Wednesday, January 16, 2019

The Prevention of 5 Percent of All Cancers in the World is Two Shots Away: The Case for the Anti-Cancer HPV Vaccine

By Lois Ramondetta, MD

Gynecological Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center; member, Texas Medical Association

Editor’s note: January is Cervical Cancer awareness month. The human papillomavirus (HPV) vaccination for preteens and teens can prevent most cervical cancers. Physicians also recommend regular screenings for women.

The Houston Chronicle previously published a version of this article, co-written by Dr. Ramondetta with Hagop Kantarjian, MD. Dr. Kantarjian also is a TMA member.

Scientists have developed a way to prevent 5 percent of all cancers with little more than two shots. It is called the human papillomavirus (HPV) vaccine, and in 2006 the Food and Drug Administration approved it for use.

The following year, Australia was one of the first countries to introduce a national HPV vaccination program. The nation dedicated itself to preventing cervical cancer associated with the virus. It worked. A study published in October 2018 estimated that — as a result of high rates of vaccination and screening — Australia will nearly eliminate cervical cancer by 2028.

It is time for the United States, and especially Texas, to use the Australian experience as a roadmap to potentially prevent and eliminate cervical cancer.

To grasp the scope of the problem, it is important to understand that HPV is a group of approximately 200 viruses, several of which are responsible for more than 43,000 cases of cancer this year. More than 80 million Americans are currently infected with HPV, and 14 million new infections occur each year. About 45 percent of American adults have been exposed to HPV infections, which cause genital warts. While HPV infections often resolve spontaneously or with therapy after six to nine months, some high-risk HPV strains can cause cancers decades later. The number of HPV-related cancers has increased drastically in the past 15 years, from 30,000 in 1999 to 45,000 in 2015.

January is Cervical Cancer Awareness
Month. 
These high-risk strains cause virtually 100 percent of cervical cancers. More alarming is an almost epidemic rise of HPV-related cancers of the oropharynx — the back of the throat, tongue, and tonsils.

Unfortunately, Texas lacks significant educational policies to encourage and promote the HPV vaccination of children to protect them from the risk of developing HPV-associated cancers later in life.

Despite a decade of solid scientific evidence confirming the value and safety of the anti-cancer HPV vaccine, there has been resistance to its broad implementation. This hesitance is driven mostly by three misperceptions: The vaccine may be ineffective; it may promote increased sexual activity; it may have serious side effects.

Of course, none of these is true.

The prevalence of HPV infections in the United States has fallen significantly since the vaccine was first introduced. The percentage of girls infected decreased from 12 percent in 2003-06 to 4 percent in 2009-12. Clearly the vaccination is working.

Furthermore, HPV vaccination and education are not associated with a change in sexual behavior. A study of the school-based state Youth Risk Behavior Surveillance System saw no substantive association between HPV legislation and adolescent sexual activities.

Finally, an extensive review after the U.S. Food and Drug Administration approved the vaccination has not shown any serious risks. Eight years of data have only helped confirm what doctors already knew — preventing HPV prevents cancer.

It is a knowledge that needs to be spread in Texas. Our state is ranked 44th for HPV vaccination rates.

The HPV vaccine is available for people up to age
26, but it could soon be available for men and
women up to age 45. 
But things are changing. Since 2011, as knowledge of the anti-cancer benefit of the vaccine has penetrated communities, vaccination rates, especially among boys, have risen rapidly.

However, even though the HPV vaccine has been available for a decade, only two states (Virginia and Rhode Island) and the District of Columbia have laws requiring vaccination for school entry. Rhode Island requires all seventh-grade students to be vaccinated. Virginia and the District of Columbia require sixth-grade girls to be vaccinated, but allow parents to opt out.

The HPV vaccine is currently available for people up to age 26. However, in October the FDA approved the HPV vaccine for men and women up to 45 years of age. That broader HPV vaccine eligibility becomes official if the Advisory Committee on Immunization Practices (ACIP) approves it next month. (ACIP is a national group of medical and public health experts that develop recommendations on vaccines.)

Other than the hepatitis B vaccine, which may reduce the incidence of liver cancer, the HPV vaccine is the only vaccine that can prevent several types of cancer. This two-shot HPV series is the best way to protect our children for decades from developing a disease associated with 5 percent of all cancers.

Physicians can also do their part to raise further awareness about the HPV vaccine. They should be talking to patients about the vaccine during every screening for HPV cancers and during routine tests like pap smears. These conversations should be a two-way street. Patients diagnosed with an HPV disease should ask their physicians how to get involved in HPV advocacy. Survivors can join support groups to further educate themselves about HPV and receive help.

We can change the culture on HPV awareness and prevention if we each step up and do our part. The time to act is now.

Dr. Ramondetta is a professor in the Department of Gynecologic Oncology and Reproductive Medicine at The University of Texas MD Anderson Cancer Center. Dr. Kantarjian is a nonresident fellow in Health Policy at Rice University’s Baker Institute and is chair of the Leukemia Department at The University of Texas MD Anderson Cancer Center.

Thursday, January 10, 2019

Protect Yourself From Bacterial Meningitis

By Kevin Francioni, MD
Pediatric resident physician at The University at Austin Dell Medical School
Member, Texas Medical Association 

Meningitis is a serious infection of the tissues surrounding your brain and spinal cord. It can result in serious neurologic impairment, or even death, if not treated adequately or promptly. As pediatricians, we often worry about this serious infection in tiny babies who have fever, but meningitis is an illness that can affect people of all ages. Meningitis can be caused by a viral, fungal, or bacterial infection, the latter of which is my focus here.

Bacterial meningitis is very serious, and can kill someone in as little as a few hours. Patients also can suffer brain damage, lose their hearing, or experience learning disabilities.

Symptoms of meningitis include new fever, severe headache, stiff neck, nausea, vomiting, and photophobia (eye pain from bright lights). Physicians can diagnose the condition with a lumbar puncture known as a spinal tap. During this procedure, a doctor inserts a needle between two bones in your lower back to remove and study a sample of cerebrospinal fluid, the fluid that surrounds your brain and spinal cord.

The bacteria that commonly cause meningitis in teens and young adults are known as Neisseria meningitidis and Streptococcus pneumoniae. Meningitis is often spread by close contact with others who have it in their body. Simply coughing on or kissing someone can pass the infection, through saliva, or spit. It often occurs among people living in close quarters like dormitories. That is why Texas law requires new or transferring college students up to age 22 to get a meningococcal vaccination and show proof before moving onto campus. In fact, according to a new study published recently in the Pediatrics medical journal, college students are more than three times as likely to contract meningococcal disease serogroup B (MenB), one type of bacterial meningitis, than other young adults aged 18 to 24.

Several vaccines help prevent meningitis. It's best to ask your
physician which shot is right for you and your child. 
Thankfully, several vaccines help prevent meningitis. They have names such as pneumococcal vaccine (PCV), Haemophilus influenzae (Hib), meningococcal conjugate vaccine (MCV) and the serogroup B meningococcal vaccine (MenB). Doctors recommend specific shots for certain ages of patients, so it’s best to ask your physician which shot is right for you or your child. Some vaccines to prevent meningitis can be given to infants and children, while others are best for college-age and older people. (Again, I suggest you ask your physician which vaccine is best for you.)

You also can help prevent the spread of meningitis by washing your hands often, and avoiding close contact with people known to have meningitis.

You can even take antibiotics if you have been in close contact with someone with specific types of bacterial meningitis (you would need to consult with your physician about this, too).

For more information on meningitis and vaccinations, please see this Texas Medical Association fact sheet (in English and Spanish) or visit the Centers for Disease Control and Prevention website:

Wednesday, December 12, 2018

Polio-Like Illness Returns to Texas in 2018

By Donald Murphey, MD
Pediatric Infectious Diseases, Dell Children’s Medical Center
Member, Texas Medical Association (TMA) Council on Science and Public Health; and consultant, TMA Committee on Child and Adolescent Health

Acute flaccid myelitis (AFM) is a newly recognized neurologic [nervous system] disorder that has appeared in patients in late summer and early fall in 2014, 2016, and 2018. The cause and the treatment are unknown. Many patients do not recover fully. 

If you’ve read the latest health headlines, you might have heard about a rare polio-like illness outbreak happening in the United States this year — and it’s making its presence known here in Texas. Acute flaccid myelitis is a rare neurological illness that leads to sudden paralysis, mainly among children. Children with AFM have sudden-onset profound weakness in their arms and/or legs, often with pain in those areas or the neck, and they often experience fever and signs of viral respiratory or gastrointestinal infection. AFM is similar to but different from polio.

We do not know the long-term outcomes, but many patients experience permanent paralysis from the disease. The cause of AFM is unknown, but it might be due to viral infection. Some physicians believe it is connected to infection with a virus called enterovirus D68. When AFM patients are tested, we often find a virus in the nose or throat, or in the intestines/stool, but not in the spinal fluid or blood. Magnetic resonance imaging of the nervous system shows inflammation in the center of the spinal cord where there are nerve cells that control movements. Testing of affected patients’ spinal fluid shows white cell inflammation but not a specific virus or germ causing the infection.

In addition to patients’ arm and leg weakness, they may also have weakness of their trunk and face. The weakness can happen quickly or increase over several days. They also might develop breathing difficulty. They usually have recent fever with cough, congestion, or vomiting and diarrhea, or have these when the weakness arises.

Photo by CDC.gov.

We have seen AFM cases in the United States primarily in three waves — in 2014, 2016, and 2018 — all around the same time of year, in late summer and fall. Nationwide, the Centers for Disease Control and Prevention confirmed 120 AFM cases in 2014 and 149 in 2016. As of early December, there are 158 confirmed cases nationwide in 2018. AFM was rare prior to 2014. Doctors around the world have seen AFM cases as well.

The initial cases in 2014 were more common in Colorado and California. The same areas saw outbreaks of severe respiratory infection with the enterovirus D68 virus. Most patients with AFM in 2014 suffered poor outcomes; as many as 90 percent experienced permanent paralysis. Scientists are still gathering data on the cases from 2016, but the outcome seems to be better. In 2016 and in 2018, some children have had complete recovery or have had significant improvement in their paralysis.

Texas experienced AFM cases in the same three years — 2014, 2016, and 2018. The Texas Department of State Health Services confirmed three cases in 2014, 19 in 2016, and 21 in 2018 (so far).

Physicians are not required to report AFM cases to the health department. The Texas Medical Association and Texas Pediatric Society encourage physicians and health care providers to report possible AFM cases to their local and state health departments and to send testing to the state lab.

Monday, December 10, 2018

Acne: Preventive Measures, Common Pitfalls, Misconceptions, and Treatment Options

By Michael Dickson, MD
Pediatric resident physician at The University of Texas at Austin Dell Medical School 
Member, Texas Medical Association 

Acne — could anything be worse? It ranges from inconvenient pimples that show up right before you leave to important social events, to a severely disfiguring and scarring condition. Either way, acne is something most of us deal with at some point, or will grapple with in the future. Acne can cause significant social anxiety and can be a real barrier to developing self-confidence.

The good news is that acne is treatable and there are things you can do to clear your skin and minimize the possibility of future breakouts. First you should understand good skin care habits, common acne myths, and various acne treatment options.

A little background is helpful. There are four main causes of acne: hormonal changes, blocked pores, inflammation, and bacteria. During puberty, hormones can cause increased oily secretions from pores. Those oily secretions can block pores leading to whiteheads and blackheads. Whiteheads can “pop” and cause inflammation. Normal bacteria present on the skin can make inflammation worse. Long-lasting inflammation can lead to scarring.

There are two simple ways to prevent acne. First, manage hormones by managing stress. Second, follow good habits to prevent clogging your pores, including keeping your hair clean and off your face, not resting your hand or phone on your face, and not wearing hats.

Even with the best prevention, breakouts can still happen. Here are five common ways you may be sabotaging your success in managing breakouts:
The four main causes of acne are hormonal changes, blocked
pores, inflammation, and bacteria. Acne is treatable. 
  1. Washing your face several times throughout the day or scrubbing your face:  Acne is not caused by dirt or poor hygiene. Rub acne treatments into the face gently.
  2. Popping your pimples: This can cause pus, bacteria, and dead skin cells to be pushed deeper into the skin, which worsens inflammation. Let the acne medication do the work — be patient.  
  3. Changing your acne treatments frequently: Many acne treatments take six to eight weeks to work and three to four months to fully clear acne. After starting treatment, acne often gets worse before it gets better. Choose a treatment and stick with it.
  4. Applying acne medication only to your blemishes: You should apply treatment to all areas that are prone to breakouts.
  5. Using a towel to rub sweat from your skin: This irritates skin and can make acne worse. Gently pat sweat from your face instead.  
Acne is frustrating enough, so here are a few things you do NOT need to worry about:
  1. Acne is NOT caused by poor diet: There is no proven link between acne and foods like pizza, chocolate, ice-cream, or potato chips.
  2. Acne is NOT contagious: Bacteria does not cause acne, but it can make it worse.
  3. Makeup does NOT cause acne: Just be sure to get makeup that won’t clog pores or is listed as non-comedogenic.
  4. Moisturizer does NOT make acne worse: Dry skin, on the other hand, does.  Moisturizers that won’t clog pores are key to managing dry skin caused by some acne treatments. 
There are many different acne treatments available — and we often combine multiple treatment types for complete acne control. Your doctor can help you learn which treatments to try, especially if you are pregnant. Here are some common over-the-counter acne treatments:

Benzoyl Peroxide (2.5 to 10%): 
  • How it works: Kills bacteria that make acne worse and prevents pores from plugging.
  • Side effects: Skin dryness, irritation, and redness. It also bleaches clothes, towels, and bedding.
  • Pro tips: Lotion-based forms have more mild side effects. Apply in the morning.
Salicylic Acid (0.5 to 5%)
  • How it works: Prevents pores from plugging.
  • Side effects: Mild stinging or irritation.
Topical Retinoids: Adapalene
  • How they work: This course of treatment prevents pores from plugging, helps normal skin turnover, and limits inflammation.
  • Side effects: Skin dryness, irritation, and redness — which typically improves after two weeks. Skin darkening; especially in individuals with darker skin. Sun sensitivity.
  • Pro tips: Apply at night and use sunscreen when outside. Use an acne-safe moisturizer to prevent side effects.
Other options are available with a prescription from your doctor, including topical and oral antibiotics, azelaic acid (a type of ointment), oral contraceptive pills, and oral Isotretinoin, a medication that targets severe acne.

With good understanding of what causes acne, proper preventative measures, strict avoidance of common pitfalls, and consistent medication therapy, acne is definitely treatable.

Monday, December 3, 2018

National Influenza Vaccination Week 2018

This article originally appeared on CDC.gov.

It's National Influenza Vaccination Week (NIVW)! Did you know that flu season can begin as early as October, it usually peaks between December and February, and it can last as late as May? As long as flu virsues are spreading, it's not too late to get a flu vaccine to protect yourself and your loved ones through fall, winter and into spring. #GetAFluVax

December 2 – 8, 2018


It’s Not Too Late!


It’s that time of year again — flu season. As family and friends are gathering for the holidays, flu activity is increasing. Get a flu vaccine now if you have not gotten vaccinated yet this season.

There are many reasons to get a flu vaccine. Flu vaccination can reduce your risk of flu illness, doctors’ visits, and missed work and school due to flu. Even if you are vaccinated and still get sick, flu vaccine can reduce the severity of your illness. Flu vaccination also can help protect women during and after pregnancy and protect the baby born to a vaccinated mom for several months after birth. Flu vaccine also has been shown to save children’s lives, prevent serious events associated with chronic lung disease, diabetes and heart disease, and prevent flu-related hospitalization among working age adults and older adults. Getting vaccinated isn’t just about keeping you healthy; it’s also about helping to protect others around you who may be vulnerable to becoming very sick, such as babies, older adults, and pregnant women.

It’s not too late to get a flu vaccine to protect yourself and your loved ones this flu season! 

Friday, November 30, 2018

When the best prescription is no prescription

By Philip Robinson, MD
California Physician, Infection Prevention

This article originally appeared on KevinMD.com.

“Get rest and drink plenty of fluids,” might not sound like adequately aggressive medical advice. If you’ve dragged yourself out of bed to visit an urgent care or your doctor’s office, you will probably feel somewhat cheated by an admonition to head right back to bed and stay there until you feel better.

Most likely, you’ll want a prescription for an antibiotic. You might even demand it.

Nearly half of the antibiotics prescribed in
the U.S. are unnecessary and can lead to a
rise of drug-resistant bacteria.
Don’t. Antibiotics are not the harmless miracle drugs the public and many physicians think they are. Side effects range from a bad rash (amoxicillin) to a ruptured Achilles tendon (Cipro) to a stopped heart (azithromycin, or Z-Pak). And if we keep using them indiscriminately, they might not work when we really need them.

Nearly 50 percent of all antibiotics prescribed in the U.S. are unnecessary and can lead to a rise of drug-resistant bacteria. The most notorious of these “superbugs” are methicillin-resistant Staphylococcus aureus (MRSA), which are resistant to many antibiotics and are associated with 11,000 deaths per year.

Bacteria could evolve into superbugs in our bodies each time we ingest antibiotics. In addition to MRSA, our community now faces drug-resistant forms of tuberculosis, gonorrhea, staph infections and gram-negative bacterial infections, which are not only drug-resistant but can pass along genetic code that allows other bacteria to become drug-resistant as well.

This bacterial evolution hastens us to a post-antibiotic era, a time when a simple bacterial infection can be deadly because antibiotics have stopped being effective.

Antibiotics can also cause infections. In their quest to eradicate “bad” bacteria, antibiotics also indiscriminately destroy the “good” bacteria our bodies need to help us digest food. This can lead to such conditions as Clostridium difficile, or C. diff, which causes severe diarrhea and is associated with more than 29,000 deaths per year.

Across the nation, we are seeing a terrifying rise in cases of C. diff, as physicians, nursing homes and patients continue to think of antibiotics as benign.

Don’t get me wrong, I am a fan of antibiotics. Without them, many simple surgeries and organ transplants would not be possible, bacterial meningitis would be universally fatal, and countless numbers of people would die from wound infections.  But I have seen doctors and patients alike underestimate the power of these prescriptions. The result has been dreadful side effects, the rise of drug-resistant superbugs and preventable deaths and illnesses.

The only way to reverse course is for doctors to limit their prescriptions of antibiotics to the treatment of bacterial infections and for patients to use those antibiotics as directed.

If you have a cold, the flu, bronchitis or some other non-bacterial ailment, don’t demand an antibiotic. An antibiotic won’t help, and in the long run it might cause more harm than good. Instead, might I suggest a less aggressive, but far more effective, approach?

Get rest and drink plenty of fluids.

Philip Robinson is medical director of infection prevention, Hoag Memorial Hospital Presbyterian, Newport Beach, CA.

Tuesday, November 20, 2018

In Throes Of Turkey Salmonella Outbreak, Don’t Invite Illness To Your Table


By JoNel Aleccia
Kaiser Health News

This article originally appeared on Kaiser Health News.

As Americans prepare to cook and consume nearly 50 million turkeys on Thanksgiving Day, an ongoing outbreak of salmonella poisoning linked to the poultry means food safety at home is more critical than ever.

Federal health officials have identified no single source of the outbreak of Salmonella Reading, which has sickened at least 164 people in 35 states during the past year.

As of Nov. 5, the bacterial strain has led to 63 hospitalizations and, in California, one death.

Many who fell ill reported preparing or eating such products as ground turkey, turkey parts and whole birds. Some had pets who ate raw turkey pet food; others worked at turkey processing plants or lived with someone who did.

Late Thursday, Jennie-O Turkey Store Sales LLC of Barron, Wis., recalled more than 91,000 pounds of raw ground turkey products that may be connected to the illnesses.

There is no U.S. requirement that turkeys or other poultry be free of salmonella — including antibiotic-resistant strains like the one tied to the outbreak — so prevention falls largely to consumers.

That means acknowledging that the Thanksgiving turkey you lug home from the grocery store is likely contaminated, said Jennifer Quinlan, an associate professor in the Nutrition Sciences Department at Drexel University.

“They absolutely should assume there’s a pathogen,” she said.

Last year, right after the holiday season, Quinlan and her colleagues surveyed more than 1,300 U.S. consumers about their turkey-handling habits. Most, they found, fail to follow safe practices, despite decades of public health warnings.

Ninety percent of those surveyed washed raw birds in the sink, even though that can spread dangerous bacteria. Fifty-seven percent reported always or sometimes stuffing a turkey before cooking instead of baking dressing separately, and 77 percent said they left a cooked bird in a warm oven or at room temperature.

Such practices can allow the growth not only of salmonella but other bad bugs, such as campylobacter and Clostridium perfringens, she said.

“All of these illnesses could have been prevented. There’s either cross-contamination going on in the home, or there’s not thorough cooking.”

Other experts contend that simply telling consumers to handle food properly is unfair and ineffective. Regulators and industry should be responsible for preventing contamination in the first place.

“They ought to be going after these guys like gangbusters,” said Carl Custer, a food safety microbiology consultant who spent decades at the U.S. Department of Agriculture. “This is a seriously virulent strain.”

This month, Custer renewed calls for pathogenic strains of salmonella to be declared “adulterants” in poultry, which would require the USDA to test products and recall those contaminated with the bacteria.

The USDA classified E. coli O157:H7 as an adulterant in ground beef after the deadly 1993 Jack in the Box hamburger outbreak. After that, the rate of those E. coli infections plummeted. Since then, the agency has named six additional strains as adulterants in certain beef products.

Efforts to ban drug-resistant salmonella from meat and poultry have stalled, however, despite years of demands from consumer advocacy groups and lawmakers.

In February, USDA officials rejected a 2014 petition from the group Center for Science in the Public Interest to declare certain strains of drug-resistant salmonella to be adulterants, saying the group failed to distinguish strongly enough between resistant and non-resistant salmonella.

In 2015, Democratic congresswomen Rosa DeLauro of Connecticut and New York’s Louise Slaughter introduced a bill that would have defined resistant and dangerous salmonella as adulterants and given USDA new power to test and recall tainted meat, poultry and eggs. It was not enacted.

“It’s very hard to get attention to food safety issues in this current political climate,” said Sarah Sorscher, CSPI’s deputy director of regulatory affairs.

Outside observers said there’s little political will for taking on the nearly $5 billion-a-year U.S. turkey industry, as well as regulators.

“I don’t see a lot of traction for making it an adulterant right now,” said Kirk Smith, director of the Minnesota Integrated Food Safety Center of Excellence.

“Salmonella is still common enough that it would be hugely impractical and costly to make it an adulterant,” he added. “It would double the cost of poultry.”

In a sharply worded statement, USDA officials refused to publicly name the producers, suppliers and brands linked to the turkey outbreak, saying it would be “grossly irresponsible and reckless” when no definite source of illness has been identified.

Because the outbreak strain of salmonella has been found at turkey-processing plants, in workers and in a wide range of food products, it will take a broad effort to detect and eradicate the source, said Smith, the Minnesota food safety expert.

“It should be a whole-system approach, starting with controls on the farm, all the way through to educating consumers as best we can,” he said.

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