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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Vol. 211 April 15, 2019 A Modest Proposal To Eradicate Measles In The U.S.

April 15, 2019

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). In 2014 there were 667 cases of measles in Amish country of Ohio. Since January 1, 2019 the U.S. has had 465 cases in 19 states.

For those of us who are used to hearing big numbers every day—size of the national debt, baseball player salaries, number of immigrants pounding on our door, etc.—these numbers don’t sound very compelling. BUT, measles is a preventable disease. One measles vaccine shot protects the recipient 93% of the time. When you add the second shot years later the individual’s protection goes to 97%. 

 Measles, the most infectious disease we know, can cause debilitating encephalitis (brain swelling), pneumonia, and, very rarely in the U.S., death in both infants and adults. Madagascar is not so lucky. Because of its poverty Madagascar has a vaccination rate of only 58% despite the population’s desire for vaccination. They had 1200 deaths in the115,000 who got measles last year. Europe had 41,000 measles cases in 2018. A community vaccination rate of 90-95% is necessary for effective “herd immunity” in which the vaccinated keep the un-vaccinated safe just be reducing their chances of exposure.

You are not likely to be exposed to a case of Madagascar measles, but if you happen to be in the Williamsburg section of Brooklyn, or Rockland County, NY, or  Portland, Washington, or near Sacremento, California, you may be exposed. These four hot spots of current measles outbreak apparently share an unintended consequence of easy-access global travel.  Unvaccinated Orthodox Jews returning from the September annual Hasidic Pilgrimage from Israel to Uman, Ukraine unexpectedly brought measles back to their unvaccinated, ultra-orthodox Jewish U.S. communities.

There is no aversion to vaccination in the Bible, the Quran, or even Sanskrit texts. It is speculated that these communities have low measles vaccination rates because of “anxiety about science”, “concern about risks of new technology”, and, especially in Soviet emigres, “distrust of the government”. 

In 1896 a Jewish man in Britain refused vaccination contending that it was against his religion. The prosecutor, also Jewish, asked the opinion of the Chief Rabbi of Britain who answered, “Hogwash.” The London court agreed.

Anti-vaxxers don’t respond to facts, They reject scientific data. They are apparently immune to dreaded stories about sick, dying children but appear to believe dreaded stories of assumed vaccine reactions. The mayor of New York City has declared a public health emergency and wants to fine any Williamsburg orthodox Jew who refuse the measles vaccine $1000. He has threatened to even close non-compliant Yeshivas. Rockland County tried to bar unvaccinated persons from public places including . . . gasp, . . . malls! A judge with a cooler head put that on hold.

After reading about the British 1896 court case a modest proposal just sprang out of my head: We should sue an anti-vaxxer, the parent of an unvaccinated child, for civil damages!

It has been recently and repeatedly affirmed that one way to get things done in America, to effect change, is to sue somebody—your spouse, your neighbor, the police, the National Enquirer, the President, whomever. 

So, all we have to do is wait until an unvaccinated child with measles exposes a vaccinated child. Since we know that the measles vaccine is not truly 100%  effective, the vaccinated child has a small chance (probably 3% – 7%) of getting measles. If the vaccinated child now with measles develops the more common complication of pneumonia, or the rare one of encephalitis, or the even rarer one of death, his or her parents could sue the unvaccinated child’s parents for all present and future medical bills, loss of school days, future loss of income due to brain damage, loss of companionship, and other compelling emotional stresses dear to personal injury lawyers. If encephalitis were the complication, the huge jury award would be enough to get the attention of even the most adamant anti-vaxxers. They would learn that their stance is not just a risk to society; it could be a large monetary risk to them personally.

References:
1. “A Modest Proposal”, Jonathan Swift, 1729 


Vol. 201 October 15, 2018 Medical Facts and Fantasies?

October 15, 2018

Hub thumbnail 2015A baby aspirin a day does not necessarily keep the doctor away.
Daily low dose (81 mg. or a baby tablet) aspirin protects you from having your SECOND heart attack, not your first one. Another recent study confirmed that aspirin gives no such protection to someone who has a normal heart history. A baby aspirin is of NO benefit for primary cardiovascular disease prevention. (Despite these repeated studies many of us continue on our merry way of taking a daily baby aspirin in hopes of preventing “the big one.” )

Ritalin is apparently better than nothing . . . and lots of other things.
ADHD (Attention-Deficit-Hyperactivity-Disorder) in school children is not helped much by non-drug therapy. A 2011 review of 54 studies showed little lasting effectiveness of neurofeedback, child behavioral training, parent training, cognitive behavioral (“talk”) therapy, dietary changes, or herbal and Omega fatty acid supplements when compared to the usual psychostimulant drugs like Ritalin. (This lack of evidence of any benefits from non-drug treatment of this common condition is disappointing. The reviewers themselves call for additional studies.)

There’s An App For It – Among things that your smartphone can do are:

  • Record and transmit a electrocardiogram of your heart rate and rhythm.
  • Ask questions to determine whether you are slipping into a depression, and send a text message to your therapist.
  • Have a trained counselor call you within an hour of you opening up a bluetooth equipped HIV self-test kit to interpret the results for you.
  • Adjust the volume and sound characteristics of the hearing aid in your ear.
  • Operate an automatic pill dispenser filled with your daily medications.
  • Give you a “text neck”. The 60 degree angle of your neck as you text puts about 60 pounds of strain on your spine. (That’s the equivalent of 4 bowling balls).
  • Measure, record, and transmit your blood pressure or blood glucose level.
  • Give you an inaccurate pulse oximetry reading if using a non-FDA approved monitoring app. (In fact, the FDA faced with the existence of about 400,000 health and wellness apps has decided to review 20 apps a year that are directly related to gathering and transmitting clinical data. – FitBits are not included in that category)

Got your flu shot yet?
This year the CDC is recommending the quadrivalent flu vaccine for everyone over 6 months old who does not have a medical contraindication. No particular vaccine brand is recommended over the others. People with egg allergies can safely receive any of the vaccines. ( The Bill and Melinda Gates Foundation is pouring money into research efforts to reduce the potential effects of one of their greatest fear, another flu pandemic.)

Parents know best.
Children sleep better if fed earlier in life. Official pediatric policy used be to start solids at 6 months. Many parents think that starting at 3 months causes longer sleep periods and less sleep problems. A study of 1300 breast-fed infants in England and Wales showed that the parents are right. Duh! (Pediatricians used to recommend starting certain solid foods at even a later age because of potential food allergies. That is no longer true.)

The “other shoe” on probiotics.
The current wisdom that “probiotics are harmless and can benefit everyone” is not necessarily true. The exploding volume of research on our “microbiome” (the bacteria in our intestines) reveals that the bacterial mix in our intestines is unique to each individual (like a fingerprint) and is “good” for us in its natural state. Probiotics can change that mix, and one study shows that some of us have guts that are not only “resistant” to probiotics, but that alteration of our natural mix by probiotics could delay recovery from some illnesses.

Why your visit to your doctor’s office isn’t the same as the “old days”.
It is estimated that a typical primary care physician needs 22 hours a day to address all of the preventive, acute, and chronic needs of an average patient panel of 2,500 patients. This includes all of the insurance-prescribed, electronically embedded (in the electronic medical record – EMR) quality measures tied to the reimbursement of the physician. (This is one reason we patients are filling out more questionnaires, clicking on more boxes on a screen, and spending more time with nurse practitioners and physician assistants when we go to the doctor’s office. “The doc can’t do it all any more.”)

Watch out. More un-immunized children are on their way to school.
A 2017 CDC telephone survey indicates that about 100,000 children in the U.S. born in 2015 and 2016 have not received vaccination against the 14 disease for which shots are recommended. This is an increase from a similar study of children born in 2011.

Too fat? Just take a pill. . . A new kind of pill.
A capsule with a long thin plastic tube is swallowed by the patient. Once in the stomach air is pushed down the thin plastic tube, the capsule expands into a balloon filling 1/3 of the stomach, the patient has sensation of having a full stomach, and the thin tube breaks off and is withdrawn. In about three months the stomach balloon disintegrates, deflates, and is passed out in the stool. It has been approved in Europe and is being tested in the U.S. hoping for FDA approval in 2020. Another start-up company is hoping that their capsule filled with gel that expands in the stomach juices and accomplishes the same thing will also be approved. ( The gel-filled capsule is a bit of deja vu for me. As a chubby pre-teen trying to lose weight, I remember taking a tablespoon of “weight-loss powder” a half-hour before a meal, waiting to let it expand in my stomach, and feeling less hungry  so I ate less. I forget its name, but I do clearly remember the time I was in a particular hurry, ate too soon after the dose, and promptly emptied my over-filling stomach onto my shoes.)

A timely tip for women.
With all the surprise disclosures of “good men” exhibiting past sexual harassment acts and even sexual assaults, how can a woman feel confident that the man she is with is not the aggressive type? A recent study suggests you can just look at his hands. The shorter the index finger is compared to the ring finger, the more aggressive the man may be. This is from a study of 300 Canadian men and women. No correlation of personality to finger lengths was found in women. Researchers associate this finding with “the amount of testosterone that babies are exposed to in utero”. ( Or could it be related to being born North of the 49th parallel?! )


Vol. 192 May 1, 2018 Infections Going Viral

May 1, 2018

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“World conditions are ripe for a pandemic like the 1918 influenza epidemic, but we, the U.S. and the world, are not prepared to fight it.” – Bill Gates, April 27, 2018

Ten experts (three of them had British accents, so they were particularly believable) agreed with Bill Gates when he presented this warning in the 2018 Shattuck Lecture at the Massachusetts Medical Society Annual Meeting in Boston last week.

The 1918 influenza virus first appeared in the U.S. in New York City and within just 5 weeks it had spread across the country to California resulting in 670,000 U.S. deaths. As you know, the flu virus changes every year and we can’t start making a vaccine until we recognize and identify “this year’s mutation”. It then takes months to produce, distribute, and administer a vaccine, so consequently our flu vaccine is always playing catch up. Since 1918 we have developed anti-viral medicines and a number of different antibiotics to combat influenza complications, so a repeat of such a lethal flu epidemic is today considered unlikely.

But it is the other viruses, the “novel viruses”, that concern the experts at this conference. For instance, 1000 “novel” viruses from different species which could potentially cross over to humans and cause significant disease have been identified over the past 8 years . Of these 1000 “novel” viruses, 891 are brand new, never before identified. Advances in genomic sequencing allow the specific identification of potentially pathogenic mutations, but as one speaker noted it has taken the U.S. Weather Service over 50 years to build a data base that allows “reasonably good” weather forecasts, so our ability to forecast the effects of new virus diseases is considered to be woefully rudimentary. (1)

We will probably receive the earliest warning signs of any new epidemic from mining the “digital exhaust” of our social networks, “flu near you” apps, crowd sourcing of symptom reporting, net-connected thermometers. upticks in certain prescriptions, volunteered Alexa conversations, Google search statistics, bot-driven AI, and locations of Uber-delivered medicines. (2)

The reasons the world is ripe for an infectious pandemic are: increasing population, increasing urbanization in developing countries, continued poverty that promotes inter-species living, routine rapid travel between countries, increasing frequency of natural disasters due to climate change, plus potential bioterrorism. Several speakers used a military preparedness metaphor, consciously using the verb “fight” and the noun “war”. For example, “If we knew our enemy was developing a new military weapon we would be throwing all sorts of resources at analyzing what the threat is, how to detect it at the earliest possible moment, how to defend against it, and how to deal with its effects if deployed. We should be doing the same for future infectious disease epidemics, and we are not.” (3)

Bill Gates was most impressive with his command of diverse, seemingly obscure facts like the per cent change of Uganda’s GDP, the identifying numbers of a new unnamed TB antibiotic, the three viruses that could mimic Ebola, and that in a recent study 4 almost random doses per year of the antibiotic zithromax reduced childhood mortality in developing countries by 50% in 2 years! He remains a man of vision as well , made it clear that the Bill & Melinda Gates Foundation would continue its support of innovative health and education efforts, and describes himself as an optimist. He nonchalantly reported that his foundation had just granted $12 million seed money to a group working with Glaxo (stock-pickers take notice) to develop a universal flu vaccine, one that would be effective against all flu virus mutations. (Such a universal flu vaccine was the #1 fervent wish of the Deputy Director of the CDC when asked for her hopes for the next ten years.(4))

 Our pandemic preparedness is not just a task for the medical/clinical sciences nor just for “new” technology.  The “old” technologies of anthropology and the fine art of negotiation were vital to a successful defense against Ebola. It was not until we recognized the cultural traditions of burial rituals of some African tribes, and persuaded them to change them, that we were able to contain the Ebola epidemic. (5)

Pandemic preparedness is not only a multi-disciplinary effort. It must also be political. Even as science advances, there must be the political will to deploy the resources before a pandemic attack . Of course, “urgent” often trumps even important “long term” needs in politics, but a pandemic is the equivalent of a war. By the time the battle is raging it can be too late to effectively marshal all the troops and equipment necessary to win. (3)

The consensus of the conference was: “The U.S. should continue to be the leader in global health security.”

References:
1. Joanna Mazet, DVM, MPVM, PhD, Professor of Medicine, University of California, Davis
2. John Brownstein, PhD, Chief Innovation Officer, Professor of Medicine, Boston Children’s Hospital
3. Jeremy Farrar, OBE, FRCP, FRS, Director, Wellcome Trust
4. Anne Schuchat, MD, Principal Deputy director, CDC
5. Mark Gordon, Esq. Co-Founder Vantage Partners


Vol.120 February 15, 2015 Disillusioned …Again and Again

February 14, 2015

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 “Scratch any cynic and you will find a disappointed idealist.”
― George Carlin

Maybe it is just that time of year, the record snowfall, the frigid temperatures, the lack of sun, but I feel like the world as I have known it is crashing down around my ears. Brian Williams has fallen off his pedestal, Bill Cosby is canceling shows all over the place, Tiger Woods is not coming back, Jon Stewart is leaving The Daily Show, Steven Colbert has already left, the towns are running out of sand and salt, and the trial of Dominique Strauss-Kahn, former head of the International Monetary Fund, has come up with the unique defense of his “aggravated pimping” “at a sex parties with “you can’t tell the difference between a prostitute and a naked socialite”.

So many of the truths we have held dear in medicine, science, politics, and society are being revealed as mere illusions. To wit:

  • Cholesterol need no longer be a nutrient of concern”. So sayeth the “nation’s top nutrition advisory panel” after 40 years of telling us just the opposite! High cholesterol levels in your blood do increase your risk for heart disease, BUT dietary cholesterol contributes only about 10% of that level. Of course, the panel couldn’t just leave it at that. According to them the REAL danger lies in foods heavy with trans fats and saturated fats. However, if you follow recent arguments in the literature closely enough you will see that there is some debate about which are the “good fats’ and which are the “bad fats.” Maybe we’ll have  to wait another 40 years for consensus.
  • Mississippi and West Virginia, among the poorest states in our country, have the best rates of measles immunization, and it is because they are the ONLY states that refuse to accept a waiver from immunizations on the basis of parental beliefs when children enter school. Mississippi’s measles vaccination rate is 99.7% for entering kindergarten students. West Virginia is at 96%. Epidemiologists have established a 94% immunized rate for measles as necessary to sustain “herd immunity”. In California and Arizona ( where thousands of Super Bowl visitors came and went back to their own states) the rates are 90.7% and 91.4% respectively.
  • Spewing sulphur gas into our high atmosphere could help block sun radiation and help cool off a warming earth. Isn’t sulphur one of those toxic pollutants given off by burning coal and other fossil fuels? Well, yes, says the National Academy of Science, but the computer models of blocking the sunlight with released sulphur have such a positive logic about them that “we should test it in some small pilot studies”.
  • Four out of five bottles of supplements taken off the shelves of GNC, Walmart, Walgreens, and Target in New York did NOT contain ANY of the herbs listed on their label. Ginseng pills “for physical endurance and vitality” contained only powdered garlic and rice. Ginkgo biloba for “memory enhancement” contained powdered radish, houseplants, and wheat. That label even claimed that it was wheat- and gluten-free! The FDA can only target products that have dangerous ingredients. It took the NY State Attorney General’s office to reveal this harmless ingredient sham, aka “profit by placebo” (NY Times, Feb. 3, 2015, pg.1)
  • Half of the health information and recommendations given on The Doctor Oz Show and The Doctors is false. Not only did 80 recommendations from each TV show picked at random from the 900 recommendations identified have NO evidence to support them, but many were even contradicted by evidence. In typical academic, “English speak” the authors suggest that “consumers and clinicians should be skeptical about these TV show recommendations”. (BMJ 2014 Dec. 17, 2014, 34)

Is there any hope for us optimists?   Well …

  • Crime rates in Boston have plummeted during this cold snowy weather. Homicide is down by 70%, rape by 50%, and vehicle theft by 46%. I guess everyone is staying inside, wearing lots of clothes,  and skipping the shoveling needed to steal a car. Rates for violent crimes in New York City, which had less snow and higher temperatures, all increased during the same period.

Vol. 118 January 15, 2015 It Ain’t Just Vaccines That People Decline

January 15, 2015

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Half of U.S. patients don’t take their medicines as prescribed by their physicians.(1,2)

We use to call such patients “non-compliant.” As “patient-centered care” became the mantra for contemporary medicine that “passive, judgmental” term of “non-compliant” was banished and replaced by “non-adherent”, a presumably less derogatory term implying a partnership of patient and physician. (3)

A cardiologist, struck by the number of her patients that did not comply with adhere to their heart medicine prescriptions, asked 20 of them who had survived a heart attack why they didn’t adhere to medications that had proven benefits of secondary prevention of a next event, an event that could cause death. (4) Their comments (listed first below)  were surprisingly similar to feelings expressed to me by parents who decline immunizations for their children (typed in bold italics ).

1. Risk Aversion
“Why take medicine that could wreak havoc on your body.”
In people with negative emotional reactions even a small risk of side-effects seemed to overpower any positive feeling about the proven benefits of a drug. Their perception of risk is greater than their perception of benefit. They are “far more sensitive to possibility than to probability”.(5)
Despite numerous studies showing that there is no probability of an association between measles vaccination and childhood autism some parents still feel that there is always the possibility. Arguing relative probabilities of vaccine side effects versus disease effects with them is not productive.

2.Naturalism
“Medications are chemicals and should not be in your body on a regular basis”.
Vitamins, herbs, and other health supplements of all kinds are often turned to because they are not “chemicals”.
“I don’t want to have any foreign proteins injected into my child”. Natural immunity, of course, depends on our body recognizing and reacting to foreign proteins so that symptoms resolve and our next exposure to the same foreign protein doesn’t make us sick again. “It is the additive proteins that we don’t want” is often the next statement from the parents. Pointing out that there are 315 “foreign proteins” in today’s vaccines  rather than the thousand’s in the vaccines before the 90’s does not reassure them.

3.Denial
“Men don’t like taking medicine because to do so they are admitting that they are not strong. Most people like to think that they are strong and mighty. …Their very sense of well-being after surviving a heart attack and quickly resuming healthy lives may convince them that medications are not necessary.”
Some parents feel that their unimmunized children are safe from disease because the rest of the children are immunized, the “herd immunity protection” argument. Pointing out that herd immunity is effective only when the community reaches the currently unachievable high percentage of immunity (a 94% threshold in measles and whopping cough) has no effect. You would think that the possibility of measles in their unimmunized child in a partially immunized community would override the small probability of side effects from the vaccine. It doesn’t with some parents.

4. Avoidance of Sick Identity
“Has having a heart attack become too easy?” People can spend more time being sick from flu than having a therapeutic cardiac cath within 90 minutes of arriving at the ER and walking out of the hospital 24 hours later.
Has the absence of children dying or being crippled by measles, polio, diphtheria, or croup dulled our ability to imagine our children in such a sick state? Sporadic epidemics of whooping-cough and croup in certain states have been successful in raising immunization rates a bit. If there were an Ebola vaccine, I wonder how the vaccination  non- adherent parents would have juggled that possibility/probability calculation for their children.

5. Difficulty Visualizing Benefits
“The benefits of cardiac medications may be imperceptible and the absence of perceived benefit is a well-documented reason for non-adherence”. Adherence to anti-platelet medications (“blood thinners”) is higher than other cardiac meds perhaps because the patient can easily visualize the “thinned” blood flowing smoothly through an unclogged pipe. That the medication is actually “doing something” is reaffirmed by the prolonged bleeding from a razor nick.
Maybe we pediatricians should develop an app and FitBit that could non-invasively measure antibody levels and send an alert to the child (via his/her own smart phone, of course): “Your antibodies against [insert tetanus, diphtheria, or whatever disease name here] have been declining for years and are now at a level that no longer protects you. Go immediately to your nearest [insert sponsoring drug/ convenience/department store name here] and get vaccinated.”

6. Avoiding Dependency
“Relying on cardiac medications is another form of addiction. I brought on this heart attack by my life style and it is my responsibility to avoid another by changing my life style.” Taking medications may be viewed as a loss of control, as “following orders” , as “being told what to do”.
This rejection of authority rings true in my experience with some parents who decline immunization for their children. It also may explain why pockets of unimmunized children who are not in poor families are sometimes clustered within tree-hugging, organic food eating, aging-hippy communities. Frustrating as this rejection of authority is to the physician, repeatedly battering the head and shoulders of these parents with all the scientific facts proving that vaccinating their child is safer than having them contract the disease is counter-productive.

The discussion with parents who decline immunizations for their children is hardly ever a rational one. Some beliefs and feelings seem impervious to facts. Certainly a parent’s personal knowledge of some child, usually a cousin or a nephew/niece, who had a vaccination and then had a seizure or who “has never been the same since” is a real conversation stopper. That personal experience can generate such deep feelings that I no longer even try to talk them out of that hole. We don’t experience that same depth of feelings if an older adult we know survives a heart attack only to die of a second one months or years later. We often feel, not knowing all the details, that “C’est la vie”.

References:
1. NEJM 2005;353:487-97 Adherence to Medication
2. J Gen Intern Med 2008;23:115-21 Secondary Prevention After MI
3. Ann Pharmacotherapy 2004;38:161-2 Adherence or Compliance?
4. NEJM 2014;372;2:184-7 Beyond Belief
5. Psych Bull 2001;127:267-86 Risk as Feelings


Vol. 114 November 15, 2014 Selected Issues for Modern Kids Listed by School Level

November 16, 2014

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“Everything I need to know… I learned in kindergarten.”
― Robert Fulghum, All I Really Need to Know I Learned in Kindergarten

 

Pre-school – Immunizations
When the first child under 2 yo. developed a severe seizure disorder after a measles vaccination it started the fire of resistance against immunizations which still burns today. Subsequent research proved that that child had a genetic abnormality as the CAUSE of her severe seizures, the Dravet syndrome. The immunization caused a fever that was a TRIGGER for the epilepsy.  One study of 14 children with onset of epileptic encephalopathy after vaccination revealed that 11 of them had a genetic abnormality, Dravet syndrome.  In a recent study of 45 children who had seizures within 24 hours of an inactivated virus immunization or within 12 days of a live virus vaccine, 65% of those children developing epilepsy after an immunization had an underlying genetic cause. The vaccines were NOT the cause. Fortunately only 16% of patients with that genetic defect will have a seizure from a fever following immunization. .(1)
Serious neurological illness is very rare after an immunization,… and the immunization does NOT cause it!

Kindergarten – IQ tests
Over 7000 pairs of twins in the UK were given the Goodenough (named for the developer) Draw-A-Person test and a standard intelligence test at age 4 and then at age 14.  The Draw-A-Person test is a common measure of “school-readiness” for 5 year olds. The drawing of a “man, a woman, and themselves” is then scored for 14 different aspects (body parts, scale, etc.) producing a score composed of 64 items.  At 14 years of age the same children were given another IQ test. “Figure drawing scores at age 4 correlated significantly with verbal and non-verbal intelligence at both age 4 and age 14.”  This contradicted a previous study of 100 children (not in UK) that showed NO correlation between Draw-A- Person scores and standardized IQ test at pre-school age.
…But, you may only be as smart as you are in kindergarten.

Middle School – Apple Allergy
A 11 year old boy with a past history of patches of eczema previously responsive to usual treatment with steroid creams developed a whole-body dermatitis that did not clear up with 6 months of treatment.  A variety of skin patch allergy tests revealed a 1+ reaction to nickel, a commonly seen cause of dermatitis in some people. Presumably he was being exposed to nickel by contact with his iPad surface that was positive for nickel. A plastic cover for the iPad resolved the rash. Cell phones, clothing fasteners, ear-piercing, video-game controllers, lap top computers , and some wind-up toys can also be sources of nickel allergic reactions by direct contact. (3)
iPads and other metal electronic products can cause a persistent allergic rash.

High School – School Start Time
Chronic sleep loss can impair academic achievement, physical health, and mental health. The American Academy of Pediatrics recently recommended that school should not start any sooner than 8:30 AM. Studies of high school seniors revealed that on average they sleep less than 7 hours a night and have difficulty falling asleep before 11 PM. The desired goal is 8.5 to 9.5 hours of sleep at night, and that “naps, sleeping later on weekends, and coffee do NOT restore optimal daytime alertness”. (4)
Later starting time for schools is good for kids.

College – Marijuana, Alcohol Use
Too much to say here about that right now. More later.

References:
1. Pediatrics 2014 Sept 15.
2. Psychol Sci 2014 Aug 20
3. Pediatrics 2014 Aug 1
4. Pediatrics 2014 Sept.


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