Smoking Cessation Programs in Jeopardy

Daniel K. Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076

dkonion@gmail.com

4/23/15

25 years of progress on decreasing smoking in Maine is threatened by proposals contained in the Governor’s budget to eliminate support for smoking cessation programs run by the Maine Center for Disease Control (CDC). I attended a public hearing on the subject last month where I heard the Dept of Human Services commissioner, Mary Mayhew, argue for a transfer of monies from those programs to reimbursements to primary care physicians. As a primary care doctor myself and a trainer of family physcians for decades, it may seem strange for me to object. But the current programs, run by multiple organizations in the state as part of what are called Healthy Maine Partnerships in collaboration with the CDC, are a direct outgrowth of many programs developed in Franklin County over the past 45 years. I’ve shared with you before in these columns the dramatic improvements in Franklin County that we observed and published, in smoking rates and other health risk factors, as well as in mortality and hospitalization rates.  Those improvements were greatest in Maine counties with lower household incomes (see January/February Mt. Vernon Community Newsletter).

We need both primary care doctors AND public health interventions to discourage smoking. Doctors need to be supportive and willing to prescribe smoking cessation medication when needed. But the heavy lifting has to be done by community activation through public service announcements, enforcement of existing laws barring smoking in public places and the sale of cigarettes to minors, provision of smoking cessation classes and “hot lines”, improvements in local laws and ordnances, etc. Those measures, crucial in what was done in Franklin County, are what the Healthy Maine Partnerships do. Their funding derives from the $50 million/year that comes to the state as part of the federal tobacco settlement accomplished in the late 1990s. Gov. Angus King recognized what was going on in Franklin then and fought to direct most of those monies to similar programs throughout the state. The rest of Maine began catching up with Franklin.

Over the years, nearly half that money has been siphoned off to help balance various budgets. And now, the current administration hopes to eliminate all support for the community programs. Their posing the choice as one between primary care doctors and the public health programs is a false one. We need both.

To be fair, the programs and the CDC have not done a good job of documenting their success. The HHS commissioner cited higher costs and higher smoking rates in Maine compared to other New England states. However, she failed to note or account for the effect of low incomes on those rates. Smoking rates are higher among the low-income population. And Maine is by far the lowest-income New England state. The programs in Maine should be required to report the efficacy of their programs on smoking rates in their territories. They don’t regularly do that now and are not required to do so.

My colleagues, Drs. Burgess Record and Rod Prior, who helped write our Franklin County paper, worked with me to present data to the Appropriations Committee showing some of those income-adjustments as well as other data that show we are making progress (see graphs), even compared to other NE states. We also seem to be making particularly good headway amongst our youth. Over the decades, I’ve watched my smoking patients all die at least 10 years prematurely. We’ve got to do a better job of helping people quit. We hope, for Maine’s sake, our legislators can preserve these programs and make them even better. Urge them to do so.

Our points:

• Smoking is the leading preventable cause of death in the US – more than 480,000 deaths annually

• Smoking rates in the US have decreased substantially since 1970, from 4,000 cigarettes per capita in 1970 to 1,000 cigarettes per capita in 2013.

• Smoking is increasingly linked to low income and education level.

• Tobacco use and addiction usually starts in the middle and high school years.  Nationally one quarter of high school students are estimated to be tobacco users. In Maine 40% were in 1995-6; now the rate is down to 13-15%, which is better than next poorest state in NE.

• Half of Maine residents have been smokers sometime during their lives, the highest rate in the country.

• Maine’s present statewide smoking rate is at the US average, around 20%

• Maine has the 9th highest rate of previous smokers who have quit.

• Smoking is an addiction.  Nicotine ranks with heroin as one of the most addicting drugs known to science.

• Combined public health and individual interventions are crucial in getting smokers to quit smoking. We need to:

  • Increase the tobacco cost through federal, state, and local taxes

  • Prohibit smoking in schools, workplaces, stores and restaurants, other public places, homes, and other indoor locations

  • Provide ndividual counseling and support

  • Encourage nicotine replacement via patches, gum, etc.

  • Provide medications such as Chantix, which help with nicotine craving.

  • <ount school, workplace, and community-based campaigns.

• The war isn’t over.  Electronic cigarette use has just reported to have tripled among teenagers. The dangers there are still being defined.

• Doctors and health care professionals can’t successfully do it by themselves.  The tobacco control programs of the Maine CDC and Healthy Maine Partnerships made a huge difference.

US CDC YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM DATA

Vaccination Alert

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

May 17, 2015

Last fall I wrote about the decreasing immunization rates among Maine school children and the threat that poses to all of us, especially them and their peers (September 2014 Mt. Vernon Newsletter). Tom Ward of Mt. Vernon alerted me today to the state-wide reports from the Maine Center for Disease Control of Measles/Mumps/Rubella (MMR) immunization rates in kindergarten and first grade for each Maine school. The report is very worrisome (http://www.pressherald.com/2015/05/17/state-data-show-dangerous-levels-of-unvaccinated-students/). Some grade schools in Maine have under 80% of children vaccinated in kindergarten and first grade.

State health policies for years have required full immunization of children before they can enter school, for the protection of all; exceptions for religious and medical reasons have never exceeded 1-2%. The recent report shows that parents of 4% of Mt. Vernon elementary school kindergarteners and 13% of first graders have not immunized their children against MMR for “philosophical reasons”, a new opt-out category now allowed by recent state legislation. Other nearby schools have done better.  The Vienna/New Sharon Cape Cod Hill school reports 7% of kindergarteners and 3% of first graders have “philosophically” opted out of MMR immunizations, 3% and 0% respectively in Manchester, and 5% and 5% in Farmington.

As I explained in my article last year, overall population resistance to infectious diseases, when immunization levels exceed 90%, is called “herd immunity” by scientists. When immunization rates drop below that level, there is a large enough pool of susceptible children present to sustain an epidemic.

Why are more parents declining to immunize their kids? Many parents understandably may worry that the number of shots recommended nowadays seems excessive. It certainly is more than our generation endured. But the return in reduced illness and mortality is substantial.

Other parents worry about the mercury preservative (thimerosal) once used, because it does cause more local reactions (sore arms). However, now it has been removed from shots for those under age 6. Probably most importantly, an initial report in 1998 of 12 children, who seemed to have developed autism after measles/mumps/rubella (German measles) shots, understandably frightened many. However, more extensive studies proved the autism/MMR connection wrong. The senior author of the 1998 paper was later sanctioned and his paper retracted because of fraud, conflicts of interest, and data falsification. Subsequent researchers have been unable to find a link. Autism is a relatively newly recognized disease and studies are continuing to identify its causes and treatments, but it is now clear autism is not caused by vaccines.

Further vaccine refinements included removing all cellular material from the whooping cough vaccine 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.

Although only MMR immunization rates are being reported in this KJ news article, I worry greatly that other types of immunization rates are falling for similar reasons, particularly those for whooping cough (pertussis), polio, hemophilus (causes bad pneumonia and meningitis in kids), and pneumococcus (causes severe pneumonia and meningitis in young children and adults). Young, pre-school children are very vulnerable; they are the first to suffer if school age kids bring these diseases, especially whooping cough, home to them before they are fully immunized. We can’t immunize babies effectively for whooping cough. We can protect them only by preventing it in older children and adults.

It has been a long road from the days of many serious common diseases, to the present where immunizations offer significant protections, but 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. I think we should go back to tougher vaccination requirements for school children and eliminate the “philosophical” option.

A New State Epidemiologist for Maine!

By Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

August, 2015

After several years of devastating cuts to the Maine public health systems and over 25% reductions in the Maine public health work force, I found the announcement below in the Maine Medical Association June 15 newsletter particularly encouraging. That a public health physician with these credentials would move across the country to help us is wonderful at anytime, but even more so in these trying times. As I’ve pointed out in these columns before, strong clinical care access and public health strategies can and do save lives and money, as we have demonstrated in Franklin County over the years (J Am Med Assoc, 2015; 313(2):147-155). So here is some good news!

“In a letter dated June 10th to Public Health Partners of the Maine CDC, the agency announced that Siiri Bennett, M.D. has accepted the position of State Epidemiologist.  Dr. Bennett is a graduate of Radcliffe College, Harvard University.  She obtained her medical degree from the University of Washington School of Medicine in Seattle, Washington and completed her residency in Internal Medicine at Mt. Auburn Hospital in Cambridge, Massachusetts.  

Dr. Bennett currently is a senior research scientist and medical data consultant in the Department of Biostatistics at the University of Washington in Seattle where she is co-principal investigator for an NIH-funded Data Coordinating Center for a multi-study collaboration looking at tuberculosis latency and reactivation and also serves as project director for a multi-study consortium looking at cardiovascular disease in patients with HIV.

Dr. Bennett is trained in applied epidemiology and research, preventive medicine and public health with well-developed skills in project planning, collaboration and project and team management.  She completed the U.S. Centers for for Disease Control and Prevention's (CDC) Epidemic Intelligence Service (EIS) program and the CDC's Preventive Medicine Residency Program in the Hospital Infections Program and went on to work as a medical epidemiologist for US CDC and the Institute of Environmental Sciences and Research (ESR) in New Zealand.  During her time with CDC, she gained experience in infectious disease outbreak investigation and control of communicable disease.  Dr. Bennett also worked as a staff medical epidemiologist in the National Immunization Program where she was responsible for coordinating the division's vaccine-preventable disease surveillance activities.  While in New Zealand, she served as project lead for a number of projects including the design and management of a national sexually transmitted infection surveillance system and provided infection control expertise and guidance to ESR on nosocomial infection surveillance.  

Dr. Bennett has published in peer review journals, presented at national and international meetings and conducted training workshops and courses in both the US and overseas.  She has collaborated with public health leaders across the world and brings with her the ability to work with people from diverse backgrounds and agencies.

Dr. Bennett's broad skill set and enthusiasm will serve the Maine Department of Health and Human Services well.  She and her husband will be relocating to Maine from Seattle.  Dr. Bennett will begin her new role as State Epidemiologist for Maine CDC on July 20, 2015.”

I am looking forward to meeting Dr. Bennett.

Statistics: Chance and Blinded Controlled Trials

“Why should I have a flu shot when I had one last year and still caught the flu later,” said my friend in frustration. “Even worse, I understand you can get the flu from the shot!” I’ve been in the public health/doctoring business for nearly 50 years, and that lament hasn’t changed much, even though the influenza vaccine’s efficacy has improved a lot. Much in life is subject to chance; most medical and public health interventions, like flu shots, have been shown to improve those chances without negative side effects.

The answer to my friend’s question of why get a shot if “it didn’t work last year”, is that, like most risk reductions, it doesn’t work 100% of the time and/or doesn’t always completely prevent its illness target. Thus people who have had flu shots still have a 60% chance of getting influenza if exposed, but the glass is nearly half full because they do have a 40% chance of not getting it. And even if they do contract the flu, they have a much reduced chance of missing work (healthy adults) or of dying (especially the very young and very old) from it.  Most people don’t appreciate these gradations of benefits; many, unconsciously or not, expect full prevention or cure from a treatment, and are surprised or frustrated when the result is less than perfect.

And the efficacy of the flu shot varies from year to year. Last year it was only, on average, 25% effective rather than the usual 60% on average. That was because the US Center for Disease Control (CDC) has to guess in May or June which variants are most likely to be around the next winter. It takes 4 months for manufacturers to produce the vaccine after being given that direction. Even though the vaccine contains 3 (trivalent) or 4 (quadrivalent) influenza virus types, sometimes the CDC guess/estimate is wrong or imperfect. They too have to play the odds in making those estimates. That’s what happened last year; the CDC guessed wrong on which strains of influenza would be the greatest problem that year so the shot was less effective, though it still helped.

So we shouldn’t let the perfect result be the enemy of a good result. Not dying from the flu is still better than the alternative, even if you get sick with it. How do we know when the intervention benefits outweigh letting nature take its course? We know when we have statistics to guide us. And they have to be good, well done statistics, not ones like the Roman physician Galen cited, I hope jokingly, when he said: “All those who drink of this remedy recover in a short time, except those whom it does not help, who die. Therefore, it is obvious that it fails only in incurable cases.”

The so-called blinded controlled scientific trial, invented in the past 100 years, has allowed us to measure the efficacy, or the lack thereof, of many previously used treatments by comparing outcomes in two groups of people with a condition (or lack of it in the case of flu shots), and administering them two different treatments, one of which is usually nothing (the “controlled” part). Hundreds and sometimes thousands of patients are studied; neither patients nor doctors know which treatment is given, thereby avoiding biased interpretation of symptoms by either (that’s the “blinding”). As a result of such trials, we now don’t: use leaches or bleeding; aspirin in little children with fever; bed rest for childbirth, back pain, or heart attacks; enemas for nonspecific symptoms; and many more examples

But many people, like Mark Twain, who complained about “lies, damned lies and statistics,” are more confused than helped by the statistical analysis of medical tests or treatments. They either should work or not work, in their minds. They get frustrated, like my friend, when the intervention works in only a percentage of the time or only partly. But we and our health are part of the natural world; we are not surprised when weather predictions are wrong some days and imperfect on others. Nor should we be surprised when flu shots prevent the flu in only some of us some of the time, and ameliorate it for some but not all; at least they are better than the alternative of no flu shots. President Lincoln once cautioned, “You can please some of the people all the time, all the people some of the time, but never all the people all the time”. So too in medicine and public health.

Oh, and my friend’s challenge that flu shots “give you the flu” is not true, but rather a misinterpretation of side effects. A flu shot is a killed vaccine, and hence cannot infect you. But the way it works is that it contains broken down pieces of the influenza virus to which your body reacts by engulfing them into your white blood cells, and then delivering them to other white cells, which make antibodies to those bits of the virus. Those antibodies kill live viruses with the same bits on their surfaces when you are exposed in the future. That process makes you feel a little “icky” (local soreness, aching, and even low grade fever) because enzymes are released from your white cells as that process happens; those enzymes cause some transient inflammation in your body. Such symptoms are side effects, which some people, but not all, can feel. Yet another layer of subtle ambiguity; sorry!

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

January, 2016

Animal Bites and Blaming the Victim

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

July, 2016

I just wrote about dog bites in the most recent June column, but several animal/human fatal encounters have made the national news recently and prompt this rumination.

Many years ago, while doctoring on Pohnpei, a large Western Pacific Micronesian island, I saw a man with bilateral Achilles tendon lacerations just above his heels. They were caused by a small (3 ft) black-tipped shark, which bit him in one heel as he was collecting shells to sell (for buttons) on a large reef in a foot and a half of water. He was with a friend, but their boat was ½ mile away across the reef. When the shark glommed onto his ankle the first time, it didn't let go, so he reached down and pulled it off. He then threw the shark as far away from himself as he could on one leg. But the fish then swam back and bit him on the other ankle, totally incapacitating him. Eventually his friend got the boat over to him and they got to shore and my emergency room. It took us all night to repair both the severed Achilles tendons. But the ER and OR staff, as well as several of his visiting friends, demurred compassion when they heard the story and said he should have known better than to throw the shark back the first time. They never explained how he could have held on to it with only one working leg.

The recent story of the California zoo gorilla, who seemed to be playing with a young boy who had fallen into the gorilla’s enclosure, has some similarities. The child wasn’t harmed but the gorilla was shot after swinging the kid through the water in a frightening way. The zoo was taken to task for shooting the gorilla, and, reasonably, for not building a more secure cage; and the mother was criticized for not watching the child more closely. I understand the public sorrow at the gorilla’s death but given the choice, how can one not support immediate action, as was done? The death at Disneyland of a 2-year old child, who was seized by an alligator, is an even more tragic story because the child died rather than the animal who attacked him.

Finally, the 7-year old boy in Maine killed by a pit bull was very disturbing, both because the dog had had previous misbehavior and because the press gave extensive coverage to a woman who was a self-proclaimed “dog counsellor”. Her contention was that people can frighten dogs into misbehaving and implied that this child did that.

I find these cases of blaming the victims of animal attacks, especially children, curious. Holding a 3 ft shark in one’s arms, 100s of yards out on a coral reef with only one working leg, sounds clearly impossible; the man tried to do what I probably would have done. Only in retrospect did it become clear it wouldn’t work. It is sad that the gorilla had to be shot but what other good choice did the zoo have for immediately getting the child away from him; surely the child’s life is the highest priority. And finally the pit bull. These are dangerous dogs and present a significant public health risk, as this outcome demonstrates. They are bred and often trained to kill other dogs. One badly injured my daughter’s small terrier in Brooklyn, NY while walking by each other on the sidewalk and both on leashes! Such dogs go for the jugular and trachea. They are like loaded guns walking around. They account for half the dog bites I’ve seen in the ER over the years. Blaming this victim directly or by implication is nonsense. To own a pit bull is crazy. Dogs such as these should be banned along with automatic weapons, which are also helping crazies kill more people than they otherwise would. I have hunted all my life, but not with such dogs or guns. Both are real threats to the public health. Gorillas and sharks are much less of a problem but we should sympathize with, not blame the victim.

The Plusses of Our Drought

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

September, 2016

This year I’ve had to water my garden and berry bushes all summer. Second hay crops are substantially reduced. Many wells will probably dry up this fall unless we begin to get significant rain. Wild fires are a greater risk. Both Flying and Parker Ponds are nearly a foot below normal summer low water levels. Even Hermine is missing us!

Can one think positively about such deprivation? Yes, certainly in several ways.

First, we have less runoff from rainstorms going into our lakes and ponds. This reduces road washouts and the amount of phosphorous thereby washing into the water bodies. And, since normally phosphorous levels are the limiting ingredient to algae growth in our lakes, we’ve seen much less algal growth this year, no green globs in Flying Pond, very clear water, and almost no gloeotrichia cyanobacteria (http://belgradelakesassociation.org/Resources/WaterQuality/ Gloeotrichia.aspx) in Parker this year. It’s nice to have cleaner water, and fish get more oxygen to grow on. Unfortunately, some folks, prompted I presume by the receding shoreline, unknowingly worsened the problem of phosphate loading by dumping crushed rock far out  into the lake at a private boat launch on Parker last week, despite it being against the law and bad for the lake.

Another big benefit of dry weather is fewer standing water puddles where mosquitoes can breed, hence fewer bites and zero cases of Eastern Equine Encephalitis or West Nile Virus in Maine animals or people! And hopefully southern Anopheles or Aedes aegypti mosquitoes never consider moving up here; we don’t need the many diseases they transmit in the South, like Zika virus, Dengue Fever, yellow fever and malaria.

And lawns need less mowing. It's all related to the huge changes induced by the clearly documented global warming, caused by the complete human take-over of the world. These last 2 years have been the hottest on record.

So enjoy the parts of the drought you can and pray your well doesn’t dry up. And take advantage of the dry year to create diversions for future storm water from your roads into the woods, not the lakes.

Beaver Fever

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

October, 2016

Tom Ward, our local weatherman among many other things, called me with a story I could leave for spring to describe. But it is so interesting, I have to tell you about it now. He called because he'd learned that a local summer resident on Flying Pond, had one of her two Labrador retrievers diagnosed by her veterinarian with "beaver fever". Tom wondered if that could affect humans as well and if there were ways to eliminate such risk.

Tom told me that one of the two dogs habitually swam for long periods of time and drank Flying Pond water constantly while doing so. The other dog, not so much. Only the water-drinking dog got sick, with vomiting, chronic cramps and diarrhea. The vet presumably made the diagnosis by examining the stool, as we physicians would in a person as well, and finding Giardia cysts or antigens (diagnostic protein pieces of the parasite) there. Such stool samples in infected individuals are often negative much of the time, so multiple stool tests over several days may be necessary to diagnose it.

"Beaver fever" is caused by the single-celled animal, Giardia lamblia. It is a common parasite of beavers as well as muskrats, dogs often, and sometimes deer. It can't be eliminated from those wild populations without eliminating the carrier populations, an impractical solution. It is spread by ingestion of cysts found in infected individuals' feces. Many dogs, including ones I know, like to roll in animal poop; often they later lick themselves to clean up. So it is no surprise they can easily ingest the parasite. It is possible this dog got it from drinking surface water, in this case from the lake; that is the most common way people get it.

Even infected, many dogs and people have no or few symptoms, but those who do, get chronic nausea, vomiting and diarrhea often along with fatigue and weight loss. The onset of symptoms is often delayed by a week or two after ingestion. The parasite lives primarily in the duodenum, the uppermost portion of the small bowel, right after the stomach. There it causes fat malabsorption, which is the cause of the diarrhea and weight loss, and sometimes actual bowel obstruction, hence causing vomiting.  It does not cause fever, so "beaver fever" is really a misnomer. The disease in dogs and humans is insidious in onset and can last months or longer, sometimes even if treated with oral antibiotics. People with immunosuppression from chemotherapy drugs, immunodeficiency diseases, or immunosuppression from human immunodeficiency virus infection (AIDS) all are made much sicker by Giardia than immuno-competent individuals.

So to Tom's question: "Is there a way to get it out of Flying Pond?" First of all, the dog may not have gotten it from the pond but rather from rolling in dog or beaver poop. But it would be very hard to prevent Giardia from being in pond water. Its cysts can tolerate cold and live in moist environments for months outside their hosts' bodies.  The wild animal hosts can usually go where they want. Town water reservoirs have to avoid human and animal contamination, micro-pore filter their water, and work to control beaver and muskrat populations in their reservoirs. People with springs as a water source also must work to protect them from fecal contamination. People and dogs shouldn't drink water from "pure mountain streams or lakes while swimming or not. The more lake water they drink, the greater their risk of ingesting  Giardia cysts. Maybe that's why the non-drinker dog didn't get sick. Giardia is endemic in Maine and many northern regions, and probably will always be. So, "don't drink the water" from our lakes or streams.

Environmental Risks in and around our Homes: Water Testing

This will be the first in a series of brief articles, with recommendations, about environmental risks at our homes in Vienna. I shall discuss the most common risks first, and how one assesses or measures them. In this article, I talk about when, how and for what you should consider testing your home water supply.

There is, of course, no public water supply going to Vienna homes. The closest we get to that is the Kimball Pond Road public spring, which is tested several times a year by its stewards. Thus, all of us are responsible for assuring the safety of our own home water; our water sources are from springs, or drilled or dug wells, unless we live without running water.

So what should you worry about, what should you test for, and how often?  

The most common contaminant are coliforms, Escherichia coli and related bacteria found in human or wild or domestic animal feces. Less commonly, Salmonella or Shigella and the Norovirus species may be transmitted in a similar way, and even less frequently, the parasites Cryptosporidium, Giardia (“beaver fever” and others.  Preventing water supply contamination isn’t rocket science; we all know the septic system should be downhill and separated from the well. But in spring flooding, especially when much of the ground is still frozen, surface contamination can occur. Grazing cattle or other domestic animal facilities can pose a risk. Surface water sources (springs and often dug wells) are more likely to be contaminated than drilled wells, because it is easier for the poopy water to get in. The consequences of contaminated water are usually mild in healthy adults, nothing or diarrhea. But the young and the old are more susceptible to more severe symptoms and bacterial spread to the blood stream (sepsis), hence causing complications and sometimes death. You can’t rely on clarity, taste or smell to know contamination has occurred, because it only takes microscopic quantities. So you should test your water when you move in to your new house, anytime you think the well may have been exposed (a flood, a new barnyard nearby, etc) and probably every 5 or so years, because even with a drilled well protected somewhat by its casing, drawing water from a well can open up new water channels over time.

Testing is relatively easy: run your water for a few minutes to clear the system and take a sample midstream in a sample bottle the testing lab supplies, refrigerate it until you mail (not over a weekend) or deliver it. Ask for “coliforms”, and you usually can get “nitrates/nitrites” with it for the same price (about $30). Nitrates/nitrites are breakdown products of bacteria (we use them to screen urine samples for bacterial infections, on those dipsticks, as some of you may know), but also can come from non-fecal lawn or commercial fertilizer. The report should come with a clear “positive” or “insignificant” answer within a week or so.

And while you are collecting and sending that water sample, consider adding, for an additional price, one or two additional tests. We live in an area with lots of granite bedrock, which can contain arsenic. It is the inorganic type that is the problem, in contrast to the organic type found in lobsters and other seafoods. Arsenic poisoning is a cause of premature dementia (looks like Alzheimer’s disease), but only the inorganic type. Several times I’ve found an elevated total arsenic level in a patient only to find on further testing that it was the organic type from their diet, and not in their water or an issue. That’s an additional $20.

Finally, if there are young children in the house, knowing if you have fluoride in your water is helpful. They need it badly and few places in Maine have it. So you could save yourself some money over time by knowing you have enough in your water without having to buy them supplements, which they will otherwise need. You can get all 3 for $60-$70 plus a bunch of other elements, like copper, iron, manganese, chromium, lead, uranium, radon, and so on; but these are either very rarely a problem or better tested for in other ways, which I’ll go into in future articles.

I use and like the State of Maine Public Health Lab for this testing (https://www.informe.org/cgi-bin/shopping/cart.pl?catalogPage=pageTwo) because I know and trust their people and systems. But there are many private, certified water testing labs in Maine (http://www.informe.org/hetl/).

Next time, I’ll discuss other potential environmental hazards in our homes. But in the meantime, know for sure that smoking tobacco anywhere and especially in your home endangers not only you, but your family as well, more than any of the risks I’ve discussed above. And home fires from stoves, faulty wiring, and careless care of flammable substances come in a close second. Please avoid those, if you do nothing else.

Feel free to call me if I can help you.

Dan Onion, MD

Vienna Health Officer, 293-2076

Town Meeting Questions: Drinking Water vs Beach Water Testing, and Hepatitis Immunization Questions

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

March, 2017

Mark Rains and Roger Reveille asked me a set of questions at our March 11 town meeting this year that others may also be wondering, so I'll expand my answers to them here.

At the meeting, Roger asked if testing the Flying Pond beach just once a year was sufficient protection and I responded that I thought it was. What I didn't say in the meeting but explained later to Roger, was that the $60 the town voted is sufficient for two tests if needed. At least a couple times in the past, I've had a borderline test and gone back to re-test a week or two later. The standard test for a swim beach is a measurement of how many fecal (poop) bacteria (Escherichia coli or Enterobacter) are in one cubic centimeter (cc) of the water. The standard swim beach test is for the E. coli. In drinking water any such contamination would be unacceptable, but for swim areas, standards are lower because people, even children, actually swallow very little water when swimming, or as the Environmental Protection Agency calls it, "recreating" there. Instead, the standard is set so that there would be fewer than 35 fecal illness episodes in 1000 people who swam there, whereas the drinking water standard would be none. I usually get 1-12 bacteria per cc of lake water; once I did get 249, but repeats were way back down. I had taken the sample just after some heavy rains, which may have temporarily washed some animal poop off the shore. I had worried about a septic system leak, but subsequent normal tests made that highly unlikely.

After the meeting, Mark asked why we didn't test as often and extensively as the Grange does the Kimball Pond spring. I explained that in Maine, lake water standards are different in the ways I just outlined above, because lakes must only be safe for swimming and fishing, not for drinking unless the water is treated (with chlorination). That's why most camp owners, who draw pond water, use it for bathing, laundry and toilets, but use bottled water for drinking and cooking.

Finally, Roger later asked me about hepatitis. The rescue/firefighters are immunized with a 3-shot immunization series against Hepatitis B. He asked when they should get boosters. The answer to that is that in immunocompetent people, like most of us and certainly firefighters, the initial series of shots leads to more than 15 years of measurable antibody levels against Hepatitis B in over 95%. And even after that, research has found that immunologic "memory" is retained and will quickly produce more antibody if challenged by a Hepatitis B invasion. This could change as new studies follow people for decades. But for now, no re-immunization or even antibody measurement is recommended. Healthcare workers, potentially exposed on a daily basis to blood, might be an exception and probably should be re-immunized after 10-15 years with a single vaccination. He also asked whether Hepatitis C too can be prevented by a vaccine. The answer to that one is no. Hepatitis C is a viral liver disease like Hepatitis A and B but almost always transmitted by intravenous drug use through needle sharing. Thus it is best prevented by not using IV drugs. There is now relatively effective treatment with shots after it is diagnosed; but that's not so good that it can be counted on to work always.

Maybe we could have more town meetings to get more public health questions and discussion?

Gun Violence in Maine, and Beyond

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

November, 2017

I am writing this on March 25, the day after huge marches to demand action to reduce gun violence were held locally and all over the country, along with some counter marches. Those marches and a recent dialog I had with Mt. Vernon's most prominent sportsman, George Smith, (see his Bangor Daily News blog) lead me to want to expand the discussion of gun violence to other related and alarmingly bad public health transformations we seem to be suffering.

In our published dialog, I said to George: " Gun violence is on the rise, as school and other mass shootings are becoming more and more commonplace. Several instances have been thankfully prevented recently in Maine. Domestic violence against women and children in Maine has been and continues to be a perennial cause of injury and death, the latter often perpetrated with guns (over 12 each year, half of all Maine homicides, and half are children under 13). And finally, suicide by guns (half of all Maine suicides) is also a major risk and increasing here in Maine. All three examples are especially impacting teenagers and young adults, and thus dramatically increase the 'years of potential life lost,' as the 'public healthies' like me use to measure the payoff of a public health issue intervention."

The mass shootings have prompted outrage and demonstrations. They have increased dramatically after the 1994 ban on assault weapons was reversed in 2004. Fixing or moderating such high-risk gun use needs doing. I've hunted all my life, as have most rural people; but these aren't hunting guns we are talking about. Access to any weapon that carries significant risks to others is no more a right than is driving on the wrong side of the road or drunk!

But it ain't just guns that are playing an increasing role in premature deaths here in Maine and the nation. So too are other deaths now classified as "unintentional deaths," like the rising number of narcotic overdoses, car crashes, falls and other accidents often associated with alcohol use, as well as diseases like hepatitis (from needle transmitted hepatitis, alcohol, and/or diabetes), and lung cancer and emphysema from smoking. Unlike mass shootings, these deaths, as well as clear suicides, seem to be rapidly increasing most in rural areas, disproportionately afflicting the white households with lower incomes and education levels, to the point that their overall age-adjusted mortalities are worsening or at least not improving overall unlike the other segments of our US population, as illustrated in sub-groups in the graphs below,. I urge you to go to the Washington Post reference #2 below, which allows you to look at those subgroups in various combinations, like urban vs rural, males vs females, White/Black/Hispanic, region of the country, and by 5-year age groups.

Most of these potential causes seem likely caused by increasing risky behaviors in the subgroups, perhaps related to the increasing income disparities in the US among segments of the population over the past 50 years, even though all have improved over their historical averages. Perhaps what matters more than one's own situation compared to that of one's parents, is how one now compares to one's peers and neighbors. When social safety nets are trimmed or dismantled, like the Affordable Care Act, MaineCare , and food stamps, we see more illness and downright despair and thus suicide, murder, accidental overdoses of opiates, and death through recklessness and/or depression.

Other research, like ours I frequently cite done in Franklin County Maine over the past 50 years, shows that community-wide engagement in preventive activities like education and social pressure can counteract some of these bad outcomes, despite socio-economic impediments. The ability to initiate and maintain community interventions seems to hinge on how much "Social Capital" the community has or can muster. In other words, can and does the community exhibit altruistic interactions and programs open to all.

Demonstrators are now demanding more gun controls since mass shootings have become commonplace. It may be that such shootings have now extended such unintentional harms from the poorest, least politically powerful of our society, into the middle classes. Our schools especially are melting pots of all classes. Their unfortunate vulnerability now may increase the likelihood of real change in gun laws and perhaps eventually even some of the income disparities, which may be causal. I certainly hope so!

Still, I think we need concerted efforts to develop and sustain local community-wide programs to reduce the despair and risk-taking among those most at risk, and to provide compassionate outreach, and evidence-based interventions to turn this nearly two-decade-long spiral of worsening mortality in our populations. Mt. Vernon and Vienna do a lot of that already through volunteers who organize community center and church dinners, Neighbors Driving Neighbors, the Grange, our churches, the food bank, the Mt. Vernon Community Partnership, and our library, and probably more I am forgetting, in addition to the many individual acts of human kindness and support we see here every day. We need to keep it up and recruit even more to participate. Kindness and caring not only enrich a community, but also save lives.