Vaccination: The bad old days

Have you ever met anyone who had diphtheria? How about tetanus? You may know an older person who had polio as a child, and most people my age can remember measles and mumps, but how about congenital rubella? Hemophilus influenza meningitis? Smallpox?

As vaccines become more effective, and global vaccine campaigns more successful, fewer and fewer people (let alone their doctors) have any direct experience with the infections we vaccinate against.

That’s why vaccine-preventable infections can be a low priority for some young parents: They’ve never seen any of them. As one dad put it not long ago, when we got onto the subject of polio risks for his two month old daughter: “What’s the point of  getting shots for non-existent diseases? It’s like you’re warning us about the dangers of buggy whips.”

That’s how my days go, sometimes…

I really like the illustration that accompanies this post (and thanks to my daughter Claire for sending it to me). The left hand column of red-tinged syringes shows how many cases of a given infection occurred each year in the pre-vaccine era. The mostly red-free column on the right lists the annual totals we see today.

The differences are dramatic, but it’s important to take note of the little slivers of red still visible next to infections like measles, mumps, and congenital rubella. These diseases and the others on the list aren’t extinct, they’re just held at bay by vaccines (and other public health improvements like clean drinking water and improved hygiene).

So keep this chart in mind when thinking about vaccinations for your child. Oh, and those bad old days? In the case of Hemophilus influenza, they weren’t so long ago: the vaccine didn’t come out until I’d been in practice for several years. I (and my patients) lived those 20,000 cases a year…

Flu shots help prevent preterm birth

A research team in Georgia recently published a study that shows the protective effect of flu vaccine for pregnant women.

Led by Dr. Saad Omer of Emory University, the team examined the records of more than 3,300 pregnant women between April 2009 and 2010. They found that those women who received influenza vaccine overall had a 40% lower likelihood of giving birth before 37 weeks of pregnancy than women who were not vaccinated. That protection increased to 72% during the peak of the flu season.

The protection extended to birthweight as well. Vaccinated women were 69% less likely to have a small for gestational age baby than were the unvaccinated women.

Dr. Omer’s study underscores the importance of flu shots for pregnant women. Keep that in mind come next October, when the 2013-2014 vaccine  comes out!

(Photo credit: International Ladies Garment Workers Union Photographs, 1885-1985)

A great book about living with polio

Anne Finger

I had the pleasure of meeting the author Anne Finger in 2010, when we were both nominees for the Northern California Book Awards. (Anne was a Fiction nominee for her short story collection, “Call Me Ahab.” Me? I lost to Dave Eggers–does he have to win every award?–in the Creative Nonfiction category.)

Anne’s legs were paralyzed by polio when she was a toddler. Her book, “Elegy for a Disease: A Personal and Cultural History of Polio” (2006) brings all the theoretical discussions of polio and vaccines down to a very personal level. “Elegy” is a remarkable read for anyone who wants to know what it’s really like to live with the damage, both physical and emotional, that polio once wreaked on thousands of American children and adults every year.

Here’s an excerpt from Publishers Weekly’s review of “Elegy for a Disease”:

In skillful prose, Finger merges memoir with historical narrative about how polio was viewed and dealt with in the years before the Salk vaccine was invented 50 years ago. Evocative and often poetic, the memoir is also a litany of the miserable, useless, even harmful treatments imposed by helpless doctors on suffering children. She offers a nuanced history, for instance, of the painful and unorthodox heat treatments espoused by Elizabeth Kenny. Finger… describes the traumatic operations, beginning when she was six, that led in turn to complications when she was in her 40s. Taught to believe that she could overcome her disability, Finger overexercised and, while living in England, attended antiwar demonstrations that were physically dangerous…

“Elegy for a Disease” is a vividly-written reminder of why we should still worry about polio in Pakistan.

A personal polio postscript…

What hath polio wrought? Pa and Ma, April 19, 1947

Actually, I owe my very existence to one particular case of polio.

Ed, one of my father’s best friends in college, had his legs paralyzed by polio in early childhood. When World War II came along, Dad went off to the South Pacific and Ed, his disability disqualifying him from active duty, took a desk job on Chicago’s Navy Pier. As fate would have it, one of the women who worked in his office was a red-haired Irish lass named Peg Dalton. Long story short, Ed thought Peg and Barney would be a good match, and 66 years later, they still are.

Bottom line: No polio, no me. I hate to seem ungrateful to the virus that made my blogging possible, but I can’t wait to see it vanish from the earth.

Do we still need polio vaccine?

A thing of the past?

I picked up a copy of this week’s Time magazine at my health club today (gotta have something to read in the sauna…) and found an excellent article on global polio eradication.

Only three countries are still considered hotbeds of the disease–Afghanistan, Nigeria, and Pakistan–and money and man-and-woman-power are pouring into those countries in a determined effort to finish off polio, much as smallpox was eradicated in the 1970s.

It’s a remarkable story, and the article is worth a read. Consider this: as recently as 1988 polio killed or paralyzed 350,000 people worldwide, but thanks to an incredible combination of medical know-how, political will, and philanthropy (in particular the Gates Foundation), there were only 215 cases in 2012.

So back to my original question–one that I frequently hear from shot-weary parents–do American kids still need polio vaccine? After all, there hasn’t been an outbreak of wild polio in the U.S. (i.e., person-to-person transmission that wasn’t imported by a foreign traveler or very rare vaccine-related infections) since 1979. And polio epidemics spread via sewage-contaminated drinking water–definitely not a problem here. Yet we still routinely give children four doses of polio vaccine by the time they start kindergarten. This isn’t Afghanistan…can’t we just quit?

There are two main arguments for continuing polio vaccination until the virus is eradicated:

• The eradication effort in those three final countries is in danger of being derailed by terrorism and war. As reported in the Time article, Pakistan is a particular problem: more than a dozen vaccine workers have been murdered by the Taliban, who believe the eradication effort is really a U.S.-backed spy network.* Since polio can spread quickly, it wouldn’t take much disruption to see the case numbers mount up. And with the ease of modern travel, we could expect infected travelers to appear at least occasionally in the U.S., as has happened in the past.
• The idea of polio spreading through sewage-contaminated drinking water in the U.S. may seem remote, but as millions learned in the wake of Hurricane Sandy, sewage treatment facilities can fail. An infected traveler in the right place at the wrong time could open a polio Pandora’s box.

Okay, I’ll admit that the reappearance of polio epidemics in the U.S. would take a combination of long-shot coincidences. But given that we’re so close to eliminating polio (and thus polio vaccine) why take a chance? Best to hang in there vaccine-wise until we can do a polio victory dance.

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*The Taliban’s fear of vaccine-worker spies isn’t entirely unfounded. A Pakistani doctor masquerading as a hepatitis-vaccine worker helped confirm Osama Bin Laden’s location just before Bin Laden was killed.

Antibiotics: Treading softer nowadays

There’s a time and place for everything.

Pediatrician Perri Klass has an excellent article on antibiotics and children in Tuesday’s New York Times Science Times. She perfectly conveys the dilemma facing pediatricians and others who care for children today. We all have stories of kids whose lives were saved by the timely administration of antibiotics, but we’re also acutely aware–more so with each passing research article–of the consequences of overusing that “magic bullet.”

The physicians who taught me back in the ’70s and early ’80s had good reason to love antibiotics. Many of them had started their careers in the pre-antibiotic era, when infections like pneumonia, meningitis, diphtheria, and others killed a lot of children. Then antibiotics came on the scene and those diseases nearly vanished–until antibiotic resistance kicked in with a vengeance, that is. We’ve been engaged in an escalating arms race with bacteria ever since.

The pro-antibiotic mindset of those times was epitomized by an elderly attending physician in my residency program who, as we were discharging a boy who’d had bad case of pneumonia, quietly said, “When I was an intern that child would already have been dead for a week.”

To his younger self, the boy’s recovery would have been a miracle. Now he believed it was simply a matter of time–and the right antibiotics–and bacterial infectious diseases would disappear entirely. Side effects? Maybe some diarrhea or the occasional allergy, but that was a small price to pay. Right?

It didn’t work out that way, of course. We’re now learning that antibiotics can have far-reaching effects on  children’s health. As Klass points out, there is concern that antibiotic use, particularly in early infancy, may be linked to a variety of chronic health conditions–even obesity, as I wrote about a few months back.

Still, there is a role for antibiotics. Kids still get pneumonia, and meningitis, and any number of infections that may come roaring back if the fear of antibiotics becomes its own epidemic. But not every ear infection needs to be nuked with pharmaceuticals.

So, when to treat and when to let nature take its course? That’s a delicate balance that those of us who learned from doctors who saw antibiotics as a “magic bullet”–which they were, at least at the start–are still working to achieve.

Photo credit: epSos.de

Early antibiotics and obesity?

An English study of more than 11,000 children has turned up an association between early antibiotic use (that is, antibiotics given to babies less than 6 months of age) and later obesity.  Interestingly, the study did not find that antibiotics given to children between the ages of 6 and 14 months increased the risk of obesity, and the effect of antibiotics on children aged 15-23 months was inconsistent.

Why would the antibiotic-obesity association be found primarily in younger babies? The authors speculate that an altered gut microbiota may be the culprit.

The germs that make up the gut microbiota (GM) are acquired at birth and shortly afterwards. By a few months of age the “core” GM is more or less set for life. An altered GM has long been associated with obesity in older children and adults (see more extended discussions in my posts here and here)–it would make sense that antibiotics given in this sensitive period of GM development would have greater impact than later on, when the GM is more stable.

The added risk of obesity from early antibiotic administration is small for any individual baby,  the study’s authors stress, but even small increases spread over an entire population can have significant public health implications.

Still, sometimes babies need antibiotics. Studies like this one highlight the unintended (but real) consequences of the overuse of a sometimes life-saving tool.

***(Photo credit: Seattleye)

One family’s history

Gram Sloan in 1918. John Francis (left) died a month later in the Spanish flu epidemic.

Yesterday was my parent’s 65th wedding anniversary. I realized in talking with them over dinner that their family stories (and mine, too, of course) provide a pretty good snapshot of how children’s health has improved in the last century, at least on the infectious disease front.

Dad’s 93 now, born in 1919 during the waning days of the Woodrow Wilson administration. His mother (my Gram Sloan) experienced a lot of tragedy with her children. She gave birth to five babies, but only three survived to adulthood. My uncle John Francis died in the 1918 Spanish flu epidemic at the age of three, and Donald was 4 years old when he died of pneumonia in 1924. The striking thing about her experience is that it was basically the norm for families back then. In 1914, the year she married, about one in four children didn’t make it to their 5th birthdays. (I wrote an essay about John Francis for Notre Dame Magazine–link is here.)

Mom is 87 and, though she and her six siblings all survived to adulthood, her childhood was one long string of debilitating infections: whooping cough, diphtheria, scarlet fever, and polio (which left her with a weakened leg), to name a few. She even received the last rites of the Catholic Church once (for diphtheria), but defied her doctor’s dire predictions and pulled through.

Together Mom and Dad had seven babies. The first, my brother James, was born a few weeks early and died at two days of age from hyaline membrane disease (now called respiratory distress syndrome). The rest of us made it through childhood relatively unscathed–oh, we had measles, mumps, and chicken pox, like every other kid, but we were spared diphtheria, polio and the rest. (Mom dragged us to the pediatrician’s office, kicking and wailing no doubt, the day the polio vaccine arrived.)

And now my kids–they’re healthy and in their twenties. Both had chicken pox, the odd ear infection, and some wheezing, but basically had pretty healthy childhoods. The same is true for all of their cousins, a few of whom now have their own healthy children. If this were a century ago, I would probably be talking about a few of them in the past tense.

My career as a pediatrician is another indicator of how things have improved. I’ll just mention what I call the “spinal tap index.” When I started in the early 80s, I did about one spinal tap a week to diagnose or rule out meningitis. Then came the vaccines for Hib, pneumococcus, and meningococcus, and with them a huge decrease in cases of meningitis. It’s been more than a year since I did my last spinal tap.

Talk to your older relatives and friends–you’ll very likely find that they have similar stories. There is much to criticize in the current state of children’s health in the U.S., but on some fronts, particularly infectious diseases, the progress has been remarkable.

Super Bowl measles

Catching something else?

Measles just won’t go away…

13 cases of measles have now been tied to two infected people who visited the Super Bowl in Indianapolis the weekend of February 5th. The cases are limited to two counties north of the city, but given the huge number of people from all over who visited Indianapolis for the festivities, public health officials–particularly those in New York and New England, where the Giants and Patriots and their many fans are located–are understandably nervous.

This illustrates the ease with which infectious diseases can travel from place to place these days. The last outbreak of measles in my area started with a European tourist who developed full-blown measles shortly after arrival. Fortunately our public health department was able to contain things quickly.

One more reason to stay on top of your kids’ vaccination needs…

Polio: A milestone in India

Polio-free for a year!

This week India celebrated a milestone many thought would never come. For the first time in its history an entire year passed without a single case of paralytic polio. The last Indian child to be paralyzed by the virus was an 18 month-old girl diagnosed on January 13, 2011. The end of polio in India had been predicted: there were 790 cases in 2009 and only 42 in 2010. Fingers will remain crossed for the near future–the World Health Organization won’t certify a country as polio-free for three years, since asymptomatic polio can circulate for some time.

The Indian government has spent $2 billion dollars fighting polio–hundreds of millions of polio vaccine doses have been administered in recent years–and it knows it will spend many more millions to keep the infection away. Polio is transmitted via sewage-contaminated drinking water, and that’s unfortunately fairly common in that part of the world. More worrisome is the proximity of Pakistan, India’s next-door neighbor, which had nearly 200 cases of polio last year. Viruses don’t respect international borders–the risk of polio resurfacing in India is substantial.

So hats off to India! It’s quite an accomplishment.