U.S. Measles Outbreak

Your family, your child & the U.S. Measles Outbreak

Parents in the U.S. have become concerned about the safety of vaccination; yet, not enough 21st century factual information about the real risks and benefits has been made available for discussion with this generation of parents.  Some pediatricians have adopted a delayed vaccine schedule for childhood immunization.  Some celebrities and lobbyists have become vocal vaccine opponents.  But, when an outbreak at Disneyland leads to 14 states, including New York, with confirmed cases of Measles in 2015, there is a very real threat of history repeating itself in death and disease incidence in our nation.

The vaccine for Measles, Mumps, and Rubella (MMR) was developed in 1963. The Centers for Disease Control & Prevention (CDC) followed the incidence of these diseases, finding that by 2002, Measles was no longer endemic in the U.S.  However, it could still be brought here through foreign travel and unimmunized persons.  From 2000 through 2011, the CDC spent $440 million on global Measles control.  Within our country, a Measles outbreak during 1989-1991 led to the federal program, Vaccines for Children, which covers uninsured, underinsured, Medicaid eligible, & Native American children. From 1994- 2013, U.S. vaccination prevented 732,000 premature deaths.  However, multiple factors contribute to underutilization of the resources available and have now led to a renewed susceptibility within this country.  These include fewer preventive visits (a recent study from 2000-2004 by the Medicaid Expenditure Panel Survey found that amongst over 8000 children ages 10-17, only 38%  had a preventive visit in the previous year), noncompliance with multiple dose schedule, underestimation of the risk of vaccine-preventable disease, & problems with verification of prior immunizations.  One in twelve U.S. children does not receive the 1st dose of MMR in time.

The Director of CDC’s National Center for Immunization & Respiratory Diseases, Dr. Anne Schuchat, has reported that in 2014, there were over 600 cases of the Measles in the U.S. This is the largest increase in the past 20 years.  The Philippines is the primary source of the U.S. outbreak.  Eighty four people infected were linked directly to the Disneyland outbreak alone.

A review of this disease and the real risks to families is both timely and pertinent. The Advisory Committee on Immunization Practices (ACIP) sets the guidelines for childhood and adult vaccination in our country.  These guidelines can be found on the CDC website or the American Academy of Pediatrics website.  The first dose of MMR is to be given 12-15 months age.  If this is delayed, studies have revealed up to a five fold increase in risk of vaccine-related complications, such a seizure.  The second dose is to be given 4-6 years of age.  The vaccine is a live, attenuated virus, but prior to 1967, a killed virus vaccine (which did not fully immunize) was given.  Vaccination during pregnancy is not advised.  Children traveling outside of the U.S. prior to immunization should consult a physician prior to travel about the child’s health and travel itinerary.

The Measles is highly contagious in susceptible individuals. The virus can incubate for up to 21 days.  Initial symptoms include malaise, anorexia, fever (>104 degrees F), runny nose, red eyes and cough.  Koplik spots are bluish gray specks in the mouth (buccal mucosa) which can appear 1-2 days prior to the classic red rash.  The rash may take 1-2 weeks to develop; it begins on the face and spreads to the arms and legs.  Diagnosis is through serologic tests, viral culture, or (PCR) polymerase chain reaction tests.  Samples of blood, nasal/throat swab, or urine can be tested. The general treatment of Measles cases is non-specific; it includes rehydration and Vitamin A supplementation.  Newborns (up to 6mo.) and pregnant women exposed to known cases can be given antibodies to fight the virus (serum Immunoglobulin).  Antivirals are occasionally used in treatment. Measles complications include ear infection, pneumonia, severe diarrhea, blindness, encephalitis (brain swelling), and death. During pregnancy, certain viruses can cause teratogenic effects (birth and developmental defects).  Fortunately, Measles (also called Rubeola) is not one of these viruses. Measles can, however, cause premature labor, low birth weight, spontaneous abortion (miscarriage), and, if a woman has active disease at birth of newborn, the baby can develop neonatal disease.  With Rubella (another virus covered by the MMR vaccine), teratogenic effects are seen.  These can include intracranial calcifications, cardiac defects, neurologic disease, and cataracts.  Women exposed in pregnancy to Rubella during the first 12 weeks can have up to 90% incidence of Congenital Rubella in newborns.

Parents of the 21st century must be “smart readers” and must initiate the conversation about childhood immunization, both in schools and the healthcare setting.  It is important to not just accept the rumor-mill, commercialization of education, & things seen on TV or read in a magazine when it comes to the well-being of children.  While a small percentage of children may be vulnerable to the complications of routine immunization, most children face greater risk in failure to receive timely immunization during childhood.  As a nation, we can do a better job in tracking childhood immunization through a national registry program.  Parents can initiate discussion between health advisory boards and school boards to ensure a safe environment for all.  We all must remember that even 21st century access to information does not equal being “well informed”, so we must go beyond the surface to obtain the substantive knowledge that allows us to stand guard for our children, our future.

 

 

January 2015

Dr. Afriye Amerson

Human Papilloma Virus (HPV)

The WHOLE truth about HPV:
What today’s woman needs to know to stay on point about the most common STD in the U.S.

September is gynecologic cancer awareness month; and I could not think of a better time to put the truth on the line about Human Papilloma Virus (HPV). Firstly, HPV is not one virus, but many; of which, thirty types infect the male and female genital tract. As scientists have studied these types in the 21st century, Harold zur Hausen was awarded the 2008 Nobel Prize for finding the link between HPV and cervical cancer. This led the National Toxicology Program to label HPV as an official carcinogen (cancer causing agent; i.e. as dangerous as asbestos). HPV viruses can cause effects from warts to cancers. There are 15-18 types categorized as high risk because they are the types which can cause cervical, vaginal, vulvar, anal, penile and scrotal cancers. The other types affecting the genital tract are low risk, and generally only cause warts (rarely leading to cancer). Both high and low risk types of HPV are transmitted sexually via genital contact, regardless of intercourse.
In the United States, nine out of ten sexually active adults will have come into contact with HPV. Most infections have no symptoms. Infection is most common during the teens and early twenties, decreasing by ages 25-28. Infection generally occurs shortly after the onset of sexual activity, and within 1-2 years, it generally either clears or goes into a latent state. It is our immune system that detects the virus and allows our bodies to develop a protective response so that only 9% or less of infections will persist in an active state for over two years. Although medical science has not uncovered answers to what actions a person can take to improve the likelihood of immune clearance of the virus, overall good health and healthy habits keep our immune systems optimal. Puberty in girls is marked, not only by beginning to have menstrual cycles, but the cervix (entry to the womb, and end of the vagina) actually “blossoms” as does a flower at springtime. The inner part of the cervix becomes exposed, and the female body actually is more vulnerable to sexually transmitted infection at the pubertal time. Studies have shown that with teens becoming sexually active earlier, there has been an increase in the incidence of abnormal cervical findings due to HPV in this age group.
Cervical cancer has a worldwide incidence of 500,000 newly diagnosed cases every year. Over 5000 women die in the United States annually from cervical cancer. The Pap smear is a screening test that takes cells (cytology) from the cervix which are evaluated by a doctor who looks at them under a microscope for abnormal/ precancerous changes (dysplasia). The Pap smear has decreased the incidence of cervical cancer drastically. Studies have shown that women who develop cervical cancer are likely to have never or rarely had Pap smear screening.
The Pap smear can be performed either by placing the cells onto a slide or in a liquid medium (most commonly done). The liquid based cytology has advantages of filtering blood, inflammatory cells, and debris, so that the doctor has a more clear view of the cells of importance. Also, testing for HPV, Gonorrhea, and Chlamydia infections can be performed from the same specimen in liquid based testing. Pap smears have been performed across the world since the 1940s, but only in the 21st century has the understanding of the causal effect of HPV been fully understood. The nomenclature of classification for reporting of Pap smears developed in 1988 (and modified several times thereafter) is known as the Bethesda Classification System. This report is sent by the lab which evaluated the Pap smear to the doctor who performed the test. The American Society for Colposcopy and Cervical Pathology (ASCCP) is the organization the defines the guidelines (standard of care) for how doctors manage abnormal results and determine what further testing and what time interval of follow up is appropriate based on these results. The general recommendations for Pap smear screening are that it begin for all women at age 21, and be done every two years until the age of 30. This is because there is a very low incidence of cervical cancer in women under 21; and, recent studies show that excisional procedures in this age group lead to an increase in premature birth (excisional procedures are done after abnormal Pap smears, but teens and young women are the most likely age group to have spontaneous clearing of abnormal results proving many procedures are unnecessary for this age group). These recommendations represent a consensus of the organizations such as American Cancer Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) that shape women’s healthcare in our country. They are based also on the widespread use of vaccination against HPV in teens and young women.
In 2006, Gardasil became the first FDA approved vaccine against HPV infection. It specifically protects against types 6, 11, 16, and 18 (the types which give rise to 70% of all cervical cancer & 90% of all genital warts). Studies show that in a person unexposed to the HPV virus, the vaccine provides 100% protection from the common types of HPV. In girls, the vaccine is indicated for prevention of anogenital warts, cervical, vulvar, and vaginal lesions & cancer. In boys, the vaccine is indicated for prevention of anogenital warts. Studies have already shown a 34% reduced rate of vulvar, vaginal, and perianal precancerous lesions, and a 20% reduction of cervical lesions. A second vaccine, Cervarix, has also been FDA approved. It provides protection against HPV types 16 and 18; and thus protects against high risk types which can cause cervical cancer but not low risk types which can cause anogenital warts and lesions. It is indicated for girls ages 9-25.
HPV incidence in young women since the introduction of the Gardasil vaccine is dropping. It is indicated for ages 9-25 of both genders. It is advisable to be given prior to onset of sexual activity. It is given in three separate doses over a six month time period. It reduces the number of abnormal Pap smears, invasive (excisional) procedures, and disease incidence. Even women who have a history of previous surgical treatment for precancerous lesions were 40% less likely to need another procedure when given the vaccination.
Parents have expressed hesitance in initiating HPV vaccination at the Pediatrician’s office for a number of reasons- lack of education about both the risks of HPV and the vaccine itself, negative stigma about vaccination, discomfort with approaching the subject of sexual activity, and poor doctor/patient communication overall about HPV. Since the introduction of HPV vaccination, only about one in five girls in the U.S. has received the HPV vaccine series. Therefore, it becomes a public health priority for OB/Gyns (Obstetrician/Gynecologists) to educate teens and young women (under the age of 26) directly in order to break down obstacles to women’s health and empower young women about their bodies, their risks for infection & disease, and their future fertility.
Worldwide use of vaccination has been a critical step in conquering deadly disease. This includes the use of both Hepatitis B and Meningitis vaccines for newborns, infants, and young children to prevent death. It includes prevention of Measles, Rubella, Tetanus, and Whooping Cough. It historically eradicated Polio, a deadly and debilitating disease. Thus, fear of vaccination is no more logical than fear of the use of antibiotics. Appropriate counseling, examination and healthcare provider guidance are always prerequisite to administration of a vaccine in order to ensure safe protocol and outcome. Most importantly, educating teen and young adults (especially in an era where all sexual/ health education in our public school system is elective) about the importance of adding HPV vaccination to their, already initiated, vaccine series in the pursuit of excellence health and disease prevention is a health priority.
As young women step into leadership roles in their schools, churches, and communities, they must be prepared to intelligently discuss the HPV epidemic in our nation and understand preventive measures against Cervical Cancer. This article prepares them to do just that in honor of Gynecologic Cancer Awareness Month.

Dr. Afriye Amerson

References & Resources:
1. American Cancer Society
http://www.cancer.org/downloads/STT/500809web.pdf

2. National Institutes of Health
http://www.consensus.nih.gov

3. American College of Obstetricians and Gynecologists
http://www.acog.org/publications/patient_education

4. US Preventive Services Task Force
http://ahrg.gov/download/pub/prevent/pdfsr/cervcanser.pdf

5. 2006 American Society for Colposcopy and Cervical Pathology- sponsored consensus conference.AmJObstetGynecol 2007; 197: 345-55
http://www.asccp.org/consensus2012

6. http://www.gardasil.com or 1-800-GARDASIL

7. Centers for Disease Control & Prevention
http://www.cdc.gov/STD/vaccines/hpv/default.htm

8. National Network for Immunization Information
http://www.immunizationinfo.org

9. http://www.hpvresource.org

10. http://www.thehpvtest.com

Childhood Obesity

Childhood Obesity
Our children do not go outdoors (spending all summer day until nightfall physically active), wear hand-me-downs, or eat primarily home-cooked food. In fact, in 2010, the CDC reported that 17% of American children were obese (13.7% in N.J.). One third of youth are overweight. Research shows that American children may be facing a lifespan shorter than that of their parents. One study published in JAMA found that children born in the year 2000 have a >30% chance of developing diabetes within their lifetime. Its time to better understand the crisis for which First Lady, Michelle Obama began the “Let’s Move” campaign.
BMI (body mass index) is a measure of weight relative to height that estimates body fat (and thus health risks). A BMI over the 85th%ile defines a person as overweight. A BMI above the 95th%ile defines one as obese. Disproportionate weight & BMI during developmental years has a permanent affect far more damaging than this phenomenon in adulthood. Total body fat cells are determined by late adolescence; so, in adulthood this number never changes. The cells can only shrink or enlarge as weight fluctuates. Thus, overeating in childhood leads to an overproduction of fat cells permanently.
Obese children have a 2-3 times greater risk of developing high cholesterol. Overweight children are at risk for heart disease by their 20s. Fatty liver changes are seen in up to one third of obese children. There is increased risk of asthma, gall stones, bone deformities, and insulin resistance with increasing weight at disproportionate (relative to the child’s height/ bony frame) levels. Obese children are at 2-5 times greater risk of developing sleep apnea, where less oxygen is delivered to the brain. New studies show that childhood obesity increases the possible development of Alzheimer’s-like brain lesions.\
By adolescence, the obese teen is now two to three times more likely to die by middle age compared to normal weight teens. There is an increased risk of the development of metabolic syndrome, in which fat and glucose metabolism is impaired. This condition is associated with a 5 times greater risk of developing diabetes, and three times greater risk of stroke or heart attack.
Nutrition must be addressed in the home and school. 6.5 million children live in low income areas that lack stores with affordable, nutritious food. The USDA reports a typical school lunch far exceeds the recommended sodium limit (500mg), and less than 1/3 of schools stay below the recommended fat content limit. The National School Lunch Program serves 31 million children. Additionally, many cafeterias offer an unregulated “a la carte” menu. Many serve over processed food that is high in sugar, fat, sodium and calories.
Our children need diets rich in fruits, vegetables and whole grains. If an obese person loses 5-10% of their body weight, this person achieves a measurable health benefit. Whole grains contain fiber, vitamins, and minerals. A balanced lunch should include 2oz of protein. This does not have to be meat; 1 hard boiled egg, ½ cup of yogurt, or 2tbspns of peanut butter suffices.
Nutritious lunch suggestions:
Carrot or celery sticks, apple slices, edamame, dried strawberries, blueberries, mixed berries, sugar snap peas, fruit smoothies, & grape tomatoes
Sun dried tomato & cream cheese on whole grain tortilla
Smoked turkey, cheddar cheese & apple in a wrap
Banana & soynut butter on whole grain English muffin
Our children also need more physical activity than provided by their team sports (obviously, this has not improved the reality of the stats!). They need constant movement sustained at least 30 minutes, vigorous enough to get their heart rates up. Without outdoor safety as a modern day option, fitness programs targeting childhood obesity have been developed. One such in our area is Master Karate Todd which airs on Verizon Fios (channel 477) on Saturday mornings 8:30 to 10am. This interactive work out engages children 4 to 10 years old (www.masterkaratetodd.com). Pretty Girls Sweat (as seen on youtube) was developed to mentor adolescent girls about the importance of fitness and sports participation. Each “meeting” involves (at least) one hour of hard-core working out. Remember to make room in your home for your child to be physically active & get off the couch or computer. Even if its just dancing to music in the mirror, our homes should not be so congested that the body is forced to be sedentary within it. As community leaders, we must individually challenge ourselves about our dietary choices (i.e. “what’s in your fridge?”) & level of physical activity, so that we may mirror to our children the example of fitness of which we aspire that they follow.

November 2014
Dr. Afriye Amerson

November is Vitamin D awareness month

Time to test your levels & raise your wellness

In the early 20th century, children in Europe and northern United States developed Rickets due to lack of sun exposure. This led to initial research into the importance of Vitamin D in the human body. Rickets (in children) and osteomalacia (in adults) occur due to poor mineralization of the collagen matrix associated with bones. The human body creates Vitamin D (from 7 dehydrocholesterol) in the skin with exposure to UVB (290-315nm) from the sun. Many Vitamin D experts advise 10-15 minutes of exposure over 40% of the skin (using facial sunscreen) daily or 20-25 minutes three times weekly to meet the body’s requirements. However, there are many obstacles to this simple option of outdoor communing with nature. Geography is the first, as latitudes above 35 degrees North (ie Atlanta) receive less UVB in winter. Fear of skin cancer, resulting in less outdoor activity and increased use of sunscreens is another obstacle to nature meeting our body’s requirement. Cedric Garland, PhD from University of California, San Diego Medical School states “responsible, routine sun exposure will save 10 lives from non-skin cancers for every 1 skin cancer death.” An SPF of 8 is sufficient to block the synthesis of vitamin D from exposure to sunlight. Age and ethnicity also contribute to the obstacles in a natural supply of vitamin D. Darker pigmented persons require more sun exposure for solar synthesis and elderly persons may have impaired skin synthesis (of up to 75%) due to age. Since vitamin D created from solar exposure is converted to its active form by the liver and kidneys, persons with organ damage also have limited capacity. Thus, in the 1940s, the supplementation of vitamin D in industrialized countries began and Rickets became rare.

However, the problem of deficiency of vitamin D was far from resolved. Studies have found that up to 93% of patients admitted to the Emergency Room for bone pain and muscle aches were found to be deficient in Vitamin D. In postmenapausal women on prescription medication for the treatment of Osteoporosis over 50% were deficient. Amongst youth, over 50% of Black & Latino teens and almost 50% of White preteens were found to be deficient in studies. Even amongst pregnant and lactating women taking a prenatal vitamin with 400IU of vitamin D, 73% were found to be deficient (90% ate fish; 93% had 2-3 glasses of milk daily in addition to the vitamin). So, if Rickets is rare, why does deficiency matter?

The 21st century has brought forward many exciting results of research on Vitamin D. Postmenapausal women who increased their vitamin D intake by 1100IU reduced their cancer risk by 60 – 77%. We know that living in more northerly latitudes of the U.S. is associated with increased incidence of ovarian, colorectal, and renal cancers. And, that incidence of Crohn’s, Type I Diabetes, and Multiple Sclerosis is higher at higher latitudes. Now, Swedish studies have shown that patients with Type I Diabetes had lower vitamin D levels than those not affected. A study of military personnel showed that with regard to Multiple Sclerosis, the incidence was 62% lower in persons with the highest vitamin D levels when compared to persons with the lowest levels. In a review of 63 scientific papers, the rates of Breast, Ovarian, Colorectal and Prostate cancers were decreased by fifty percent with vitamin D supplementation (1000IU for men & 1500-2000IU for women). Thus, the significance of vitamin D is far greater than its contribution to bone metabolism and the maintenance of bone health.

Vitamin D regulates calcium and phosphorus absorption by the intestines, and deficiency can result in only 10-15% calcium & 60% phosphorus absorption. Vitamin D also affects the healthy development of red blood cells, regulates cell growth, secretion of insulin and parathyroid hormone, and is a modulator of the immune system. So, it has an important role in anti inflammatory, neuroprotective, and cellular regulatory functions. Psorias and wound healing are improved with vitamin D via skin production, topical or supplemental forms. New research has shown that vitamin D reduces the rate of physical decline in seniors. Increasing levels resulted in improved performance speed and proximal muscle strength.

Deficiency (<20ng/ml) in utero can cause growth abnormalities and childhood skeletal deformities. Studies have shown that increased vitamin D levels in pregnancy reduced the development of offspring’s autoantibodies to cells of pancreas. Deficient levels are associated with a 30-50% increase in the risk of Colon, Prostate, and Breast cancers. Deficiency is also associated with Depression and Schizophrenia. Published studies of elderly women show that those with the lowest vitamin D levels are the first to fall; and, supplementation reduces fall risk. Osteoporosis affects one third of women in their sixties and two thirds of women over eighty. The risk of developing this disease is reduced by calcium and vitamin D supplementation. Studies have also shown that taking vitamin D reduced the risk of Multiple Sclerosis, Rheumatoid Arthritis and Osteoarthritis.

Vitamin D is now well understood to be one of the body’s best defenses against certain cancers, psychiatric conditions, skin & respiratory infections, autoimmune diseases; as well as being a major regulator of bone health and maintenance of physical performance. Normal levels in blood tests (25 hydroxyvitamin D) should be at least 40ng/ml. Dietary sources include salmon, mackerel, sardines, tuna, and cod liver oil (also contains vitamin A which some experts say can inhibit uptake of vitamin D). Dairy is not an adequate dietary source. Supplements are generally with calcium over the counter. The calcium citrate maleate is less likely to cause kidney stones than calcium carbonate. At least 800IU daily should be supplied by supplement. Persons found to be deficient are given 50,000IU/week for six to eight weeks, then levels are rechecked. Persons found to be insufficient are given 1000-2000IU/daily. The cost of supplementation has been estimated at 5 cents/person. This pales by comparison to the health care costs from the medical consequences of widespread deficiency. So, “move over turkey”, this Thanksgiving you may want to consider adding an oily fish to the meal of gratitude. Or, alternately, you can plan a quick Black Friday excursion closer to the equator.