How’s your Hearing—What??

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

December, 2019

This column is largely about public health issues, i.e. issues that have a general population health impact. Most often those involve the prevention of diseases with direct or indirect effects beyond the individual to at least portions of the rest of the population, as immunizations do.  Last month I wrote about sleep, which has only indirect public health implications resulting from sleepy people driving home from work or elsewhere, or generally not being their best. Mt. Vernon’s John Olson thanked me for the insights it gave him and suggested I might write about hearing loss as a sequel. The only public health issues there are in the possibilities in preventing or diminishing the afflictions; nevertheless, I suspect hearing loss is of interest to many, so here goes!

Deafness is a relatively rare condition until people reach retirement age. Sure, a few youngsters suffer it, but by the time people reach age 70, nearly half of them are significantly deaf by formal testing. Deafness rapidly develops in most of the other half over the next 2 decades; well over 90% over 90 suffer have hearing loss, according to epidemiologic statistics. That number seems a little high to me, but many with the disease hide it well; for instance, they start agreeing with me after the first repeat, even though they have no clue what I just said. So, my impression of how many have significant hearing loss, is undoubtedly an undercount.  

Almost all deafness is due to injury or blockage of both ears. Thank the Lord we are given two ears by evolution, so knocking out one ear is only a minor inconvenience.  Here is how hearing works. Each ear is made up of 3 parts: 

•External ear, the ear lobe and canal

•Middle ear (the ear drum, ear bones, and the air-filled space drained by the Eustachian tubes to the back of the throat

•Inner ear, very complicated, containing:

-Semi-circular canals, like 3 small gyroscopes lined with hair-cell, which, via the 8th cranial nerve, alert the brain where little sand grains inside each canal land, in 3 dimensions, to tell you where you are in relation to gravity

-Cochlea, another long, coiled tube like a snail shell, also lined with hair cells that are twitched by each different frequency in the normal hearing range, low to high, roughly 0.5-2.5 cps [cycles per second, or “Hertz”) 

Deafness is caused predominantly by presbycusis, Greek for “old hearing”, which means the cumulative effects of aging on hearing, almost always from recurrent exposure to loud (at or over 85 decibels) noise, be it music, chain saws, or many other things you can imagine. That level  is a consensus of professionals, although there are no national standards or clinical trials (not surprising, since who would volunteer to be a subject in a study where they might be subjected to high decibel noise daily for many years, to see what happens!) Loud noise repeatedly hitting the middle C hair cell in the cochlea, causes that cell eventually to be damaged. The high-pitched hair cells above high C are the most sensitive to such injury. So, high pitch hearing is usually lost first. And because consonants provide a major part of word meaning, the loss of their whispery, high pitched sounds severely impacts a person’s ability to interpret other’s speech. Vowel sounds are in the 0.5-1.5 cps range and hence are lost much later. Manifesting very similarly is much rarer interference or damage to the auditory nerve from medicines, like the reversible ear-ringing caused by aspirin in moderately high doses (over 1 gm daily), permanently from some medicines, classically antibiotics, like streptomycins, or other diseases like Menniér’s Disease. These types of losses are all categorized as a Sensory-Neural (S-N) hearing loss.

The second most common contributor to presbycusis is ear wax in the external ear. Usually this normal mixture of dead skin, sweat and oil stays soft and leaks out of the canal on its own or with the help of warm water in dry climates like winter. But if it does not, it can build up into very firm, dark -brown plugs. Ineffective efforts to dislodge it with fingers, Q-tips or other tools can pack it even more firmly against the ear drum causing a “conductive” hearing loss. Ironically hearing aids do this very well too. Older people have less oily skin secretions and hence get this condition more easily. Usually it can be prevented by simply running warm water into the ear canals while bathing or showering. And for people with recurrent wax impaction and resultant conductive hearing loss, a family member can gain the skill of looking in there weekly or monthly to prompt more room temperature water irrigation with a bulb syringe and frequent ear drops to soften the impacted wax.

Clinicians can distinguish between S-N and conductive hearing loss by looking in the ear and with simple tuning fork tests called Rinné and Weber. 

So, what can we do to help/cope?

First, prevention: 

•Avoid loud noise damage. Ear protectors work fine, though they can be uncomfortable on a hot summer day. Wear them or ear plugs, which I think are a little less good because they are harder to get a good fit. Make your nearly adult kids to protect their hearing at concerts or using machines; they may thank you decades later.

•Be sure you are not given medicines that can cause permanent damage unless you must have it to survive.

•Run bath water into your ear canals while bathing 

Second, accommodate:

• If wax impaction occurs, regularly check for impacted wax and irrigate the ears clear.

•Speak in low frequencies to presbycusis sufferers. Men’s voices work better than women’s; women can speak in their lowest voices. Don’t shout; that diminishes the clarity of consonants, which are crucial to understanding speech. Look at the person, so they can see your lips move; use confirming gestures. They can begin to learn lip reading that way.

•Hearing loss accompanies dementia often, and each makes the other worse. Isolation can be due to either, and accommodating hearing loss can slow progression of dementia.

•Hearing loss also causes depression; sufferers withdraw from contacts because of frustration with not being able to participate in conversations. Find ways to engage anyway.

•Many users experience “recruitment,” which is a condition where the useful loudness of sound lies in a very narrow decibel range. You may have spoken louder and louder to a deaf person who suddenly says “quieter, you don’t have to shout”; you know then that you overstepped their narrow range. The same can happen with a hearing aids.

•Use assistive devices, just as you would a cane with a bad set of knees. A cheap stethoscope in the sufferers’ ears and held toward you can markedly improve their understanding. Electronic devices are often available at churches, as they are for TV sets and telephones. 

•Explore hearing aids, though beware, there are a lot of shysters out there. Get an evaluation at a hospital audiology center (MaineGeneral centers in Augusta and Waterville, and elsewhere). The problems with hearing aids are that they are moderately hard to keep working, especially with concomitant cognitive problems. They magnify all sounds, not just the ones you want to focus on. Aids can be very expensive, in the many $1000s. 

So, practice prevention starting now, wherever you are on the hearing spectrum. Prevent ear wax build up if you or family members have a problem. Use assistive devices sooner rather than later.

Did I help, John?

The VIENNA PLANNING BOARD

Has cancelled its regularly scheduled meetings for November and December in view of the holidays. However, the Board will hold a make-up meeting on Wednesday, December 11 at 7:00 PM at the TOWN HOUSE on TOWN HOUSE ROAD; at which the Board will hold a

PUBLIC HEARING

to consider an Ordinance regarding setbacks from roads and property lines, on which the Board has been working. We expect to have draft copies available at that time.

--Creston Gaither, secretary, Vienna Planning Board

The Polls are open at the Vienna Community Center  from 8AM to 8PM.

====================================================================

Questions Appearing on the November 5, 2019 Ballot

Question 1:  Bond Issue

An Act To Authorize a General Fund Bond Issue To Improve Highways, Bridges and Multimodal Facilities

Public Law Chapter 532

Do you favor a $105,000,000 bond issue to build or improve roads, bridges, railroads, airports, transit and ports and make other transportation investments, to be used to match an estimated $137,000,000 in federal and other funds?

Question 2:  Constitutional Amendment

RESOLUTION, Proposing an Amendment to the Constitution of Maine Concerning Alternative Signatures Made by Persons with Disabilities

Constitutional Resolution Chapter 1

Do you favor amending the Constitution of Maine to allow persons with disabilities to sign petitions in an alternative manner as authorized by the Legislature?

Sleep

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076  -- dkonion@gmail.com November, 2019

Many people experience “problems” sleeping at some point in their lives, more often the older they get and when travelling across several time zones. My wife and I have experienced both recently. I’ll review the issues and some do’s or don’t solutions.

First, aging gradually speeds the internal body clock. When experimenters house teens or adults in a room with a constant level of light 24/7, they tend to develop their own endogenous rhythm, waking and falling asleep at the same times every day after a week or so. Those between 25 and 45 years old tend to exactly match the 24-hour cycles of our earth’s spin around its axis. Teens and younger adults tend to settle into moderately longer, about 25-26 hours., wake/sleep cycles. Older people shorten their days to that of their endogenous (built-in) body clock cycles of less than 24 hours; and the older they are, the shorter those cycles are, down to 21-22 hours a day. So, by the time people reach retirement age, their natural cycle will tend to have them waking up earlier and earlier every day and going to bed earlier and earlier too. Teens are the opposite, going to bed later and waking up in the morning later and later. That’s why the recent big push makes sense, to allow teens to arrive at school later than their middle-aged and older teachers and superintendents tend to schedule classes. Each group’s tendencies are curbed by the sun and scheduled activities.

Travel across time zones can be heartening in one direction, and more stressful going in the opposite direction. So, an old guy, like me, is thrilled to find, when travelling east five time zones to England, he can stay up until after midnight easily, and sleep until 9 am local time instead of awakening at 5 or 6 am for a few days. Teens and young adults traveling west, find that their usual late to bed, late to rise, fits the normal pattern of their elders for the first few days after they arrive. For all, correction for time zone travel is more rapid if one gets some sun or any daytime outdoor exposure around noon local time for a few days.

So usually, the young have trouble falling asleep in the evening, and the older have trouble sleeping late in the morning. The safest and best solutions are to go with the flow. Avoid sedation with medications or alcohol. Antihistamines (like Benadryl, Sominex, Tylenol pm, and many others), can sedate (make you sleepy) somewhat, but are likely to cause confusion the older a person is, because of their effect on the brain. Typical benzodiazepine sleep medicines (Valium, Librium, Ativan and many others), likewise can cause confusion . in spades and are more likely, the older a person is, because their metabolism of such drugs is slower. Alcohol can make people sleepy, but it has an awakening effect several hours later. And the flickering light of a bedtime TV can mess up wake/sleep cycles. Daytime exercise, at least 4 hours before going to bed, can facilitate falling asleep more soundly. 

So, understand your body clock cycles’ tendencies and don’t fight them too hard. Regular bed and awakening times help; avoid shift work, if you possibly can.

Sleep well!  Happy Holidays! And get a flu shot soon; tis the season (see Mt V newsletter, Nov. 2018, p5 about why)!

Influenza This Year in Maine

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

December, 2018

Winter is coming and so is influenza. Last year we had a bad year and there was a lot of bad press about immunizations, so let's review this annual epidemic and what we know so far this year.

Influenza is an infectious disease of the upper and lower respiratory tract (nose, throat, breathing tubes and lungs themselves) caused by an influenza virus. Two major types of influenza infect humans, A and B.  "A" types cause most of the disease, injury and death; "B" types are less common and more benign, but are still hard on, and sometimes fatal, to babies and the elderly. Influenza viruses survive over the centuries because they change their coat every few years. Those are, on Type A viruses, surface proteins called hemagglutinin (H) (with subtypes 1-5), and neuramidase (N) (subtypes 1 and 2), against which our bodies make effective antibodies when we are infected or immunized. By changing those coat proteins through genetic natural selection every few years, the slightly different flu virus becomes more infectious because people haven't been previously exposed to that version.

To treat this common disease, boost your family's immunity with a flu shot every year, so none of you catches it or maybe get only a mild case. Years, when most of us have already been infected by and/or immunized against the circulating H/N combination types, cases of illness are fewer and less severe. The US Centers for Disease Control (CDC) makes an educated guess each year about which recent subtypes are going to predominate, and incorporates 3 or 4 of those into vaccine manufactured each fall. The vaccine is egg-based, so the rare person who is truly egg protein allergic (I’ve never met one), can’t take the shot and must use available alternative vaccines.

When the virus changes its coat, as it always does, and/or the US CDC hasn't guessed right, and/or we haven't done a good job of immunizing everybody, then we have worse epidemics. Their severity is usually measured by elementary school absence rates over 20%, higher than average emergency room and office visits for "influenza-like" illnesses, hospitalizations, and deaths.

When given the standard shot into our arm muscle, most of us do fine, suffering at most a mildly sore arm for a day or two. Many claim to have “gotten the flu from the shot,” but this is not possible because there is no live virus in the shot. Most, I think, are describing an aching from the body’s healing up the injection site and getting rid of the dead virus parts, thereby enhancing new antibody formation; that's why the shots work.

The US CDC monitors and regularly reports vaccine "efficacy", calculated as the percentage of people who, after having had a flu shot, later have a worrisome enough illness to prompt a medical visit. But illness visits could also reflect unusually easy access to medical care, and/or other factors. And those numbers are from the same 5 states every year, never Maine. Last year that "efficacy" was only 40%; it usually is around 50%, but occasionally is as high as 60% and rarely as low as 10%. Publicizing only the "efficacy" statistic seems quite misleading. I'd rather they emphasized hospitalization and/or mortality rates, both much "harder" outcomes and calculated for all states. Last year, Maine hospitalization rates for flu were almost 70% higher than in the previous year, confirming a bad season.

Important things to know, understand, and recognize: 

•Influenza is not a viral cold (sore throat, under 100°F temperature degrees, and the patient still able to function). Nor is it gastroenteritis , predominantly nausea, vomiting and diarrhea from gut germs, which we often also call “flu.”

•The vaccine:  This year the vaccine is directed against 3 (trivalent) or 4 (quadrivalent) types: influenza A/H1N1, A/H3N2, B/Colorado and B/Phuket. And we have designer vaccines with the added 4th virus' proteins at quadruple doses, and also with "adjuvants", all to enhance the effect for older or other high risk people. Childhood vaccines for ages 6 months to 8 years old are similarly specific to that age group and usually require two doses. The vaccine can also be given by nasal spray. So far this year, Maine CDC graphs (below) look good with only 34 cases in Maine. But last year at this time, things looked similarly good, so there's no telling for sure. Even if the vaccine match turns out less than ideal, you should get it and not let the perfect be the enemy of the good.

•Three ways people get sick with the flu and to watch out for: 

1. Rapidly super sick patients with overwhelming viral pneumonia: Usually young people, mostly teenagers and young adults. They get sick one night with chills, often have a fever over 101, become prostrate (flat out sick) within hours, always have cough, which may or may not produce sputum; their lungs fill with fluid making them short of breath; they can get confused, turn blue and can die within hours if not hospitalized. If you see these signs, get to an emergency room ASAP, DO NOT DELAY!! Rare, but extremely dangerous.

2. Another group in trouble with delayed complications: especially in toddlers and elderly, who get the usual flu symptoms with fever over 101°, productive cough, feel rotten all over, may have some vomiting (rarely diarrhea), who then develop a secondary bacterial pneumonia. They start to get better after 3-5 days then relapse back with high fever, get sicker again, with more cough, more sputum, if not too weak to produce it, and can die in a few more days if not diagnosed and treated with bacterial antibiotics. Get them to the emergency room as soon as that regression to bad happens.

3. Finally, the rest of those with influenza, have sore throat, fever/chills, cough, feel lousy, often still try to work, then gradually improve over a week and get back to normal within 7-10 days.

•Effective antiviral drugs that help those in groups 2 and 3 above: oseltamivir (Tamiflu) 75 mg and several similar drugs work to ameliorate severity and complications if started within 48 hours of symptoms. Many clinicians will want to test a throat swab before prescribing these but when the flu season gets bad, most will figure hoof beats mean horses and prescribe it even over the phone if your symptoms fit. These drugs also work at lower doses to prevent having flu or at least reduce its complications when a family member has it.

•Think of your friends and neighbors. Don’t work or visit with them when you are sick, if you can help it; not 100% effective because you are spreading the virus a couple days before you get really sick, but worth doing.

Now, late October-early November is the time to get a flu shot. Earlier immunization risks getting the flu while the flu is still peaking in March and April (see 2nd graph below) as the immunization begins to wane 6 months after the getting it. Getting a pneumonia immunization (pneumovax), if you are due, is a good idea too, especially for older adults, because complicating pneumococcal pneumonia (group 2 above) causes many flu deaths.  I had my flu shot 2 weeks ago in mid-October, which should protect me into April. So please get yours!

There is some hope that this annual dance will change soon. After decades of trying, the first universal flu vaccine, a nasal spray, is about to enter its first human trials. It appears to be able to  generate immunity to parts of the virus that are the least variable from strain to strain and thereby protect against all human influenza strains. That would get rid of all this trying to guess which flu strain will be the problem next year. 

(For more information, see:  https://www.cdc.gov/flu/about/season/flu-season-2018-2019.htm)

Maine Cases This Year as of November 24, 2018

Maine so far this year compared to Last Year (week 0 = January 1-7)

Watch Out for Radon!

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

November, 2018

A physician acquaintance of mine died this summer of lung cancer at a premature age of 61. He’d never smoked, nor had other family members. Lung cancer in non-smokers always seems strange to us in the field; and his cancer wasn’t the common squamous cell type, but instead was an adenocarcinoma, a type more often seen with radon than with smoking. His nurse daughter guessed the disease could be related to the very air-tight home he and his wife had built 25 years ago. She tested for radon in the air and found levels over 10 pCi/L (pico Curies per liter), a level well above the tolerable levels of 2-4. She probably found the culprit since, after chronic smoking and the second hand smoke others in the house are exposed to, radon exposure is the next most common cause of lung cancer in the US. When radon exposure is combined with cigarette smoking, lung cancer rates are 35 times higher than from smoking alone.

Radon is ubiquitous in our soils, gravels and rocks, but you can’t smell or taste it, even inside the house. It is a breakdown product from Uranium 236 and Radium 22, and is found all over Maine. Usually it is brought into a basement or house by air seeking the lower pressures there, through basement floor or walls, or up through fill or slabs from surrounding soil or rock. It also can contaminate water from drilled wells (not springs or other surface water), and thereby add to house contamination. Its radiation is carried by the heaviest type of particles, with 2 protons and neutrons, hence very “heavy” so they cannot go through even paper. But they can cause ionizing damage when they nestle against the lining of the lung, where they cause damage to the cell genetic material (DNA), and over time cause mutations that can allow cells to duplicate too fast, and thus become cancer.

You find out if you have a radon problem by testing the air in your house; you can also test the water, and especially should if you find elevated air levels. I did it when I moved into our house 35 years ago, and it was ok at readings of 1.5-2.7 pCi/L. Since then we have tightened up our house to save heat and put in a Heat Recovery Ventilator (HRV) system. Last month I took a sample and a repeat both in the basement (the recommended place) with the HRV off, to see where I was. Both values were 4.1, a level that should prompt abatement action, given its cancer risks. I now will check levels with the HRV on, since such a system is one of the remediation options for radon in the air. I will also test well water levels to be sure we aren’t drinking radon. I was feeling badly about my test results, when, coming out of the state lab, I met a co-worker, who had just dropped off her 2nd samples after getting an initial air reading of 9; she had never tested her new house bought 15 years ago. Bigger problem! Nowadays state laws require testing by an independent lab with the sale of any house. My daughter near Albany bought a new house and on testing found levels close to 20; she now has normal levels having installed a $5K system that shunts air coming into the basement to outside pipes, with air pumps at roof level where it exhausts.

Detecting and fixing radon elevations is a cost and a bother. Tests at the Maine State lab cost $30 per air test and the same for water; other commercial labs charge about the same. I tried a mail order one I bought at Home Depot, which cost $25 but $40 to ship to Texas! But the testing sure can pay off with less future disease risk.

And while you are at it, I’d also suggest testing water every 5 years for bacterial contamination, as well as for arsenic, another contaminant in our rocks and a cause of increased lung cancer risk ($20 each). Those are the basics; you can order those and many other water and air test packages at the Maine State water quality testing on line (https://www.maine.gov/dhhs/mecdc/public-health-systems/health-and-environmental-testing/standard.htm).

Stay safe!

Vaping

What is it? Risks/Benefits?

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

January 2019

Devices to deliver heated solutions of liquid nicotine ("e-juice”), mixed usually in propylene glycol or glycerol, have become popular. They are in the form of "pens" which have a reservoir for the nicotine, a heating element to vaporize it, and a battery to do the heating. They thus produce a nicotine-saturated vapor, which is inhaled, hence "vaping". At least 13-15% of adults have now tried this new way to rapidly absorb nicotine into the blood stream, usually not to feed their nicotine addiction but to help them stop old fashioned "burn" cigarettes and thus avoid the 1000s of bioactive chemicals therein, which cause various cancers (lung, head and neck, bladder) as well as ischemic heart disease. Studies so far suggest that there may be some marginal health benefit when these devices are used alone to assist adult smoking cessation as long as they are not used with a few conventional cigarettes daily.  However, public health research shows that most people end up using the two together, and thus suffer the worst of both. Smoking cessation is more safely and reliably accomplished with nicotine patches, gum, or other proven medications, along with group or counselling support (see Vienna Newsletter, Feb-Mar, 2014: p6). Nobody yet knows if passive exposure from "nicotine vapers" is a significant risk to others nearby as it is for cigarettes. The adverse effects of vaping are only beginning to be understood, not surprisingly, since it took us 50 years to prove definitively the bad things smoking tobacco causes.

There are many proven as well as potential dangers to vaping. First, the rechargeable batteries can explode and burn, causing bad burns to the face or inside the pocket they are carried in. Nicotine causes faster heart beats and sometimes arrhythmias like atrial tachycardias or fibrillation. And nicotine itself is of course addicting and thus can prompt withdrawal symptoms, which often lead to higher use and/or use with regular cigarettes. Because the heat vaporized glycerol or propylene glycol liquid nicotine mix produces propylene oxide, formaldehyde, and acetylaldehyde, all known cancer-causing chemicals, most researchers expect that eventually we will see higher cancer rates in chronic or past users. Finally, some of the flavorings, especially sweet and cinnamon ones, added to attract new users to vaped nicotine mixes, break down, when heated, into diacetyl and benzaldehyde, compounds known to irritate the respiratory tract and thus can cause chronic bronchitis.

A second group of accidental or intentional users of vaped nicotine, are children and young adults respectively. The latter are now higher users than adults above age 25; surveys in 2015 reported that 15% of 11th graders had tried vaping nicotine. Nicotine impedes brain as well as global body development in the fetus if the pregnant mom uses either conventional tobacco or vaped nicotine. Accidental nicotine liquid exposure in young children from their eating, inhaling, or getting it on their skin or eyes, is just as bad as their eating real cigarettes; together both are responsible for 1000s of poison control center calls annually in the US. Over half of all such calls for nicotine liquid exposure are in this young age group; many are fatal. In teenagers and young adults up to age 25, studies show impaired judgment and other brain function maturation, and higher addiction rates to nicotine and other substances over time with chronic use. Unfortunately, there are few controls on use by these more vulnerable age groups. I went on Amazon today and could have bought all the equipment and supplies to get started myself for under $50. It's the wild west out there.

Finally, it's not just nicotine that can be used in these vaping devices. Inhaling caffeine and various vitamins this way, judging from the Amazon displays, is popular. Like the liquid nicotine, no one knows the long-term effects of sucking small particles of known and unknown substances into the lungs, but scarring and other damage seems likely over time. Lung replacements come hard. And, of course, liquid marijuana infusions can be taken this way too with rapid and extensive absorption; that too has similar bad effects on brain maturation in the young adult population.

So, my advice is: be cautious, read the surgeon general's report on vaping (https://e-cigarettes.surgeongeneral.gov/); don't vape when pregnant; keep nicotine out of reach of young children; talk about the potential dangers with your teenage and young-adult kids and grandkids. Only opiates and alcohol use present a greater danger to them. I'm sure that someday we'll look back and say, "why didn't people realize this could happen and do something!"

Immunizations in Children

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

April 2019

In these current times, some parental reluctance to immunize children is bringing back the old days a bit. There was a case of mumps in York county just last month. In Maine, during the first 3 months of 2019, there were 145 cases of whooping cough (pertussis) and 48 cases of chickenpox (varicella). And that’s not a one-off either; in 2018 there were a total of 446 cases of whooping cough and 252 cases of chickenpox! And right now, there are measles epidemics spreading across the country with nearly 500 cases reported this spring, the most since 1994; the closest cases are in Massachusetts. It’s a potentially a fatal disease in young and/or sickly children, especially in developing countries where it has a 2-10% mortality in kids and in rare cases can cause an encephalopathy 20 years later in adults who had cases as children.

What immunizations are currently required for children to attend public school in Maine? These immunizations, all of which, but for tetanus, are against communicable diseases, i.e. they are caught from those around us who are already infected and spreading the disease: 

•Required for kindergarten entry:

-5 DTaP (4 DTap if 4th is given on or after 4th birthday)*

-4 Polio (if 4th dose given before the 4th birthday, an additional age-appropriate inactive polio vaccine should be given

-4 MMR (measles, mumps, rubella)

-1 Varicella (chickenpox) or reliable history of having had the disease

•Required for 7th grade entry: 

• 1 Tdap

• 1 Meningococcal conjugate (MCV4)

•Required for 12 grade entry:

-2 Meningococcal conjugate vaccinations; only 1 dose, if 1st given after 16th birthday

* DPT, or DTaP, or Tdap are all immunizations against diphtheria, tetanus (lock jaw), and pertussis (whooping cough)

Fifteen years ago, I began seeing whooping cough cases for the first time in my professional life right here in Kennebec County. By being vaccinated against just diphtheria, tetanus (lock ja), pertussis (whooping cough), and small pox, my generation escaped diphtheria, whooping cough, and tetanus (which nearly killed an unimmunized farm boy in Oregon last year). When I was a boy, I recall adult neighbors pointing out houses where whole families were wiped out in a winter by diphtheria during the great depression in the 1930s; and as an intern in Seattle, I did, see some cases of it in unimmunized skid row residents. Small pox has been virtually eliminated now and we no longer immunize against it. Sure hope none of those come back!

Infants under age 2 are the most susceptible to whooping cough, especially under 3-6 months and if their mother’s immunity is low or absent. Those infants are too young to vaccinate and must rely entirely on either not being exposed, or breast milk and placental transfer of immunity. Half of those under 3 months with whooping cough require hospitalization and some die every year in the US. But even teenagers and adults suffer “the cough that lasts 100 days”. And they spread it to the unimmunized. Maine cases, usually fewer than 20-50/yr, have skyrocketed in the last few years (see first paragraph). 

Much of the concern of parents, who opt their children out of public school immunization requirements under the “philosophical” exemption, derives from a 20-year old controversy surrounding the MMR (measles, mumps, rubella) vaccinations; that controversy has been scientifically put to bed long ago (see below). But a change in Maine law 10 years ago allows parents to send children to school unimmunized if they have a “philosophical objection” to vaccines. Those children now constitute 4.6% of all children, while the religiously exempt remain under 0.4%, and the medically exempt (e.g. those with bad eczema, immune suppression, or other complicating conditions) about 0.3%. Maine’s opt out rate is one of the highest in the United States. In the best of circumstances, because of families moving in and out, it is impossible to get higher than 95% of children immunized at any one time, so an additional 4-5% opting out leads to a population barely 90% immunized and heading in the wrong direction. Most of these diseases, and clearly whooping cough, can continue and spread whenever 5-10% or more of the population is susceptible. The Maine legislature is debating tightening these rules again right now.

National data for 2018 not yet available

Things have changed a lot since “the good old days”. Kids get many more vaccinations and because of that, many fewer serious illnesses. A good thing, since we have many fewer children around. When I started practice in Maine in 1972, the state had 25,000 births per year. Smaller family size has cut that number to around 12,500 now. Many medical risks have been reduced over these decades. Child car seats and safer cars have dramatically reduced traumatic injury and death for adults and children. Sunblock now prevents severe sunburn and its consequences. Medical advances save many more children and adults, who would have died in the old days. All these improved survivals have allowed more and more people to reach their old age, a “squaring off of the survival curve”, as epidemiologists call it when the survival curves look more and more like a rectangle than a right triangle (compare 1900 with 1997 in the graph). 

A big part of this “squaring off” is due to improved immunizations against childhood diseases, eliminating that awful 20% mortality in the first 5 years of life one sees on the 1900 graph line. Diphtheria, whooping cough, tetanus shots (DPT) were first used in the military, then with school kids in the 1930s. So I, like others of my generation, didn’t catch those diseases but did suffer and survive mumps, chicken pox, German measles, and regular measles, still a major killer of young children in un-immunized developing countries. Mumps orchitis caused sterility in several of my male classmates in junior high. Chicken pox so scarred the lungs of a fellow medical intern when he was younger, that he never could walk upstairs without resting. And while German measles didn’t bother us kids much, it caused miscarriages and birth defects when mothers caught it for the first time when they were pregnant. Remember “rubella parties” to expose and thus immunize young teen girls? 

Then there were the really scary diseases, like polio; remember the March of Dimes? Public swimming pools would close when epidemics started, because it is spread by fecal (poop) contaminated water. Only 10% of the kids infected developed paralysis, but that was so devastating, all feared it. Also less well known but nearly as devastating were bacterial pneumococcal and Hemophilus influenzae infections of ears that then led to meningitis, pneumonias and abscesses. And most adults can probably still recall cases of meningococcal meningitis, killing young adults, especially those in high school or college or the military, mostly within just a few days. Bad stuff. All are now preventable with vaccinations; we docs almost never see these diseases anymore in this country.

Overall population resistance, or group immunity, is achieved when immunization levels exceed 90% and get closer to 95%. Why the reluctance of some parents to immunize? Many understandably also worry that the number of shots seems excessive. It certainly is more than our generation suffered. But the return in reduced illness and mortality is substantial. Other parents worry about the mercury preservative once used (thimerosal), but now removed from shots for those under 6, because it does cause more local reactions (sore arms). And an initial report in 1998 of 12 children who had autism after measles/mumps/rubella (German measles) shots, understandably frightened many. More extensive studies have since proved that connection wrong. The senior author of the 1998 paper was later sanctioned and his paper retracted when fraud, conflicts of interest, and data falsification emerged. Autism is a relatively newly recognized disease and continuing studies are attempting to identify its causes and treatments, but it seems pretty clear autism is not caused by vaccines. For instance, autism incidence has not declined despite the removal of mercury stabilizers. Further vaccine refinements have included changing the whooping cough vaccine to one devoid of any cellular material to reduce vaccine fevers. Many killed vaccines do still contain aluminum salts because they are benign and act as “adjuvants”, chemical enhancers of the immune response needed to protect.

So, how are our schools doing? Well, according to the Maine CDC, the Cape Cod Hill School’s kindergarten class in 2015-16 had 7% kindergarteners exempted without MMR vaccines, and 93% MMR immunized, whereas 3% of first graders were exempted. In 2018-2019, again 7% of kindergarteners were exempted and 93% MMR immunized (I can’t find first grade results). Small numbers, but worrisome trends. And our Franklin County is not doing so well as a whole (more on that next month). 

It has been a long road from the days of many serious common diseases, to the present where immunizations offer significant protections, but only imperfectly unless all participate. If we are to live, work, and play together, we cannot allow immunization opt-outs, any more than we can allow driving on the wrong side of the road. Parents falsely hoping to protect their own children by avoiding vaccinating them appropriately, jeopardize the health of all of our children and all of us.