Avoid The Spots, And Worse

How epidemics happen: first, a vulnerable population. Then bring into that population a highly contagious infection.  Recently that’s measles.  Unvaccinated kids are often in clusters where not vaccinating is culturally popular- like Washington State and southern New York.  Then someone visits from another country with spotty vaccination, carrying measles.  It’s highly contagious- carriers cough in a room, and mucus particles stay in the air for 2 hours.  During that time, an unvaccinated kid enters, breathing in those particles.  A week or two later, she starts coughing, has a high fever, pops out in a spotty rash all over.  However, she’s already been shedding virus to other kids 4 days before breaking out herself!  How do you keep the lid on a virus like that?

Of course, vaccines.  When epidemics happen, the sheen is suddenly off having unvaccinated kids, and clinics cannot keep up with vaccine demand.  It’s hard for public health officers not to crow “I told you so!”  We don’t advocate vaccinations because it’s cool, and certainly not for secret payoffs from pharmaceutical companies; the companies couldn’t care less.  Vaccines are such a financial dog for them that in the 1980s, Congress had to intervene so they wouldn’t stop making the stuff.  They’d rather be making scads of money on Viagra and other drugs they advertise.  When’s the last time you saw ads for vaccines?

Non-vaccinating is frustrating for pediatricians because to us, who “live the data,” the benefits are so clear, the risks so minimal.  Throughout our careers, we read the studies, debate the statistical design, and see in practice how effective vaccines are.  When non-vaccinators say “I did my research,” they didn’t pull the data, do their own statistical analysis, and find study design wanting; they read some cranks on the internet.  Like climate scientists, we who know the actual numbers are reminded of Senator Daniel Patrick Moynahan’s words: “Everyone is entitled to his own opinions, but not his own facts.”

The consequences of this are life-and-death.  Doctors who counsel parents have been sued, even when warning parents on not vaccinating. If the child then contracts a fatal, vaccine-preventable illness, the parents argue in court, “But he didn’t tell us our child could die!”  Your child could die.

Once at a party a mom came up to me and whispered, “So what’s the real truth about vaccines?”  As if we kept quiet, I’d confess about the piles of money drug companies are paying us pediatricians to administer unnecessary vaccines.  It was a little exciting- for the first time in my life someone thought I was part of a conspiracy!  Cue the James Bond music!

Unfortunately for my income, the conspiracy theory about vaccines is a myth.  As we mentioned above, vaccines are the least favorite things for pharmaceutical companies to make. The profit margins are slim, the insurance burden is great, and they make lots more on the medications you see advertised on TV.  If they made so much money on vaccines, why aren’t they running ads for them?

And what about those corrupt researchers?  I’ve met many researchers, and can attest that few do it for the bucks.  They’re nerds and careerists who’d rather make associate professor than make money.  They live for clean data, elegant study designs, and the admiration of their colleagues when they publish a good paper.  They’re nice folks who do good science to save kids’ lives.

How can we get non-vaccinating parents to understand?  For years the American Academy of Pediatrics has advocated not kicking them out of practices.  The strategy is to see the kids, gain the parents’ trust, and teach them the importance of vaccination.  If the parents still don’t listen after some time, then the doctor can release the patient from their care, since the parent-doctor trust is broken.

A recent editorial in the AAP newsletter advocated a more aggressive approach.  The author evokes the great Indian leader Mohandas Gandhi, quoting him that we should “cling to the truth,” and in all ways stand up for it.  This means pushing for stricter laws on vaccination and school participation, and boycotting antivaccine businesses.  Picketing, striking, and even fasting are tools to show our seriousness.  This includes keeping non-vaccinated children from practices, schools, and extracurricular activities, where they could infect others.  We don’t want to punish these kids for their parents’s folly, but we don’t want other kids to catch life-threatening illnesses either!


Sometimes I wonder what I’d be like if I was born in 1800.  I’d be crippled, since I have an arthritis requiring regular medication.  Once the arthritis affected my eyes and without medication, I might’ve become blind.  Then one time a mosquito bite on my calf got infected, my knee swelled up, and it took surgery and a month of antibiotics to clean up.  In 1800 the cure for this infection, to save the patient’s life, was a mid-thigh amputation.  Without anesthesia.

Modern medicine gives me lots to be thankful for, not being a one-legged, blind, crippled guy.  In the late 1800s anesthesia was invented, so patients didn’t have to be strapped down and shriek through their operations.  Also at that time aseptic technique was discovered, so that patients wouldn’t get infected during surgery.  Before that, surgery was a last ditch effort to save people, since many died from bacteria introduced in surgery.  Then in the 1930s, antibiotics were invented, another breakthrough that made today’s whole Scott possible.  Finally, the 20th century brought anti-inflammatory and non-narcotic pain medication.  In the 1800s the only pain medications available were opioids like laudanum, which was opium dissolved in alcohol.  That would’ve made me a one-legged, blind, crippled narcotic addict.

My pediatric patients have lots to be thankful for as well.  When I was a kid, if a child developed leukemia, the most common pediatric cancer, he was certain to die within months of diagnosis.  Today, leukemia has cure rates above 90%.  The majority of my cohorts who had cystic fibrosis, sickle cell disease, congenital heart defects, extreme prematurity, were dead by the time I had my fifteenth birthday.  Today most of these kids will live into old age.

Finally, in 1900, one in ten babies died before their first birthday due to infections like diphtheria, tetanus, and, pertussis.  One in three were dead before age 5. Thanks to improved living conditions and vaccinations, these deaths are rare.  During my own 26 year career, the invention of  meningococcus, pneumococcus, and H. Flu vaccines have emptied pediatric wards that were once filled with kids with meningitis and blood infections.  Modern medicine has kept me whole, and countless of my own patients.

What if there was an apocalypse, and technology reverted back to the way things were in, say, 1800?  The best-selling book, Station Eleven, explores what life might be like if a flu epidemic wiped out the majority of the world’s population, and civilization collapsed.  The book jacket come-on asks, “What would you miss most?”  Coffee?  Electric lights at night?  Recorded music?  Air-conditioning?

If this sounds like science fiction, don’t get too comfortable in that thought.  In 1919 the Spanish Flu epidemic was unimaginably huge.  One in four people on the planet got sick.  Millions and millions died.  In some towns, so many were sick that there weren’t enough able-bodied to bury the dead.  Today, when things go bad with water supplies after hurricanes in parts of the world, there are still cholera and typhoid epidemics.  One bad virus could turn the whole world into post-Katrina New Orleans, with few left to keep the lights on, bury the dead, and maintain order.

The movie Contagion, with an all-star cast including Gwyneth Paltrow, Laurence Fishburne, and Matt Damon, tells a more likely scenario.  In this film, the flu epidemic wipes out a lot of people and whole cities are quarantined, with resulting movie mayhem.  However, the CDC and government keep a lid on things while struggling to isolate the virus and develop a vaccine.

So this Thanksgiving, be thankful for the good things modern medicine has given us.  Like we discussed above, medical advances have kept so many more children alive than a hundred years ago- kids with infections, cancers, sickle cell disease, cystic fibrosis, and extreme prematurity.  Don’t let thanksgiving become complacency either. Though we rarely see kids with diseases we vaccinate against- meningitis, pertussis, polio- doesn’t mean they’re not out there, waiting.  Make sure your kids have their vaccines.

When I worked in the Philippines in 1998, where many don’t have the luxury of vaccination, I saw two kids die of tetanus.  One was an un-vaccinated teenager from a rural village.  He had stepped on a sewing needle, which inoculated him through his foot.  He died a slow death by asphyxiation, as his chest wall muscles spasmed and wouldn’t allow him to breath.

Be thankful for vaccination! 

The Mumps Is Not A Muppet

This week’s guest columnist is Dr. Rati Venkatesh, a Family Practice resident at University Hospital and Clinics here in Lafayette.

This winter we’ve seen nearby outbreaks of Mumps in Arkansas and Texas.  Last week a mother brought her 3 year-old daughter into the Emergency Department worried about just that.  The girl had fever and headache and mom had just heard the news.  Instead the girl turned out to have influenza virus, which causes many of the same symptoms.  But this raised the question: what exactly is the Mumps?

Though it sounds like a muppet character, the mumps is an illness caused by a highly contagious virus.  The classic sign of mumps is swollen parotid glands, which are glands at the back of your cheeks.  When they swell you look like a chipmunk. Mumps usually starts with fever, headache, and maybe vomiting.  Symptoms also include cough, runny nose, poor appetite, muscle aches, and generally feeling run down.  Sure sounds like the flu- no wonder that mom was worried!

The biggest concern about mumps is that in rare cases it can cause encephalitis, or brain infection and swelling.  In teenagers and adults, it can also cause exquisitely painful swelling of testicles or ovaries.  Before the mumps vaccine was invented in 1967, people were understandably scared of this disease. Now with the MMR (Measles/Mumps/Rubella) vaccine, mumps has mostly passed into history books, except for the occasional case.

If there is a nearby outbreak, what do you do?  First, speak to your doctor.  If your child has concerning symptoms, she can order the mumps blood test.  A big clue to whether your child has the mumps is exposure- was your child around someone with mumps? Figuring this out can be tricky, because it can be weeks after exposure before you begin to have symptoms.  Who remembers where they were two weeks ago- it’s tough enough remembering what you had for lunch yesterday!  So usually when it comes to the individual kid, we count on the classic chipmunk-cheeks to make the diagnosis.

How do you get the mumps anyway? Transmission is by respiratory droplets, which means an infected kid coughs and sneezes, or wipes his slimy hands, on his playmates.  The new victims stick those virus-laden droplets on their fingers, into their noses and mouths.

So to prevent mumps, kids should do the things to prevent catching other infectious diseases, like colds and stomach viruses: they should wash their hands.  Frequent hand-washing should be taught and encouraged at home and school.  Hand sanitizer dispensers are readily available in public places, and are a reasonable substitute.  I teach kids to wash hands to the Happy Birthday song- if you wash all surfaces of your hands using the amount of time it takes to sing the song, you’ve done a great job of disinfecting.

Also use disinfectant wipes to clean household and school surfaces.  Those respiratory droplets and their viruses can linger on tables and doorknobs, and contaminate unsuspecting hands that touch them later.  Teach your kids to cough and sneeze into the crook of their elbows- this keeps grubby hands from infecting surfaces too.

If your child gets the mumps, the only treatment is for symptoms- there’s no medicine to make it go away quicker.  Use acetaminophen (Tylenol) or ibuprofen for pain and fever.  The chipmunk cheeks or swollen testicles of mumps can really hurt, so don’t skimp on those medicines!  Ice packs can also soothe these sensitive parts.  Most kids and adults get over mumps in about 2 weeks.  Occasionally children need hospitalization for pain control or IV fluids.  If they get encephalitis, they’ll need intensive care to control brain swelling.

Vaccination is great protection against mumps.  Kids get their first MMR shot at 12 months-old, and the second before kindergarten.  This vaccine is very safe, much safer than the car ride to the doctor’s to get it!  Some get a mild fever a week after vaccination, but serious complications are quite rare.  Like any vaccine, your child is incredibly more likely to catch and be harmed by mumps, than be harmed by the vaccine.

So all concerned moms and dads out there, if your child has flu-like symptoms (cough, fever, headache, fatigue) with swollen cheeks, it might be the mumps!  See your doctor for testing.  But with vaccination, odds are you won’t ever be in this worrisome place.

When Pediatrics Got Boring

It was 1990, my second year of residency.  I was in Emergency seeing a boy with swollen left eyelids.  I explained to his mom that he could have an infection that sometimes spreads into the eye socket, and the boy “might need a CT scan to see behind the eye.”

As I was talking, I pried open the boy’s eyelids to examine the eye itself and had one of those “Whoa!” moments: the eyelids themselves weren’t swollen, they were puffed out because the boy’s eyeball was sticking out of the eye socket; pushed out by infection. “He definitely needs a CT,” I corrected, not skipping a beat, “and possibly surgery to clean out the infection.”

This condition is called orbital cellulitis, and was quite common due to the bacteria Hemophilus Influenza (a.k.a. “H. Flu,” and no relation to the viral Influenza we get “flu shots” for).  But that year of my residency, the vaccine against H. Flu came out.  Vaccines had already existed against some viruses and a few bacteria like tetanus, but H. Flu was different, and required a pharmaceutical breakthrough.  That same breakthrough enabled invention of vaccines against Pneumococcus and Meningococcus, two other bad bacteria that caused lots of meningitis, blood infections, and pneumonia.

In the 26 years since, pediatrics has gotten, well, kinda boring.  Wards that used to be filled with sick and dying children infected by these bacteria, emptied out. You could almost hear the crickets chirping.  Which is great for kids.  However, the success of these vaccines and their predecessors- measles, diphtheria, pertussis, etc- has led to complacence about their need. Everyone used to know of a child who died or had brain damage from one of these diseases.  But now, “out of sight, out of mind.”

A recent poll of parents who don’t get their child vaccinated has revealed this false sense of security.  Many parents are afraid that vaccines are dangerous, but now even more think that they are just plain unnecessary.  But the scientific fact is that vaccines are safe, safer than riding in cars.  They may seem unnecessary just like seat belts might seem unnecessary when you’re just driving around-  right up until you get in a crash.

When kids get lacerations and need stitches, we always check if they are up-to-date on tetanus.  If they’re not vaccinated, we ask the parents to allow a tetanus shot. Tetanus infects deep wounds, and is deadly.  If parents are reluctant, I tell them about my experience in the Philippines.

In medical school I spent a month there, where for many, vaccines are an unaffordable luxury.  During that time I saw two kids die of tetanus- one teenager who stepped on a needle, one newborn who had her umbilical cord painted with some concoction by a village healer.  Tetanus is also called Lockjaw because it causes muscles to freeze up, including the jaw and chest muscles used for breathing.  When those lock up, the child slowly dies of asphyxiation.

Despite pediatricians’ recommendations, some parents won’t get their kids vaccinated. Some think they’re unnecessary, like we discussed above. They’ve been lulled into complacency, since they don’t know anyone whose died of the diseases we vaccinate against (see how that worked?).

Some worry that vaccines are dangerous.  They hear vaccines cause autism, or contain poisons.  There are even internet sites which claim vaccination is a money-making conspiracy between drug companies and doctors.  I’ve had moms whisper to me, “What’s really the truth about vaccines?” like it’s a big secret.

The truth is vaccines are simply a modern technology, like cars and cell phones, and everyone seems comfortable with those.  Vaccines have been extensively studied and tested for safety.  In fact, vaccines are safer than riding in cars, and we certainly know more about vaccine safety than we do about cell phones!

It’s frustrating for pediatricians trying to convince these parents otherwise. There’s a psychological phenomenon called cognitive dissonance, wherein if someone has a set belief, no amount of facts will sway that belief.  This phenomenon explains why people support political candidates despite data, or the candidate’s own past words, that highlight that candidate’s insincerity.  If you’re pulling your hair out because your political opposites just won’t see reason, that’s how pediatricians feel when discussing vaccines.

So give your pediatrician a break- get your kids vaccinated.  Oh, and you also might save their lives.


Vaccinations: The Good Old Days Weren’t So Good

In the late 1940s and early1950s, families had two big worries.  One was of a third world war with the horrible new weapon, the atomic bomb.  The second was that children would get polio.  Polio was on the rise.  Every summer a new epidemic claimed more victims than the last.  Polio crippled kids.  Imagine worrying that your child would end up in a wheel chair, or with permanent need for crutches and leg braces.  Too many times, polio killed. 

Then in 1955, a research team headed by a Dr. Jonas Salk perfected a polio vaccine.  A huge immunization effort mobilized.  Dr. Salk was hailed as a national hero; everyone saw his picture and knew his name.  In a few years, polio and the mass fear it caused were all but gone. 

Before 1990, vaccines were universally seen as a good thing.  They prevented diseases that had cursed mankind for centuries.  Everyone wanted their kids vaccinated against these ancient killers: tetanus, measles, pertussis, diphtheria, smallpox, polio.  They weren’t often nice deaths either: tetanus, pertussis, and diphtheria kill by suffocating the child.

Then in 1990, researchers had the last big breakthrough in vaccines- vaccinating against killer bacteria.  The last of the really bad actors, Haemophilus Influenzae, Pneumococcus, and Meningococcus, began to disappear.  Ancient fears disappeared.  Generations since have forgotten how in 1900, one out of every ten babies died before they got to their first birthday. 

People since have begun to ask: why are we putting these chemicals into our children’s bodies?  Why are they enduring these painful shots?  No one seems to be dying around us.  Now people are starting to refuse to get their children vaccinated.  1990 is also when the Internet began to rise.  The Internet is great for spreading information, but it is also great for spreading ignorance.  Search for vaccinations on the net, and you will get lots of sites on how immunizations are somehow poisonous to your child.

My message is simple: don’t get complacent about the good vaccines do.  No one seems to be dying of these contagious diseases because of vaccines.  Vaccines are safe.  Vaccines work even when they are all taken at once.  If you want more information on vaccines, go to the experts: the American Academy of Pediatrics. 

And get your children their shots.

Why Does My Child Need All Those Shots?

The room was suffused with pale light.  There was no noise, no breeze.  Two children lay on hospital beds, sedated.  The only sign of distress would come every few minutes when one of them would tense his whole body, breathing hitching, face clenched.  Both children were almost certain to die.  They had tetanus.

It was 1989, and I was rounding with pediatric residents in a hospital in the Philippines.  I was there for a month-long elective during medical school, and spent my mornings learning about diseases we rarely see in the United States.  We rounded on our two tetanus patients every morning, doing what little we could, and waiting.  Finally one morning when we came by, the room was empty.   

  In the Philippines, vaccinations are a luxury that many cannot afford.  One of the children was a teenage boy who stepped on a pin.  A tiny injury, but the pinhead must have held a few spores of the Claustridium Tetani bacteria.  Driven deep into his foot, where there was little of the oxygen that prevents tetanus from growing, the infection flourished.  The other child was a newborn who had had his umbilical cord painted with a dirty concoction by the village healer.

When someone gets infected with tetanus, the bacteria puts out a poison that causes all the body’s muscles to freeze up.  Some of the strongest and most obvious muscles are those one chews with- hence the slang “Lock jaw.”  In the Philippines, where they have few Intensive Care Units, the best the doctors can do is give the patients Valium in an attempt to help the muscles relax.  The room was so quiet and calm because any noise, any breeze, any stimulation triggers the muscle spasms. 

However, such treatment is a fool’s errand.  The muscles spasm anyway, most concerning the muscles of the ribcage.  When they spasm, the patient can’t breathe.  Tetanus is a slow death of oxygen starvation.  Even with more high-tech intensive medicine in the US, tetanus still kills up to a third of its victims. 

In the days before vaccines such infections terrified people.  Diseases like tetanus and diphtheria killed individually.  Other epidemic infections, like polio and influenza, killed in waves.  In 1919, 1 to 3% of the world’s population died of Spanish Influenza; one out of every four persons on the planet was sick with fever and cough.  In some places, there were not enough well people to bury the dead.  In 1952 the polio epidemic had every parent in the United States worried that their child would end up a leg-braced cripple, or dead.

But these days, such terrors of the past have been forgotten (except in movies like Contagion, which was all the more scary because it was so scientifically accurate).  Vaccinations that prevent such diseases have made us feel safe from deadly infection.  And now, in such an atmosphere of comfort, people forget why we vaccinate.  Some even question the safety and use of vaccination.  Myths about vaccination dangers have become mainstream “knowledge.”

Here are some more commonplace vaccine myths- all NOT true:  If you take too many vaccines at once, they don’t all “take.”  Fortunately, this is not how the immune system works- it does not have limited “energy” to take on new tasks.  Another myth is that you can’t take a vaccination when you are sick with a cold or on an antibiotic.  Again, the vaccine will “take” and not make you any sicker, except a few vaccines that might give you a small fever.

The bigger myths are more scary: vaccines cause brain injury, vaccines poison.  These side effects, if true , are very rare.  Concerned doctors and scientists have been trying for decades to find a connection between these alleged bad side effects and the vaccines, and have been unsuccessful.  Thus this wisdom still holds true: your chance of being harmed by a disease is gigantic compared to your chances of being harmed by the disease’s vaccine.  In other words, getting the vaccines is safe; getting the diseases is not. 

So make sure your kids get their shots on time.  Get your shots too- tetanus and flu.  That is the best way to avoid…..CONTAGION!