After my son contracted a mild but annoying case of poison ivy this week I decided it’s time to figure out once and for all what the nasty stuff looks like. Most of us have heard “leaves of three, let it be” but correctly identifying poison ivy can be tricky. The website “What Poison Ivy Looks Like” has pictures of it in different growth stages and in different settings as well as pictures of particularly gruesome rashes that people have gotten from it.  There’s a poison ivy poster, a fact page and a quiz on the website.  But the “Skin Rash Hall of Fame” is not for the queasy. I had no idea it could get that bad.  The site states the following in reference to the severity of reacitons:


According to the Wall Street Journal, research soon to be published in Weed Science (is your subscription up to date?) indicates that poison ivy has gotten MUCH nastier since the 1950’s. Leaf size and nasty oil content are way up.

The American Academy of Dermatology has a page dedicated to education about Poison Ivy, Sumac and Oak with pictures to help identify all three.

Your best bet is always to avoid it, but stocking up on some cortizone cream is not a bad idea if you plan to garden or play outside.  Severe reactions require the attention of a doctor.

Sonny Purdue brings tax breaks to the rich, Emory hosts cancer symposiums, Carter meets with UN over world maternal health

Tax Breaks

Good news if you’re rich! Sonny Perdue has signed a bill “that will give insurers millions of dollars in tax breaks for selling the plans.” These plans benefit mostly wealthy consumers.

In Georgia, Millions in Tax Breaks for Insurers on High-Deductible Plans

Emory Town Hall for African American Women

Emory’s Winship Cancer Institute will host a town hall to address breast health issues for African American women on May 15 at 6 p.m. The meeting is free and open to the public.

Breast Cancer Town Hall

The following day Winship will host a scientific symposium on triple negative breast cancer – a fast moving cancer that disproportionately strikes African American women and is resistant to current therapies. This symposium is targeted to health care professionals and is free. May 16 from 8 am to 5 pm.

Triple Negative Breast Cancer Scientific Symposium

Carter, UN

President Carter is meeting with the UN secretary and 40 global health leaders this morning at the Carter Center to discuss global maternal health care. Some of the goals they will discuss include:

  • reducing child and maternal mortality;

  • eradicating extreme poverty and hunger;

  • universal primary education;

  • combatting AIDS, malaria and other diseases.

UN Chief, Carter to discuss world health problems

Exercise

A NYT article this week touts the benefits of exercise. I know this falls into the “duh” category but it is interesting how exercise can help prevent or delay onset of many chronic diseases. It can also mitigate the effects of existing chronic disease. According to the author, Jane Brody, exercise can:

“…lower the risk of heart attack, stroke, hypertension, diabetes, obesity, depression, dementia, osteoporosis, gallstones, diverticulitis, falls, erectile dysfunction, peripheral vascular disease and 12 kinds of cancer.”

as well as improve the health of people with chronic diseases like rheumatoid arthritis, multiple sclerosis, Parkinson’s disease, congestive heart failure or osteoarthritis.

In addition to helping with chronic disease physical exercise may be one of the best ways to stay sharp mentally.

Measles

In other news, Measles Infections in the US are at the highest rate in 7 years. The infections are occurring almost exclusively in people who were never vaccinated and are expected to increase as the disease is highly contagious. Officials warn that measles can cause serious complications and even death.

The CDC measles update reports 64 cases in 9 states so far this year. The same report warns:

“Worldwide, 20 million cases of measles still occur each year, and the disease is a significant cause of vaccine-preventable death among children. In 2005, 311,000 children under age 5 died from the disease.”

The Last Word (from me)

April 1, 2008

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.

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

February 19, 2008

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

January 10, 2008

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