Indian Medicine

The cases of 11 infants who contracted pertussis from a health care worker have renewed calls to get adolescents and adults vaccinated against the infection, particularly if they work in a hospital or other medical setting.

"We think it's very important that people do everything to prevent pertussis in infants, and this means immunizing teens, adults, parents of infants and people who are taking care of infants. It means immunizing health care workers," said Don Murphey, MD, lead author of the paper outlining the incident published in the June 6 Morbidity and Mortality Weekly Report. He is also the medical director of occupational health at Cook Children's Medical Center in Ft. Worth, Texas. The infants were infected at another hospital in the community.

The outbreak occurred a year before the Food and Drug Administration's 2005 approval of Tdap -- the vaccine that includes the pertussis immunization -- for adults and adolescents. This step was followed by recommendations from the Advisory Committee on Immunization Practices urging that all adolescents and adults receive the preventive, with those working for a medical institution viewed as especially high-priority targets. The American Medical Association encourages health care workers to be immunized for their own protection and to reduce transmission to others. But most experts suspect that many health care professionals remain unimmunized and that the risk that outbreaks will continue remains high.

"Patients should have the right and every expectation that they're not going to get diseases that they didn't have when they went into the exam room or hospital," said Greg Poland, MD, professor of medicine and director of the vaccine research group at Mayo Clinic in Rochester, Minn.

No data have been collected on how many health care workers have received the Tdap vaccine, although numbers pertaining to the general adult population are not encouraging. According to statistics released in January from the Centers for Disease Control and Prevention's National Immunization Survey, 2.1% of 18- to 64-year-olds had received it. Also, a study published in the November 2007 issue of the journal Infection Control and Hospital Epidemiology found that 87% of health care workers were not planning to receive it.

Experts are concerned because health care workers are more likely to get pertussis in the course of their job. They also are more likely to transmit it to those most likely to experience complications.

A 2007 study said 87% of health care workers didn't plan to get vaccinated against pertussis.

"[Pertussis] is clearly a hundred-day cough in adolescents and adults," said Grace Lee, MD, MPH, assistant professor of pediatric infectious diseases at Harvard Medical School in Boston. "Vaccination protects them and their families. It protects the patients." She has published several papers on the cost effectiveness of this vaccine.

Some medical institutions are piggybacking pertussis vaccination efforts onto those for influenza. In some ways, pertussis vaccination is easier because it doesn't have to be given annually or during a narrow window in the fall and winter like flu vaccine, but motivating health care workers to get the shot is challenging. It's fairly new -- some people are not aware of it or that protection from childhood pertussis immunization likely has waned. Also, even though cases of pertussis have increased among adults, it's still viewed as a childhood disease. So the vaccine may not be viewed as vital for adults.

"This does require a whole new kind of paradigm, and we need to educate both the professional staff and others in the hospital about why we're talking about whooping cough," said William Schaffner, MD, president-elect of the National Foundation for Infectious Diseases and chair of the Dept. of Preventive Medicine at Vanderbilt University School of Medicine in Nashville, Tenn.

The price of the vaccine also may be a barrier, although studies have shown that vaccination saves money by reducing disruption and the need for prophylactic antibiotics caused by outbreaks.

Washington -- Vaccines have long been considered one of public health's greatest and most life-saving achievements, yet they continue to spark controversy. In recent weeks, protesters in Washington, D.C., claimed that childhood vaccines are unsafe, while in Albany, N.Y., others rallied against a mandatory vaccine bill in that state.

Parents attempting to do the right thing for their children are often caught in the cross fire.

Now along comes a new book, Do Vaccines Cause That?! A Guide for Evaluating Vaccine Safety Concerns. It summarizes the research findings on vaccines and presents a method for analyzing that research. The book is by Martin Myers, MD, a pediatrician and executive director of the nonprofit National Network for Immunization Information, based at the University of Texas Medical Branch in Galveston, and NNii science writer Diego Pineda. NNii provides information about vaccines on its Web site (www.immunizationinfo.org). Affiliates include the AMA, the Infectious Diseases Society of America, the American Academy of Pediatrics and the American Academy of Family Physicians, which support its work. NNii does not accept pharmaceutical company funding, Dr. Myers said.

The authors evaluate the long-running controversy linking vaccines with rising rates of autism as well as claims suggesting vaccines' possible association with asthma. The book also delves into the effects of multiple vaccines on a child's immune system.

Although parents are its intended audience, physicians and others in the health care field can benefit from reading it, according to former Health and Human Services Secretary Louis Sullivan, MD, and Samuel Katz, MD, chairman emeritus of pediatrics at Duke University in Durham, N.C. Together they wrote the book's forward.

"One hopes -- anticipates -- that besides a broad lay audience, health care personnel at every level will take advantage of this book to augment their own perspectives so they can discuss vaccines more comfortably and convincingly with the families for whom they are responsible," write Dr. Sullivan and Dr. Katz.

It remains to be seen whether the new book will answer all queries. "You are going to continue to see parents doing their own research and coming up with a lot of questions," said Barbara Loe Fisher, a frequent critic of vaccines and co-founder of the National Vaccine Information Center, a nonprofit, parent-led organization that seeks to change the mass vaccination process to allow more opt-out flexibility regarding immunizations. She said she looks forward to reading the book but wonders if it will address the issue now being raised about the effect on children's health of recent expansion in the recommended vaccine schedule.

"I've seen the number of vaccines double and the number of doses triple," Fisher said. "No matter what is published in that book, it is still an outstanding question until health authorities give us the answer as to why so many highly vaccinated children are so sick."

AMNews recently talked to Dr. Myers about the book.

AMNews: Why did you write this?

Dr. Myers: For a couple of reasons. The first, and maybe the most important, was that readers of our [NNii] Web site asked us to. They liked the essays on our site and asked us to put them together in a book.

The second was when we went to bookstores to see what was available, we could only find anti-vaccine materials and advocacy books. But we couldn't find a book written to help parents sort their way through conflicting information.

It is meant as a tool to help parents understand what they are hearing and how to evaluate it. We do not advocate. Each section of the book was reviewed by technical experts and parents. We had a panel of parents read the book and tell us whether we were clear or not.

One of my favorite anecdotes concerns a parent who acknowledged that the book was informative but also said it was boring and not the kind of thing a parent is going to read. So we went back and started over.

We hope it's helpful for parents who want more evidence and also to those who need help sorting through the evidence.

AMNews: What's in it for physicians?

Dr. Myers: As Dr. Katz and Dr. Sullivan wrote in the forward to the book, we do review the evidence in some detail. We want to have it all there. They noted that it's something that health professionals should read also, since it's the one place where it is compiled.

A number of physicians at meetings said they were anxious to see the book because they thought it would help them talk to parents.

AMNews: Do physicians and researchers have difficulty communicating clearly to lay people?

Dr. Myers: We use words in a different way. We included a table of words in the book and what they mean to vaccine researchers and what they mean in common English. As we started to compile that table, we kept finding more words.

"Bias" is one of the words. "Plausible" is another. "Significant" to the scientist means it is probably not due to chance, but it could be. But when a parent hears the word significant, it means important.

Then there is the phenomenon of the missing information. If it turns out that a safety concern is caused by the vaccine, like it was with intussusceptions and [the first] rotavirus vaccine [which was withdrawn in 1999], it doesn't take very long to prove it. [Two new rotavirus vaccines were licensed in 2006.] But you can never prove a negative. You have to have lots of studies done by different people, and it might take years until the scientific community says, 'OK, the weight of the evidence is so compelling we think we can reject this.' We used a quote from Einstein that Diego found: 'Many experiments will never prove me right, but one experiment can prove me wrong.'

AMNews: How great is the danger posed by unimmunized children?

Dr. Myers: We have a section in the book called 'community immunity' that addresses how important it is for children to be immunized to protect neighbors. It's an important concept for people to understand that when immunization levels go down, outbreaks can occur.

Attacks of misinformation on vaccine safety can cause that breakthrough. We saw it with whooping cough in the 1970s and 1980s. And we saw it with measles and mumps in the United Kingdom just recently.

AMNews:So are the same vaccine safety debates occurring in other countries?

Dr. Myers: The same discussion on vaccines causing autism was held in England and Europe related to the measles vaccine -- that argument has been discredited now. But as a result, parents became confused and didn't immunize their children, and they had an outbreak of measles and an epidemic of mumps which spread to the United States.

Washington -- The Upper Cardozo Health Center, located in an economically and ethnically diverse section of Washington, D.C., has enrolled more than 17,000 low-income individuals, and most are non-English speakers. These patients, who hail from more than 90 countries, still receive a full range of primary and preventive health services.

Across the river in Virginia, the Community Health Network in Fairfax is providing similar care for a similarly diverse population.

How do they do it?

More physicians than ever would like to know. Encountering patients whose grasp of English is less than proficient is not unusual in medical practices. More than 55 million people in the nation, or nearly 20% of the population, speak a language other than English at home. And more than 24 million residents speak English less than "very well" and may be considered limited English proficient, or LEP, according to Steve Hitov, managing attorney of the National Health Law Program's Washington, D.C., office. He moderated a June 16 briefing on the importance of language services for quality health care.

The National Health Law Program also released a report, "Serving Patients with Limited English Proficiency," that resulted from a 2007 survey of 260 members of the National Assn. of Community Health Centers.

"Eighty-one percent of general internists treat LEP patients frequently -- 54% at least once a day or a few times a week," Hitov said.

54% of internists treat patients with limited English proficiency at least once a day or a few times a week.

Luis Padilla, MD, the medical director of the Upper Cardozo center, which operates under the umbrella of Unity Health Care Inc., and Christina Stevens, program director of the locally funded Fairfax Community Health Network, provided examples of the problems faced by safety net health care centers as well as their solutions.

Both centers recruit bilingual staff members. At the Cardozo Health Center, whose patients speak primarily Spanish or Amharic, an Ethiopian language, 17 of the 19 primary care professionals speak Spanish, Dr. Padilla said. More than 90% of the support staff are bilingual or multilingual. In addition to Spanish and Amharic, the staff speaks French, Chinese, Tagalog, Farsi, Vietnamese and Tigrinya, a language spoken in the African country of Eritrea.

"We have one of the few pharmacies to provide Spanish labels," Dr. Padilla added.

Reading skills count, too

Many of the patients seen at Dr. Padilla's health center also are illiterate in their own languages, and a national community partnership program called Reach Out and Read has been adopted to promote childhood literacy. Literacy promotion is a focus at well-child visits, he said.

The center also has a language line with interpreters available for more than 100 languages and dialects. The service is accessed via speaker phone in exam rooms.

Underlining all this activity is the 2004 D.C. Language Act, which was enacted to provide residents with limited proficiency greater access to services and activities in their own languages. To comply with the law, the health center faces ongoing challenges, Dr. Padilla said. Among them are the continued recruiting of bilingual health care professionals and the development of resources and staff to assess how patients process the information provided and to measure the degree to which it is understood.

The Fairfax safety net program was established to provide primary health care services to low-income, uninsured residents. It was begun as a temporary operation until a federal program came along. But they are still awaiting the feds' arrival, Stevens said.

Eighty percent of their patients are LEP and, although Spanish is the primary language for more than half, there are at least 70 other languages represented at the clinic.

Referrals to specialists who do not offer interpreters was cited as a major problem by Stevens. Another is family members who wish to serve as interpreters but also interfere with the clinical process and insert their own views.

The Fairfax center found similar solutions to those used in in the district. All health care professionals are bilingual, and there are language service lines in all exam and interview rooms, Stevens said.

To guide the way toward a world in which there are more health centers like the two featured in the briefing, the AMA and other organizations developed in 2001 a set of principles for providing health care access to people with limited English proficiency.

They include offering language assistance at no cost at all points of contact and in a timely manner; providing both verbal and written notice of the right to receive language services in a patient's preferred language; and assurances that the language assistance is competent.

NEW YORK (Reuters Health) - Older adults with type 2 diabetes may have a steeper mental decline as they age, a large study suggests.

Diabetes is known to raise the risk of a number of major health problems, including heart disease and kidney failure. More recently, studies have also linked diabetes to speedier mental decline and dementia in older adults.

These latest findings, published in the Journal of the American Geriatric Society, confirm those earlier reports -- and suggest that the longer a person has had diabetes, the more substantial the cognitive decline over time.

For the study, researchers led by Dr. Olivia Okereke, of Harvard Medical School in Boston, examined data from the Physicians' Health Study and the Women's Health Study -- two long-term projects looking at the health of thousands of U.S. men and women.

The researchers looked at the association between diabetes and late-life cognitive impairment in 5,907 men and 6,326 women. Participants were in their early 70s, on average, when they were first assessed for memory, thinking and other cognitive abilities; they were tested again roughly two years later, and women had a third test around the four-year mark.

In general, Okereke and her colleagues found, men and women with diabetes performed more poorly on the initial cognitive tests, then showed a more marked decline on subsequent tests.

In addition, participants with longer-standing diabetes tended to be in worse cognitive shape at the outset, and show a steeper decline over time.

There are several plausible reasons why diabetes might fuel age-related mental decline, according to the researchers.

One is that diabetes can damage the blood vessels that supply the brain, diminishing blood flow and thereby contributing to cognitive problems.

In addition, people with diabetes typically have chronically high levels of the blood-sugar-regulating hormone insulin. And some research suggests that elevated insulin concentrations may boost the body's levels of amyloid-beta protein, which build up to form the "plaques" seen in the brains of people with Alzheimer's disease.

More studies are now needed to find out precisely how diabetes affects older adults' mental function, Okereke and her colleagues conclude.

SOURCE: Journal of the American Geriatrics Society, June 2008.

Copyright © 2008 Reuters Limited.

NEW YORK (Reuters Health) - Even among people with a normal weight, having a big belly may be deadly, a new study shows.

"People should not only look at their weight, but also consider their waist," Dr. Annemarie Koster of the National Institute on Aging, the lead researcher on the study, told Reuters Health.

Being overweight or obese is clearly bad for one's health, but the best way to gauge whether a person's fatness is putting them at risk has been "controversial," Koster and her team write in the American Journal of Epidemiology.

Body mass index, or BMI, has been the standard measurement used, they add, but the way fat is distributed throughout the body -- especially at the waistline -- may be even more important than how many excess pounds a person is carrying.

To investigate the relationship among belly fat, BMI and mortality, the researchers followed 245,533 men and women participating in the National Institutes of Health-American Association of Retired Persons study. Study participants ranged in age from 51 to 72 at the study's outset, and were followed for nine years.

Among men, the researchers found, those in the top fifth based on their waist circumference were about 22 percent more likely to die during the study period than men with trimmer waistlines, independent of BMI. A similar risk was seen among women.

In addition, people considered to be abdominally obese based on World Health Organization guidelines -- a waistline of 35 inches or more for women, or 40 inches or more for men -- were 20 percent more likely to die over the nine-year study than their peers with slimmer waists.

The findings were true for smokers and non-smokers, healthy people and those with chronic illness, and across all the ethnic groups the researchers looked at, which included non-Hispanic whites, non-Hispanic blacks, Hispanics, and Asians. In fact, there was evidence that mortality risk climbed more quickly with waist circumference among Asians, particularly men.

While the danger of abdominal fat -- in particular visceral fat, which collects around the internal organs in the abdomen -- is becoming clear, Koster noted, the reason why a fat belly is bad for health is still not well understood. "More research is needed there," she said.

SOURCE: American Journal of Epidemiology, June 15, 2008.

Copyright © 2008 Reuters Limited.