Archive for the ‘In the news’ category

Goodbye, Flumist: Why science is important

June 23, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Yesterday the CDC announced that its Advisory Committee on Immunization Practices (ACIP) voted to stop recommending the nasal spray flu vaccine, Flumist, for anyone. Bottom line: it doesn’t work. Though their recommendation against the use of Flumist still has to be approved by the CDC director to make it “official”, it’s pretty much a done deal. The AAP’s president has already endorsed the announcement, too.

Bye, Flumist. We’ll miss the ease of use and the not-scaring-children part, but the data’s clear. The mist doesn’t work. There was a sliver of good news, though—we have solid surveillance data from last year re-confirming that the traditional flu shot does work, with an estimated effectiveness of 63% last year. That’s not outstanding, but it’s pretty good. From a public health point of view preventing 63% of influenza cases can have a huge impact. Remember: every case prevented is one fewer person out there spreading influenza. Effective vaccinations not only help the person who got the vaccine, but the whole family and community.

Older data, at one point, had shown that Flumist was as effective (or even more effective) than the flu shot. For a few years, the mist was even considered the “preferred product” for children, because it seemed to work better.  Last year, Flumist lost its “preferred” status when data emerged showing that it wasn’t looking as good as the shot. Now, enough newer data has accumulated to show that at least against the strains that have been circulating recently, Flumist doesn’t work at all.

There’s going to be a scramble (again!) this year to ensure an adequate supply of injectable flu vaccine. I don’t know if MedImmune will suspend the Flumist program, or if they’ll still try to sell their product – but I am sure that there are a lot of docs out there scrambling this morning, trying to cancel Flumist pre-orders and increase our orders for alternatives. In the long run, that will be better for everyone. In the short run, it’s a problem. Families ought to plan to get their flu shots as early as possible this year, before they run out.

Science isn’t a set of answers, or a body of knowledge etched on a stone somewhere. It is a method of arriving at the truth, involving repeated observations and the continuous re-assessment of data. Estimates of vaccine effectiveness (and safety) are initially based on licensing studies, but they’re then adjusted by real-world data that continues to be collected, year after year. We should always make the best decision we can, based on the best data, even if that means we have to sometimes admit we’ve made a mistake, or that we have to change our minds. That’s not a weakness of science or medicine – that’s a strength. We can’t always promise to get it right, but we’ll keep studying and learning and trying to do it better.

Squirt!

Protect yourself from cell phone radiation journalists

May 31, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

The media is agog over a new study, one tailor made for clickbaiting. Staid, boring old Wall Street Journal proclaimed “Cellphone-cancer link found in government study.” Mother Jones called the study “Game Changing”, and NaturalNews’s headline screams “Massive government study concludes cell phone radiation causes brain cancer.” (They also say “On all of these issues, Natural News has always been right!” Google it if you want. I’m not providing a link.)

The new data is from a preliminary release of data from 2,500 rats and mice. It hasn’t been peer-reviewed yet, or scheduled for publication. We have no idea what happened to the mice involved in this study – they weren’t mentioned. Maybe they were busy.

The rats were kept in an underground bunker (which protected them from the sun, a much larger source of radiation exposure.) Special enclosures exposed the experimental rat volunteers to cell phone radiowaves starting at gestation, through the first two years of their lives. Intense radiowaves bathed their entire bodies for 10 minutes on, 10 minutes off, 18 hours a day. For two years. Extrapolating from rat lifespans, that’s equivalent to about 50 human years. Think about that exposure: 50 years, starting before birth, using cell phones mashed up against your entire body for 9 hours a day. I get it, they want to use an absolutely maximal exposure to find even a small signal of increased risk. But does that sound remotely realistic?

Compared to the control rats, male (but not female) exposed rats had small numbers of cancers in their brains and hearts – in most groups, 1 or 2 out of 90. The control rats had zero across all of the subgroups, which is itself a surprise – these were lab rats bred to develop cancers, so cancer-causing exposures could be studied. The control (unexposed) rats also had a weirdly high early death rate (remember, this group didn’t have cell phones. They were bored to death, maybe.) In all seriousness, that seems to be a big flaw. Since cancer takes time to develop, rats in a shortened-lifespan group would almost certainly have fewer cancers at autopsy. Still – zero? Were they looking hard enough?

The new study certainly raises some good questions. How could radiowaves contribute to cancer? There’s no established plausible mechanism at these levels. Why were the results only seen in male rats? What about the mice, were they similarly affected? Why did the non-exposed rats die off early, and could that explain the effect? How do these exposures compare to a typical human way of using a cell phone, holding it in your hand to text or use an app? These are good questions. Too bad journalists covering the study didn’t try to answer them.

Ironically, just a few days earlier, a much larger study (of 45,000 people) showed exactly the opposite. What, you didn’t hear about the huge Australian study that showed no increased risk of brain cancers since the introduction of cell phones 29 years ago? Perhaps the science media is more concerned about rats than Aussies. They’re certainly more eager to get your clicks than to provide accurate or useful information.

A rat.

Toxic mold? No, toxic scam

May 10, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Props to a local reporter here in Atlanta for uncovering quackery – not just quackery, but outright fraud. Randy Travis (not the other Randy Travis) with Fox5 has investigated an unlicensed non-doctor, Michael Pugliese, who operates the National Treatment Centers for Environmental Disease right near my practice in Alpharetta, GA.

Though his victims are told to call him doctor, it’s unclear what (if any) medical training Mr. Pugliese has had. What is clear is that worried people from around the country have gone to his clinics for treatment for all sorts of ailments. After a $3,300 up-front fee, all of them, based on his testing, are told that they’re suffering from the ill-effects of mold. And all of them are sold a variety of supplements and nose-sprays, some of which are made in his laundry room. Adding insult to injury, they’re told to eat canned chicken three times a day. That’s just weird.

Read more details of the investigation here and here.

The whole “toxic mold” thing is another money-draining, predatory quackfest. It’s not clear at all that mold causes any of the neurologic symptoms or other Big Problems it’s being blamed for – but that hasn’t stopped lawyers from suing, and scamsters from setting up fake labs and giving themselves fake credentials.

Mold can be an eyesore, and sometimes makes houses smell musty. Some people are allergic to indoor molds, which can then trigger symptoms like itchy eyes or noses, or worsening asthma symptoms. These symptoms can be prevented and treated by talking with a primary care doc or allergist.

But beware: there are a whole lot of scammers out there looking to take advantage of people. These are people who are hurting, and who have genuine concerns, and they’re looking for answers. It’s sad how many of these alt-health fraudsters are so eager to suck their bank accounts dry, preventing them from getting the real help they need.

 

Zika update!

April 4, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

I last wrote about Zika in January*, and there’s a whole lot more we now know about this mosquito-borne virus. And still a lot we don’t know. Time for a Q&A-styled** update!

 

Give it to me straight, doc. Does Zika really cause birth defects?

Yes. As is typical for scientist-written press releases, early reports this winter were equivocal—you’d see phrases like “is associated with” or “likely caused by”. That’s because unlike pushers of GMO-free foods, real scientists try to respect the intelligence of their audience. Back then, it was clear that there was both a big spike in cases of Zika-associated illness during pregnancies (mostly in South America), and a big spike in cases of microcephaly and other neurologic birth defects. But did one cause the other?

More-recent reports have included evidence of Zika in the brain tissue of affected fetal brains, and also in the brain and nerve tissues of children and adults suffering from neurologic symptoms during Zika infections. It’s clear that Zika is a neurotropic virus – it likes to invade neurologic tissue.

We also know more about the structure of Zika. At the molecular level, we know it has a structure that interacts with brain cells. That is completely cool—we know exactly what the virus looks like and how its molecules are arranged. That’s one step away from designing a vaccine. All of this research was done in just a few months. Science!

 

Is Zika coming to America?

It’s already in America, dummy. South America, which (last time I looked) was part of America. Oh, you mean North America? Which includes Mexico? Which is also part of America? Maybe you should just start over.

 

Is Zika coming to the United States?

It’s already here. Zika-virus associated infections have been reported in almost every US State, though at least so far the only locally-acquired cases have been transmitted through sex. (No, not sex with mosquitoes, you sicko.)

 

OK, so that means as long as I don’t have sex with anyone who’s been traveling, I’m protected, right?

Maybe for now, but not for long. Over 300 cases of Zika have occurred in the continental US, and even more in our Caribbean territories. And the mosquitos that transmit ZIka, by mid-summer, will be found in a wide swath of the US, across the entire souther border, reaching up into Ohio and Missouri. It is only a matter of time before local mosquitos stare biting people with Zika infection, and then spreading it to other people.

 

 Yikes. I’m glad I’m not a pregnant woman!

So are we. We’ve seen the quality of your questions here, and frankly it would be better if you didn’t reproduce.

 

I meant I’m glad only pregnant women need to worry about infections. Right?

Nope. Pregnant women, and their unborn babies, are clearly at the highest risk. It looks like about 25% of the time, infection during pregnancy results in fetal damage—though that’s an estimate based on preliminary data.

We do know that most infections in otherwise-healthy children and adults result in no symptoms whatsoever. Probably only 1 in 4 or 5 people with Zika develop symptoms, which include fever, joint aches, and rash. But a small number of people also go on to develop serious complications, which can include brain inflammation or Guillain-Barre Syndrome. Though these conditions after Zika infection are rare, we really don’t know exactly what the risk is, or who’s likely to progress to serious Zika-related illness.

 

What should I do if I think I have a Zika virus infection?

Testing is available through public health agencies, and is routinely recommended for pregnant women living in or traveling to areas with active transmission. For the rest of us, health-care providers can help decide whether testing is needed. Go see your doctor.

 

What’s the best way to prevent infection?

Right now, there’s no vaccine, though one is actively being developed. The best way to prevent infection is to avoid mosquito bites and travel to areas with high rates of infection. You can find maps and other resources through the CDC Zika Prevention site.

The bottom line with mosquitoes: wear long sleeves and long pants, keep mosquitos out of homes with nets, screens, doors, and air conditioning, and use a mosquito repellant that actually works. Those typically contain the active ingredients DEET, picaridin, or “oil of lemon eucalyptus.” Of these, DEET is the standard—it’s been around since 1957, and it works, and as long as you don’t drink the stuff it’s safe.

 

*I wrote about it weeks before the story was picked up by the so-called “mainstream media.” Yet, still, no Pulitzer. Am I bitter? Of course not.

**Some “journalists” say slapping together a blog post in Q&A format shows laziness and a lack of creativity. Those people should go stick their journalistic heads in buckets of icy cold water. It’s Saturday morning, it’s beautiful outside, and you guys are getting get what you pay for. Srsly.

 

Coming to America

It’s time to rethink pertussis prevention

February 8, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

A large, sobering study published in the March, 2016 edition of Pediatrics illustrates just how far we still need to go to effectively control pertussis.

Pertussis, also known as ‘whooping cough’, is a serious illness. Older children and adults get to enjoy a horrible cough for about three months—a cough that sometimes makes people vomit, break ribs, or pass out. Seriously. You haven’t seen a “bad cough” until you’ve seen the cough of pertussis. Worse: in little babies pertussis can cause breathing problems, seizures, and death. Though its caused by a bacteria, antibiotics (unless given very early) are ineffective at reducing the length or severity of pertussis. Prevention, in this case, is worth far more than a pound of cure.

Up until the mid-1990s, infants and children routinely received the whole-cell DTP vaccine (DTP = diphtheria, tetanus, pertussis.) It worked at preventing all three of these diseases, but had a relatively high rate of side effects, mostly fevers. Many of the suspected more-serious side effects (like encephalopathy and seizures) are now known to have been caused by genetic conditions, not the vaccine, but nonetheless parents and doctors alike welcomed a newer vaccine, the acellular DTaP. This newer vaccine, which replaced DTP in the United States by around 1998, caused fewer fevers, and was thought to cause fewer serious reactions, too.

The problem is that it just doesn’t work as well. And as the first generation of infants to get an all-DTaP series starts to go through adolescence, we’re starting to see the unintended consequence of that vaccine change.

In the current study, researchers used a huge database of information from the Kaiser Permanente system of Northern California. We’re talking solid, big-data research, here, the kind of study that requires consistent and reliable data across a huge set of patients. In this case, about 3.5 million patients across 55 medical clinics and 20 hospitals, using centralized labs and an integrated medical records system. If health things happen to this population, Kaiser knows it.

In 2010 and again in 2014, California experienced large epidemics of pertussis. A total of 1207 cases were among Kaiser teenagers, all with complete records of their pertussis vaccination status. And the results aren’t anything to be happy about. In the first year after an adolescent pertussis (Tdap) booster, the vaccine was about 70% effective in protecting against pertussis. Not great, but not terrible, either – until you look a few days down the road. The vaccine effectiveness drops off dramatically, year after year, down to only about 9% by four years after receipt of the vaccine.

Why does Tdap seem to provide such poor protection—much worse than was seen in the original licensing studies? It’s a generational change, and it goes back to the shift from DTP to DTaP in the mid-1990s. By now, these teens in California are old enough to have received DTaP, not DTP, as infants. The authors looked at the specific ages of pertussis cases during the 2010 and 2014 outbreaks, and the trends support the conclusion that teens who received DTP as infants get good, lasting protection from Tdap; teens who got DTaP do not.

Now what? Clearly, we need a more-effective vaccine, perhaps even resuming the use of whole-cell pertussis vaccine, at least for the earlier doses. But in the meantime, we have to do the best we can with what we have. Vaccinating pregnant women with Tdap does effectively prevent pertussis in their babies, especially when they’re the youngest and most-vulnerable. And adults (who got DTP as children) should get Tdap boosters too, to protect the children around them. Another idea (floated by the study authors) is to use Tdap in teens not as a routine booster, but as a strategy to control local outbreaks, taking advantage of the higher effectiveness seen for the first year after vaccination.

I don’t have the answers. I’m not happy to see studies like these, but examining and re-examining vaccine safety and effectiveness is something we need to continue doing, with an open mind, relying on solid evidence. Bottom line: with pertussis, we need to do better.

Whooping crane

More water means slightly less weight in New York schools

February 1, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

A simple, safe, and cheap intervention looks like a good way to help fight obesity in our schools. But not by very much.

A study published January 2016 in JAMA Pediatrics, “Effect of a school-cased water intervention on child body mass index and obesity”, looked at the effects of installing new water dispensers in New York City school cafeterias. 1227 schools, including 1 065  562 students,  participated in the observational study, which tracked student weights and BMIs, comparing trends before and after the new equipment was installed.

Those new dispensers are called “water jets” in the study, and I *think* they’re just those typical water cooler things that offices use, with a big jug of water on top and a little flappy valve to get cooled water into a cup below. The study description says they both chill and oxygenate the water “to keep it tasting fresh”, and cost about $1000 bucks each. Furthermore, they “are relatively easy to use” (pretty clever, those New York kids.) The authors pointed out that participants were weighed and measured by PE coaches, whose scale-using skills have “previously been found reliable” (pretty clever, those New York coaches.)

The results: after these water jets became available, there was a statistically significant drop in BMI of about 0.025 points (it was just a touch more effective in boys than girls), and the percentage of children in the schools who were overweight dropped by .6-.9%. (from about 39% to about 38%).

I know, not very impressive. The statistics are solid—whether the authors looked at trends over entire schools, or at trends among individual students before and after water jet availability, these weight parameters did drop. And the drop is, technically, statistically valid and real. That’s how it’s been reported in the media. The New York Daily News said “Water machines available in schools can help kids lose weight.”

But the drop really wasn’t very much. Going from 39% to 38% overweight is good, but I think we ought to try to do better. You can lead a student to water, but studies like this show it’s hard to make them actually lose weight.

What should we do with all of this yellow paint?

New Zika travel alerts especially for pregnant women

January 18, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

What animal kills more people, year to year, than any other on the planet? The lowly, annoying mosquito. They fly around poking their snouts (I think) into person after person, spreading infections like malaria, yellow fever, and dengue. And new infections, too—like West Nile virus, which first appeared in Uganda in 1937. Infections don’t seem to recognize the borders of countries and continents, and West Nile has now become the most common mosquito-borne encephalitis in the US.

Now, the CDC is warning travelers against an even newer virus named “Zika”. Like West Nile, Zika was first found in Uganda, in a research station in the Zika rainforest (Zika means “overgrown” in the local language.) It remained an uncommon cause of human infection until the mid-2000’s, when the virus was first spotted outside of Africa and Southeast Asia. Since then, it has spread worldwide, throughout the warmer areas of the globe, leading to a large outbreak in Brazil that may have started with visitors to the 2014 Soccer World Cup. Brazil has probably had 500,000-1.5 million cases of Zika virus infection in the last few years.

Zika had been thought to cause only mild disease, with fever, rash, and joint pains. But at around the same time as the cases spiked in Brazil, health authorities there noted an alarming increase in health problems in newborns, especially a failure of brain growth called “microcephaly.” It’s since been shown that an unborn fetus can catch Zika virus across the placenta, and it’s very likely that the Zika virus infection is causing problems in the developing baby. We don’t know exactly how that’s happening, or when, or exactly when pregnant moms and babies are vulnerable.

What we do know is that like malaria, dengue, West Nile, and Chikungunya, Zika virus is spread by mosquitoes, and the best way to prevent transmission is to prevent mosquito bites. Stay inside at dusk, wear protective clothing, and use a chemical mosquito repellant containing DEET or picaridin.

The CDC has also now issued a “Level 2 Travel Alert” for areas with active Zika transmission, including Brazil, Puerto Rico, Mexico, and most of the rest of Central and South America. That means “practice enhanced precautions”, and applies especially to pregnant women.

Meanwhile, in the US, the first reported case of Zika virus infection occurred in Texas in November, 2015, in a woman who had recently traveled to El Salvador. And a resident of Puerto Rico recently developed Zika with no history of travel off the island—meaning that Zika is probably being transmitted by local mosquitos, now. It is only a matter of time for mosquitos in the rest of the warmer parts of the US to start spreading it around here.

It’s a big world, and the health problems of Africa are our health problems, too. New infections will continue to emerge. We’d better keep paying attention, and keep an eye on those mosquitoes.

Ew, Zima


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