Vaccination

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In regards to public health, survival, and longevity we would be hard pressed to not consider modern vaccination as one of the top 2 or 3 developments in the history of mankind.

The History of Vaccine Development and Implementation

If you like history and science then you will be inspired by the story of Jonas Salk and the development of the flu vaccine and later the Polio vaccine.

Enjoy the book: Splendid Solution: Jonas Salk and the Conquest of Polio

 

Prior to effective vaccines:

Diphtheria killed 10,000 people per year in the 1920’s.

Polio afflicted 50,000 children per summer in 1940’s-50’s

Measles infected 500,000 people per year in U.S.

1918 Spanish flu killed up to 50 million people worldwide.

1957 70,000 deaths in the U.S. from H2N2 Asian flu

1964 Rubella kills thousands of children in the U.S.

Key events in history of vaccine development:

1796, Europe, Edward Jenner experimented with inoculation with cattle version of smallpox and then learned it protected against Smallpox.  This was the birth of the vaccine era.

100 years past, 1877 Pasteur formulated the germ theory and did experiments with weakened germs to prevent rabies.  He developed inactivated rabies vaccine in 1884.

By mid century Jonas Salk and Albert Sabin developed the Polio vaccines still used today to rid the civilized world of polio.

Timeline of vaccine development:

1914 Rabies and Typhoid vaccines licensed in the U.S.

1915 Pertussis vaccine was introduced.

1930 Scientists learned to culture viruses in labs, paving way for vaccines for viruses.

1938 FDR founds the March of Dimes to develop treatment and prevention strategies for polio.

1942 Influenza A/B was developed by the Armed Forces Epidemiological Board, Jonas Salk.

1945 Inactivated flu virus licensed in the U.S., Jonas Salk

1947 DTaP was licensed in U.S. for children

1949 Last case of smallpox in the U.S., another 20 years before disease was irradiated in world.

1952 57,628 cases of polio in the U.S.

1955 Inactivated polio vaccine licensed in U.S., Jonas Salk

1961 Oral Polio vaccine was licensed by Sabin.

1962 JFK signs mass immunization assistance program

1963 First live virus Measles vaccine was developed.

1966 National Measles campaign decreases incidence to 10% of pre vaccine era.

1967 global smallpox eradication campaign

1971 U.S. stops Smallpox vaccine program

1973 Measles and Mumps vaccine licensed.

1974 Meningococcal vaccine licensed

1977 Pneumococcal vaccine developed for 14 strains of the 88 known to cause disease.

1977-Small Pox was eradicated from the world.

1979 las case of wild polio in U.S., unvaccinated religious group.

1981 first hepatitis B vaccine

1985 HiB vaccine for meningitis licensed.

1991 last case of polio in western hemisphere

1995 first childhood immunization schedule was developed by AAP, AAFP

1995 hepatitis A vaccine licensed.

1998 Rotavirus vaccine licensed.

2006 Zostavax for Shingles was licensed.

2009 Gardisil licensed to prevent genital warts and cervical cancer, nearly 100% effective for cancer prevention.

2010 Gates Foundation pledges $10B for Vaccine Decade.

How Vaccines Work

When we become infected with live germs our immune system reacts using B cells, T cells and Macrophages.  As a result of the reaction the invading germs can be killed or contained and our body retains memory T cells to immediately fight the same or similar germs in the future.  This whole process of fighting a new infection can take several weeks for the immunity to ramp a response, it is during this time that susceptible victims may die or need antimicrobial medications to assist their body in curing the illness.

Vaccines are made of weakened germs, or fragments of germs, or killed germs to induce our immunity.  As the body’s immune system reacts to the germ like particles in the vaccine, antibodies are created.  These antibodies then provide subsequent protection for months or years or even a life time.  If a our body is exposed to a live germ, for which we have received immunization, then our memory T Cells and B cells and antibodies are loaded and ready to react to the live germs and the host may have a more minor illness or not even become ill at all.

There are several types of vaccines depending on the germs being targeted.  Some have live but weakened viruses, like MMR and Varicella.  Some vaccines have only killed germ fragments and some cause immunity to toxins that germs produce inside a victim.  Often, many doses and boosters are necessary to provide adequate immunity in a recipient of the vaccine.

Link to the CDC: How Vaccines Work

Vaccine Recommendations and Schedules

Summary:

9 child and adolescent vaccines to be given

Annual flu shots

DTaP every 10 years

Shingles shot at age 50-60

Pneumonia shots (2) at age 65, or earlier for special populations

Travel Vaccines for special circumstances: Yellow Fever, Rabies, Typhoid, hepatitis and Malaria antibiotics.

Resources:

Travel Vaccine: http://wwwnc.cdc.gov/travel/destinations/listResources:

CDC Vaccines and Immunizations: http://www.cdc.gov/vaccines/recs/immuniz-records.htm

Vaccine Controversies

Vaccines can absolutely be revolutionary and dramatic in their affects on human disease.  A successful vaccination program can literally eliminate or dramatically diminish the incidence of an infectious disease in a society.  I have seen the virtual elimination of several disease just in my career due to the development and deployment of vaccination.  In medical school, while doing pediatrics rotation, we had a child with Haemophilus meningitis.  Our teacher told us, you won’t see that anymore, there is a new vaccine being implemented to eliminate it.  He was right, I’ve never seen, nor heard of a patient with this deadly disease in my career.  I’ve seen Rotavirus go from being one of our most common pediatric admitting diagnosis to now being virtually unheard of.  I’ve had a few patients with post polio syndrome, and will never see another new case in my lifetime.

That doesn’t mean that side effects don’t occur.  I’ve seen a healthy adult get a rare side effect called Guillain Barre Syndrome from flu vaccine.  We had given him vaccine one day, the next day he had trouble walking into my office, I saw him outside my window.  That night in the hospital after many normal tests and scans to rule out stroke and tumors and ruptured discs I knew he had GBS.  We had to transport him to UNMC for lifesaving plasmaphoresis.  He needed months of rehab to recover.  Gillian Beret is more common with an actual live case of influenza than it is with vaccine.

Researchers have falsified data and performed retrospective pseudoscientific and unsound investigations into a link between vaccine and Autism.  They have been discredited and have personally profited as professional witnesses and proponents of chelation therapies that they developed and profited from.  No properly done scientific investigation has shown a link between vaccine and Autism.  This fear mongering is blamed for scaring thousands of parents into denying MMR vaccine to their children resulting in more that 10,000 deaths from Measles in the world.  The incident has been called the “most damaging medical hoax in the last 100 years.”  The preservative has since been removed from the MMR vaccine, but is used in trace amounts in flu shots.

link to Thiomersal controversy:

Thiomersal controversy

Vaccination and the Law

State Laws

State laws establish vaccination requirements for school children. These laws often apply not only to children attending public schools but also to those attending private schools and day care facilities. All states provide medical exemptions, and some state laws also offer exemptions for religious and/or philosophical reasons. State laws also establish mechanisms for enforcement of school vaccination requirements and exemptions.-CDC website

Nebraska vaccine requirements

Vaccine Laws in Nebraska

 

 Vaccine Costs

 

A rough calculation of the cost of vaccine and administration.

Ages 2,4,6 months: $490 per visit

Ages 12,15 mos.: $350 total, another $90 at age 2 for hep A.

Kindergarten shots: $290

plus annual flu: 60/year=$720

7th-12th grade: 20+177×3+112×2, plus annual flu ($60)=$1195

Total cost to immunize through age 18 = $4115 

Note: almost all costs are covered by insurance with no copay or deductible.

Link to vaccine costs

Vaccination Rates

MMR compliance for kindergartner age is 94%.

Adolescents: Meningococcal, HPV and dTaP:

HPV: 36% female, 13% male

dTap: 87%

Meningitis: 79%

Access to Vaccines

VFC

The Vaccines For Children (VFC) program is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay. CDC buys vaccines at a discount and distributes them to grantees—i.e., state health departments and certain local and territorial public health agencies—which in turn distribute them at no charge to those private physicians’ offices and public health clinics registered as VFC providers.-CDC

Private Insurance

BCBS website indicated “No charge for preventive services/screening/immunizations.”  Meaning that deductibles and copays should be zero.  Check with your insurance company to confirm.

 

Vaccination for impoverished nations

World Wide

If developing countries vaccination rates could be brought up to 90% compliance it is estimated that 2 million children’s lives could be saved each year.

Bill and Melinda Gates Foundation:

$44B endowment, $27 B from Gates.  Warren Buffet has donated billions of dollars and pledged even more with conditions.

$10B has been spent or pledged to vaccinate the world.

Conclusions:

God has blessed mankind with many remarkable scientists and doctors throughout our history.  Please take advantage of the incredible blessing of vaccination for yourself and your family.  Vaccines are incredibly safe, relatively cheap, and very effective at preventing devastating diseases that plagued our ancestors.  There is no more natural way to prevent infectious diseases than to use vaccines to educate your bodies natural immune system to help keep you and your family healthy.

References:

WHO

CDC

Obesity

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 Definition

Body Mass Index is a term used to define obesity.  It is ratio of weight to height.  Calculated as Wt.(kg)/Ht.(m^2)

BMI over 25 is overweight, BMI of 30 is obese

Height:                              overweight wt.:                                         obese wt.:

5’4”:                                       145                                                         174

5-6:                                        155                                                         186

5-8:                                        164                                                         197

5-10:                                      174                                                         209

6’:                                          184                                                          221

6-2”:                                       194                                                         233

6-4”:                                       205                                                         246

Body Fat method:

May be used as an addendum, especially for muscular builds from weight training.  Various techniques to measure.

  • Fit women 21-24%
  • Fit men 14-17%, a six pack abdominals is 8%.

Obesity:

  • Women:32%
  • Men:25%

Body Fat charts and pictures, 

http://www.builtlean.com/2012/09/24/body-fat-percentage-men-women/

Prevalence

Adult

  • 1/3 of U.S. adults are obese, 78.6 million people

Childhood

  • 17%, 13 million children and adolescents
  • Increased 3 to 6 fold (600%) since the 1970’s.
    • associated with head of household educational levels and socioeconomic status

by State and Country

  • highest Arkansa, Mississippi, West Virginia
  • Lowest: Colorado, California

by Race

  • Blacks: 48 %
  • Hispanics: 43 %
  • Whites: 33 %
  • Asians: 11 %

by Age

  • highest age 40-59 (39.5%)

Causes:

Genetic

  • drive to eat,
  • sedentary nature,
  • metabolism, minimal differences in most people
  • fat burning capacity or increased tendency to store fat.

Psychological

  • Overeating and eating “comfort foods”
  • can be associated with stress and depression.

Social/Cultural

  • Our social events can be centered around food,
  • often high fat and carbohydrate items
    • When the last time you had your family over to meet at the park or recreation center and go for a walk or swim or bike ride.

Behavioral

  • Habits of eating are developed over time.
  • Family habits from childhood are reflected in adult habits.
  • Lack of education on nutritional principles can be perpetuated in families.
  • Lack of motivation for long term health consequences of our behavior and lifestyle

Associated Medical Conditions:

  • Diabestes
  • Heart and VascularDisease
    • Coronary Artery Disease, Atrial Fibrillation, Congestive Heart Failure, Stroke, Hypertension, blood clots
  • Obstructive Sleep Apnea
  • Cancer
    • virtually every organ and type of cancer is associated with obesity
      • obesity can increase breast cancer risk by 30%
  • Arthritis
    • every pound of body weight contributes 7 psi to joint surface pressure
    • an extra 50 pounds contributes 350 psi on back and hips and knees
  • Infertility
    • Polycystic Ovarian Syndrome
    • increased incidence of labor and delivery consequences, like c/sections
  • Hormones
    • low testosterone
    • elevated estrogens in men and women
      • “man boobs” and female hormone related cancers
  • Psychological health
    • depression
  • Sleep pathology, Obstructive Sleep Apnea

Costs:

  • 190 Billion Dollars annually in the U.S. in direct and indirect costs are related to obesity
  • 21% of all health care spending in the U.S.
  • Obese individuals have medical costs estimated to be 30% greater than normal weight peers
    • $3,000 per obese individual per year

Treatments:

Lifestyle

  • Losing weight is not achieved by going on a diet or starting a fitness program.
  • Losing and maintaining a healthy weight requires a lifestyle change.
  • Lifestyle is defined by components involving nutrition, activity level, hobbies, and habits.

Nutritional Principles:

  • 3 meals and 3 snacks, with good eating habits:
    • eat slowly, put fork down after each bite
    • put your food on a plate, don’t graze around a buffet
    • environment:
      • don’t eat in front of TV, it’s distracting and leads to overeating.
      • drink plenty of water with your meal, have a glass of water before the meal
  • low added sugars (10% of calories from added sugars)
  • low in saturated fats(10% of calories),
  • Mediterranean dietary principles
    • fish, lean meats, legumes, fruits, vegetables, nuts, whole grain breads, plant based fats- canola and olive oil).
  • See the new guidelines: http://health.gov/dietaryguidelines/

Exercise: 

  • 30 min/day most days of the week,
  • 2 resistance weight training sessions per week.

        Adults exercise recommendations:

  • 150 minutes per week of moderate aerobics and 2 or more sessions of resistance weight training for all major muscle groups.

        Children exercise recommendations:

  • 60 minutes of physical activity every day, including at least 3 sessions of muscle building activities and 3 sessions of more intense aerobic activity like running.

Worksite Physical Activity

  • park and walk,
  • take the stairs,
  • stand up at work station,
  • use breaks to walk,
  • short walk after lunch.
  • Wellness programs:
    • motivate employees to attain health goals,
    • pay for fitness memberships,
    • give discounts on health insurance,
    • office contests to promote healthy goals.
    • Work station design:
      • stand up desks.
      • treadmill desks.

Medications:

  • Meds can reduce weight by 10-20% while taking.
  • May not result in persistent weight loss if stopped unless significant lifestyle changes are adopted.

Available Medications: 24 drugs on the market for obesity

Phentermine, generic

  • formerly part of infamous Phen/Phen combination
  • stimulant, acts to inhibit apetite

Orlistat, called Xenical

  • blocks absorption of some of the fats we eat
  • GI side effects are poorly tolerated

SGLT-2 inhibitors (Farxiga, Invoking, Jardiance)

  • Diabetes drugs, very expensive

GLP-1 agonists (Byetta, Victoza, Bydureon, Tanzeum, Trulicity)

  • Diabetes meds, very expensive, injections

Buproprion/Naloxone, called called Contrave

  • can be poorly tolerated with GI side effects

Topiramate/Phentermine, called Qsymia

  • can be poorly tolerated

Lorcaserin, called Belviq

  • 5 HT 2 serotoninergic receptor agonist

Surgery for obesity:

Restrictive procedures, shrink the stomach capacity:

  • Gastric Band
  • Gastric Sleeve
    • most popular modern procedure

Malabsorption surgeries, to prevent the digestion of calories:

  • Gastric Bypass
    • may have increased mortality and complications in some centers

Results of surgical procedures :

  • surgery can reduce all cause mortality by 50% in 5-7 years
  • surgery can reduce incidence of diabetes by 80% in 5 years

Summary/Call to action:

     Obesity is a common American malady.  Obesity has dramatic and expensive adverse affects on our health.  There are several successful strategies and treatments for obesity.  There is plenty of research showing the positive affects of losing weight.  Set a goal for your weight, develop a strategy to achieve your goal.  Measure your progress.  If not achieving your goals then seek help from friends, family, obesity support groups, or see your doctor for assistance in achieving this important goal.

References:

USPSTF

Up To Date

AAFP

CDC, http://www.cdc.gov/healthyweight/index.html

Dementia

Dementia

Dementia is our most-feared illness…Dr. David Perlmutter

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Definition:

Dementia is a common term used to describe a collection of symptoms, it is not a diagnosis.  The DSM, diagnostic and statistical manual for medical diagnosis uses the following definition.

Evidence from the history and clinical assessment that indicates significant cognitive impairment in at least one of the following cognitive domains:

  • Learning and memory
  • Language
  • Executive function
  • Complex attention
  • Perceptual-motor function
  • Social cognition

Furthermore, these conditions must be met:

  • The impairment must be acquired and represent a significant decline from a previous level of functioning
  • The cognitive deficits must interfere with independence in everyday activities
  • In the case of neurodegenerative dementias such as Alzheimer disease, the disturbances are of insidious onset and are progressive, based on evidence from the history or serial mental-status examinations
  • The disturbances are not occurring exclusively during the course of delirium (such as during an acute illness or intoxication)
  • The disturbances are not better accounted for by another mental disorder (eg, major depressive disorder, schizophrenia)

Manifesting as difficulty with one or more of the following:

  • Retaining new information (eg, trouble remembering events)
  • Handling complex tasks (eg, balancing a checkbook)
  • Reasoning (eg, unable to cope with unexpected events)
  • Spatial ability and orientation (eg, getting lost in familiar places)
  • Language (eg, word finding)
  • Behavior

Incidence/Prevalence/Costs:

  • 5.3 million Americans have dementia in 2015
    • Estimates for 2025 are 7.1 million
      • Nebraska has 33,000 cases
  • 5% of population in their 70’s have dementia
  • 25% of population in 80’s
  • 6th leading cause of death
  • 1 in 3 Americans have a demential condition at the time of their death
    • less than 1/2 of patients are aware they have a diagnosable dementia
  • most victims are over 65,
  • women have higher incidence at a ratio of 2:1.
  • higher incidence in hispanics and Black races.
  • Costs U.S. $226 billion in 2015.
  • Medicare costs are 300% higher for a senior with dementia than one without.

Types of Dementia:

Alzheimers Dementia, called AD

  • AD is responsible for 60-80% of dementia.

Vascular Dementia

  • Vascular disease is the second leading cause.

Dementia of Lewey Body, called DLB

  • manifests with hallucinations (visual and dramatic),
  • trouble walking,
  • tremor (like Parkinsonism)

Frontotemporal, FTD

  • manifest more as behavioral variant of dementia
    • change in personality,
    • lack of inhibition,
    • OCD behaviors,
    • apathy

Parkinson’s Disease with Dementia, PDD 

  • 30-40% of PD patients get dementia over course of their disease

 Cause:

 

Reversible: Minority of cases of dementia are from reversible causes (1%)

  • Thyroid disease
  • Vitamin Deficiencies
  • Hydrocephalus
  • CNS tumor
  • Depression
  • Alcohol or Drug abuse
  • Medications side effects:
    • pain pills,
    • sleeping pills,
    • sedatives,
    • anxiety meds,
    • depression meds,
    • anticholinergics (IBS, OAB meds),
    • antihistamines, benedryl, Tylenol PM
    • some Blood Pressure meds,
    • antipsychotics,
    • seizure meds.
    • Stress

Irreversible:

  • AD-protein tangles in the brain, Tau protein
  • LBD-amyloid proteins deposited in the brain, similar to AD
  • Creutzfeldt Jacob Disease, CJD
    • Prion infection in the brain, like Mad Cow Disease in cattle
  • Stroke, or combination of many mini-strokes over time
  • Parkinsons Disease, PD
  • Infections:
    • HIV,
    • Hepatitis
    • Meningitis/encephalitis(WNV, Syphilis)

Symptoms, differentiating dementia from forgetfulness or aging:

Dementia is characterized by:

  • Difficulty remembering recent events, familiar people.
  • Having to be told over and over.
  • Forgetting major events even happened, like a vacation.
  • Difficulty planning
  • Difficulty with following directions, like a recipe you’ve made several times.
  • Getting lost in familiar areas.
  • Difficulty balancing a check book.
  • The person doesn’t notice the issues, others do.
  • Become anxious, irritable with minor events or changes in routine.

Forgetfulness, or normal aging is more characterized by:

Diagnosis/Evaluation:

Your doctor can use several tools to determine if you have dementia.

  • MiniCog testing, can be given at home by family member or caregiver:
    • recall 3 familiar objects after 1 minute of time.
    • Draw a clock face with numbers and hands to display the correct time.
    • If fail MiniCog, further testing is needed.
  • MME: 30 point exam done at doctor’s office

Treatment:

There are treatments available for dementia.  First and foremost is to determine if there is a reversible cause.  Several non-medical strategies can be helpful for dementia.  Modification of vascular risk factors has a favorable outcome in slowing the progression of dementia.

  • Diet,
    • Heart healthy, Mediterranean diet
  • Exercise
  • Social engagement.
    • socializing with friends and relatives
    • games
    • reading
    • learning new skills
    • formal education
    • active hobbies
    • volunteerism

There are medical therapies available to help with dementia.

Medications:

1. Acetylcholinesterase inhibitors (Exelon, Aricept)

  • Can be used in all causes of dementia, score of 26 or less in MMSE.
  • First line treatment in early dementia.

2. Memantine (Namenda)

  • NMDA receptor antagonist, may be protective of neurons.  May have modest benefit in moderate to severe dementia.
  • Used in combination with AcetylCoA inhibitors for moderate to severe dementia.

 3. Vitamin E, 2000 U per day

  • May have some benefit in Dementia,
  • should not be used in combination with Memantine.

Prevention:

Several strategies have been found to delay the onset or slow the progression of dementia.

  • At the Alzheimer’s Association International Conference® 2014, a two-year clinical trial of older adults at risk for cognitive impairment showed that a combination of physical activity, nutritional guidance, cognitive training, social activities and management of heart health risk factors slowed cognitive decline.-1
  • Onion Model of cognitive decline:
    • Aging affects the brain like pealing the layers of an onion.
    • The more layers we build up over our lifetime the longer it takes to peal.
    • The core of the onion is equated to our ability to live independently with quality of life.
  • Learn a new skill (bilingualism delays the onset of dementia by 4 years), engage in formal education.  Stay socially engaged, volunteerism.  Active hobbies that require planning, thinking.
  • Practice Vascular health:
    • Good diet
      • Mediterranean diet:
        • fish, nuts, whole grains, fruits and veggies, olive oil, low in saturated fats (red meat, butter, cheese, sour cream, processed foods),
    • control weight, 
    • exercise, 
    • treat high blood pressure, 
    • control your cholesterol through diet, exercise and medications if necesary, 
    • aspirin may be appropriate 
      • (age > 65 with other vascular risk factors)
    • Don’t smoke,
    • get enough sleep,
    • manage stress (circle of influence vs circle of concern).
  • Avoid excess alcohol, 
  • evaluate and treat depression.

Research:

  • NIH spends $6B on cancer research,
  • $4B on heart disease research,
  • $3B on HIV,
  • but only $480M on AD.
  • Future research is focusing on the protein tangles in the brain and inflammation.
    • Immunizations
    • Antibodies against the proteins
    • Anti-Inflammatories

Conclusion/Call to Action:

Dementia is unfortunately very common.  As we live longer we will have increased incidences of health conditions related to aging.  Our actions, or lack thereof, when we are younger can influence the development and severity of dementia.  Be proactive about your health through preventive and protective habits.   Take action when you are healthy to diminish the impact of conditions associated with aging such as dementia, heart disease and cancer.

Resources:

An Unintended Journey, A Caregivers Guide to Dementia

Bible Verses-Alzheimer’s/Dementia/Memory Loss Activity Book for Patients and Caregivers

Shadowbox Press activity books for Dementia patients

http://www.alz.org

References:

1. Alzheimer’s Association,

2. Web MD

3.Up To Date

4.American Academy of Family Physicians