Belgium. J Antimicrob Chemother. 2001; 48:235-240.
8. White DG, Zhao S, Sudler R et al. The isolation of antibiotic-resistant salmonella from retail ground meats. N Engl J Med. 2001; 345:1147-1154.
9. McDonald LC, Rossiter S, Mackinson C et al. Quinupristin-dalfopristin-resistant Enterococcus faecium on chicken and in human stool specimens. N Engl J Med. 2001; 345:1155-1160.
10. Sorensen TL, Blom M, Monnet DL, Frimodt-Moller N, Poulsen RL, Espersen F. Transient intestinal carriage after ingestion of antibiotic-resistant Enterococcus faecium from chicken and pork. N Engl J Med. 2001; 345:1161-1166.
11. American Medical Association. Antimicrobial Use and Resistance. House of Delegates resolution 508 (A-01), June 2001. www.keepantibioticsworking.com/library/uploadedfiles/American_Medical_Association_Resolution_508_-_.htm.
12. Animal Health Institute. Statement on AMA Resolution on Animal Antibiotics. June 20, 2001.http://www.ahi.org/News Room/Press Release/2001/June/ama.htm.
13. Olsen SJ, DeBess EE, McGivern TE et al. A nosocomial outbreak of fluoroquinolone-resistant salmonella infection. N Engl J Med. 2001; 344:1572-1579.
14. Richardson L. Animal agriculture's BSOD. California Farmer. 2001; 284:6.
15. Falkow S, Kennedy D. Antibiotics, animals, and people—again! Science. 2001; 291:397.
16. Marshall E. Scientists quit antibiotics panel at CAST. Science. 1979; 203:732-733.
17. Kriebel D, Tickner J. Reenergizing public health through precaution. Am J Public Health. 2001; 91:1351-1355.
18. Aarestrup FM, Seyfarth AM, Emborg HD, Pedersen K, Hendriksen RS, Bager F. Effect of abolishment of the use of antimicrobial agents for growth promotion on occurrence of antimicrobial resistance in fecal enterococci from food animals in Denmark. Antimicrob Agents Chemother. 2001; 45:2054-2059.

SFMS-Sponsored School Vaccine Bill Passes Legislature

Thu, 23 Aug 2012 12:19:07 GMT

The California Senate passed AB 2109, a bill that would require a parent or guardian seeking a personal belief exemption from school immunization requirements to first obtain a document signed by a licensed health care practitioner. AB 2109 was sponsored by SFMS and the CMA, and was authored by Assemblymember Richard Pan, MD.

AB 2109 preserves a parent’s option to exempt their child from immunizations, but ensures that such a decision is an informed one and that the parent is aware of the individual and public health risks of not immunizing their child.

California is one of 20 states that allows for the broad use of personal belief exemptions from immunizations that are required for children to enter school. Currently in California, obtaining a personal belief exemption is simple — parents are only required to sign their name to a two-sentence standard exemption statement on the back of the California School Immunization Record or provide a signed written statement.

Over the past decade, the number of parents in California choosing to exempt their children from school immunization requirements has increased dramatically. The increase in personal belief exemptions and resultant decreases in community immunization rates could have a significant impact in public safety, giving rise to outbreaks of diseases such as measles, mumps and pertussis.

The bill now goes to the governor’s desk for his signature.

Why We Walk; Join SFMS for the Golden Gate Walk on September 15

Thu, 09 Aug 2012 14:54:07 GMT

By Peter Curran, MD, SFMS President. Adapted from the President's Message in the July/August 2012 issue of San Francisco Medicine.

Your San Francisco Medical Society is sponsoring the American Heart Association Heart Walk in Golden Gate Park on September 15. The executive committee of the SFMS Board voted unanimously to sponsor a booth at the event to showcase organized medicine's commitment to local health improvement efforts. Volunteers and survivors representing several local hospitals will walk a scenic three-mile course in Golden Gate Park to raise awareness for fighting heart disease. An additional benefit of supporting the walk is the message it gives the community about physicians' resolve in advocating for health in our own neighborhoods. Much appreciation for the work of Dr. Shannon Udovic-Constant, Ms. Jessica Kuo, and the membership committee at SFMS in organizing this and other community-related activities.

Community service is not new to organized medicine in California. The SFMS membership has pioneers in local community advocacy. The San Francisco Free Clinic, founded in 1994 by SFMS members Tricia Hellman Gibbs, MD, and Richard Gibbs, MD, was awarded the Public Health Heroes Award for Health Care Delivery in 2006 for its service in providing medical care to the uninsured “working poor” in San Francisco. In addition to providing a vital service to the community, the clinic has given primary care training to young physicians and students from several medical schools, including UCSF. Similarly, SFMS member Marcus Conant, MD, one of the first physicians to diagnose and treat AIDS patients in 1981, founded the San Francisco AIDS Foundation and, later, the Conant Foundation, which expanded AIDS awareness to the legislative arena on behalf of patients. Adam Schickedanz, MD, a UCSF pediatric resident, started the Financial Fitness Program at San Francisco General, which provides crucial financial information and services to underserved patients with needs that go beyond health issues. Schickedanz’s program was awarded a $10,000 grant by the SFMS and the San-Cop Foundation and continues to grow.

At a time when organized medicine is struggling to remain relevant in the midst of health care delivery reform, perhaps it is simplistic to think that participating in a local Heart Walk will change medicine’s fortunes or even grow membership within SFMS. But public health and advocacy, which remain tenets of our mission at SFMS, are relevant regardless of the political climate of the times if they are done with conviction in support of the greater community benefit.

That is why we walk. Please lace up your walking shoes and join me on September 15 in Golden Gate Park. Training recommended but not required.

Click here for more information about SFMS' participation of the Golden Gate Heart Walk and ways you can get involved.

Environmental Chemicals: Large Effects from Low Doses

Mon, 11 Jun 2012 15:09:35 GMT

By Laura N. Vandenberg, PhD; R. Thomas Zoeller, PhD; J.P. Myers, PhD

Virtually all safety standards for chemical exposures are determined through a process that assumes that high-dose testing will reveal relevant risks because “the dose makes the poison.” For many well-studied contaminants this is a reasonable assumption, but for compounds that behave like hormones, it is demonstrably false. The public health implications of this conclusion are enormous, because it means that many—likely dozens, plausibly hundreds, possibly thousands—of today’s chemical safety standards are too weak by orders of magnitude.

The basis for this conclusion derives from endocrinology. In endocrinology, it is well established that the impacts of hormones (such as estrogen) at high doses can differ from those in the "physiological range" of normal circulating levels of hormones in serum; it is at these concentrations that hormones interact with their receptors to cause physiological and developmental changes by altering gene expression. Indeed, hormones at abnormally high doses are often overtly toxic, through mechanisms that have nothing to do with receptor action.

As research has expanded into the effects of endocrine-disrupting chemicals (EDCs), it has been shown that they follow the same rules that hormones follow. Unfortunately, this runs counter to the core assumption that forms the basis for all toxicological testing done to establish regulatory standards: High-dose testing will be informative about low-dose impacts.

The EPA defines an EDC as “an exogenous agent that interferes with the synthesis, secretion, transport, binding, action, or elimination of natural hormones in the body that are responsible for the maintenance of homeostasis, reproduction, development, and/or behavior.” Although Rachel Carson examined the effects of many environmental chemicals on health and reproduction in her landmark book Silent Spring, work on EDCs really took shape in 1991, when a group of scientists met at the Wingspread Conference Center in Racine, Wisconsin, to discuss research on the effects of environmental chemicals on sexual development. The Wingspread attendees produced a consensus statement stating, “We are certain of the following: A large number of man-made chemicals that have been released into the environment, as well as a few natural ones, have the potential to disrupt the endocrine system of animals, including humans.”

EDCs are now understood to be any chemicals that interact with the endocrine system, including chemicals that act as agonists and antagonists of hormone receptors, including estrogen, androgen, thyroid, glucocorticoid, retinoid, and others. To determine the mode of action of these chemicals, both in vivo (animal) and in vitro (cell culture) assays have been developed. While most chemicals on the market today have never been tested for safety, much less for endocrine disruption, these assays could be used to test new chemicals for hormonal activity prior to their entry into the environment through the food supply, packaging materials, or as waste; they are also widely used to test for their hormonal activity many chemicals that are already in use. Chemicals with a wide range of uses, including detergents, plastics, cosmetics, pesticides, pharmaceuticals, and flame retardants, among others, have been shown to have endocrine-disruptor activities.

In 2002, the National Toxicology Program (NTP) examined evidence for what has been termed “the low-dose hypothesis,” i.e., the theory that EDCs could have actions at low doses. What is meant by “low doses”? Typically, these are doses in the range of what humans experience in their everyday lives—residues on food, in the air, in dust, and in drinking water. Low doses are often within the range that traditional toxicological testing has determined to be “safe.”

The question is whether EDCs are safe at the doses the typical person experiences. To determine what doses are safe, regulatory toxicology usually starts by administering large doses of a chemical to animals, identifying the highest dose at which no effect is found, and then extrapolating downward to calculate a safe dose. Those “safe” doses are rarely tested. Yet EDCs, like hormones, defy the toxicological dogma: Low doses can have effects that are not expected from high-dose exposures. In fact, these effects can be observed at doses orders of magnitude beneath the highest dose that produces no effect using traditional approaches. The mechanisms by which chemicals cause high-dose effects usually are completely unrelated to mechanisms that EDCs employ at low doses, and the effects of high and low doses can be on completely different endpoints.

In our review of the EDC literature, we found hundreds of examples of these types of responses, termed nonmonotonic responses, in cultured cells, animals, and even human populations. Many of these chemicals have effects at low doses, providing strong evidence that calculated “safe” doses of these chemicals are not, in fact, safe.

Are these chemicals adversely affecting human health? Many of the earliest epidemiology studies examining the effects of EDCs studied occupationally or accidentally exposed individuals, i.e., people who were exposed to relatively high doses, either acutely or over longer periods of time. Now a large number of epidemiology studies have focused on environmentally exposed individuals, i.e., people who are exposed to EDCs from everyday life. These studies show that many of the effects observed in cultured cells and controlled animal experiments accurately predict what epidemiologists are observing in human populations: Associations between human exposures and disease endpoints consistent with the “low-dose hypothesis.”

So where do we go from here? As scientists, these findings suggest for us that EDCs, as a chemical class, act very similarly to the hormones they mimic or block: They act at low doses, with effects that are more pronounced when exposures occur during critical periods of development. Just as hormones have nonmonotonic relationships between dose and effect, nonmonotonic effects of EDCs are expected. This means that high-dose testing is insufficient to establish the safety of low doses.

In our review, we propose some changes to the way risk assessors determine safety of EDCs:

“Safe” doses of chemicals, and chemicals in the range of human exposures, should be tested;

Regulators should assume that EDCs produce nonmonotonic dose responses;

More sensitive endpoints should be included in chemical testing.

What can the average person, or patient, do to reduce EDC exposures? This is, of course, an important issue for health care practitioners and others invested in improving public health. Several studies suggest that making small lifestyle changes can have dramatic effects on exposure levels. Patients should be encouraged to make lifestyle choices that reduce known EDC exposures. However, the lessons learned from the published literature seem to be clear: Even low doses, including reduced exposures from changes in consumer behavior, cannot be considered safe. Thus, widespread changes to chemical safety regulations are likely to have the widest effects on human health.

We encourage physicians, nurses, public health administrators, and others working in the medical field to read our recent review and to get involved with the many scientific societies that support new approaches to chemical regulation that better reflect current scientific understanding than do standard toxicological procedures. Your expertise provides an important voice to help the risk assessment community develop new approaches to chemical risk assessment, especially as it pertains to EDCs. Hormones are important signaling molecules that dictate the health of individuals throughout the life course, and therefore the effects of EDCs simply cannot be ignored.

Laura N. Vandenberg, PhD, is with the Center for Regenerative and Developmental Biology and Department of Biology at Tufts University. R. Thomas Zoeller, PhD, is with the Department of Biology at the University of Massachusetts in Amherst. J.P. Myers, PhD, works for Environmental Health Sciences in Charlottesville, Virginia.

References

Vandenberg LN, Colborn T, Hayes TB, Heindel JJ, Jacobs DR, Lee D-H, Shioda T, Soto AM, Vom Saal FS, Welshons WV, et al. (2012). Hormones and endocrine disrupting chemicals: Low dose effects and non-monotonic dose responses. 2012. Endocrine Reviews. Online 2012 Mar 14.
Kavlock RJ, Daston GP, DeRosa C, Fenner-Crisp P, Gray LE, Kaattari S, Lucier G, Luster M, Mac MJ, Maczka C, et al. Research needs for the risk assessment of health and environmental effects of endocrine disruptors: A report of the U.S. EPA-sponsored workshop. 1996. Environ Health Perspect. 104;715-740.
Carson R. Silent Spring: 25th Anniversary Edition. 1987. New York: Houghton Mifflin Co.
Wingspread Consensus Statement. In Chemically Induced Alterations in Sexual and Functional Development: The Human/Wildlife Connection. T. Colborn and C. Clement, eds. 1992. Princeton: Princeton Scientific Publishing, pp. 1-8.
Melnick R, Lucier G, Wolfe M, Hall R, Stancel G, Prins G, Gallo M, Reuhl K, Ho SM, Brown T, et al. Summary of the National Toxicology Program's report of the endocrine disruptors low-dose peer review. Environ Health Perspect. 2002. 110;427-431.
Rudel RA, Gray JM, Engel CL, Rawsthorne TW, Dodson RE, Ackerman JM, Rizzo J, Nudelman JL, Brody JG. Food packaging and bisphenol A and bis(2-ethylhexyl) phthalate exposure: Findings from a dietary intervention. Environ Health Perspect. 2011. 119;914-920.
Hunt PA. Assessing chemical risk: Societies offer expertise. Science. 2011. 331;1136.

Prop 29: Good vs. Evil

Mon, 04 Jun 2012 13:40:52 GMT

By Steve Heilig, MPH

Originally posted on sfgate.com, June 4, 2012.

Did you pay any taxes last year? If so, and even if you don’t smoke tobacco, some of your money went to pay for the costs of tobacco-related disease—and helped put money into tobacco industry coffers as well.

If you don’t like that deal, Proposition 29 won’t fix it, but it will help.

Just in case there is one reader out there who is still undecided regarding Proposition 29, here are a few concise items to consider.

I’ve followed the debate closely, and posted about it once before. There has been a heated debate in medical/public health forums about some of the specifics of the proposition. I’ve read many of the online comments on many stories to see if I’ve missed some compelling argument against raising the tobacco tax in our state. And I’m left with this impression: Proposition 29′s passage would represent a victory of good over evil.

We all must know the basics by now—tobacco kills, is marketed aggressively to kids and the poor, and many of the resulting health costs are borne by taxpayers. Prop 29 would level the playing field a bit by getting California into the mid-zone of tobacco tax rates. It would deter some smokers from starting or get them to quit. The research would help us find better prevention and treatment. The real choice is thus: Do we all want to keep paying the costs of smoking while subsidizing the tobacco industry’s profits, or reduce the number of smokers and find better ways to prevent and treat tobacco-related disease?

It’s not even a new tax—it’s an increase in an old one. It’s not an unfair one—the current “arrangement” is unfair, especially to the poorer and younger people who are more likely to be smokers. The revenue would not go out of state, the net economic result would be positive… and so on, all contrary to the tobacco-industry propaganda being widely parroted with help from tobacco funds. Most important is the fact that a tax increase will lead to there being less smokers.

Big Tobacco knows all this as well as anyone—they would not spend so many millions of dollars, buying votes and advocates to fight 29, if they did not know it would deter smoking. The list of otherwise respectable organizations who have been bribed by tobacco funds is sad and sordid, as detailed here and here.

Big Tobacco’s strategy is detailed in an internal memo from the last time a tobacco tax increase was proposed: ‘The tobacco industry is currently losing the public relations war with the general public… the only way to defeat any of the hostile tax increase measures currently in circulation for the November ballot in California, is to build a coalition of groups more favorable to the public without the fingerprints of tobacco on it.‘”

In other words, they know they have to use deceit and lies. My favorite op-ed on Proposition 29 came from the Solano-Napa Times-Herald, titled “Big Tobacco has No Shame”. They note: “The shameful, deceitful, irresponsible ad campaign by Big Tobacco on California’s Proposition 29 seems so transparent that one would think it was a theatrical satire rather than a duel to the death. But a duel to the death it is.”

I may be jaded and perhaps biased (although I should add, I would receive nothing from the revenues Prop 29 would gather), but I still think marketing disease and death is evil. Besides that, I don’t like paying for it, but I do think helping tobacco addicts is a good thing, and preventing addiction even better. And so, I voted yes on Proposition 29.

SB 1318 Health Care Worker Vaccination Bill Passes Senate with Bipartisan Support

Thu, 31 May 2012 09:50:28 GMT

SB 1318 (Wolk), which would require all health care workers in health care facilities, including physicians, to either receive the influenza vaccination or wear a mask in patient care areas during flu season, passed the state Senate today by a vote of 23 to 9.

The bill is co-sponsored by SFMS/CMA.

In California, several counties (Sacramento, Yolo, and San Francisco) and numerous hospitals have gone beyond state law and have already instituted mandatory vaccination policies that include a masking requirement for the unvaccinated. The California hospitals with the highest vaccine compliance rate are those that have such policies in place.

“SB 1318 has passed out of two policy committees and now, through a full Senate vote with bipartisan support,” says CMA President James Hay, MD. “We know that higher vaccination levels among staff have been associated with a lower risk of hospital-acquired influenza cases. SB 1318 will help to keep the numbers of hospital-acquired flu fatalities low. CMA applauds the California Senate for seeing this bill through.”

The bill now heads to the Assembly.

CDC to Baby Boomers: Get Tested for Hepatitis C

Mon, 21 May 2012 12:12:39 GMT

The U.S. Centers for Disease Control and Prevention (CDC) issued a draft recommendation that all baby boomers born between 1945 and 1965 get a one-time blood test for Hepatitis C.

Most cases of the potentially deadly disease occur in this age group, and most were infected in their teens and 20s and don’t know they are infected, the agency said.

“CDC views this as an unrecognized health crisis and we needed to take a bold action because current strategies weren't working,” said Dr. John Ward, director of the division of viral hepatitis at CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

Deaths from the virus topped 15,000 in 2007, according to the CDC.

“The great majority of people—75 percent—of the 3.2 million Americans living with hepatitis C are in the so-called baby boom generation,” Ward noted.

Hepatitis C can be treated with antiviral medications, and as many as 75 percent of those infected can be cured, he pointed out.

If hepatitis C is not detected and not treated, it can lead to cirrhosis of the liver or liver cancer.

Current CDC guidelines call for testing only individuals with certain known risk factors for hepatitis C infection. But studies find that many baby boomers do not perceive themselves to be at risk and are not being tested.

By targeting baby boomers, CDC believes that an additional 800,000 people living with hepatitis C could be identified and more than 120,000 hepatitis C-related deaths prevented.

The proposal will be available for public comment and then finalized later in the year.

Source: CDC press release, May 18, 2012.

SB 1318 Moves Out of Senate Committee

Thu, 26 Apr 2012 09:39:26 GMT

SB 1318 (Wolk), which would require all health care workers in health care facilities, including physicians, to either receive the influenza vaccination or wear a mask in patient care areas during flu season, moved out of the Senate Labor and Industrial Relations Committee this afternoon. The bill is co-sponsored by SFMS/CMA.

Influenza is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness and, at times, can lead to death. Some people, such as seniors, young children and those with certain health conditions, are at high risk for serious flu complications. SB 1318 will help to keep the numbers of hospital-acquired flu fatalities low.

"The bill would protect our most vulnerable patients—infants, seniors and those who are immune-compromised," Wolk said. "It would ensure that health care workers receive the influenza vaccination, or wear a mask during influenza season. It's a choice: Get vaccinated, or wear the mask. We want to decrease the deaths from influenza, and increase the safety at hospitals."

In California, several counties (Sacramento, Yolo and San Francisco) and numerous hospitals have gone beyond state law and have instituted mandatory vaccination policies that include a masking requirement for the unvaccinated. The California hospitals with the highest vaccine compliance rate are those that have such policies in place.

SB 1318 passed the Senate Committee on Health and Labor and Industrial Relations, and is re-referred to the Committee on Appropriations.

Bill to Provide Parents Immunization Information to Prevent Outbreaks

Fri, 02 Mar 2012 14:10:29 GMT

Aimed at reducing infectious outbreaks, Dr. Richard Pan (D-Sacramento) introduced AB 2109 to provide parents with health information that they can use to help keep their children and other members of the community safe and prevent epidemics like the 2010 pertussis outbreak that caused over 9000 infections, 800 hospitalizations, and ten deaths in California.

“Parents are on the front line when it comes to protecting the health of their children and their communities,” he said in a statement. “This bill empowers them with up-to-date, accurate information about immunizations.”

The number of unvaccinated children has grown over the last decade, partly because some parents fear there is a link between the shots and autism, a theory that has been repeatedly disproved in scientific literature. California is also one of 20 states that allow parents to sign a form that excludes their children from having to receive the immunizations.

AB 2109 would simply ensure that parents receive accurate information about immunizations from a licensed health care practitioner before they decide if they will sign the form. AB 2109 is sponsored by the California Medical Association (CMA), the American Academy of Pediatrics, and the California Immunization Coalition.

“As physicians, we want to know that our patients have all the information they need to make sound medical decisions,” said CMA President James Hay, MD. “AB 2109 will help parents learn all of the benefits and risks associated with immunization, as well as the health risks of the diseases themselves. This is sound legislation that will greatly contribute to children’s and the public health.”

16% of Kids' Daily Diet Consist of Sugar

Thu, 01 Mar 2012 10:13:21 GMT

A new report released by the Centers for Disease Control and Prevention’s National Center for Health Statistics found that about 16% of U.S. children’s daily calories come from sugar.

By sugar, the report means sugars in processed foods like soda, cakes, and ice cream. It also includes sweet substitutes like corn syrup, high fructose corn syrup, malt syrup, fructose sweetener, honey, molasses, anhydrous dextrose, crystal dextrose, and dextrin. Boys consumed about 362 calories from added sugars compared to 282 calories for girls. The sugary consumption increased with age, beginning at 218 calories for boys between the age of two and five, which increased to 442 calories for teens ages 12 through 19.

Please join SFMS and CMA to support AB 1746, which would ban the sale of sugary sports drinks on middle and high school campuses throughout California. Our members believe this bill will help fight childhood obesity and diabetes.

Source: CNN News, February 29, 2012.

CMA Sponsors Bill to Ban Sugary Drinks in Schools

Tue, 21 Feb 2012 16:22:04 GMT

The first CMA sponsored bill to be introduced this year was AB 1746, authored by Assemblymember Das Williams, which would ban sugary drinks from being sold on middle and high school campuses.

CMA took a policy position in support of the ban after its House of Delegates approved the resolution submitted by SFMS members Shannon Udovic-Constant, Arti Desai, and Adam Shickedanz introduced the resolution “Marketing of Unhealthy Food and Beverages to Children” at the 2011 HOD. The full CMA press release is posted below.

California Medical Association Sponsors Bill to Ban Sugary Drinks in Schools

AB 1746 will help fight childhood obesity and diabetes

Sacramento—On Friday, Assemblymember Das Williams (D-Santa Barbara) introduced AB 1746, which would ban the sale of sugary sports drinks on middle and high school campuses throughout California. They are currently prohibited on elementary school campuses. Existing education code bans the sale of sodas in schools; this legislation would expand that to include sugary drinks.

Beverages like these are among the most prominent factors contributing to our nation’s obesity epidemic. "One in three California students is overweight or obese. We know that sugar-sweetened beverages, including sports drinks, are a major contributor to the problem," said James T. Hay, MD, California Medical Association (CMA) President. "There is a common misconception that sports drinks, also known as electrolyte replacement beverages (ERBs), are healthy, yet many contain high-fructose corn syrup and/or other calorie-laden sweeteners that have been linked to the rise in childhood obesity, the primary cause of type 2 diabetes. CMA is pleased to join Assemblymember Williams and other groups committed to public health in sponsoring this bill."

Sports drinks are designed to replace fluids after intense exercise and generally contain sodium and potassium to improve fluid absorption in the body. The United States Department of Agriculture (USDA) states that ERBs may be useful when large quantities of fluids are lost through sweating on a daily basis, and/or by those who perform continuous exercise for more than 60 minutes. However, the USDA concludes that there is no need to substitute sports drinks for water as a primary form of fluid replacement.

“Sports drinks are an inappropriate option for California students. They were designed for athletes who have been sweating for an hour or more, not for children as they walk across campus or eat their lunch. Assemblymember Williams’ bill will close a loophole that has allowed the beverage industry to continue using California public schools to sell products that contribute to childhood obesity and diabetes,” said Harold Goldstein, MD, Executive Director of the California Center for Public Health Advocacy (CCPHA).

The American Academy of Pediatrics states that children should be given water before, during and after exercise, with the exception of small amounts of sports drinks for children exercising in hot, humid conditions for more than one hour. The current school day does not include the kind of rigorous activity that warrants ready access to sports drinks.

“This bill aims to set the example of making healthful choices in life,” Assemblymember Williams said. “Research shows that these sugary drinks directly relate to higher incidents of obesity and many youth—and adults—are still consuming them unnecessarily. These drinks should not be a replacement for water.” CMA joins CCPHA as a sponsor of the bill.

Free Hep B Screening This Month

Thu, 02 Feb 2012 12:29:25 GMT

Up to 5.3 million people, or 2 percent of the U.S. population, are living with chronic hepatitis B or hepatitis C according to a 2011 Institute of Medicine report. These diseases are more common than HIV/AIDS in the U.S., but most people who have them are unaware until they develop liver cancer or liver disease many years later. The Asian communities have been disproportionately burdened with this disease in particular. UCSF, as one of the partners of the citywide San Francisco Hep B Free Campaign, offers free screening and vaccinations to target the Asian community in the Bay Areas regularly. These events are conducted by the UCSF Medical and Pharmacy school students and UC Berkeley students from the San Francisco Hep B Collaborative, with physician faculty members supervising and supporting the event. UCSF will host 2 free screening events:

Saturday, February 4, from 9 am to 12 pm at UCSF (2330 Post Street, Ground Level). Both screening and vaccination are free.
Saturday, February 11, from 9 am to 12 pm at the Chinatown Public Health Center (1490 Mason Street). Screening is free and vaccination is $10.

For both events above: No fasting or appointments are necessary.

Join SFMS at California Cancer Research Initiative Campaign Launch

Mon, 30 Jan 2012 10:48:05 GMT

The California Cancer Research Act (CCRA), or Proposition 29, is a ballot initiative that will be on the June 5 primary ballot. Through a $1 per-pack tax on cigarettes, the CCRA delivers over $855 million per year to pursue potential cures of cancers and other tobacco-attributed diseases including Heart Disease, drive down smoking rates by investing in proven smoking cessation and tobacco control efforts, and assist tobacco law enforcement.

Prop. 29 will increase tobacco taxes for research and prevention; the SFMS carried a resolution to the CMA annual meeting last year urging support of CRCA and the CMA endorsed the initiative last week (scroll down to view the SFMS resolution).

Wednesday, February 1

3:00 pm to 3:30 pm

San Francisco City Hall, Polk Street Entrance Steps

SFMS President Peter Curran, MD will be among the speakers at the campaign launch for the California Cancer Research Act this Wednesday at 3:00 pm on the steps of City Hall. Please join the rally and support our speakers.

Speakers:

Mark Di Giorgio, American Lung Association

David Veneziano, CEO, American Cancer Society, California Division

Eric Mar, Member, San Francisco Board of Supervisors

Peter Curran, MD, President, San Francisco Medical Society

Karen Licavoli, VP for Program Development, BREATHE CALIFORNIA

Sandra Peters Kaiser, American Heart Association

SFMS Resolution: SUPPORTING THE CALIFORNIA CANCER RESEARCH ACT

Author: Robert Margolin, MD

Endorsement: San Francisco District VIII

Whereas, the California Cancer Research Act (CCRA) qualified for California's next statewide ballot after its supporting coalition submitted over 600,000 verified voter signatures; and

Whereas, Cigarette smoking and other uses of tobacco remain the leading causes of cancer in California, and a leading cause of many other life-threatening health problems, including heart disease and emphysema.

Whereas, California’s cigarette tax is currently 87 cents per pack (with an equivalent tax on other types of tobacco products) and is levied on cigarette distributors who supply cigarettes to retail stores; and the CCRA would increase the existing excise tax on cigarettes by $1 per pack effective 90 days after its passage; and

Whereas, the state-mandated independent analysis of the CCRA indicates that it would have the following major impacts: Increase in new cigarette tax revenues of about $855 million annually by 2011-12, declining slightly annually thereafter, for various health research and tobacco-related programs; Increase of about $45 million annually to existing health, natural resources, and research programs funded by existing tobacco taxes; and Increase in state and local sales taxes of about $32 million annually; and

Whereas, the funds would be allocated thus: 60% provide grants and loans to support research on prevention, diagnosis, treatment, and potential cures for tobacco-related diseases such as cancer and heart disease; 15% to provide grants and loans to build and lease facilities and provide capital equipment for research on tobacco-related diseases; 20% would be used for to- bacco prevention and cessation programs administered by the California Department of Public Health (DPH) and the California Department of Education; 3% would be allocated to state agencies to support law enforcement efforts to reduce smuggling, tobacco tax evasion, illegal sales of tobacco to minors, and to otherwise improve enforcement of existing law; and 2% deposited into an ac- count that would be used to pay the costs of tax collection and expenses of administering the measure; and

Whereas, the coalition supporting CCRA is led by the American Cancer Society, American Lung Association in California, American Heart Association, Campaign for Tobacco Free Kids, Stand Up To Cancer, and Livestrong; with CMA conspicuously absent thus far; now be it

RESOLVED: That CMA will support the California Cancer Research Act (CCRA) and advocate its passage by California voters: and be it further

RESOLVED: that CMA will join the coalition of other organizations such as the American Cancer, Lung, Heart, and anti-tobacco groups in educating and advocating for the CCRA’s goals and passage.

For more information, visit http://californiansforacure.org/.