Archive for the ‘In the news’ category

Pertussis is making a comeback – what’s the best protection?

June 12, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

Pertussis is also known as “whooping cough”, or sometimes “the 100 day cough”, or sometimes “DAMMIT WHY CAN’T I STOP COUGHING?!”. It is truly miserable. In adults and teens, three months of coughing – and I mean serious, loud, hard coughing, sometimes until you break a rib, vomit, or pass out – is not fun. Young babies, instead of coughing their little heads off, sometimes just stop breathing.

Unfortunately, it’s making a comeback. Both national statistics and our experience at my offices are showing increasing numbers of pertussis cases. Pertussis had become very uncommon with widespread vaccination by the 1980s. Why is it back?

(Aside: about 25 years ago, in my very first month of training as a pediatrician, I was taking care of a newborn in the emergency department who stopped breathing. Completely. Just stopped. Turned blue and floppy. I was terrified, but kept my cool and performed mouth-to-mouth resuscitation. The baby did fine. Later, my attending told me to never use my mouth on a baby – there was resuscitation equipment literally hanging on the wall behind me that I didn’t think to use. Oops. Later, I found out the baby had pertussis.)

The first pertussis vaccine was developed in the 1930s, and in the 1940s it was combined with tetanus and diphtheria vaccines to create the “DTP” vaccine. This was very effective at preventing pertussis, but it was quite “reactogenic”. DTP commonly causing fevers and sometimes febrile seizures (which, by themselves, are harmless – but really scary.) There were cases of encephalitis and dramatic developmental regression seen, too, though it’s become clear since then that these were cases of the genetic condition Dravet Syndrome, which unfortunately starts showing symptoms around the time DTP was given. The quest was on for a pertussis vaccine that caused fewer fevers, and a newer, more purified “acellular” DTaP was developed.

After extensive studies showed that the DTaP was effective and caused fewer fevers, the acellular vaccine replaced the older, “whole cell” vaccine in the US and many other developed countries in the 1990s. And, at least at first, things seemed to go well. Pertussis cases remained low.

But we’ve seen a steady increase in cases over the last 10-15 years. Part of that could be ascertainment bias – there are newer, better, and faster tests for pertussis that have come into wider use, and doctors think about testing more kids for pertussis now that’s clear there are more cases. That doesn’t explain all of the increase.

A study published this week in Pediatrics has helped clarify what’s going on. About a half million children managed at the huge Kaiser Permanente system in Northern California were studied, looking at their pertussis vaccine status and the rates of proven cases of pertussis in the group. Almost 750 cases of pertussis were documented in these children from 2006-2017, revealing some important conclusions:

  • Pertussis risk, overall, was 13 times higher in unvaccinated versus fully-vaccinated children. The vaccine is protective.
  • Still, 80% of the cases occurred in children who had received the full set of doses. Pertussis immunity dropped off over time – and the longer since the most-recent dose, the more at-risk a vaccinated child became.

So what should we do?

First: widespread, continued universal DTaP vaccinations in infancy and Tdap boosters for preadolescents is still a good idea. It is far better than not vaccinating. The Kaiser data clearly shows vaccinated individuals are at lower risk. Since one of the highest risk groups for severe disease is newborns, vaccinating pregnant women is a key strategy. Though maternal pertussis immunity after Tdap doesn’t last long, it does last long enough to transfer protective antibody to the unborn baby, providing crucial protection during the first few months of life.

But we clearly need a better vaccine and other strategies to provide better, more-lasting protection. Alternatives are being studied, including a nasal-spray pertussis booster and new, adjuvanted vaccines that can hopefully provide more-lasting protection safely. New vaccines take many years to study, so don’t expect anything on the market soon.

In the meantime, we need to do the best we can. Make sure you and your children are fully vaccinated against pertussis, and follow the recommendations for all vaccines. We need to be a better job developing better tools, but in the meantime we could be doing a better job using the tools we’ve already got.

Chicken pox vaccine prevents shingles, too

June 10, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

A study published today in Pediatrics confirms good news about routine chicken pox vaccination in children: it also prevents shingles. Smaller studies had seemed to show this was likely, and this huge new study of over 6 million children nails it down. And: the benefit seems to apply to all of our children, even those unable to be vaccinated.

A little background: chicken pox and shingles are both caused by the same virus, named “Varicella Zoster Virus”, or VZV. When people first catch this very contagious illness, they get a painful and itchy rash accompanied by fever – that’s chicken pox. It’s a miserable experience – I remember when I had it, a summer long ago – that can also lead to complications like pneumonia, life threatening skin infections, and encephalitis. Even when you’ve recovered from chicken pox, the sneaky devil-virus hides in your nerve cells, waiting for an opportunity to swing back into action. And that recurrence of symptoms is what’s known as shingles, or “zoster” – a very uncomfortable rash that can leave lasting pain that can very difficult to control. Zoster especially likes to pop back up when you’re already sick or having other health problems, just to give you an extra poke in the eye.

“Remember me?” VZV says. “Have some pain!”

A vaccine to prevent VZV infections was developed in Japan in the 1970’s. It was specifically targeted at first for children undergoing chemo for leukemia, because so many of them were dying of overwhelming VZV infections (in people with suppressed immune systems, primary or recurrent VZV infections can be devastating.) The vaccine was very successful in saving lives and preventing misery in these children, which led to more-widespread testing in healthy kids and the adoption of widespread chicken pox vaccinations in the 1990’s. Later, it was shown that two doses worked better than one, and the current guidelines in the US recommend two doses be given routinely to all children starting at 12 months of life. This protects not only the children who get the vaccine, but their families and their communities, including people who can’t be vaccinated and children and adults on chemo or other medicines that suppress their immune systems (By the way: there are a lot of these people around. Including some of your friends and their children. Immune-suppressing “biologic” agents are now used routinely to improve the lives of people with psoriasis, Crohn, rheumatoid arthritis, and many other diseases. You’ve got friends, neighbors, and coworkers on these medicines. You can help protect them.)

A fair question to ask: do routine chicken pox vaccines also prevent VZV from recurring – that is, do they prevent shingles? Those studies in immunocompromised children showed it definitely did, but we needed years of data to prove that it was also effective in the broader population, because shingles may occur many years after chicken pox. And now, we’ve got solid data.

This study was done at six sites in the US, mostly in California, following the medical records of 6,372,067 children for 12 years. The results are impressive. First: rates of zoster/shingles dropped dramatically in the whole population, by about 50%, over the 12 years. Even in children who weren’t vaccinated, zoster is boing prevented by the use of this vaccine. But the effect was much larger children who did get the vaccine, and larger still among children who got the full course of two doses rather than one.

Vaccine science is always evolving, and important studies continue – there is always more to learn. All of the good evidence so far had shown that this vaccine was preventing both chicken pox and shingles, and this long-term, huge study adds to the evidence. Make sure your children and your family are up to date on their vaccines, including this chicken pox vaccine, to best protect yourself and your community. We’re all in this together, folks. Do the right thing. Vaccinate.

 

Measles update: Which adults need a dose of MMR vaccine?

May 9, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

While the vast majority of measles cases in the US and worldwide are occurring in unvaccinated children, a fair percentage is also occurring in adults.  With more-widespread transmission of measles, it’s becoming more important for all of us – yes, that includes parents – to make sure we’re well-protected.

Measles is probably the single most contagious infection that humans face. The key to preventing the return of widespread measles is in keeping vaccination rates high, so even if there is a case it cannot spread or cause an outbreak. Once there’s a neighborhood, school, or community with a concentration of unvaccinated individuals, it’s only a matter of time before measles returns and spreads widely.

Though we’re used to our children getting vaccinated on well-established schedules that ensure vaccines are safe and effective, many adults have fallen through the cracks.

People born before 1957 are presumed to be immune, because measles was so widespread in the past that almost all children contracted the infection.

Adults considered at “high risk” include healthcare workers, international travelers, those who are living in communities with outbreaks, and university students (I would also include all adults who teach and work in universities, though that’s not part of the official CDC high risk group). If you’re in these groups, you should have had TWO doses of MMR to ensure immunity. If you’ve only had one, get another; if you’re not sure if you’ve had any, get two doses. The second dose should be 4 weeks or more after the first.

Other adults (those born after 1957 and who do not live in a community with measles transmission) are considered immune and protected if they’ve had one dose of MMR.

For people born between 1957 and 1968, there’s a catch. Some of the measles vaccine used then was an inactivated vaccine that didn’t confer good immunity. If you have documentation that your vaccine was the “live” vaccine, that’s the good one. If you’re not sure which you received, get one dose of the current MMR to make sure you’re protected.

An alternative to receiving the vaccine, if you’re unsure of your vaccine status, is a blood test for measles titers (IgG antibodies.) If your titers are high, you’re protected; if they’re low, you need another dose of MMR.

The MMR vaccine shouldn’t be given to people with compromised immune systems or pregnant women, though it is fine for nursing moms.

Bottom line: if you’re an adult and you’re not sure if you’re adequately protected, you should receive at least one dose of MMR.

 

From the CDC:

Current outbreaks

More info about measles

 

What’s the best timing for my child’s measles vaccine doses? Should we give them early?

May 7, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

As the US endures its largest measles outbreak in 25 years – one that’s almost certainly going to get worse before it gets better – we’re getting a lot of calls and questions at my office. What’s measles, what’s the best way to prevent it, when should the vaccine be given to adults and children? I’m going to do a series of mini-posts, just focusing on one question at a time. We’ll see how this format works out – let me know if you like it!

The measles vaccine is given as “MMR”, which teaches the immune system to fight off measles, mumps, and rubella. It’s a very effective vaccine that confers lifelong immunity. A single dose is about 93% effective, and two doses get that up to 97%. There aren’t many other preventive interventions in medicine that are even close to that good.

The first dose should be given between 12 and 15 months of age, though at this point I’d say 12 months is better. Why wait until 12 months? Earlier than that, babies may still have enough antibodies from their mother to partially block the effectiveness of the vaccine.

But in some circumstances, you should get that first dose early, as early as six months. If there’s a high risk of exposure, an early dose (though imperfect) will give at least some protection. That dose should then be repeated at 12 months. Who’s at high risk of exposure? Anyone who’s living in a community with cases of measles – that includes, as I’m writing this, areas of New York, Michigan, and California. Plus the Philippines, Israel, and Ukraine. And, really, most of Europe. If you’re traveling with your baby under 12 months out of the US (or even within the US), you should look at the news and talk with your child’s doctor about getting an early dose of MMR.

The second dose of MMR is traditionally given at age 4-6 years, prior to school entry. But that timing was chosen for purely administrative reasons –kids almost always come in for a preschool physical, and they also need doses of polio and DTaP vaccines, which must be given after the fourth birthday. But that second dose of MMR can be given much earlier. It will be just as safe and effective if given any time 4 weeks or more after the first dose. So if the first dose is given right at 12 months, the second dose could be given at 13 months (or, more likely, at 15 months, since that’s when the next check-up age falls.)

Again, if you’re living in or traveling to an area experiencing a measles outbreak, you should get that second dose early. There is no downside. Honestly, there’s no reason why any of our young babies should wait until age 4 to get it – it’s just a bit of history and convenience that placed the second dose at age 4. If your children do get the second dose early, keep in mind that they do not ALSO need a dose at age 4 (though a third dose will not be harmful, it’s just not necessary.)

 

More info:

The nitty gritty details about the history of the MMR vaccine and its timing

Measles from the CDC

Telehealth leads the way in antibiotic overprescribing

April 8, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

You’ve seen the ads, and you may have even gotten a flyer in the mail directly from your insurance company. Use an app to make a quick video call to get the medical care you need. No waiting rooms, no appointments, no having to be touched or even sit in a room with a physician – just the magic of the internet, and you’ll get what you want.

But will you get what you need?

Today a study was published in Pediatrics showing that pediatric remote telehealth visits are far more likely to result in an antibiotic prescription than an in-person visit with a doctor. Researchers looked at a total of about 500,000 visits for acute respiratory symptoms (typically common colds) from 2015-2016, matching visits by things like age, medical complexity, location, and the diagnosis. They then looked to see how many of the encounters resulted in an antibiotic prescription, separating out telehealth, urgent care, and primary physician visits. By telemedicine, here, they looked only at direct-to-consumer telemed visits, the kind you’ve seen advertised by private companies and promoted by your insurance.

Before we look at the numbers, let’s ask:  how many of these visits should have resulted in an antibiotic prescription? Among respiratory diagnoses, infections that typically “need” antibiotics include strep pharyngitis, otitis media (ear infections), sinusitis, and pneumonia. By the way, even these infections don’t necessarily always need an antibiotic – in many cases, they’ll improve just fine and just as quickly without a prescription. But for a generous benefit of the doubt, let’s assume all visits with these diagnoses should have ended with an antibiotic prescription, and that visits for diagnosis with a viral cause should not have resulted in an antibiotic.

The study found that among all of the visits examined that had a clear-cut diagnostic code, 27% were for a diagnosis that should typically result in an antibiotic prescription. Keep that figure in mind – 27% of these encounters, to fit within well-established, evidence-based guidelines, should have had an antibiotic prescribed. The other 73% were for viral infections (almost all of these were for common colds.)

So how did the groups do in this study? Primary care physicians prescribed antibiotics 31% of the time/ That’s pretty darn close to 27%, so good on them. Urgent care centers didn’t do quite as well in meeting the guidelines, prescribing antibiotics at 42% of visits. And the telemed visits did the worst, prescribing antibiotics 52% of the time, about twice as often as they should.

Why should anyone care? Antibiotic overuse is a huge problem. On a community level, we’re creating legions of superbugs becoming resistant to ordinary antibiotics. We’re also risking c difficile colitis, allergic reactions, and other health problems. But worst of all, to me, is that these antibiotic prescriptions create a creepy, self-fulfilling over-reliance on prescription medications. In a way, overprescribing is a good business model – it leads to repeat business, as your patients grow to expect to need a prescription for every cough. But it’s certainly not helping anyone become healthier.

Telemedicine is here. I get flyers directly from my insurance company, encouraging me to try it out instead of visiting my doctor. It’s quick, it’s easy, and it’s cheaper for the insurance company. They love it. And I think telemed does have a role for diagnosing and treating some health problems (especially mental health issues or follow-ups that don’t require a physical exam.) But the way it’s commonly done now isn’t delivering good care. We need to figure out the best way to deliver quality medicine via telehealth platforms – not medicine that’s cheap, quick, and harmful.

Chocolate best for cough? How to spot misleading headlines

February 25, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

I’ve got a new course out – The Skeptic’s Guide to Health, Medicine, and the Media available in video from The Great Courses or audio from Audible. Both have trial offers, free returns, yada yada, check it out! I didn’t cover the chocolate-for-cough story below in the course, but if you find it interesting, or want to learn more about the best way to review health articles with a skeptic’s eye, this course is for you! Why not buy a copy for a friend, too? (Hey, never hurts to ask!)

Everyone loves chocolate, and nobody likes to cough. So when headlines like these appeared, it made a big media splash:

Apparently Chocolate Might Be Better for Treating Coughs than Honey and Lemon – from UK’s Metro

Chocolate Fights Coughs Better Than Codeine, Says Science – from allrecipes.com

Chocolate Is a Better Cough Suppressant than Medicine, Study Says – from The Atlanta Journal Constitution

Never Mind Honey and Lemon, the Best Cure for a Cough is CHOCOLATE: Leading Professor Busts Common Cough Myths… — from The Daily Mail

Looks good, huh? Chocolate for a cough – and the headlines say it’s better than medicine, based on Science! These are legit, big news organizations (well, maybe not allrecipes.com, but I threw that in there to illustrate just how pervasive these stories can get). You’d think they would have dug a little bit to see if their own headlines were true.

But they didn’t. If you want to know what The Science really says, you have to read past the headlines and past the media spin. The best way to do that is to look at the actual study – where the information, originally came from. If you review the articles above, many just point to each other, or quote experts. But with a little digging, I found the actual study that lead to these headlines here.

So what did the study actually show? They didn’t compare chocolate to codeine, or honey, or lemon – so any headline that made that comparison is false. And the study medicine itself wasn’t just chocolate, it was a mixture of three active medicines in a chocolate base. So any conclusion that it was the chocolate itself that made the difference is, well, silly and unjustified.

The study compared the chocolate-mixed medicines (a brand called “Unicough”) to another kind of cough medicine, called “simple linctus,” which contains a single ingredient not found in Unicough. If the authors wanted to look at the potential effect of the chocolate, they should have compared two identical products, one with and one without chocolate. But that’s not what was done.

And: the study itself was negative. That is, for the primary endpoint of the study, there was no difference in cough among people taking the chocolate-containing Unicough versus the “simple linctus.” There were some differences in what are called “secondary outcomes,” but that doesn’t mean the study showed that Unicough was superior. And: the study itself was funded by the manufacturer of Unicough, and one of the authors was a Unicough employee. Somehow that wasn’t mentioned in the fawning media stories.

The chocolate-for-cough study was misrepresented, and its conclusions reported incorrectly. Unfortunately, this is common in media portrayals of health news. There were some skeptical outlets that tried to present the other side of this story, but as so often happens the voice of reason was too little, too late. The story had already developed a life of its own. If you think chocolate might help your cough, go ahead and try it – but don’t be fooled by headlines like these.

Eager to learn more about interpreting media stories? Check out my new course! I cover many more examples of both good and bad reporting, and will teach you how to tell the difference. They’ve got it at Amazon too! What are you waiting for?! Go buy buy buy now!

Rabies, bats, and a tragedy in Florida. How to protect your kids.

January 17, 2018

The Pediatric Insider

© 2017 Roy Benaroch, MD

You’ve probably already seen the news: a 6 year old boy in Florida has died of rabies. He had handled a sick bat (some reports said he was trying to rescue the critter), and that was enough contact to transmit the virus. Once symptoms begin, rabies in almost always fatal – so the only way to prevent this from happening again is to avoid contact, and get rabies prophylaxis (a series of injections) if there’s an exposure.

 

Is rabies common?

Yes – in a way. In the US there are only a handful of human cases a year (43 cases from 2000 through 2013, the most recent statistics I could find.) But there are an estimated 60,000 deaths a year worldwide. So, travelers, be especially wary of animal exposures overseas. In fact, if you’re traveling to the developing world to an area with likely animal exposures and no access to medical care, it may be wise to get rabies immunizations beforehand.

 

How can people catch rabies?

It’s a zoonotic infection, meaning we catch it from animals. Only the saliva transmits rabies virus, so most infections come from bites (or sometimes scratches, since animals aren’t always so keen on washing their hands with soap and water.)

Any mammal could potentially become sick with and transmit rabies, but in the US almost all transmission is from a few carnivorous animals: bats (by far the most common source, accounting for all but 4 of those 43 cases), raccoons, skunks, foxes, coyotes, and bobcats. Small rodents (rats, mice, squirrels) and lagomorphs (rabbits, hares, and pikas) would very rarely be possible carriers. Animals with rabies may act sick, and may be especially aggressive or bitey, so always be wary of any sick mammal, especially bats.

Worldwide, the most common source of human rabies are domesticated and semi-domesticated dogs. A campaign to vaccinate pets and farm animals has virtually eliminated this kind of transmission in the US – so keep vaccinating your animals!

 

What are the symptoms of rabies?

The incubation period is typically 1-3 months, though it can be days or years after exposure before symptoms develop. It’s a quickly progressive illness that often begins with acute anxiety, pain and other sensory abnormalities, unstable blood pressure and pulse, and sometimes “hydrophobia”, an extreme fear of water. (Hydrophobia is a historic name for rabies.) These symptoms progress to coma and death.

There have been three reported survivors of rabies over the last 20 years, all teenage girls treated with a very aggressive protocol of intense medical support, including medical-induced coma and artificial ventilation. Despite this care, most patients will die.

 

What should I do to prevent rabies?

Make sure domestic animals are vaccinated, and take them to the vet if they’re sick.

Approach wild animals with respect, and teach this to your kids, too. Wild animals should not be approached, or trapped, or captured, or kept as pets. If you see an animal that’s acting sick, especially a mammal, stay away. If it’s the kind of mammal that’s likely to transmit rabies (a sick or wild dog, or a raccoon, skunk, fox, coyote, or bobcat), contact animal control or your county health department. Keep children away.

  

What if someone gets bitten or scratched by one of these animals?

First, clean the wound with soap and running water. Then go see your doctor, or go to the emergency department. Do not delay. If necessary, post-exposure injections can be given which will virtually guarantee that rabies won’t occur. These injections will not help once symptoms begin – they must be given before rabies develops. Public health people and other experts consider the circumstances of every case before deciding whether rabies prevention is needed – don’t rely on this post, or what you read on the internet, to decide if you need rabies shots. Go see a doctor right away if there’s been a potential exposure.

If it is possible to do it safely, trap or capture the biting animal. That will prevent other people from getting exposed, and will allow health authorities to test the animal for rabies.

In some circumstances, a biting animal can be observed in captivity for 10 days for signs of illness.

 

What about bats?

Bats are a special circumstance. They’re the most common rabies transmitter in the US. And small bats, especially, could potentially bite a sleeping person without anyone noticing. Young children may not be able to communicate exactly what happened during a bat incident. So if there’s a bat that’s been in a room with a sleeping child, or a child who’s been playing with a bat or near a bat for any reason, go see a doctor. (If you can capture the bat, or kill the bat and bring the carcass including the head, that can help – only if you can do this safely.)  Even if the risk of transmission is low, the consequences of not treating a rabies exposure are horrible.