The Last Word (from me)

This is the last I’ll post about this subject for a while but I thought this was an interesting after thought published in the New York Times today.

Inoculated against facts by Paul Offit

Excerpt:

 The vaccine court should return to the preponderance-of-evidence standard. But much damage has already been done by the Poling decision. Parents may now worry about vaccinating their children, more autism research money may be steered toward vaccines and away from more promising leads and, if similar awards are made in state courts, pharmaceutical companies may abandon vaccines for American children. In the name of trying to help children with autism, the Poling decision has only hurt them.

Autism & Vaccines: Beating a Horse that Won’t Die

There was widespread coverage this week of a 9 year old Georgia girl whose family received a settlement from the vaccine injury fund (Department of Health and Human Services’ Division of Vaccine Injury Compensation) after investigators conceded that her autism was linked to a bevy (some say 5, some say 9) of thimerosal-containing-vaccinations she received at 19 months old. Scientists are saying that in this case that the patient had an underlying cause – a mitochondrial disorder – that predisposed her to this development (see the Genetic Polymorphism section of my original vaccine post). Whether this condition was aggravated by the thimerosal or the effect of the vaccines on her immune system is unclear, though in some articles it is implied that it was more likely brought on by the stress of her body’s immune response to the shots. While this does seem like a more plausible connection many parents will not let go of the thimerosal link despite statistics that indicate otherwise.

WebMD: Thimerosal Down but Autism Rising

FDA Thimerosal in Vaccines

I have synthesized some of the mainstream coverage of this case pulling out excerpts from each article. The excerpts are not necessarily indicative of the conclusions reached for each source but rather interesting pieces of a large, often misleading, emotional, very confusing puzzle.

AJC

The language in the document does not establish a clear-cut vaccine-autism link. But it does say the government concluded that vaccines aggravated a rare underlying metabolic condition that resulted in a brain disorder “with features of autism spectrum disorder.”

New York Times

There are two theories about what happened to Hannah, said her mother, Terry Poling. The first is that she had an underlying mitochondrial disorder that vaccinations aggravated. The second is that vaccinations caused this disorder.

WebMD interview with the girl’s father, a neurologist

The experience with Hannah, Poling says, has not turned him against vaccines. “I want to make it clear I am not anti-vaccine,” he says. “Vaccines are one of the most important, if not the most important advance, in medicine in at least the past 100 years. But I don’t think that vaccines should enjoy a sacred cow status, where if you attack them you are out of mainline medicine.”

CNN

“…within 48 hours after receiving nine routinely administered childhood vaccines in July 2000, the girl’s health rapidly declined, she said.”

NPR

CDC officials decline to talk about the Poling case, but they say it should not be used to draw conclusions about risks for other children.

Washington Independent

Over the past decade, nearly 5,000 claims from parents with kids on the autism spectrum have flooded the court. To deal with these numbers, the court set up an Omnibus proceeding, similar to those established to deal with asbestosis claims. The court has been planning to run nine test cases out of the bunch. These test cases, which deal with various theories of how the vaccines might have caused autism, would then be used to resolve the thousands of other cases.

The Washington Independent article is titled “A Reopened Can of Worms.” Anyone who thinks this particular can of worms was ever closed back up hasn’t been paying attention. I have friends who don’t even have kids yet that are worried about vaccinating their future hypothetical children. Other parents, including some who have advanced degrees in health related fields, are leaving pediatricians who deride them for questioning the vaccine schedule or wanting to spread out vaccines. Many who believe that some of these patients’ autism is being caused by the immune response to so many shots being given at once hypothesize that spreading the shots out would decrease that perceived risk.

Spreading out vaccines does place a greater burden on the public health system and a greater burden on individual practices who have to absorb the additional time required to spread the vaccines out. Because of this it is easy to understand from a logistical standpoint practitioners resisting this movement. Additionally spreading out vaccines could make it harder to track what an individual child has had, as well as place an undue burden on poor families who would not want to pay for multiple “well baby” visits.

In order to come up with an effective solution practitioners, patients and public health entities – government related or not – need to rebuild mutual trust and respect and tackle this growing fear and growing problem of autism together.

Dr. Google

There’s been a little back and forth going on the internet about the evils/benefits of patients who Google. Let’s face it, if you have access to the internet and you or a loved one have an ailment chances are – you’re probably going to use the vast resources available to you on the internet to educate yourself. When you use Google alone it can be hard to distinguish good science from bad.

There are tools that you can use to search for reliable information including WebMD (a company with a local presence, by the way), University Hospital Sites such as Johns Hopkins (our own Emory points you to Medline Plus), the National Institute of Health’s Medline (included in MedlinePlus searches) and there is a new site called Organized Wisdom which purportedly has health professionals screen their links to health information sites. The information appears to be well organized and referenced.

A quick search for Alzheimers points to articles by MedLine Plus, Health Central, American Alzheimers Assoc., The National Institute on Aging, and the American Health Assistance to name the first batch. There are, however, Google ads on the search pages with dubious seeming links that might be distracting.

Patients need to be very discriminating about the kind of information they allow themselves to absorb from the internet. Anecdotal evidence can be extremely emotionally persuading to a patient who feels vulnerable and very, very misleading. This is usually found either on discussion boards or compiled by partisan organizations. It is this kind of evidence that has threatened vaccine initiatives and compromises everyone’s health. No wonder doctors are so skeptical about their patients bringing in stuff from Dr. Google.

Despite many physicians’ wish to stick their heads in the sand until this internet fad passes, patients will continue to search and try to educate themselves, and they should, but with caution and discrimination. And if doctors don’t want their patients glomming onto dubious anecdotal research then they need to be willing to point their patients in the right direction. The time needed to invest in patient education strategies can be recouped in both patient retention and by having to spend less time battling erroneous information.

A Word on Vaccine Safety

Since I started this blog with a vaccination calendar, I’m going to weigh in briefly on the thimerosal issue. The preservative thimerosal has been removed from most children’s vaccines but remains in the traditional flu vaccination. The FluMist nasal spray does not contain thimerosal. In the past decade or so many parents of autistic children have expressed concern that there is a link between the thimerosal in vaccines and autism. I recently attended a conference (American Medical Writers Association) here in Atlanta where I attended several seminars and discussions dealing with this issue. Emory University, the CDC (Centers for Disease Control), NIH (National Institutes of Health) and many other public health organizations participated in this conference. I attended every session that had anything to do with vaccinations. Based on what I heard from this conference, my own research, and more importantly the consensus of every legitimate Public Health Organization, there is nothing to indicate that there is any correlation between the two.

Science

Studies have been performed by parties with a wide range of interest in this subject including by the pharmaceutical companies themselves whose interest would clearly be self serving. But researchers at teaching facilities, the CDC, and the NIH have all tested this hypothesis and no one is finding a link. This article published by the New England Journal of Medicine compiles several studies with these results:

“Among the 42 neuropsychological outcomes, we detected only a few significant associations with exposure to mercury from thimerosal. The detected associations were small and almost equally divided between positive and negative effects…”

and comes to this conclusion:

“Our study does not support a causal association between early exposure to mercury from thimerosal-containing vaccines and immune globulins and deficits in neuropsychological functioning at the age of 7 to 10 years.”

Genetic Polymorphism

At the conference there was some intriguing informal discussion of a possible link through genetic polymorphism which vaguely means the tendency of a certain gene (associated with neurological deficits or autism), if present, to mutate detrimentally in the presence of a certain substance (thimerosal). In other words, for those who are genetically predisposed to develop a disorder on the autism spectrum this tendency may be triggered or exacerbated by the introduction of the substance thimerosal into the system. It seems like a somewhat plausible theory which as of yet has not been substantiated or similarly obliterated by research findings. Even if this theory were to eventually be substantiated it would affect only a tiny portion of the general population and account for a small fraction of autism cases.

Confirmation Bias

From my understanding the reason so many parents are convinced that there is a link between the two has to do with the timing of the MMR shots (Measles, Mumps, and Rubella usually given in a simultaneous combination). This shot is given to most children at around 18 months. Often the diagnosis of autism is made between 18 months and 3 years of age. Several parents claim to have observed a distinct change in behavior in their child after this particular vaccination. Once these groups of parents found each other (many on the internet) a strong faction coalesced that eventually led to the CDC and the AAP (American Academy of Pediatrics) recommendation for removal of thimerosal from vaccines. Both of these organizations have since maintained the safety of thimerosal in childhood vaccines based on scientific evidence.

This recommendation was based on only anecdotal evidence which can be very emotionally persuasive but really has no bearing on scientific evidence and is usually viewed by most scientists and physicians as nothing more than a coincidence. This dismissal often has the unfortunate effect of alienating the other party (in this case the parents) who then become defensive and are pushed further down the path of confirmation bias.

Mercury

One of the pieces of information that was the most illustrative to my understanding of vaccine safety was the distinction of different kinds of mercury.

For instance different types of alcohol have different effects on the human system:

Methyl alcohol = antifreeze = death

Ethyl alcohol = vodka = intoxication

The same also applies to mercury:

Methyl mercury = toxin = brain damage

Ethyl mercury = thimerosal = vaccine preservative

Of course the effects of all of the above substances on humans depend largely on the dosage.

Patient Education and Communication

One of the most important things that I see missing is from the patient education handouts you are given when your child is about to receive vaccinations. The form explains what the risks of vaccinating your child are – usually soreness at the site of injection and sometimes fever. The information I would like to see included are the risks of NOT vaccinating your child.

• These diseases can be devastating. This has been lost in our collective memory as much of the current generation responsible for vaccinating their own children has no direct experience with them.
• For vaccines to work to protect the public health, rates of immunization must be maintained at certain level to protect what’s known as community immunity.
• The timing of vaccines is important. The risks carried by catching the disease are most dramatic during certain ages of a child’s development. The current vaccine schedule has been designed to optimize protection during these vulnerable windows of time.

Communication between physicians and their patients might be one of the most important and most overlooked opportunities to build public confidence and achieve ideal immunization rates. It can be exhausting, frustrating and repetitive for pediatricians to try to reeducate each parent who comes in with concerns about vaccine safety. However the pediatrician is the key point of contact between public health organizations and the public on this issue and therefore charged with this huge responsibility and opportunity.

Links

NIH FAQ on Thimerosal http://www.niaid.nih.gov/factsheets/thimerosalqa.htm

CDC FAQ on Thimerosal containing vaccines http://www.cdc.gov/flu/about/qa/thimerosal.htm

A British MMR Fact Sheet that does touch on the risks of not immunizing http://www.mmrthefacts.nhs.uk/resources/pdf/leaflet.pdf

New England journal of medicine study http://content.nejm.org/cgi/content/full/357/13/1281

CDC announcement expanding FluMist recommendations for 2-49 year olds (up from 4-49 year olds)http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5646a4.htm

Food for thought

Over the holidays I had the pleasure of gaping stretches of time just for reading! One of the books I completed was Atul Gawande’s newest book “Better: A Surgeon’s Notes on Performance.” Dr. Gawande is a surgeon and an amazing writer. The premise of this book is (to paraphrase from an interview) as a whole most physicians are average, by the definition of average, and average in medicine is unacceptable as there are lives at stake. He looks at ways to refine performance in medicine to become Better. What he discovers makes a better physician strikes me as what that can make anyone better at what they do. He sums up his conclusions in two places. On page 226 of the hardcover he boils down achieving success to these three important traits:

1. Aggressiveness
2. Diligence
3. Ingenuity

On page 251 he references a lecture he gave to graduating medical students on How to Become a Positive Deviant (ahead of the Bell Curve). Here he’s got 5 suggestions:

1. Ask an unscripted question
2. Don’t complain
3. Count (or measure) something
4. Write something
5. Be willing to change

I recommend this book to clinicians and laypeople alike. His storytelling is engaging, eloquent and his perspective illuminating. Whether you want to be a better doctor or just become a better patient advocate for yourself or loved ones – the information in this book is fascinating and well told.

Links

Atul Gawande
http://www.gawande.com/

His latest New Yorker article “THE CHECKLIST” (more intriguing than it sounds
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

My favorite article of his (reprised in the book “Better”) “THE BELL CURVE”
http://www.newyorker.com/archive/2004/12/06/041206fa_fact

AJC illustrates why Grady should matter to you

Seems like there’s several articles a month about Grady these days. Today in the AJC Gayle White highlights 9 reasons why Grady could matter to you.

The 9 issues are:

1. excellent trauma care – one of only four Level One Trauma centers in Georgia and the only one in Atlanta
2. unparalleled ambulance ability – 90,000 trips per year and can transport exposed CDC workers
3. infectious disease care including interntaionally recognized HIV care
4. medical education – 900/1000 of Emory’s residents and almost all of Morehouse’s train at Grady
5. mental health care – many of these patients would be on the streets without Grady
6. neonatal care – 30 high risk infants per day
7. poison control – home to Georgia Poison Control handling 200,000 calls per year including pets
8. sickle cell care - world’s largest center for adults with this disease
9. burn unit - one of only 2 in the state

The politics of Grady’s issues today run deep but mostly stem from debts to Emory and Morehouse who train a large portion of their residents at Grady. Fulton county, the city of Atlanta, surrounding counties whose residents benefit from Grady, Emory and Morehouse need to come to an agreement that secures Grady’s future.

Grady Memorial Hospital

Emory University

Morehouse School of Medicine

FluMist Availability

Here’s a link to the CDC’s Q&A about FluMist.

Local Places to Get FluMist that are willing to provide to Non-Patients

Grady Neighborhood Health Clinic
30 Warren Street SE
Atlanta, GA  30317
404 6169304e
 

Richard Weil MD
105 Collier Rd NW
Atlanta, GA  30309
 

Local Places To Get Flu Mist that Accept Current Patients Only

Dekalb Pediatric Center
484 Irvin Court
Decatur, GA  30030
Current Patients Only
 

Peachrtree Park Peds
3193 Howell Mill Rd. NW
Atlanta, GA  30327
 

Kidcare Pediatrics
2177 Godby Rd
College Park, GA  30349
 

Southside
Michael Adams
1046 Ridge Ave. SW
Atlanta, GA  30315
404 5646918
 

Hammad, Platner
Caroline Charles-May
285 Boulevard, NE Ste 235
Atlanta, GA  30312
404 5250633
 

Elizabeth Norwood MD
1100 Cleveland Ave
East Point, GA  30344
 

Mohammad Tomeh MD
Mohammad Tomeh
1203 Cleveland Ave
East Point, GA  30344
 

David Roe MD
105 Collier Rd NW
Atlanta, GA  30309
 

Geoffrey Simon MD
3091 Maple Dr NE
Atlanta, GA  30305

Visit the FluMist Finder to see if your Primary Care Physician may provide FluMist

Flu Shot Availability

I have compiled a list of upcoming flu clinics by date.  I will update this list in two weeks.   This is simple formatting but if you want it in a pretty table format, click on Flu Shot Clinics. 

Publix  
1544 Piedmont Ave, NE
404-898-1850
11/1
4 pm – 8 pm
$30

CVS
1043 Cleveland Ave in East Point
404-767-2034
11/3
10 am – 2 pm

Publix
2155 N Decatur Rd. in Decatur
404-638-6015
11/8
10 am – 2 pm
$30

Publix
950 W. Peachtree St., N.W.
404-253-3544    
11/9     
10 am – 2 pm    
$30

Publix  
2325 Cheshire Bridge Rd, N.E.  
404-638-1900    
11/10   
10 am – 2 pm    
$30

CVS    
520 Boulevard Se         
404-624-0022    
11/12   
10 am – 2 pm    

Nextcare          
1220 Caroline St. #230  
678-916-3610    
11/13   
8 am – 8 pm      
$25

Publix  
1001 Ponce de Leon     
404-892-9229    
11/13   
4 pm – 8 pm      
$30

Publix  
2969 N Druid Hills Rd   
404-638-6022    
11/15   
11 am – 2 pm    
$30

Publix  
2900 Peachtree Rd, NW
404-848-0330    
11/17   
12 pm – 4 pm    
$30

Welcome

Welcome to SEATLPHB (Southeast Atlanta Public Health Blog). It’s a mouthful and probably sounds like a bar in the Pacific Northwest, but it’s the most descriptive acronym we could come up with (yet).

We’ll be publishing articles about Public Health and Safety issues as they relate to the communities in Southeast Atlanta including East Atlanta, Grant Park and S.A.N.D (South Atlantans for Neighborhood Development).

During these first few months we’ll be covering issues ranging from vaccine safety, finding a specialist, injury prevention and managing allergies to profiling local institutions, clinicians and discussing politics and stem cells.

As we grow and bring in more contributors we hope to introduce voices of local public health figures, schools, and organizations.