Tdap Booster Vaccinations

Several years ago an epidemic of whooping cough (pertussis) was ongoing in affluent areas of California and Arizona. Epidemiologists from the Center for Disease Control (CDC) and National Institute of Health (NIH) descended on those areas to determine the cause of the life threatening illness to very young children.

Much to their surprise, grandparents were inadvertently transmitting it to their new and not completely vaccinated grandchildren. As youngsters, these grandparents took the suggested DPT series of shots believing they were resistant to diphtheria, pertussis and tetanus for life.

Like most things, as we get older, the immune system just doesn’t work as well. The immunity to pertussis waned and adults were catching the adult version of whooping cough in the form of an upper respiratory tract infection with bronchitis. The adult version resembled a run of the mill viral upper respiratory tract infection with a prolonged barking cough. This was just the type of infection which infectious disease experts were suggesting we do not treat with antibiotics and instead let our immune systems fight off independently. Unknown to us was the fact that even after we stopped coughing, if this was in fact adult whooping cough, we could transmit the pertussis bacteria for well over a year after we stopped coughing.

The solution to the problem was to give these adults a booster shot against pertussis when they received their tetanus shot booster. It is recommended that we get a tetanus booster every seven to ten years.

Tdap, produced by Sanofli Pasteur, was the solution and an international campaign of vaccination was begun. The campaign was successful but what do you do seven to ten years later when the next tetanus shot is due? In a study sponsored by the manufacturer, adults 18- 64, were given a second dosage 8-10 years after the first Tdap shot and tolerated it very well. Blood levels for immunogenicity taken 28 days later showed the benefit of the second shot.

The data has been submitted to the CDC and its vaccination Prevention Advisory Panel for consideration for a change in the recommendations on vaccinating adults.

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Marijuana, Pain Relief and the Facts

On a daily basis patients of mine come in for office visits complaining of wear and tear injuries, as well as aches and pains, and their methods of dealing with chronic pain. As we all know, aging is a part of the normal life process.

For instance, as we approach 70 years old we typically lose three quarters of our functioning kidney cells (nephrons) but do well with our limited reserve as long as we do not constantly call on that reserve. When we take nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen to relieve pain we are challenging that reserve leading seniors to look for alternatives. Opioids, even when appropriate, have become taboo so alternatives are being searched for.

Medical marijuana has become a very hot topic recently.  It is being heavily marketed as a pain relief alternative in several forms.  However, what little legitimate research has been conducted indicates it is not very good at relieving non cancer related chronic pain.

Not a day goes by when several patients reveal they are using cannabis products obtained out of state for pain relief with no consideration of how it interacts with the medications they are already taking. Recently, strong public relations campaigns for legalizing medical marijuana have led to its legalization in different forms, in various states, even if it doesn’t work. A select group of investors have positioned themselves to make vast sums of money from a product with little documented upside and potentially unknown downsides.

At the same time that medical marijuana enters mainstream medicine there is a similar legislative and marketing push to legalize marijuana for recreational use. Once again, a well-financed lobby of investors is trying to sell the concept of marijuana being less troublesome than legalized tobacco or alcohol. In the last few weeks there have been several articles appearing in reputable medical journals and periodicals such as the Wall Street Journal, New York Times and New Yorker magazine all examining the known results of liberalizing marijuana use in three states.

First of all, today’s marijuana is far stronger and potent than the “love generation’s” weed of the 1960’s with a higher percentage of the hallucinogen THC. To that point, states that have legalized marijuana have seen a tripling of visits to the emergency department for psychotic behavior. Also, violent crime and murders have tripled in many jurisdictions. A growing body of evidence indicates auto accidents have increased as a direct result of marijuana’s use.

Medically speaking, there is little research evaluating marijuana as a drug. Many questions remain.  What is the minimal dosage to create an effect? What is the dosage that can cause medical illness? How does the mechanism of delivery affect the final effects such as smoking versus vaping versus eating the product? Beyond the stoners’ credo of “start low and go slow” there is little data to evaluate the product as a pharmaceutical drug and or how it can interact with other drugs prescribed for you.

I am far from an anti-marijuana critic. I’d just like to know what I’d be getting in to before I consider hallucinating. It seems to me that before we liberalize marijuana use, the product needs to be put through the type of research and scrutiny the old Food and Drug Administration (FDA) put a product through before it was approved for public use.

Chocolate as a Cough Suppressant

Well before Valentine’s Day, and conspicuously in the middle of cold and flu season, Alyn Morice of the University of Hull in Yorkshire, England published a study showing that dark chocolate derivatives may be more effective than codeine in suppressing a cough. In a small study of 163 individuals, each with a cough due to an infection, her group randomly assigned them to a group receiving a codeine based cough syrup or a chocolate cocoa based syrup called Rococo. Their results showed that within two days the chocolate based recipients felt significant improvement in their cough compared to the codeine based group. A similar study had previously been performed at the imperial College in London showing that theobromine, a product in cocoa, is superior to suppressing coughs over codeine.

Professor Morice believes the properties in cocoa are demulcent and help relieve irritation and inflammation. “This simply means it is stickier and more viscous than standard cough medicines, so it forms a coating which protects nerve endings in the throat which trigger the urge to cough. This demulcent effect explains why honey and lemon and other sugary syrups help.” They believe chocolate has additional helpful ingredients so much so that they advise sucking on a piece of dark chocolate as a mechanism of relieving a cough. We now have some science to back mom’s hot chocolate and hot cocoa for a cold and a cough.

Winter is the Season for Upper Respiratory Tract Infections and Influenza

It’s the season for winter viral upper respiratory tract system infections. It is also influenza and influenza- like illness season.

Winter brings crowds of people indoors together and holiday travel places crowds together in indoor areas as well. These viral illnesses are transmissible by hand to mouth transmission and airborne particle transmission with coughing. The viral particles can live with minimal water on surfaces for long enough periods of time to infect patients who unknowingly touch a foreign surface and bring their hands up to their mouths. Hand washing frequently is an essential part of preventing the transmission of these diseases. Common courtesy such as covering your mouth when you sneeze or cough and not coming in close contact with others when ill is essential.

Research has shown that consuming an extra 500 mg a day of Vitamin C can prevent colds and reduce the intensity of a cold if you catch one. You must take the Vitamin C all the time and in advance of exposure. Waiting until you have symptoms has no positive effect. Viral upper respiratory tract infections usually include fatigue, runny nose (coryza), sore throat (less than 90 % of adult sore throats are not a strep throat).

If you have been around a sick child age 2-7 who has a fever, swollen neck glands and an exudative sore throat your chances of having a strep throat are increased. Fever is usually low grade, less than 101, and short lived. Very often patients develop viral inflammation of the conjunctiva or conjunctivitis. While this is very contagious to others, it is self-limited and rarely requires intervention or treatment.

Caring for a cold involves listening to your body and practicing common sense solutions. Rest if tired. Don’t go to the gym and workout if you feel ill. If you insist on going, warm up slowly and thoroughly and, if you do not feel well, stop the workout.

Sore throat can be treated with lozenges. Warm fluids including tea and honey (honey is antimicrobial and anti-viral), chicken soup, saline nasal spray for congestion and acetaminophen for aches and pains or fever are mainstays of treatment. Over the counter cough medications like guaifenisin help.

Some of the viruses affect your gastrointestinal tract causing cramps and diarrhea. Nausea and vomiting are sometimes present as well. The key is to put your bowel to rest, stay hydrated and avoid contaminating or infecting others. Clear liquids, ice chips, shaved ices, Italian ices or juice pops will keep you hydrated. A whiff of an alcohol swab will relieve the nausea as well. If you are having trouble keeping food or fluids down call your doctor. If you are taking prescription medications, call your doctor and see which ones, if any, you can take a drug holiday from until you are better.

Influenza is more severe. It is almost always accompanied by fever and aches and pains. Prevention involves taking a seasonal flu shot. Flu shots are effective in keeping individuals out of the hospital from complications of influenza. They are not perfect but far better than no prevention. If you run a fever of 100.8 or higher, and ache all over, call your physician. An influenza nasal swab can confirm influenza A and B 70 % of the time.

The new molecular test which can provide results in under an hour is far more accurate but not available at most urgent care or walk in centers or physician offices. Immediate treatment with Osetamivir (Tamiflu) and the newer Peramivir are effective at reducing the duration and intensity of the infection if started early. Hydration with clear fluids, rest, acetaminophen or anti-inflammatories for fever in adults 101 or greater and rest is the mainstay of treatment. Prolonged fever or respiratory distress requires immediate medical attention. Call your doctor immediately.

I get asked frequently for a way to speed up the healing. “My children are coming down to visit. We have a cruise planned. I am flying in 48 hours on business.”  I am certainly sympathetic but these illnesses need to run their course. They are not interested in our personal or professional schedule and everyone you come in contact with is a potential new victim. If you are congested in the nose or throat, and or sinuses, then travelling by plane is putting you at risk of severe pain and damage to your ear drum. See your doctor first. Patients and pilots with nasal congestion are advised not to fly for seven to ten days for just this reason.

If you have multiple chronic illnesses including heart disease, lung disease, kidney disease and you run a fever or feel miserable then call your doctor and make arrangements to be seen. It will not necessarily speed up the healing but it will identify who actually requires antibiotics and additional follow up and tests and who can let nature take its course.

Experimental Drug Stops Parkinson’s Disease Progression in Mice

Researchers at Johns Hopkins University School of Medicine published an article in Nature Medicine Journal outlining how administration of a drug called NLY01 stopped the progression of Parkinson’s disease in mice specially bred to develop this illness for research purposes. The medication is an alternative form of several diabetic drugs currently on the market including Byetta, Victoza and Trulicity. Those drugs penetrate the blood brain barrier poorly. NLY01 is designed to penetrate the blood brain barrier.

In one study, researchers injected the mice with a protein known to cause severe Parkinsonian motor symptoms. A second group received the protein plus NLY01. That group did not develop any motor symptoms of Parkinson’s disease. The other group developed profound motor impairment.

In a second experiment, they took genetically engineered mice who normally succumb to the disease in slightly more than a year of life. Those mice, when exposed to NLY01, lived an extra four months.

This is positive news in the battle to treat and prevent disabling symptoms in the disease that affects over 1 million Americans. Human trials will need to be established with questions involving whether the drug is even safe in humans? If safety is proven then finding the right dosage where the benefits outweigh the risks is another hurdle. The fact that similar products are currently being used safely to treat Type II Diabetes is noteworthy and hopefully allows the investigation to occur at a faster pace.

Parkinson’s disease is a progressive debilitating neurologic disorder which usually starts in patient’s 60 years of age or greater. Patients develop tremors, disorders sleeping, constipation and trouble moving and walking. Over time the symptoms exacerbate with loss of the ability to walk and speak and often is accompanied by dementia.

Allergies Worsening Due to Climate Change

The American Academy of Allergy, Asthma and Immunology and the World Asthma Organization just concluded their joint congress in Orlando, Florida. One of the topics of concern is how climate change is making everyone’s allergy symptoms much worse.

We read about more powerful hurricanes and cyclones, seasonal tornadoes occurring out of season, horrible beach erosion and flooding due to large volume rains, lack of rain causing poor harvests leading to waves of migration for survival for animals and humans. Climate change also exacerbates allergy symptoms. Nelson A. Rosario, MD, PhD, professor of pediatrics at Federal University of Parana (Brazil) discussed longer pollen season and increased allergens caused by fallen trees and ripped up plants, mold growing following flooding and irritants in the air due to wildfires. An international survey in 2015 found that 80% of rhinitis patients blamed their symptom exacerbations on climate change items. Pollen seasons have more than doubled in some areas.

The argument should not be about whether climate change is due to cyclical planetary changes or man-made pollutants. It should be about what we can do as a society to maintain economic growth while limiting man made contribution to adverse climate changes. The health and survival consequences of not addressing this issue will ultimately involve our survival as a species.

More on Shingrix, the Shingles Vaccine

Recently, the FDA approved a new shingles vaccine called Shingrix. It is a two shot series with the suggestion made that the second shot should be taken 2 – 6 months after the first one. Shingrix will replace the original shingles vaccine Zostavax. Shingrix is recommended in all patients over 50 years old.

For those of you who have had the original shot, Zostavax, the new vaccine is still recommended. It is covered by Medicare Part D which means you must take it in a pharmacy or walk in center not in your doctor’s office. While this makes NO sense, it is the rule. If you have had shingles it is still recommended you take the new vaccine (Shingrix).

Shingles is a skin rash and painful skin condition caused by the chicken pox virus Varicella. When you have chicken pox and complete the infection course you are immune but the virus remains alive forever, living in sensory nerve endings along the spinal cord. One third of adults will have an outbreak of this varicella virus which will appear along the path of a sensory nerve or dermatome on one side of your body. It will go through the full cycle of rash, pustule and then scab that the chicken pox did. A significant number of patients will continue to have pain over the involved skin for prolonged time periods in what we call post herpetic neuralgia. The pain is described as severe as an eye scrape, passing a kidney stone or going through labor and delivery.

The original shingles vaccine, Zostavax, protected against the rash 51% of the time and against post herpetic neuralgia 67% of the time. This efficacy dropped to about 30% after four years. The new vaccine, Shingrix protects against the rash over 90% of the time and against the pain syndrome 85-90% of the time while lasting for more than four years.

Only five percent (5%) of patients receiving Shingrix develop side effects. The most common are fever, myalgia and chills. In view of this, I am suggesting to my patients we allow the vaccine to be on the U.S. market for a year to see the adverse event profile and, if safe, we then start the series of shots.