Vol. 218 September 15, 2019 Vaping and Fatal Pneumonia

September 15, 2019

“The rise in vaping-associated illness is a frightening public health phenomenon.”

– Andrew Cuomo, NewYork Governor

 

Severe pneumonia in over 400 people, including 10 deaths, in 36 states have been associated with vaping certain products. The CDC is investigating the phenomenon as a mysterious, previously unrecognized epidemic. Patients from 18 to 88 years of age have been arriving at Emergency Rooms with severe shortness of breath, cough, little or no fever, and a chest Xray with markedly abnormal diffuse infiltrates. Blood cultures show no bacteria, and the response to the usual antibiotics is sluggish or absent. Some patients require intubation and artificial ventilation in order to maintain oxygenation of their blood. A few die. All have a history of vaping, most often using flavored vaping solutions purchased “on the street” or over the internet, i.e. not from licensed vape shops.

The speculation at this point is that flavored vaping solutions have additives that are causing this illness.  The current focus is on Vitamin E oil, added to flavored vaping solutions as a thickening agent. Vitamin E is well recognized as a beneficial skin emollient and an oral nutrient supplement, so it sounds harmless and enjoys a “good-health” reputation. It is inexpensive and readily available, so is a “logical” additive for cheaper, unlicensed vaping solutions sold on the black market (“street-made”) and the internet. The street vendors use the cheaper additives to cut the expensive THC oil and make more profit per vaping cartridge.

In an e-cigarette the Vitamin E oil is heated up and vaporized by a battery-fed hot wire, and the vapor is inhaled. As the temperature of the Vitamin E oil vapor lowers to the normal body temperature of 98.6 degrees Fahrenheit the Vitamin E vapor in the lungs reverts to its liquid form, oil. Any form of oil is extremely toxic to lung tissue. Just ask any physician who has dealt with a patient with oil-aspiration pneumonia, sometimes called “lipoid pneumonia“. The first case report of lipoid pneumonia after vaping was actually reported in 2015 in the journal Chest  as a unique, interesting, never-before seen case of a 31 yo. West Virginian woman who required intubation in the ICU after presenting to the ER in severe respiratory distress after vaping.

There are so many additives in vaping solutions that it is not absolutely certain that Vitamin E oil is the culprit, but some of the counterfeit vaping solutions used by recent respiratory-distress patients contained more than 50% Vitamin E oil!  A 2015 Harvard study that tested 51 of 7,000 vaping solutions found Vitamin E oil in all the flavored ones, and it commented on the potential dangers of inhaling flavored vaping solutions. None of the vaping solutions containing “only” nicotine  or marijuana (THC) contained Vitamin E oil. By the way, the FDA and the various state cannabis commissions have NO idea of the ingredients and additives in vaping solutions. There are currently NO regulations requiring the listing of vaping solution ingredients, even those sold in licensed vape shops. “The cannabis commission does not regulate the ingredients in licensed marijuana stores’ vape cartridges. . . Licensed producers can source their ingredients from anywhere.”

As an aside, this reminds me of a story told by my cousin, a biochemical Ph.D candidate in the 1960’s researching how chlorophyll (the green substance) carried on photosynthesis. In his chromatographic analysis of all sorts of substances, including tobacco, he determined that Marlboro cigarettes had no tobacco in them. They appeared to be made of cabbage leaves infused with nicotine. Incensed (he was a smoker), he wrote an emphatic letter to the company documenting his findings and scolding them for false advertising.. The company’s response was a polite letter pointing out that at no time did they claim in their ads that their cigarettes had any tobacco in them, that they merely promised a smooth taste  . . .and “good luck on your quest to synthesize an artificial chlorophyll.”

The CDC is foraging ahead aggressively with detailed investigations, state legislatures are composing all sorts of ingredient disclosure laws for vaping manufacturers, and, I am sure, many personal injury lawyers are trolling for potentially lucrative suits. In the meantime, I think it would be the better part of valor if everyone stopped vaping until the dust . . . er . . . the vapor settles. Who would guess that we would ever say, “It appears to be much safer to just smoke a joint!”

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Vol. 217 September 1, 2019 Understanding Medical News of Famous People

September 2, 2019

David Andrews, veteran center for the New England Patriots, and Ruth Bader Ginsburg, veteran Supreme Court Justice, have both been in recent newspaper headlines (in different sections of the paper, of course) due to their new medical diagnoses, “clots in the lung” for Andrews and “pancreatic cancer” for RBG. Most articles devote significant space to speculation about their prognoses, i.e. when can Andrews return to play in the NFL and will Ginsburg outlast Trump’s presidency? Why do the answers seem so elusive, and almost always end up with “it depends”?

 

“Clots in the lung” are pieces of blood clots that travel through the blood steam after breaking off from blood clots in the legs (deep vein thrombosis or DVT). In the lungs the clots can clog or drastically slow down the flow of blood through lung vessels and is called pulmonary embolism (PE). PE may often produce no symptoms or cause chest pain, cough, difficulty breathing, and sudden death.

PE is treated with so-called “blood thinners” aiming to reduce the risk of more emboli traveling to the lungs. Neither of the two classes of anti-coagulation drugs actually thin the blood. Both interfere with the multiple steps of coagulation needed to form a clot, thus reducing the chance of more pieces of clot breaking off and traveling to the lungs.

How long is drug treatment necessary? It depends. The shortest duration of 3-6 months is recommended for “provoked” PE, an embolism from a leg or pelvic clot provoked by an injury, surgery, infection, cancer, or other recognizable event. An “unprovoked” PE, one without a recognizable event, is usually treated for longer periods.

It is probable that Andrews’ PE was related to a football injury, a “provoked” PE, so that anti-coagulation treatment will last for at least 3-6 months. Hence he is out for the season, since it would be dangerous for him to play football with an intentionally defective blood clotting mechanism. If his PE was not the result of an injury, then it was “unprovoked” and treatment duration may be even longer.

RBG just completed treatment for her third bout of cancer. She was treated for colon cancer in 1999, “early” pancreatic cancer in 2009, and a cancer in her lung was surgically removed in December of 2018.  This recent treatment consisted of 3 weeks of highly focussed radiation to a small malignant mass in the part of the pancreas (the “head”) that surrounds the bile duct that goes from the liver to the small intestine. A stent was placed in the bile duct presumably because even this highly focussed radiation could cause the duct to swell and obstruct resulting in her becoming jaundiced. Her doctors did not identify the mass as colon, lung, or pancreatic cancer, but reported that it was localized with “no evidence of cancer elsewhere”.

That last bit of news is significant since the prognosis of pancreatic cancer depends on the stage of disease, from 1 to 4. Stage 1, local disease, has a 5 year survival rate of 12-14% while Stage 4, widespread disease, has a 5 year survival rate of 1%. Survival rates are statistics based on the outcomes of hundreds of patients and can not be reliably applied to an individual patient. RBG has especially proved that herself. In a recent interview RBG remarked that “a certain Senator who predicted my early demise after my 2009 diagnosis of pancreatic cancer is now dead himself while I’m still alive.”

Because of the fallacy of applying the mortality statistics of hundreds of patients to an individual, the honest doctor realizes that a prognosis often can not be given accurately. That knowledge is also colored with the emotion of difficulty breaking bad news. One study showed that only about 37% of oncologists were able to give an “honest” prognosis to a cancer patient under treatment. When the doctor did give a prognosis, it was often overly optimistic. 

So, what is the prognosis for Andrews and Ginsburg? It is relatively save to say that Andrews will not play NFL football this season and that Ginsburg, a champion statistic outlier for 86 years, will probably be sitting on the bench when the Supreme Court resumes in October. After that, who knows what will happen. The doctors may guess, but they don’t know either.


Vol. 216 July 1, 2019 Public Opinion About High Health Care Costs

June 30, 2019

‘TIS THE SEASON FOR POLS AND POLLS

 

As the presidential election summer season heats up with Democrat’s TV food fights and President Trump’s relentless echoes of 2016 campaign rhetoric, the frequency of public opinion polls on political issues and candidates is increasing. What do polls show about what people think about health care costs? The New England Journal of Medicine just published an analysis by three authors of 14 public opinion polls on health care costs done in 2018-2019 (1)

Two-thirds of the U.S. public thinks that reducing health care costs is a top priority for both President Trump and Congress in 2019 (second only to “strengthening the economy” at 70%).

About 90 % of respondents picked the following priorities as “extremely important”:
Reduce prescription drug prices
Reduce the overall cost of healthcare
Do not cut Medicare insurance benefits
Maintain insurance coverage for pre-existing conditions.

Half of respondents reported that health care costs had “actually affected their household a lot”.
40% were “not satisfied” with how much they had to pay for health care.

Why did respondents think that health care costs were so high?
drug companies charge too much …………. 78%
hospitals charge too much ……………………. 71%
Insurance companies charge too much ….. 71%
new drugs, treatments, and technology…….62%

The expert opinion consensus is that the over $500 Billion (yes, that’s a “B”) cost of “unnecessary services”, “inefficient delivery” , and “excessive administrative cost” is a significant cause of the high cost of our health care, but only 23% of public poll respondents thought so.

“At this level, unnecessary health care costs and waste exceed the 2009 budget for the Department of Defense by more than $100 billion (OMB, 2010). Health care waste also amounts to more than 1.5 times the nation’s total infrastructure investment in 2004, including roads, railroads, aviation, drinking water, telecommunications, and other structures. To put these estimates in the context of health care expenditures, the estimated redirected funds could provide health insurance coverage for more than 150 million workers (including both employer and employee contributions), which exceeds the 2009 civilian labor force. And the total projected amounts could pay the salaries of all of the nation’s first response personnel, including firefighters, police officers, and emergency medical technicians, for more than 12 years.” (2)

How did people think we could reduce healthcare cost?
Nearly 90% want the federal government to negotiate drug prices for Medicare
65% want the government to limit charges by hospitals and health professionals
65% want to allow 50-64 year olds to buy into Medicare
52% support “Medicare For All” with little or no private insurance.

Which government?
State 50%  (favored by 60% of Republicans)
Federal 50%  (favored by 70% of democrats)

By what mechanism?
Private insurance competition  (60% of Republicans)
Government insurance program (65% of Democrats)

A majority agreed on two unacceptable ways to reduce costs?

  1. Restrict access to treatments and prescription drugs via “expert opinion” of cost/benefit ratios.
  2. Tax incentives to individuals to buy high-deductible insurance plans.

Only 25% of the public polled were concerned that Medicare would run out of money in 10 years, i.e. little concern about the aggregate cost of health care. Most considered the cost problem as one of high prices rather than of over utilization.
Also, the public is highly skeptical that ANY approach will greatly reduce healthcare prices.

So, despite the consensus that reducing health care costs should be a high priority for President Trump and Congress, there is an obvious partisan divide about how to do it; a partisan divide that continues to make us (the U.S.) unique as the only developed nation lacking universal health care insurance for its people.

References
1. NEJM 380;26 June 27, 2019
2. Best Care At Lower Cost, National Academy of Medicine, Institute of Medicine, 2013


Vol. 215 June 15, 2019 Sometimes Even Good News is “Fake” News

June 16, 2019

A lesson in evaluation of a cost-reducing health care program:
a learned, scientific critique of a controversial Medicare reimbursement program.

 

“The Hospital Readmissions Reduction Program (HRRP) was established in 2010 by the Centers for Medicare and Medicaid Services (CMS) with a “goal of reducing ‘preventable’ re-hospitalizations by imposing financial penalties on hospitals with higher-than-expected readmission rates in the 30 days after a hospital discharge”. This was one of several new “Pay For Performance” (PFP) programs aimed at lowering federal health care costs by tying Medicare reimbursement to hospitals, physicians, and even home care agencies to the use of more appropriate (read “lower cost”) medical care delivery settings.

After implementation of the HRRP, hospital readmission rates did decrease nationwide for the targeted diagnoses of heart failure, acute myocardial infarction, and pneumonia. So, the federal government ended up reimbursing less money to those hospitals that had higher-then-expected “preventable” patient readmission rates . “Great!”, said some policy makers, “it saved us some money. Let’s expand the program to ALL conditions treated in the hospital.”

“Whoa”, said by a group of research physicians from Harvard and Washington University Medical Schools, both known as liberal academic institutions, ”let’s look at the data.”

  1. The proportion of patients that returned to the hospital within 30 days after discharge actually did NOT change.
    .        .Patients returned to the hospital within 30 days after discharge for care, BUT they weren’t “readmitted”. Instead a significant number of those returning to the hospital were treated for up to 3 days in Observation Beds/Units or overnight in an Emergency Room bed. HRRP did not measure use of Observation Units or overnight stays in the ER. No wonder the “readmission” rates went down.
  2. If a patient dies within 30 days after hospital discharge they obviously can’t be “readmitted”.
    .         .The HRRP statistics did not measure mortality rates. A hospital keeping sicker patients alive by readmitting them for appropriate care rate might have the better outcomes, i.e. a lower death rate, but it would be penalized for having a higher readmission rate. In fact, the financial penalties for higher readmission rates under HRRP are much higher than the penalties for a higher death rate under Hospital Value-Based Purchasing program (HVBP), another federal PFP program.
  3. “Risk adjustment” of patient illness severity is notoriously varied and difficult to standardize.
    .          . “Risk-adjusting” of illness severity, for example, recording the different illness severity between the heart failure patient on two drugs and slightly swollen ankles versus the patient on multiple heart drugs for decompensated heart failure, is very difficult to standardize. Some of the early enthusiasm for HRRP and its reported improvement of risk-adjusted readmission rates may have been the result of improved medical record coding of co-existing conditions. (This is well-known as “gaming the system”, legal and even ethical, sort of like taking advantage of tax code loopholes, but it does nothing to improve the quality of care.)
  4. Social risk factors like patient poverty and poor community resources like lack of public transportation and diminished access to primary care were omitted from risk-adjustment factors.
    .          .Safety-net hospitals (those in poor areas) can be penalized under HRRP as a result of such factors. “The evidence that social risk factors influence readmission rates is incontrovertible.”
  5. HRRP may even have increased the death rates for patients with heart failure.
    .          .Four independent studies showed that the death rates for patients with heart failure INCREASED significantly after implementation of HRRP. The increase was concentrated among the patients who were NOT readmitted, suggesting that the use of ER beds and Observation Units “may adversely affect patients who would benefit from higher-level care.” Two other studies found different results which suggested that HRRP was more beneficIal to patients with acute heart conditions rather than patients with chronic heart failure.The three authors urge several steps to correct what they consider a faulty, positive evaluation of HRRP before jumping into expanding the program to ALL patients admitted to a hospital. This failure to correctly evaluate HRRP “underscores the consequences of implementing national policies after [evaluation that does not include] a control group.”They also urge “policymakers to seek input from frontline clinicians and patients who understand the real-world effects of HRRP. . . . If HRRP is improved it might be transformed from a regressive penalty program to a progressive program that improves patient care.”

    Q.E.D.

    Reference:
    “The Hospital Readmissions Reduction Program—Time for a Reboot”, Drs. Wadhera, Yeh, and Maddox, NEJM 380;24 June 13, 2019.


Vol. 214 June 1, 2019 JUULING AND SCHOOLING

June 1, 2019

“Nicotine addiction begins when most tobacco users are teenagers, so let’s call this what it really is: a pediatric disease.”
-David Kessler, MD. Commissioner of FDA, 1995

 


When I was a young parent my kids’ souls were threatened by the dangers of  “sex, drugs, and rock ‘n roll”. THEIR kids are facing a new triple threat, “marijuana, video games, and vaping”. Vaping? (pronounced with a long ”a”) Really? (pronounced with a short “a”)

How can inhaling flavored water vapor with either no or just a touch of nicotine be dangerous? Let Jonathan Winickoff, MD, MPH, Professor of Pediatrics at Harvard Medical School and Director of the MGH Tobacco Research Treatment Center list the reasons:

First of all, there is no water in vaping solutions. Vaping is NOT inhaling water vapor. It is inhaling particulate matter of numerous chemical compounds in mostly propylene glycol and glycerin. When heated these compounds degrade to formaldehyde. The vapor also contains carcinogenic organic and inorganic chemicals, cytotoxic nano-sized metallic particles from the heater coil, silicates (like in sand), and ALWAYS nicotine. All vaping solutions contain nicotine despite the label that says “contains no nicotine”, or even more cleverly “contains no nicotine tar”, which means of course “no tar”. Currently there are no FDA regulations about labeling vaping solutions. Companies can label and market anyway they wish without any accountability.

Vaping solutions are flavored to lure teens into using because teen age vaping does lead to dependency on nicotine and a significant percentage of teenage vapers go on to smoking cigarettes (“combustible tobacco”). This assures a continued revenue stream for tobacco companies. Mint, menthol, and mango are apparently the favorite vaping flavors (gives new meaning to “3M” doesn’t it). Flavors in cigarettes were banned by federal law in 2009 except for “menthol and mint”, but the federal ban specifically did not apply to e-cigarettes. There are over 8,000 vaping flavors available.

Juul (jewel) is the most successful vaping company owning about 75% of the market. Juul is so successful that it has become a verb, as in “Do you Juul?, Lets Juul.”

A Juul pod of vaping solution contains about 200 “hits” or puffs which is the equivalent of a pack of 20 cigarettes. Pods are used in devices that previously looked like cigarettes, hence the term e-cigarette, but now vaping devices can look like pens, superhero figures, a miniature coke can, and, most  commonly, a computer thumb drive. One middle school kid laughed at his father’s confusion by saying, “We don’t use thumbdrives any more. Every thing is in the Cloud. If you see a kid with a thumb drive, he is vaping.”

Taking 300-400 hits a day is common. Unfortunately taking an occasional hit as an “experimental rite of passage” can progress to increased use and an unrecognized dependency. JuuLing periodically on the week ends can lead to withdrawal symptoms of anxiety, distraction, and increased body movements on non-use school days. Those are the same symptoms of ADHD.

A popular device, a Sourin Drop, is available in many different colors and is small enough to hold (“conceal”) in the palm of your hand/ It is a refillable device (unlike a JuuL pod which you buy pre-filled) that lets you mix flavored vaping solution and marijuana (THC) so that they can be inhaled together as a mixture.

Juuls are much easier to use than cigarettes to use; you don’t need a match, there is very little aroma, there is no butt to get rid off, they can be used in NO SMOKING zones, and there is certainly no tell-tale stain on your fingers.

A pod cost about $4 and can be bought online easily without proof of age despite the requirement to be over 18.. Needham, MA was the first town in America to ban sales to those under 21, and Hawaii was the first to establish a state-wide ban. Fourteen states have now followed Newton’s example and prohibit stores from selling vaping solutions to those under 21.

Tobacco companies are investing heavily in e-cigarettes. They know that the younger a person is when nicotine is introduced the more likely they will become a life-time tobacco user. They deliberately, purposefully, and relentlessly market vaping to young people. Nearly 40% of high schoolers and nearly 15% of middle schoolers have vaped at “least once”. Use of vaping in places where smoking is prohibited also helps produce a second income stream for tobacco companies.

A lot of this “threat-to-teen-agers-talk” does sound like old hat to some of us old guys , but vaping has the potential of some serious unattended future consequences for our youths. Most of us did survive the dangers of sex, drugs, and rock’n roll after all, and what will be the inevitable triple threat for future teen agers : “space dust, AI simulations (‘feelies’), and audio-visual implants?”

Action plan:

  1. Call your Massachusetts statehouse representative to support the passage of H. 1902 which bans the sale of “all flavored tobacco products” in Massachusetts.
  2. Lobby in your own town to ban the sale of flavored tobacco products to anyone under 21 years of age.
  3. Let your kids and grandkids read this blog.

Vol. 213 May 15, 2019 Fake Nutritious Foods

May 15, 2019

        “Food packaging can be very confusing”

                           -Whitney Linsenmeyer, Ph.D, R.D., St. Louis University

In case you haven’t noticed, the widespread proliferation of nutritious sounding labels in food marketing continues; as in “natural”, “local”, “fresh”, “farm-to-table”, “organic’, and even “gluten-free”. Consumer Reports On Health has tracked food marketing and packaging trends for years. Its June 2019 issue highlights “8 foods that seem healthier than they really are”.

Veggie Sticks – Even if not always green, what could be more nutritious than vegetables?
A professor of nutrition at Boston University calls them “produce pretenders”. Made with potato flour and starch, oil, salt, and just enough vegetable powder to give it color, it is “not much better nutritionally than a potato chip”. A better choice: 4 cups of air-popped pop corn with less calories and much more fiber. Hold back from adding salt and butter.

Rice Cakes– Even the whole-grain brown type of rice lacks fiber and, like other rice products, may contain arsenic.
Flavored varieties can load up on sugar and salt. If you are going to use a rice cracker/cake at least put peanut butter, sliced banana, or humus with a tomato slice on it for more protein and fiber.

ARSENIC!? – It has been known for years that rice picks up arsenic from the soil in which it grows. Arsenic (chemically a “heavy metal” ) is a natural element in the soil. It’s truly “natural”, as in “found in nature”. It is found in trace amounts in all types of rice.  Brown rice can have 80% more arsenic than other types.  The region also makes a difference with Texas rice at the high end and California rice at the lower end. Can it poison you? NO. The FDA permissible arsenic level in drinking water is 10 parts per billion (ppb). One brand of rice cake grown in Mexico tested at 17 parts per billion, and the FDA directed the U.S. company importing it to change its manufacturing process.

Spinach Wraps – That healthy-looking green hue is often just due to food coloring.
The amount of spinach in it can be negligible. Most wraps are made with refined white flour so have very low fiber content.

Protein Powder – Most Americans consume enough protein in their daily food. No supplement is necessary.
The downside of these powders is that some brands have been found to have significant levels of heavy metals and other toxins. Peanut butter in your smoothie is a more reasonable way to add protein if you wish.

Turkey Burgers – They may be no more nutritious than regular beef burgers. Wait a minute, is nothing sacred?!
“Butterball ground turkey” has the same calories and saturated fat amount of a beef burger because of the inclusion of dark meat and skin, but “Butterball ground turkey breast  has about one-tenth the saturated fat.

Bran Muffins– Here it is a matter of size. Muffins are often cupcakes.
The Au Bon Pain raisin bran muffin weighs in at 5 ounces and packs 430 calories and 31 grams of sugar. If really desiring more bran, go with all-bran cereal.

Granola – How can a mixture of oats, fruit, and nuts not be good for you?
It’s the calories of the added sugars, fat, or whey protein concentrate. Better choice: make your own with shredded wheat cereal with some sugar and almonds added.

Instant Oatmeal – It is so “instantly” digested that it can give you a spike in your blood sugar and a shorter period of hunger satisfaction.  Packets flavored with brown sugar or maple syrup can contain more than 9 grams of added sugar. Cooking “steel-cut” oats (round kernels) or microwaving “rolled” oats (steel-cut oats crushed flat) and serving with fruit, a little fruit butter, or cinnamon is a better choice.

Obviously its the added sugar, salt (sodium) and/or saturated fat that belies the “nutritious” label. A recent report from the National Academy of Medicine recommends that the maximum adult daily sodium intake should be 2,300 mg. The average daily sodium intake of Americans is above 3.400 grams.

Now that restaurants are listing calorie counts in their menus you may think you are home-free in striving to eat healthy, BUT Applebee’s Cedar Salmon has only 370 calories AND 19 grams of sugar and 1530 mg of sodium, Chipotle’s Vegetarian Bowl has a whopping 11.5 grams of saturated fat and 1830 mg. of sodium, while even Panda’s Express “Black Pepper Chicken” has close to one-half of the daily requirement of salt.

Reading food labels can be difficult . . . confusing. . . and time-consuming.

PS: A couple of my kids and their kids are not going to like this blog since some of these foods are their favorite “healthy snacks.”


Vol. 212 May 1, 2019 MMR Vaccination Updated and DTaP Explained

May 1, 2019

YET ANOTHER STUDY PROVES THAT MEASLES VACCINE DOES NOT CAUSE AUTISM
An eleven year study of 657,000 Danish children showed that those who received the MMR vaccine had no increased incidence of autism. In fact, the girls who received the vaccine had a 5% reduction in their risk for autism. In Denmark all vaccinations are free of charge and voluntary. When 95% of children in a community are vaccinated against measles the 5% of unvaccinated children are protected through “herd-immunity” due to the reduction of exposure to the highly contagious measles virus.

Measles was declared “eradicated” in 2000. Since then we have had unexpected U.S. measles outbreaks in 2014 and presently we are breaking all records for new cases (78 cases just this very week). Since January 1, 2019 the U.S. has had 465 cases in 19 states. Recent U.S. measles outbreaks in Brooklyn, NY, Portland, Oregon, and Rockland County, NY were caused by unvaccinated visitors to an annual Jewish pilgrimage in the Ukraine returning to their unvaccinated orthodox Jewish communities in the U.S.

Surrounded by states with nearly 700 new measles cases Dayton, Ohio is voicing concern about a measles outbreak in their city. Of the 9 counties in Ohio 8 have measles vaccination rates between 90 – 93%. Montgomery County, Dayton is the county seat, has a rate of only 88%. Remembering that herd immunity is achieved at 95%, Ohio, which requires proof of vaccination within 14 days of school attendance, is considering rewriting their current reasons for exemption (about 9% in Montgomery County) of “religious, medical, or reasons of conscience.”

THERE IS NO HERD-IMMUNITY FOR TETANUS
The “T” in the DTaP vaccine stands for tetanus. Tetanus is not a contagious disease like measles. It is caused by wound contamination with a bacteria that causes intense, painful muscle spasms, clenched jaw (“lockjaw”), and extremely unstable vital signs.  The tetanus vaccine is the only protection against tetanus.  It is rare because most children receive the tetanus vaccine. Oregon in 2017 reported its first case of tetanus in thirty years. An unvaccinated 6 year old sustained a cut on his forehead while playing on a farm and developed tetanus. His 2 month hospitalization cost $800,000. The total bill for his care including rehab services and transportation exceeded $1 million. Upon discharge the parents continued to refuse any immunizations for him  including a tetanus vaccine booster to complete their child’s protection!

PERTUSSIS (“WHOOPING COUGH”) OUTBREAKS HAPPEN IN THE SPRING
The “P” in DTaP immunization stands for pertussis and the standard recommendation is to get 4 DTaPs before age 18 months ,starting at 2 months, with a booster at 6 years and as a teenager. Our periodic pertussis outbreaks can not be blamed wholly on anti-vaxxers who refuse immunizations because the pertussis vaccine is not as effective as other vaccines in maintaining protection; the immunity created by the vaccine wanes over time. The little “a” in front of the “P” stands for “acellular”. The acellular vaccine has less of the side effects of injection site pain, temporary fatigue, and a fever than the earlier vaccine that contained cells of the bacteria. But, this newer vaccine (introduced in the late 1990s) produces a smaller increase in and a shorter duration of immunity. “P” vaccinated people can get pertussis, but unvaccinated children and adults are 8 times more likely to get pertussis.

Pertussis immunization is now recommended for all pregnant women since protective antibodies pass through the placenta to the unborn child affording protection to the infant in the first months of life. Pertussis can be diagnosed in some one with a persistent cough by a simple nasal swab done in the office, and it can be treated effectively with antibiotics.

WHAT ABOUT THE “D” IN DTaP?
Diphtheria is a bacterial disease with a terrible sore throat. When severe it can form a membrane in your throat that blocks off your air and sometimes it produces a toxin that attacks the heart, causing death.  In 1921 the U.S. had 206,00 cases of diphtheria with 15,420 deaths.  The diphtheria vaccine is so effective that such cases are extremely rare in the U.S. Herd immunity is important in diphtheria. The CDC estimates that 94% of kindergarten pupils in U.S. are immunized against it. The Soviet Union, India, and Yemen remain areas with large numbers of diphtheria cases.

“Good ole” Montgomery County, Ohio had one of the last reported U.S. diphtheria cases; a teen age girl with a bad sore throat in 2014. That rare event got lots of press coverage which might be why Montgomery County is a particularly skittish about a possible measles outbreak in 2019.

Diphtheria can be treated effectively with antibiotics and anti-toxins. Any contacts of the person with diphtheria can also be treated to prevent spread of the disease. A simple skin test (Schick test) identifies people with no immunity to diphtheria, so efforts to control its spread can be highly targeted.

MY MODEST PROPOSAL MAY NOT BE THAT “FAR OUT”
My previous blog suggesting that one way to change the behavior of anti-vaxxers would be to sue the parents of an unvaccinated child for neglect to recover the cost of the medical treatment, loss of wages of caretakers, loss of school performance, continued rehabilitation of complications, etc. of any person who then got measles from the unvaccinated case. Perhaps that might send an effective message to anti-vaxxers of a personal financial risk where scientific data holds no sway. What if the parents of the Oregon tetanus-afflicted child were sued by tax payers in Oregon to “recover” the medical care costs of nearly a million dollars presumably borne by Oregon’s tax payers?


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