It's Spring Allergy Season- Some Allergy Basics

It's Spring Allergy Season- 

Some Allergy Basics

As we glory in the return of a warm sun, of the return of new life as plants start to grow and green, we also start to think about allergies.

Of course, allergies to many things occur all year round, including food allergies, allergies to pets, allergies to dust and mold.

But there is one sort of allergy that is defined by its seasonality- allergy to pollen.  Like dust and mold allergies, pollen allergies are responses to substances in the air.  But these substances only appear during cycles of plant reproduction, which largely go dormant during the winter, but burst onto the scene every spring.

This week we can all see trees flowering, and so the great burst of spring pollen allergy is upon us.  Before talking specifically about this, let's do a quick reminder of what all allergies are about.

What is an Allergy?

All allergies are reactions to some substance from outside the body, and they are reactions that appear to serve no helpful purpose.  All allergic reactions are also united in being in the category of inflammation.

If all allergic reactions are types of inflammation, what is inflammation?   Inflammation is a series of events that living organisms use to fight off other living organisms.  It turns out all sorts of inflammation involve some combination of five events:  redness, swelling, warmth, pain, and loss of function.  A great example of a common inflammation is a mosquito bite.  The mosquito saliva causes four aspects of inflammation to occur- redness, warmth, swelling, and pain (or itch).

But there are lots and lots of inflammations, including all infections, many types of injury, auto-immune events, nearly every medical situation finds inflammation present.

So what makes any inflammation an allergic sort of inflammation?   The answer to that requires us to mention that there are two sorts of allergies- classic and alternative.   Alternative allergies are reactions that are not yet fully described, as when someone states they have an allergy to gluten.

Our discussion will focus on classical allergy.

What is Classical Allergy?

So classical allergy is a very specific type of inflammation that only happens when some item outside the body connects to a special type of antibody and once connected that paired unit activates the allergic reaction.

The special type of antibody is the E-class of antibody. There turns out to be 5 such classes.  The M and G classes are involved in fighting off infections.  An A class provides a barrier to infections in all the linings of the body.  There is actually a class, the D class that no one knows what it does.  And then there is the E class, which does two things- it helps clear out infections from worms, and it causes all classical allergies.

The way classical allergies work, all such allergies including to foods, pollen, dust, pets, molds, is that the item you are allergic to is able to connect to an E-class of antibody.  Once that link occurs, the antibody triggers a release of compounds such as histamine that create the allergic inflammation, the allergic reaction.

Four things are common to all classic allergies:
1.  One is that there is a very specific E-class antibody that will only accept attachment to one and only type of molecule.
2.  The second is that a key property of the E-class antibodies, is that they all have their stem planted in a special cell called the mast cell.
3.  The third universal of all classic allergies is that all mast cells are packed with compounds that cause blood vessels to get leaky and draw in inflammatory cells.   If those contents are released for any reason, the area around these cells gets red, swollen, very itchy.
4.  The sequence in every classical allergic reaction, then, is always the same:

• Item that you are allergic to connects with the antibody that will only connect with that item
• Once the allergic material and antibody link, the stem of the antibody activates release of inflammatory chemicals that create the allergic reaction

A key property of all allergic reactions is that once the inflammation, the allergic reaction, passes, no lasting harm to the body remains.   Of course, the most severe allergic reactions can drop blood pressure and impair breathing.  But the point here is that once the allergic reaction is over, there is often no lasting damage present.  This is in marked contrast to more damaging forms of chronic inflammation like arthritis, diabetes, or Crohn's disease.  So, if the allergic reaction can be blocked, usually all harm is avoided.

Spring Allergies- How Best to Manage and Treat
When it comes to the hay fever appearing now, in the spring, we are talking about a classic allergy to pollen.
Pollen is in the air, so the allergic reactions to it are seen where air hits the body- the nose, the eyes, the throat, and the lungs.

In every part of the body that pollen contacts and causes a reaction, the same inflammatory reaction described above happens.   The only difference is in the impact of inflammation in different parts of the body.
What does that mean?  Well, for every part of the body affected, another symptom occurs:

• In the eyes- red, itchy, watery and/or mucusy eyes, with or without swelling
• In the nose- runny nose, congestion, itchy nose, sometimes redness and swelling
• In the throat- sore throat, mucus in the throat
• In the lung- cough and/or wheeze, mucusy cough

So what to do?  There are 4 key strategies to manage springtime (and other) allergies:

1. Avoid contact- this is hard, pollen is in the air, so avoidance is hard, but some homes have air filtration systems that might help do this at least a bit.
2. Antihistamines- these common drugs are incredibly safe, and incredibly helpful.  They allow the pollen to link to the anti-pollen antibody, and even allow histamine to be released, but they block the impact of histamine and so block any allergic reaction!   There are two types of antihistamines:  oral and ocular- swallowed or dropped in the eye.  The common oral antihistamines- claritin, zyrtec, and allegra- are non-sedating and each last 24 hours a dose.  Benadryl is also oral, but is more powerful, lasts only 4 hours a dose, and does make people sleepy, and young children agitated.   There are also eyedrop antihistamines that are very safe and are great for eye symptoms- these include Naphcon and Opticon (over the counter) and Patanol (by prescription)
3. Antileukotrienes- these drugs like antihistamines block all allergic reactions.  The main drug used in this category is Singulair or Monteleukast.
4. Steroids- Steroids are a very potent treatment option as they work by wiping out the mast cell, the cell that the allergy antibody attaches to, and that is the source of all the allergic reactions.   No mast cell, no allergic reactions.   The main steroids used are nasal and lung inhaled steroids and steroid creams for eczema.

The usual strategy is to start with antihistamines and/or Singulair.   If allergic symptoms remain problematic then steroids are added- usually inhaled steroid for the nose and or lung.

Usually these steps suffice.  But sometimes spring allergies are so severe that further steps need to be considered, including allergy shots which can actually change the production of the person's allergic antibody.

Bottom Lines

1. Every spring we seem surprised at just how dramatic spring hay fever is.  TV and magazines often dramatize the sudden flare of hay fever with headlines such as, "This is the worst allergy season in **** years."  But the fact is that every spring there is a very dramatic burst of suffering from pollen allergies, to don't be surprised when it hits.
2. Allergies are a type of inflammation.  One that is marked by itch, and always be reaction to something outside the body, but once the itchy inflammation passes, usually no lasting harm is noted.
3. Classic allergy always involves the sequence of some specific item you are allergic to connecting to an E-class of antibody, thereby opening up a mast cell to discharge a slew of inflammatory chemicals- histamine for example.   To be allergic to something means you have that E-type of antibody and that it is loaded on mast cells, ready to go if that item contacts the antibody.
4. Spring allergies occur from such a reaction to pollen.  Mainly tree and grass pollens.
5. Pollen allergies cause reactions where air hits the body- eyes, nose, throat, and lungs.  And, it should be mentioned sometimes an itchy skin rash.
6. First line of treatment usually is an antihistamine.  Oral for nose, throat, and lung issues, ocular for itchy eyes.   These include once-a-day forms like Claritin, Zyrtec, and Allegra.  For more severe reactions, Benadryl should be used every 4 hours.  For eye reactions, antihistamine eye drops are very helpful.
7. If antihistamines and/or Singulair fail to help well enough, steroids come next.  Nasal steroids include Flonase, Flovent, Rhinocort, Nasacort.  These are essentially identical medications and very interchangeable, and many are now over the counter.  Nasal steroids are helpful for nasal symptoms.  For wheeze and cough we turn to inhaled steroids such as Flovent, Asmanex, and Pulmicort.
8. The use of antihistamines, Singulair, and and/or steroids (nasal, lung) help the vast majority of people with spring allergies.  But, for those few who are not helped, other interventions are available as well.

Spring Allergies are a big event every year.  We are here to help and can often offer tremendous relief.

So, here is to a glorious spring and to your health!

Dr. Arthur Lavin 

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Women who used the drug during pregnancy gave birth to babies with birth defects, including cleft palates and lips, club feet, heart defects and craniosynostosis – a condition in which the skull is abnormally shaped and may not have enough space for the brain. This can cause vision problems, eating issues and mental impairment.

The study of 900,000 Danish women in August 2013 review found “2-fold increased risk of cardiac malformations with ondansetron (Zofran), leading to an overall 30 percent increased risk of major congenital malformations.”

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

A Major New Initiative to PREVENT Autism and other Neuro-Developmental Disorders- Project TENDR

A Major New Initiative to PREVENT Autism 

and other Neuro-Developmental Disorders- 

Project TENDR

As so many families know all too well, the chance that our children will develop some form of autism, or other neuro-developmental disorders such as ADHD or intellectual and learning disabilities has risen dramatically in the last 20 years.   The risk has risen to the point where now roughly one in six American children will develop on of these neuro-developmental disorders (NDD).

For most the time that we have watched these risks expand, there has been little hope of actually reducing the chances that our children would develop one of these NDD's.  Much progress has been made in the diagnosis of these disorders and in approaches to treatments.   But what about actually halting this most cruel epidemic?  Imagine if a path forward could be created that would reduce the chance that a family's child would develop autism, ADHD, and/or a learning disability.

This is not such an improbable hope.  We have known for many decades that a number of chemicals can have profound effects on how the human brain develops.  The most familiar example is lead. Exposure causes many complex neuro-developmental disorders, and removing from the environment is saving a tremendous number of children from these troubles.

Many years of solid, scientific research is just now coming to fruition, opening the door to identifying just which chemicals in our environment are causing autism, ADHD, and learning disorders.   Many of the nation's leading researchers in this field are ready to gather the findings they have observed over decades of work.  Roughly 50 of these top experts will be meeting in June and September of this year to craft 2 public position papers.

This effort is organized under the name of Project TENDR (Targeting Environment & NeuroDevelopmental Risks).   Project TENDR is being led by Dr. Irva Hertz-Picciotto, widely regarded as one of the world's foremost epidemiologists of neurodevelopmental disorders, and Ms. Maureen Swanson, of the Learning Disabilities Association of America.  They have put together an Organizing Committee of 15 leading authorities on this subject, including researchers from Harvard, University of Washington, University of California, California EPA, Columbia, and the NIH.  I have been deeply honored to serve on Project TENDR's Organizing Committee primarily to help with policy implementation efforts.

The participants in the two workshops include the full breadth of expertise on this subject and include scholars from all the same schools as the Organizing Committee, as well as the American Academy of Pediatrics, the US EPA, Johns Hopkins School of Public Health, and many other leading schools and agencies.

The first position paper from Project TENDR will be crafted in June of this year, and will identify the chemicals in our environment likely to cause the most autism, ADHD, and learning disorders.

The second position paper from Project TENDR, to be crafted in September of this year will propose an approach to actual reductions from these neurotoxins.

We all are used to being barraged by claims of this or that item causing this or that malady or medical problem.  And we have seen it turn out in too many cases that the dangerous substance really presented no harm at all.  So it is only natural to be skeptical, to wonder, will this Project TENDR really identify substances that truly cause these terrible conditions?   Even more to the point, can we truly expect that if exposure to the key chemicals Project TENDR identifies is reduced, will fewer children have autism, ADHD, and/or learning disabilities?

I am very hopeful the answer is yes.  Project TENDR is not the result of a casual inference, or an emotional hope, or a passing fad.   The statements and plans from Project TENDR will be reflecting decades of careful scholarly study, by dozens of nationally recognized leaders in this field, from a wide array of the nation's leading institutions and agencies.

Given the depth of this effort, I have been very pleased to participate by introducing the concept to two leaders in our Federal government, Senator Sherrod Brown, and the United States Surgeon General, Dr. Vivek Murthy.   Dr. Hertz-Picciotto has been active in presenting Project TENDR to US Congresswoman Doris Matsui of California's 5th District.

Earlier in March of 2015, I was deeply honored to be able to present Project TENDR to Senator Brown's health care aide, and to meet with the Surgeon General, Dr. Murthy.

Senator Brown has long been an advocate of helping families with autism, and to finding a path to reduce the risk of developing it.  He is a long-time member of the Congressional Autism Caucus.  Many families who come to Advanced Pediatrics have seen the photo of the Senator meeting with me here in our pediatric office in 2010, and it was at this meeting that we began our collaboration in the issue of autism.  In 2011, the Senator hosted an Autism Roundtable in the US Senate meeting rooms, where the head of the National Institutes of Mental Health, leading researchers, met.  I was honored to chair this Roundtable, with the goal of finding a path towards preventing autism, of reducing its incidence.  

Our Surgeon General, Dr. Vivek Murthy was recently sworn into office.  I was very honored that he accepted my request to meet and discuss Project TENDR.  Of course, the Surgeon General cannot endorse a scientific claim or a program unless it has met particularly stringent evaluations.  I am very pleased that as a result of our meeting, the office of the Surgeon General will be giving Project TENDR guidance on how best to pursue this necessary level of independent evaluation of our claims that certain chemicals in the environment, if their exposure was reduced, could reduce the chances of a family's child developing a neuro-developmental disorders.  Attached is a photo of the Surgeon General with me just after our meeting.

Preliminary estimates from the Project TENDR experts suggests that if we reduced the exposure from the top neuro-toxic chemicals by as little as 20%, the country could experience drops in the chances of our children developing autism, ADHD, and/or learning disabilities by 15-40%

Above all else, I am most excited that families in our community could one day experience some relief from the very real worry that their child may develop one of these very difficult conditions.

I will be keeping everyone updated as Project TENDR begins its work.  Let us all hope for much success.

To your health,
Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

A Visit with My Granddaughter, Some Thoughts on Infancy

A Visit with My Granddaughter, 

Some Thoughts on Infancy

My wife and I just concluded an incredibly wonderful and moving visit with our son, daughter-in-law, and 8 month old grand-daughter, all visiting from Hong Kong!

As nearly everyone would agree, children are astounding.   They bring such amazing powers of optimism, youth, newness into our world, and much. much more.    I have been incredibly blessed to live in the midst of childhood all my life.   Our work grants us the incredible gift each of you grant us, the gift of trusting us with helping you care for your child.

The experience of grandparenting introduces a new perspective, an additional level of amazement with childhood, in addition to that we relish from parenting and being a pediatrician.

As a friend who recently became a grandparent observed, when you are a parent, you are very excited about the next step your child is about to take, their is a bit of urgency in wondering how they will turn out.   But as a grandparent, you are less concerned about next steps, and you take a special pleasure in simply immersing yourself in the moment.

And so it is with this in mind that my wife and I immersed ourselves in Evie's later infancy.  We have an incredible set of days together, and we both truly got to feel the power of this stage of life.  Together with the richness of sharing this stage of later infancy with many of you, these experiences inspired some thoughts about infancy.

The main thing that impressed me about infancy this time was its mystery.  No newborn speaks in words.  Emotions that seem very familiar to us- happiness, sadness, rage, frustration- are clearly in evidence from day one, but the actual nature of the thoughts behind the feelings is mysterious, since no young infant speaks.  Further, it seems that if they could, we would likely be very surprised at how different their thoughts are from ours.  Again, since no one that age has spoken, we don't know how their thinking would be different, but it certainly appears to be different.

The very word infant emphasizes the non-verbal nature of their world.  Infant literally means, cannot speak (in- Latin for not, and -fant comes from a Latin word meaning speak).

So this is a world of non-verbal connections and communications.

The other aspect of infancy that is so distinctive and powerful is that many infants, though not all, love to be held, cuddled, to be close physically with those they care for and love.  It is nearly impossible to feed an infant (by breast or bottle) without holding them.   Most love to be rocked to sleep, or held during the day.  We don't really have this sort of contact with older children.  Having that much contact with an older child is even called "babying" them.   So being a baby means lots of contact, which is a unique hallmark of this stage of life, but one that endures in tender moments all our lives.

One more thought to share has to do with personality.  I find personality profoundly interesting.  We all know that each person we know has a particular way about them, a flavor, a style, a personality, that endures across a lifetime.  We can see it emerge soon after birth, and we see it stay steady over many years and decades.  Even after not seeing someone for many, many years, it is always remarkable how very much the person remains the same person no matter what troubles and time have occurred.

We see the power of personality, really of being human, in infancy, in full force.  Those of us with several children always remark on the power of how each child's personality is very different, and how those differences are evident at birth.

Our time with our granddaughter brought the power of personality to our attention in full force.  As our granddaughter and given the extensive time we had together, we had the great pleasure of truly connecting to this young 8 month old girl.  She turns out to be a very happy baby, beaming a smile and curiosity nearly all day long, in a very individual way.   What came to mind in enjoying our time together is what it takes for someone to sustain a positive outlook.  This infant gets hungry, she gets dirty diapers, during this trip she was exposed to a huge number of new people, she experienced jet lag, her routines were disrupted, and yet she time and again found a way to return to her style, a happy outlook.    We were able to directly observe stresses occurring, and her mind and system's work to maintain her stance.  

And what we saw is present in all infants, but our close look with our granddaughter made this aspect of being human so powerful and dramatic.   It is truly remarkable that each of us walk around, with all that happens to us at any moment, in any day, across time, and maintain our equilibrium, remain who we are.  And in the moments of infancy, before speech can cover our tracks at all, this power of steadying, of creating a stance, of being who we are is truly spectacular.   What an accomplishment our mind achieves all the time!

Bottom Line
This may turn out to be simply another gush from a proud grandparent, and in many ways it is.  But also I hoped to share some observations, some experiences that are so moving when spending time with our infant granddaughter.  They include:

• The wonder of personality, how the mind creates it and sustains it no matter what happens over such long times
• The centrality of touch in infancy, an age of being held
• The non-verbal nature of infancy, a stage of life that literally means cannot speak
• And, ultimately, the wonderful mystery of infancy.

And no discussion of infancy would be complete without mentioning how powerful love is.  How we all yearn to connect and how having a baby in the family brings everyone together. 

We are very grateful for being in the world of children and families, including ours!

To your health,

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Back in Order- repairs in the office

Back in Order-

Pipes to be Repaired this Friday, March 27

In contrast to our usual post- information you can use, and that is useful across the community, this post is just about some repair work taking place in the office.

As those in the practice know, we have had to hang an Out of Order sign on our bathroom too frequently over the years.

We are very pleased to let everyone know that our landlord has identified faulty pipe paths as the reason for this inconvenience, and will be repairing it this Friday, March 27.

The good news is that our bathroom should be back in order by next week!

But we want everyone to know that for the repairs to take place, our office needs to close early this Friday.   So, the office will close at Noon, this Friday, March 27.  

Please be sure to get all requests for prescription refills in by Noon this Friday.

Dr. Lavin will remain available throughout Friday afternoon and the weekend by phone, without interruption at our usual number, 216-591-1515.

We will be open as usual first thing Monday morning at 9AM next week.

Sorry for any inconvenience this may cause, but we look forward to our bathroom working for years to come.

To your health,

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

In Celebration of LEGO'S

In Celebration of LEGO'S!

This weekend, I came across a fascinating history of the powerful tool for imagination, LEGOS.

An unlikely source of poetic inspiration, I came across the article while waiting at my favorite barber's, in the April 2015 issue of Popular Mechanics (it also has Corey Kluber on the cover!).  The article, by Michael Paternini, tells a rather extraordinary story.

It began inland, in Billund, Denmark, in 1916, with Kirk Christiansen when he started a furniture business. Wood scraps from making furniture started his toy making business in 1934, which he called Lego, from the Danish leg godt, which means play well.  More on that later.

About 11 years later, after WWII, he visited England and came across a plastic molding machine.  He was the first person in Denmark to buy this machine and run it in Denmark.  The machine at first made hollow rectangular bricks of plastic.  But in 1958, Lego patented a plastic brick with internal tube and studded surface that allowed for instant stability, clutch power, and yet a young child can join and separate them.

In 1958 the Lego group has 150 employees, by 1960 the number was 450, and today they employ 14,000 people.  The company makes about 55 million separate Lego pieces a year.  Paternini goes on to observe that right now there are about 100 Lego bricks for every human on earth.  The company has been very successful.  Kirk Christiansen's grandson, the current head, is estimated to have personal worth of $10 billion.

So, the numbers are very impressive, but even more so is their celebration of play.  Play is fun, of course, but human play is also the highest level of cognitive functioning too.   There are few, if any, significant advances in human history that did not rely on play.   And play, sadly, is under tremendous pressure, if not assault, in the childhood of American children today.  From the first day of kindergarten through the first day of college, today's American child can expect to take over 100 standardized tests, experience thousands of hours of homework, and be subjected to tremendous pressures to conform to very narrow definitions of success.

And so, not only are Lego's a great toy, but a highly unusual opportunity for children to play.

One fact jumps out beyond all others in this recounting of the Lego story:  If you are given just six Lego bricks, each with 8 studs, the number of possible combinations of those six bricks, is over 900 million!!  

That's right, 6 Lego pieces can generate nearly 1 billion different constructions!

The makers of Lego blocks have since teamed up with cognitive scientists of play at MIT and together they discuss the interesting balance of constraint and creativity.  The constraint is that each Lego block has a fixed shape, and none are round.  The creativity comes from the staggering variety of shapes, including round shapes that the blocks can form.

Children enjoy Lego constructions in a wide variety of ways.  They enjoy mastering reading the non-verbal construction manuals that accompany kits, and they enjoy making up their own designs.  Again a great range of possibilities.

Some families have raised concern that their child(ren) focus too much attention on Lego play.   Sometimes the issue of hyperfocus which is a symptom sometimes seen in children who struggle with paying attention to school work have, is raised as a problem of play with such toys as Lego blocks.

The evidence to date suggests that having fun with toys such as Lego blocks in not the cause of disinterest in school.  More likely, many children simply prefer play to homework.

Bottom Line

Lego blocks, like many fun activities that promote play, are great fun and terrific opportunities for our kids to play.  

Play is in short supply for many children,  and should be celebrated!

To your health,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Illusions should pass, but people should not be attacked

Illusions should fall, but it's still good to be reasonable

Over the last few days, I have been sent a link by a number of people to a recent piece by the late-night talk show host.  It is his take on the recent concern about the threat of measles, but also a very harsh attack on families who have struggled with the issue of immunization.

Given the number of people who have sent this clip to me, it is clearly catching a lot of attention, and I thought a response was in order.

The clip highlights two rather striking realities about our national conversation on immunizations:

1.  A dramatic shift in our thinking and feeling on the measles vaccine is happening right now.

2.  Much of the feeling associated with this shift is unnecessarily belligerent and mean-spirited.

Our Affair with False Claims
In 1998, a physician with transplant medicine experience published a paper in one of the world's oldest and most prestigious medical journals, The Lancet, in which he raised concern that the MMR vaccine caused autism.  He later went public calling for the MMR vaccine to stop being used.  Fairly rapidly, other scientists took a look at Wakefield's claims and found they had no basis in fact.  The London Times conducted an extensive investigation and exposed Wakefield's work as fraudulent.

Science began exposing Wakfield's work as early as the year 2001, and by 2004, enough evidence to expose Wakefield has accumulated that serious steps began to be taken against his credibility.

In 2010, England revoked his license to practice medicine.

But none of the exposure of how fraudulent Wakefield's claims have been have had any impact on the public mood, until now, some 11 years after his work was first exposed.

For me, what is most interesting about the Wakefield hoax is not that it happened, but how we the public relate, because such processes are common when it comes to immunizations.

Some time ago, we posted a blog and post on the remarkable book, On Immunity, by Eula Bliss, a gifted writer.  This is easily the most thoughtful and profound book on the issues we all face when considering medical decisions, and a tremendous reference on the story of immunizations.   This story goes back well beyond Edward Jenner and his work on smallpox inoculation in 18th century England.   The work of immunization can be traced to at least a century before that in India, thence to Turkey, and from Turkey, remarkable, to the United States via Cotton Mather whose family remains prominent in Cleveland to this day.   The gift of immunization, namely the eradication of deadly diseases, has always been met with worry and resistance, now for centuries.

More recently, in modern America, the questions raised about immunizations have led to two movements against immunizations that each lasted about 15-20 years.  One was quite strong in the 1970's and 1980's and it was based on the claim that the DTP vaccine caused mental retardation.   As with our more recent movement against immunization, the claim was rapidly disproven, but it took nearly two decades for the claim to vanish.   And this claim has clearly vanished.  There is essentially nobody around today who really believes that if a child gets a tetanus shot it will cause them to become mentally retarded.   But this was a hotly held feeling for a very long time, and it actually led to a change in the DTP, the creation of the now used DTaP, a weaker vaccine with fewer side effects.

And so it was with this current claim, that the MMR causes autism.  Within a few years, evidence was at hand that the claim was untrue.  But the power the claim had on our minds remained quite powerful for another decade.

Equally fascinating to us is how a very passionately held claim suddenly evaporates.  No one knows what triggers the claim vanishing, but these false claims always end up collapsing.  The fact that false claims collapse is no surprise, but it is intriguing that they persist, and intriguing that the moment of their collapse never bears any relation to any new facts emerging.  It is as if the passion surrounding a controversial claim needs 10-20 years to go through its process, and only then will it collapse.

One dramatic illustration of what we are talking about is the fact that in 2000, measles had been eliminated from the US.   In response to worries about MMR, the number of people protected by the MMR against measles began dropping, and measles outbreaks started up again in our country in 2007.  From 2007-2014 there have been twenty measles outbreaks.  But for 19 of these 20 outbreaks, the fact that measles caught fire again here had no impact.  The outbreaks were reported, but essentially no one cared.   During this time, in our public imagination, the worry that the MMR might cause autism trumped the worry that measles could cause harm.

Not this time.  This 20th outbreak came after the claim that MMR could cause autism really began collapsing.  And now this time, the measles epidemic has caused a furor, a firestorm.

As recently as early 2014, no late night comic would touch on public worries about measles, no one cared.  But now, it is all the rage.

So, just as the claim that the DTP vaccine can cause mental retardation suddenly disappeared from public imagination in the United States, the claim that the MMR vaccine can cause autism is also, but it's happening right now.

Being Thoughtful During Reactions in Any Direction

And so, we are living through a very dramatic shift in public mood and perception.

Again, anyone really interested in this subject would greatly enjoy the masterful treatment of it in the book On Immunity.

Curiously, the shift has moved our country from one strongly held feeling to another.   Initially the feeling was a sense of unease, and for many, a sense of dread that the MMR vaccine might cause autism.  Now the feeling is a sense of unease, and for many, a sense of dread that measles could present a danger.

I would propose that at any time, no matter what the nation is upset or worried about, that a minimum of respect for the concerns of others be honored in practice as well as intent.

As the book On Immunity so beautifully illustrates, there is complexity in medical decision making, particularly when it comes to being a parent who imposes a treatment on their child.

Many parents over the years have expressed concern for the presence of various preservatives in immunization materials.  These have included such ingredients as mercury.  As a result of these concerns, nearly all immunizations used in our office arrive in single dose syringes that contain no mercury.   Other ingredients of concern have included formaldehyde and aluminum.  The aluminum is necessary to stimulate the immune system to react to the vaccine, no aluminum, no immunity from the vaccine.   The formaldehyde is in extremely tiny amounts left over from the processing of the vaccine and not an active ingredient.  Both the formaldehyde and aluminum have been studied and found not to cause harm since the amounts are so low.

The reason I review these three ingredients is twofold:
1.  To let people know that the vaccines we recommend have been used after very careful scrutiny and enormous studies of risk, and found to be very, very safe.
2.  The second is to let people know that people in the community who raise questions of course have a right, and duty as parents, to raise questions.

The swing from one strong feeling to another strong feeling has led to a shift from a very strongly held worry about vaccines, to a very strong held worry about those who do not vaccinate.

This swing has led to the emergence of a whole new discussion across the nation- should actions be taken against families that delay, or do not immunize their children?  Some have even called for doctors to not see families who make these choices.

It is at this point that we call for calm and respect.

A closer look at the controversy about what doctors should do will hopefully encourage us all to be both calmer and more respectful.

As we think about it, several reasons come up, many of them compelling, for seeing the decision to exclude people for their medical choices from doctors' offices as not helpful to anyone:

1.  The doctor's office is a place of help.   The last thing a doctor should do is turn away someone who wants to be helped.   Most families have questions about immunizations, it's one of the more helpful things pediatricians do, it does not make sense to turn away people looking for answers.  Excluding people from care because others object to decisions or perceive harm could lead down a very odd road.  Imagine doctors telling people who smoke that they can no longer come see them, or people with any complex health choices to weigh.   Not only is that a bad idea, but it violates a very key principle of the profession:  the doctor's office is a place of help.
2.  If there is a disagreement or point of discussion around a subject, it usually does little good to respond to that by cutting off the conversation.   For families that have concerns about immunizations, it does little good to respond by not allowing the conversation to take place.  It doesn't help the doctor understand the concern, and it doesn't help the family explore their concern.
3.  For those who feel strongly about everyone getting immunized, pursuing a policy of not allowing people who question immunization to come to the doctor actually will increase the number of children not immunized.  Cutting people off tends to reduce opportunities to discuss options rather than expanding them.
4.  The doctor's office is not the main source of exposure to any illness.   Take the current measles outbreak.  Most of the cases were caught in Disneyland, not the doctor's office.  Many families are currently concerned that if unimmunized children come to the doctor's office, their child will be at heightened risk of catching preventable illnesses, like measles.  But keeping access to a doctor limited to those unimmunized does not really change the risk of anyone catching those illnesses.
5.  When an outbreak of a preventable illness occurs, immunized children spread it too.  In the last measles outbreak, about 1 in 6 of those walking around with measles were immunized.  When an outbreak occurs, there really is no safety in isolating those who are not immunized, we are all one community living together, whatever our choices are.

So, as one might suspect, it turns out the only way to protect a community from vaccine preventable, serious infectious diseases is to have as much of the community be immunized as possible.  Infections spread across great areas, and that transmission can only be stopped if enough people are immune and unable to spread the illness.

Taking actions on an individual level has no impact, and the actions recommended all tend to be counter-productive as noted above.

BOTTOM LINES
1.  We are all living through a rather amazing transition in perception.  The MMR, and other immunizations, are moving from items of some worry, to highly valued protectors.  Worry is shifting from the vaccine to the disease.

2.  Right now, there is an incredibly sharp spike in feeling about immunization, this time the worry is with not getting immunized.  Blogs, late night comedians, daily conversations are seeing a sharp rise in calls for action to demand everyone be immunized, including calls to restrict access to medical care.

3.  It turns out the only way to keep one from catching a vaccine preventable disease is to have the whole population reach a safe level of rate of immunization.  If a whole population dips below that rate, then everyone can spread it, even immunized people.  There is no protection in trying to avoid people who have not been fully immunized.

3.  As during the time when most worries were directed at the vaccine, this time calls for being reasonable and thoughtful.   To that end, it is worth keeping in mind that our primary purpose as doctors is to help.   And it simply does not help anyone to deny help to those with questions.

4.  Those interested in perhaps the best, most thoughtful treatment of this issue might greatly enjoy On Immunity, a comprehensive treatment of the subject.

5.  Putting it all together, we at Advanced Pediatrics will continue what we always try to do- be available, be helpful, answer questions, offer disease prevention.   I have full confidence this approach is the safest, most helpful, and most informative approach we can imagine.


And to that end, we again thank you for the honor of being asked to help,
Dr. Arthur Lavin

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