9th 13th December

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On Wednesday we only had two hours of school so after class we all went to Hlnes place where we hung out before going to McDonalds for lunch they call it McDos. It's different but I'm not sure how to explain it. We got so much food but it was so good We also got McDonalds balloons After lunch we went and looked around the shops before going back to Hlnes to watch a DVD.Thursday evening

14th 20th December

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I'm turning into a snowman Its so cold here 7 degrees when walking to school and it doesn't normally get any warmer than 2 degrees during the day. The town fountain is completely frozen over but still no snow .17th SNOW Today was amazing When I woke up and looked out my window I saw that the roofs and footpaths were a little white then while getting ready for school I saw tiny snowflakes

The Taj

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From Jaipur to Agra and the Taj Mahal with several forts and mosques along the way. We spent a couple of days in Agra quite a small town. As for the Taj...what a wonderful wonderful legacy With such a well known icon and so many pictures over so many years you would think it would be very hard for the reality to live up to the expectations...but not so. The approach which we hadn't seen

A Feliz Cumpleaos with my nuevos amigos

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Sorry I haven't written in so long this is in fact a good thing since I have not been bored for quite some time New volunteers in Oruro as meant an expanded social circle and more to do after work I have a new roommate and so stuff around the house gets split in two and I have someone to hang out with at night. She organized my birthday party that rocked I was woken up at 8h30 by singing at

Varazslatos Varanasi 36 nap

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Folytatodik a Varanasi csodavilag a barangolasaink soran a kovetkezo szossszenetek ragadtak rank az itteni eletbolNo toilet no shower still smell like flowerShiva Power 24 hourAz ovarosban egy kis poloboltban a nyomas No Boat no rickshaw no Hashish no pashmina No Problem Szoval igen csak ramanosek lehuzosak azert a turistaiparban munkalkodo Varanasiiak egy picit mindig megprobalnak

South Africa 2010

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So Here I am in South Africa with ten of my greatest friends Duncan the South AfricanTomOllieHugoAmeliaNatEddieEmilyGussy and of course myselfWe flew on the 12th december and arrived on the 13th a horrendously long and dull journey thatnk go dfor the extensive film collectionWe trundled off to Gatwick Airport after my mother had cooked gussy meals nat and I a last meal with champagne i

Water aid charity hopes to raise money by auctioning a fantastic luxury holiday in St Lucia.

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Water aid charity hopes to raise money by auctioning a fantastic luxury holiday in St Lucia.A holiday of a lifetime at the awardwinning Windjammer Landing Villa Beach Resort in Saint Lucia is now up for grabs and all proceeds go to the Water Aid Charity Just a Drop. The winner will receive return flights for two people from London or Manchester and 10 nights half board accommodation courtesy o

Crdoba

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Hola AmigosThis blog is a little late I stayed in Crdoba last week so I apologise for that but the sentiment is thereSo from Puerto Iguaz which I believe is where we left off...I took a bus to Crdoba. I left at 13.15 and arrive in Crdoba at midday. That is one long bus journey But I got a flat bed champagne sweets films and a massive fleecey pillow so it was actually pretty good

The Art of Construction

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Before I left SwedenUK I was telling people about WWOOFing and how we were planning a stay on a hippie commune and on a ranch... Well Ro fitted in the commune before I got to Canada fortuitously as it turns out not sure I would have been prepared for the public nudity involved in showering in the middle of the lawn and ranches seem to be rather too popular. I tried to get us on to one for

Meine Letzten Tage

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Ich schreibe meinen letzten Eintrag so denke ich.Bin nach 2 Wochen Dauersurfen in Casa Grande und einem schmerzhaften Abschied von Santa Marta nun noch 2 Tage in Bogota. Ich habe tolle Bilder gemacht die irgendwann einmal hier auftauchen werden.Nach Hause zu gehen wird wahrscheinlich mehr schmerzen als ich mir gedacht haette. Irgendwie habe ich mich an dieses Leben hier und die Menschen gewoehnt

Company and Camp

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Believe it or not December is more than half over It has been a very full month for us so far. December 4 brought the arrival of the Fuller family Burt Michelle Kelsey Morgan Rachel Mack and Samuel. They are staying with us until the 27th. As you can imagine adding seven more people to our household and the logistics of meals bathing laundry cleaning and having enough water has

Somnath Porbandur Dwarka

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We headed towards Somnath Jyotirlinga temple. Somnath temple one of most important Lord Shiva temple. The history of this temple is a true proof of the Glory of India in past. Before rise of west india was richest country in the world. Christopher Columbus landed in 1492 in West Indies when he tried to reach india from west. There where specialist persons who made maps in britain who were finding

Hungry for more in Budapest

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We ended our transit tour by being unceremoniously dumped at the Budapest International train station at 11pm at night. It was deserted there wasnrsquot a taxi in sight. Whatrsquos more we had no local money. Thankfully we did manage to find a taxi reasonably quickly which whisked us of to our hotel for a long awaited stretch out and sleep.Budapest is an interesting town in that itrsquo

Leaving Work for New Adventures

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Welcome to our BlogWe have left the beautiful Kaikoura in search of new lands and adventures The last few days were manic but we managed at 20kmhr in 1st gear to crawl over the Hundalees wtih our possessions. They have been left in the new house ready and waiting for our arrival in a year and a half It was a slow trip and a busy few days loading and unloading gear. Thanks to all those that h

Canada

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Getting there sucked but that's because at that point we were still in America. For some reason we flew with America Airlines who are rubbish. No meal on a 4.5 hour flight crappy staff they only showed one Christmas movie and I didn't even get to sit next to Ross. Nope I sat next to a fat snoring fat man and Ross sat next to a pretty lady with a little dog in her bagAs soon as we got to Toro

Measles

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It looks like the H1N1 pandemic is fading fast. I am amazed at how lucky we were, at least in the hospitals where I work. A month ago all the ICU beds were full, most of the ventilators were in use and we were wondering how we were going to triage the next batch of patients who needed advanced life support and we had none to offer. Then, right as we reached maximum capacity and had no more wiggle room, the rates plummeted. We skated right up to the edge of the precipice, looked down, and did not have to jump.

The pandemic has not been as bad as expected, but it was still no walk in the park. Nationwide H1N1 killed maybe 10,000, with 1,100 in children and 7,500 among young adults (ref). Oregon has had 1200 hospitalizations and 68 deaths. We had about 8 deaths from H1N1 in my hospital system. We would have had twice that number, but one of our hospitals is a trauma center and offers ECMO (Extra Corporeal Membrane Oxygenation) and we managed to save a number of people who would have died if they had been in a lesser hospital. The national statistics mirror our experience. None of the deaths were in the elderly. Pity the vaccine was slow to be produced as it could have prevented the majority of those deaths.

Are we done with H1N1? Will it become part of seasonal flu? Will it have a third comeback, fueled by holiday travel? Will it mutate and increase virulence? Will it recombine with avian flu to generate a new strain? Is this THE pandemic that comes every 30 years or so, and we will not see another until after I am long dead?

How am I supposed to know? I can’t see the future. Or can I? Mr. Randi, listen up: I am thinking I will be eligible for that million dollar prize. I am receiving future information from the Large Hadron Collider, curiously delivered inside a baguette. I think I can predict the next infection to sweep the US.

Measles.

Easy call, huh?

I have seen a grand total of one case of measles in my career. It was in an unimmunized young male who picked up measles traveling to Africa. I had not expected to see another case thanks to immunization. I am no longer certain that will be the case.

Measles, due to the rubeola virus, is a typical virus, with the usual fever, cough, runny nose, red eyes and a generalized, maculopapular, erythematous rash. One of many childhood infections that have plagued mankind. Measles is very infectious, with 90% of household contacts exposed developing the disease. It is one of those infections that is easy to acquire in the waiting area of a doctors office.

Case fatality rates in the West are low, about 0.3%, while in the third world it kills up to a third of infected children. About one in a thousand get encephalitis.

In the old days, everyone developed measles with about 3 million cases a year, with relatively little, but devastating, morbidity and morality.

“Before measles vaccine, nearly all children got measles by the time they were 15 years of age. Each year in the United States about 450 people died because of measles, 48,000 were hospitalized, 7,000 had seizures, and about 1,000 suffered permanent brain damage or deafness.”

Much of this is preventable by the vaccine. No vaccine is perfect, and the measles vaccine is no different. Measles vaccine is about 90-97% effective in preventing infection, depending on the population studied. Or to think of it another way, 3 to 10% of the population would remain susceptible to the disease even if we had 100% of the population vaccinated.

Thanks to Dr. Andrew Wakefield, fear of MMR induced autism is highest in Great Britain and as a result measles vaccination rates have fallen. Perhaps it should now be Mediocre Britain, at least where vaccines are concerned.

Vaccination rates have fallen in England, and at one point 20% of children were susceptible to measles, mumps and rubella. Since the English refer to vaccination as ‘the jab’ I am surprised they get anyone to take the vaccine. It’s like referring to colonoscopy as riding the python. Who would want that?

“A particularly significant decline was observed between 2000 and 2004, which can arguably be attributed to deterioration in public confidence about the safety of the MMR (Reference).”

vaccination rates

As a result, measles boomed.

measles rates

All due to Dr. Wakefield’s report in the Lancet, which evidently should have been published as work of dark humor in Punch.

“More importantly, the controversy appeared to affect parental decision-making. Uptake rates for MMR in England fell from 87.4% in 2000-01 to 79.9% in 2003-04, the lowest figure at any time since the widespread introduction of the triple vaccine in 1990-91. The decrease was especially significant given that the single vaccines alternative was only available from private medical clinics, at a cost of around £200.

The Wakefield study has been widely discredited, and MMR uptake has recovered to an extent: in 2007 vaccination rates stood at 84.6%. Meanwhile, measles notifications in 2006 and 2007 were the highest for almost a decade. (Reference)”

I wonder, as an aside, about responsibility. One of the refrains of the antivax crowd is that big pharma is protected from any liability from vaccine injury. Big pharma cannot be held responsible. I wonder, when the causes of autism are finally elucidated and vaccines are definitely exonerated as we have the answers to the etiology of autism, if Dr. Wakefield, AoA and Ms. McCarthy will assume the responsibility and liability for all the morbidity and mortality their actions caused. I am sure they will happy to step up to the plate and offer restitution to the affected families.

There was, of course, another paper out of Poland, “Lack of Association Between Measles-Mumps-Rubella Vaccination and Autism in Children,” this month exonerating the MMR as a cause of autism. Poland has an interesting history with regards the measles vaccine:

“The MMR vaccine was introduced in Poland later than in most other European countries. For the past 10 years, the MMR vaccine has been gradually replacing the single-antigen measles variety. When it was first introduced, MMR was not covered by the national health service of Poland. Parents who wished to vaccinate their children with MMR, as opposed to the single mandatory measles vaccine, had to pay extra. For this reason, few children were immunized with MMR. The Polish mandatory vaccinations schedule did not include MMR for all children until 2004.”

As a result,

“Poland’s heterogeneous population (ie, vaccinated with MMR, vaccinated against measles only, nonvaccinated) serves as a unique sample group for studying the debated association of these vaccines with autism in children.”

In comparing the three groups they found no association between MMR and autism. None. In fact, they found “a lower risk of developing autism for children vaccinated against measles, with the lowest risk being found for children vaccinated with MMR.”

This finding is dismissed by the authors as perhaps

“the decreased risk of autism among vaccinated children may be due to some other confounding factors in their health status. For example, health care workers or parents may have noticed signs of developmental delay or disease before the actual autism diagnosis and for this reason have avoided vaccination.”

Dr. Gorski also thought the finding was a fluke. Part of the argument against MMR being protective being that having one child in the family with autism would make it unlikely for other children in the family to get the vaccine out of fear of the vaccine causing autism when, in fact, it is due to perhaps inherited causes. The lack of vaccination actually being a marker for families with other predispositions to developing autism.

I am not certain that is true. As the authors report:

“This serves as evidence that, despite extensive media coverage of the debated association between MMR and autism, public acceptance of this vaccine remains very high. The situation in Poland is different to that of many European countries, where MMR vaccinations by age 2 years fell more than 10% and were followed by measles outbreaks. In this time, Poland’s already high rate of measles immunization even slightly increased.”

Seems that the Poles were immune to the anti-MMR hysteria, although I cannot say with certainty. If so, then the finding of the protective effect of vaccination, given the study population, may be valid.

Me? I think everything is due to an infectious disease. Infections are the One True Cause of All Disease. While this is the first study to demonstrate the protective effect of the MMR, remember that measles, mumps and rubella area neurotropic viruses with encephalitis a known complication. There has long been a suspicion of viral infections altering the brain to unmask schizophrenia and there is an association between borna virus and OCD. Could a subtle neurologic infection exacerbate a predilection towards autism? I do not think it is out of the question. But that is my delusion.

Vaccination rates have fallen in some segments of the US population as well. In the US, low vaccination rates are found primarily in the children of the well-to-do and often are clustered in alternative schools. There are dozens of schools with vaccination rates under 80%, with some schools having vaccination rates of 5% (reference).

Well, fine, you may say to yourself: they can get the measles or other vaccine preventable diseases. At least it will stay in the those enclaves of unvaccinated children. My kids are vaccinated and in schools where vaccine rates are high. My kids are safe. I would have thought the same thing.

Herd immunity and the models that try and predict what levels of immunity are needed to protect a population are based on the assumption that unimmunized people are randomly distributed in a population, not clustered in alternative schools.

In the Journal of Infectious Diseases this month is a description of a measles outbreak in Canada where clusters of unvaccinated populations helped perpetuate a measles outbreak even though overall community vaccination rates were high (“Long-Lasting Measles Outbreak Affecting Several Unrelated Networks of Unvaccinated Persons”):

“Despite a population immunity level estimated at ?95%, an outbreak of measles responsible for 94 cases occurred in Quebec, Canada. Unlike previous outbreaks in which most unvaccinated children belonged to a single community, this outbreak had cases coming from several unrelated networks of unvaccinated persons dispersed in the population. No epidemiological link was found for about one-third of laboratory-confirmed cases. This outbreak demonstrated that minimal changes in the level of aggregation of unvaccinated individuals can lead to sustained transmission in highly vaccinated populations. Mathematical work is needed regarding the level of aggregation of unvaccinated individuals that would jeopardize elimination.”

The graphic shows how schools acted to magnify the epidemic:

outbreak

The isolated measles virus was genotyped and almost all isolates were identical, demonstrating how infectious measles can be with what was presumptively minimal contact.

As the discussion said:

“An important assumption of mathematical models predicting elimination, however, is the random distribution of susceptible persons in the population. In reality, unvaccinated individuals are not distributed at random. Religious groups opposed to vaccination are often tightly knit communities. Our outbreak involving 2 unrelated alternative schools attended by children whose parents were resistant to vaccination on philosophical ground demonstrated that these persons also aggregate. The spontaneous interruption of this outbreak, despite the current level of aggregation in unvaccinated children, suggests that endemicity was not likely to be reestablished in this population. The continued propagation throughout many generations of cases, however, raised the possibility that a minimal change in the overall vaccine coverage in the population or in the level of aggregation of unvaccinated individuals can lead to sustained but protracted transmission despite an immunity level near 95%.”

Lest you think this outbreak epidemiology is limited to measles, the US northeast experienced a similar outbreak with mumps, where clusters of unvaccinated populations help magnify the spread of disease.

A child with mumps came to the US from, hey, I’ll be damned, England, thank you Dr. Wakefield, where, thanks to low uptake of the MMR (the second M standing for mumps) there is a mumps epidemic. The index case went to a religious camp and gave it to the other campers, who in turn went to other collections of unvaccinated people to start their own epidemic and so on. In this case there was little spread into the wider community that “might be attributable to generally high vaccination levels and little interaction between members of the affected religious community and persons in surrounding communities.”

It appears that collections of unvaccinated people may serve to magnify the ability of diseases to spread in a community. Those unvaccinated children in the alternative schools may be unlikely to keep their infections to themselves.

My million-dollar prediction? Measles will be imported into the US in a student from Mediocre Britain. That student will visit an alternative school and start an epidemic in the school. Measles will be spread from school to school and into the community and will be difficult to control.

It will occur in 2012. The Mayans, along with the other indigenous peoples in North and South America, were killed by the millions by vaccine preventable illnesses like measles, pertussis, mumps and smallpox. The real reason the Mayan calendar ends in 2012 is the end of the world will be due to the return of vaccine-preventable diseases.


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Are the benefits of breastfeeding oversold?

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As a mother, I am a passionate advocate of breastfeeding and I breastfed my four children. As a clinician, though, I need to be mindful not to counsel patients based on my personal preferences, but rather based on the scientific evidence. While breastfeeding has indisputable advantages, the medical advantages are quite small. Many current efforts to promote breastfeeding, while well meaning, overstate the benefits of breastfeeding and distorts the risks of not breastfeeding, particularly in regard to longterm benefits.

As Joan Wolf explains in an article entitled Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign:

… Medical journals are replete with contradictory conclusions about the impact of breast-feeding: for every study linking it to better health, another finds it to be irrelevant, weakly significant, or inextricably tied to other unmeasured or unmeasurable factors. While many of these investigations describe a correlation between breast-feeding and more desirable outcomes, the notion that breast-feeding itself contributes to better health is far less certain, and this is a crucial distinction that breast-feeding proponents have consistently elided. If current research is a weak justification for public health recommendations, it is all the more so for a risk-based message that generates and then profits from the anxieties of soon-to-be and new mothers…

Wolf describes the problems with many studies of breastfeeding, particularly those that focus on long term outcomes:

In breast-feeding studies, potential confounding makes it difficult to isolate the protective powers of breast milk itself or to rule out the possibility that something associated with breast-feeding is responsible for the benefits attributed to breast milk. As the number of years between breastfeeding and the measured health outcome grows, so too does the list of possibly influential factors, which means that the challenge is magnifiedwhen trying to evaluate long-term benefits of breastfeeding… Breast-feeding, in other words, cannot be distinguished from the decision to breast-feed, which, irrespective of socioeconomic status or education,could represent an orientation toward parenting that is itself likely to have a positive impact on children’s health. In instances such as this, in which the exposure (breast-feeding) and confounder (behavior) are likely to be very highly correlated, confounding is especially difficult to detect. When behavior associated with breast-feeding has the potential to explain much of the statistical advantage attributed to breast milk, the scientific claim that breast-feeding confers health benefits … needs to be reexamined.

But even studies that may be biased show limited, if any, long term benefits of breastfeeding. The World Health Organization published a comprehensive review of the evidence  in 2007, Evidence on the long-term effects of breastfeeding, by Horta et al. According to the authors:

…[T]here is some controversy on the long-term consequences of breastfeeding. Whereas some studies reported that breastfed subjects present a higher level of school achievement and performance in intelligence tests, as well as lower blood pressure, lower total cholesterol and a lower prevalence of overweight and obesity, others have failed to detect such associations.

Objectives: The primary objective of this series of systematic reviews was to assess the effects of breastfeeding on blood pressure, diabetes and related indicators, serum cholesterol, overweight and obesity, and intellectual performance.

The authors reviewed the existing scientific literature on 5 specific claims.

1. Does breastfeeding leader to lower blood pressure?

The authors reviewed two meta analyses and three studies:

According to Owen et al, the association between breastfeeding and lower blood pressure was mainly due to publication bias, and any effect of breastfeeding was modest and of limited clinical or public health relevance. In spite of not being able to exclude residual confounding and publication bias, Martin et al concluded that breastfeeding was negatively associated with blood pressure. They argued that even a small protective effect of breastfeeding would be important from a public health perspective… Three large studies were published since the last review, two of which found no association and one found a protective effect of breastfeeding.

Both meta-analyses may have been affected by publication bias… Lack of control for confounding is another methodological issue, as pointed out by Martin et al…

In summary, the present updated meta-analyses show that there are small but significant protective effects of breastfeeding on systolic and diastolic blood pressure. Publication bias is unlikely to explain this finding because a significant protective effect was observed even among the larger studies. However, residual confounding cannot be excluded because of the marked reduction in effect size after adjustment for known confounders.

2. Does breastfeeding lead to lower cholesterol levels?

[N]o significant effect was observed in children or adolescents, mean cholesterol levels among adults who were breastfed were 0.18 mmol/L (6.9 mg/dl) lower than among non-breastfed subjects… [T]he observed reduction associated with breastfeeding corresponds to about 3.2% of [the] median.

3. Does breastfeeding reduce the risk of overweight and obesity?

The evidence suggests that breastfeeding may have a small protective effect on the prevalence of obesity. In spite of the evidence of publication bias, a protective effect of breastfeeding was still observed among the larger studies (>1500 participants),.. This effect seems to be more important against obesity than against overweight.

Because the great majority of the published studies were conducted in Western Europe and North America, we are not able to assess whether this association is present in low and middle-income settings.

4. Does breastfeeding lower the risk of type 2 diabetes?

Evidence on a possible programming effect of breastfeeding on glucose metabolism is sparse. Studies assessing the risk of type-2 diabetes reported a protective effect of breastfeeding, with a pooled odds ratio of 0.63 (95% CI: 0.45–0.89) in breastfed compared to non-breastfed subjects. On the other hand, two other studies failed to report an association between HOMA index, a measure of insulin resistance, and breastfeeding duration, and a study on fasting blood glucose levels was also negative. At this stage, it is not possible to draw firm conclusions about the longterm effect of breastfeeding on the risk of type-2 diabetes and related outcomes…

5. Does breastfeeding raise the level of school achievement or intelligence?

This meta-analysis suggests that breastfeeding is associated with increased cognitive development in childhood, in studies that controlled for confounding by socioeconomic status and stimulation at home. The practical implications of a relatively small increase in the performance in developmental tests in childhood may be open to debate. However, evidence from the only three studies on school performance in late adolescence or young adulthood suggests that breastfeeding is also positively associated with educational attainment.

The issue remains of whether the association is related to the properties of breastmilk itself, or whether breastfeeding enhances the bonding between mother and child, and thus contributes to intellectual development. Although in observational studies it is not possible to disentangle these two effects, the positive results from the randomized trial carried out by Lucas et al suggest that the nutritional properties of breastmilk alone seem to have an effect.

In the case of these five longterm outcomes, the existing scientific evidence shows that breastfeeding has either no benefit or a small benefit.

Adriano Canttaneo, an pediatric epidemiologist and enthusiastic supporter of breastfeeding, writing in the Journal of Pediatrics and Child Health in 2008 in The benefits of breastfeeding or the harm of formula feeding? cautions against making sweeping and unsupported claims about breastfeeding:

… We do not need to use weak and shaky arguments to convince mammals to breastfeed. What we need is effective care to let them breastfeed as much and as long as they wish.

Breastfeeding is desirable and beneficial, and we should promote breastfeeding as much as possible. However, breastfeeding advocates should not overstate the benefits of breastfeeding or overstate the risks of formula feeding. Rather, we should do whatever we can to allow women who wish to breastfeed to start and maintain breastfeeding for as long as they would like.


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