Pertussis: The Preventable Epidemic

Pertussis, also known as whooping cough is the only vaccine-preventable disease that is on the rise. After 1940 when Pertussis vaccine became available till 1980, there was a steady decline of this deadly childhood disease in the United States. If you thought pertussis was history, think again. Since 1980 the number of cases in the U.S. has risen to more than 3 million a year. More cases are being reported among adults and adolescents who experience a milder but just as stubborn form of the disease as infants. Since pertussis initially resembles other common colds the disease is probably under reported.

Babies under the age of one year get the infection from those who are closest to them. Family members, friends, caregivers are usually the source. We have only recognized in recent years, the role of adults around the infant to be a potentially dangerous reservoir of the disease. Adults are susceptible to pertussis, because the vaccine you received as a child wanes over five to ten years. If one member of a household has it, there's a 90% to 100% chance that other susceptible household members will catch it.

The vaccine is administered at 2, 4 and 6 months of age. A fourth dose is administered between 12 and 18 months, and a fifth after age 4. Teens need another booster shot between 11 and 18 years of age. All adults should have a single adult booster of Tdap (tetanus, diphtheria, and acellular pertussis) vaccine. Even when your baby is vaccinated, he or she may not be fully protected until they have received at least 3 doses of the infant pertussis vaccine. In order to create a “cocoon of safety” around your infant, those in close contact with the baby should receive a single dose of Tdap.  

The infection is spread easily through mucus droplets broadcast by profound coughing and sneezing. It can take 3 weeks or more to develop symptoms after exposure to the infection. You can give it to others until you've been treated with antibiotics for five days, or until you've been coughing for 21 days. The swelling and inflammation to airways is actually caused by toxins secreted by the bacteria. After 21 days of the infection the bacteria will die off but have already released their damaging toxins. Early recognition and treatment is important to minimizing the effects and preventing spread of the acute infection to others. Pertussis (whooping cough) causes spells of coughing that make it hard for a child to eat, drink, or breathe. The cough is often followed by a "whooping" sound as the person gasps for air, which is how the condition got its name. Some historians referred to the disease as the “100 day cough”. Serious side effects from the coughing fits are common in children. The choking and gasping can be fatal in children under one year of age. The disease is most serious in infants, especially those too young to get the vaccine or not fully protected. Babies with whooping cough are often hospitalized. With older kids and adults, the disease is milder and can cause several weeks of exhausting coughs. Although rarely fatal in adults and older children, time loss from school and work is substantial.

Early detection is important in limiting the spread of the disease. Appropriate antibiotic therapy for the person suffering with the condition and their close contacts needs to be started as soon as possible. Late recognition and treatment fails to change the course of the disease. Many weeks of coughing in the affected individual will continue even if the spread is limited. Testing specimens from a nasal swab can be helpful in identifying pertussis only in the first couple weeks. Many patients do not seek medical evaluation till later. The results of testing also causes further delay. Precise recognition can be difficult. Treatment is often started in the context of clinical symptoms and known outbreak in the community.

This punctuates the importance of prevention and a proactive approach to immunizations of both children and adults in our community. The best way to help protect babies against pertussis is to get infant vaccinations in a timely fashion. Adolescents and adults should have a single dose of Tdap booster. 

Food Borne Illness

Holidays, family and food go together. Many parties at home or work, pot-luck or gourmet dining, lots of folks will be dining together sharing fun and food. It's a great time to be mindful about food borne illnesses. With many hands in the kitchen and serving dishes you want to be sure you don't spread anything other than the seasonal joy. A staggering number of people are affected by food-borne illnesses most of which are preventable with a small but consistent effort in handling, storing and preparing your food. Thousands are hospitalized with serious complications and tragic outcomes. The most common presentation is severe intestinal distress. Anyone with a chronic illness or compromised immune system is at risk as well as young children, pregnant women and the elderly. However even perfectly normal healthy adults can be adversely affected by severe or life threatening food poisoning. Survivors can recover completely or be left with disabling kidney, neurologic or cardiac problems.

Two of the culprit bacteria E.Coli and Campylobacter are found in some familiar and some not so obvious food products. Consumption of raw eggs has gotten a lot of attention in recent years. Recipes that call for raw should be avoided or use a pasteurized egg substitute. Eggs are available that have been through a pasteurization process in the shell. They can be safe to use and are typically identified by a small red "P" on the packaging as well as their higher price.

Raw meats are also well known to be carriers of bacteria that can cause illness. Whole raw chickens were studied and found to have alarming rates of these common bacteria that cause severe gastroenteritis. Researchers found that two thirds of several hundred chickens purchased randomly at 100 different stores across 22 states to be contaminated with salmonella or campylobacter. Food and agriculture scientists are working to improve the safety and hygiene in commercial food processing. However it emphasizes the importance of thoughtful handling, storage and preparation of your own food. Bagging raw meats carefully and separately at the point of purchase will avoid contamination of other foods and packages in your grocery bag. Prompt refrigeration of raw meats when you get home is imperative. During preparation a separate cutting board should be used for meats only. Cleaning the board, countertop and utensils is critical in preventing cross-contamination. Use an inexpensive insta-check thermometer to determine adequate internal temperatures for doneness when you cook.

All raw produce should be washed before consumption even if it is identified as being washed and ready to eat. Remember that "organic" may mean healthy but does not mean "clean". Different fruit and vegetables have been the source of outbreaks. You cannot recognize the good or bad ones by inspection alone. Obvious over-ripe or damaged fruits and vegetables in general should be avoided. Since 1996 in the U.S. there have been more than thirty outbreaks of diseases associated with contaminated bean sprouts alone. Any product that is consumed raw or lightly cooked is of potential danger so greater care must be exercised. Young children and pregnant women are most vulnerable to some of the associated infections.
Two other products that have been a common source of problems are raw cookie dough and pet foods. How many people succumb to the seduction of raw cookie dough or eat it intentionally. Researchers determined that the culprit in the cookie dough was actually flour. Further investigations demonstrated 13% of whole wheat flours and some flour based mixes to be contaminated with Salmonella or E.Coli. Generally flour is a raw product that is not subjected to heat treatment to kill bacteria. So if consumed raw there are some risks until it is used and cooked properly.

Dry pet foods and pet treats are around the kitchen and fed to our pets in the same area. The task is often delegated to young people or performed casually without concern. They have been shown to contain some of the same bacteria capable of causing serious problems. Canned pet foods are usually heated and vacuum sealed. Nonetheless they carry similar risks when the unused portions are carried over for the next meal, the next day or even worse, lost in the back of the refrigerator. Pet food manufacturers have recalled products almost three dozen times in the last two years over concerns of salmonella contamination which can adversely affect our pets and us.

What can we do? The four basic rules are clean, separate, cook and chill. Don't forget to wash your hands. The hands are often the contaminators as much as anything else. For more information, visit the government Web site foodsafety.gov. With a small amount of consistent effort you can enjoy a healthy and happy holiday!

Drug Poisoning in Children on the Rise

A recent study published in the Journal of Pediatrics blames greater availability of prescription medications in the household for a rise of accidental drug poisonings in children. The large majority of these accidents which lead to serious poisonings, hospitalizations and even death are from young children finding and ingesting drugs by themselves. Failure to poison-proof a household may play a role. The larger problem is simply the increased use and availability of prescription medications including pain medications, narcotics, sedatives for sleep, muscle relaxants for injury and cardiovascular prescriptions. Dosing mistakes for pediatric patients account for only a very small portion of the problem. Past emphasis by FDA and other professionals has minimized therapeutic mistakes and does not account for the rise of serious drug poisoning in children. The offending medications are often not even drugs that are commonly used for children.

The most recent surveys show that 55% of adults have taken a prescription medication within the last week and 11% have taken five or more prescription drugs within the preceding week. The use of over-the-counter medications such as common anti-inflammatory products and acetaminophen has increased and created more prevalence in the home. However the largest increase in poisonings remains from prescription medications. Therefore there are more adult medications around that are toxic to toddlers and young children. Medications of seniors or grandparents were estimated to be involved in these accidents only 10 to 20% of the time. These products are often stored in containers or pill reminders that are not child resistant. The rise of more serious admissions for accidental poisonings and the types of drugs ingested, point to the greater availability of medications in the child’s environment, without adequate precautions for protected access.  

Some experts believe there are limitations to education about prevention and poison-proofing the home for toddlers and young children. The consensus among experts in behavior is that the best efforts in childproofing will result in prevention 90% of the time. Even that would be improvement over the status quo. The typical pattern for accidental ingestion is during the period of time that the medications are in use by an adult. They are probably left out for convenience without recognizing the hazard they present to a curious young child. Medication in locked cabinets is generally considered inconvenient which limits the accessibility especially when needed two or three times a day. The recent information sheds light on the prevalence of prescription medications in a household and the serious risks of self ingestion by children. Some experts have suggested new types of packaging that would restrict the access to medication by limiting the amount. This means flow restrictors for liquid medications and containers that would dispense only one tablet at a time. Such changes would have to be applied to both adult and pediatric products to have any beneficial effect.

Renewed education for all consumers about where the risks are that may be overlooked is an important first step. More thoughtful storage and access to prescription medications is necessary to restrict access to young children. In general the situation gives one reason to pause and consider society’s overall increased use of powerful medications such as opiates and sedatives which have clearly been on the rise. In turn, it has indirectly increased the risks to our children. Preventive measures need to take steps to decrease the immediate risks while evaluating the larger picture of a society that emphasizes appropriate use of therapeutic prescription drugs.

Food Storage Tips

Seventy to eighty million people a year in the United States get food poisoning resulting in over 100,000 hospitalizations and numerous deaths. Only 20% are attributed to restaurants and food workers. Many cases are somewhat self-inflicted by poor handling and storage of food in the home. Whether it is summer picnics, cookouts or holiday dinner season, proper food handling and storage is critical to keeping your family safe and enjoying your celebrations with food.

Handling your food properly as soon as purchased means prompt and proper storage until it is ready for consumption. Raw meat products are a common source where it is important to avoid cross contamination with other products. Separate clean packaging in plastic until it can be promptly refrigerated or frozen is important in avoiding the spread and proliferation of harmful bacteria. Effective refrigerator temperature is 40 degrees Fahrenheit and freezers at 0 degrees to ensure safe storage. Carefully store meats in clean leak-proof bag, double wrapped tightly with suitable freezer wrap or plastic. Storing on the bottom shelf of the refrigerator will avoid possible dripping on other foods. Fresh meats or fish should be consumed within 1-3 days. Five days can still be satisfactory for some whole products such as a roast or chops. On average, frozen meat products should be consumed within six months, sooner for products like ground beef. Some whole roasts can be safely frozen for up to 10-12 months. Even if safe, this pushes the limits of food product integrity. Monitor the temperatures in your refrigerator and freezer to ensure no temperature fluctuations are occurring due to mechanical malfunctions or weather conditions.

Check use-by or sell-by dates on food packages. Remember, these dates do not apply once the package is open even if restored properly. Best-if-used-by dates provide the most reliable information. They take into account normal handling and use of the product. Any package new or leftover can get lost in the refrigerator. You cannot safely judge a food product by the appearance, smell or taste. If in doubt, please throw it out! It is not worth the risk of consuming tainted food. Condiments often remain open in the refrigerator for long periods and are easily forgotten. Storage of condiments on the door is a suitable location in the refrigerator by design. Even the few acidic condiments that may be safe for longer will lose integrity of quality and taste; they still should be replaced after two months. Fresh eggs should always be stored in a protective carton in a more consistently cool area. Do not store on the door where they are subject to temperature fluctuations and breakage. Fresh produce should be stored in perforated bags that allow air circulation and evaporation of moisture. Do not wash them before storage. The moisture will speed decay and decrease shelf life dramatically. Except for selected items like a hard aged salami or cheese that contain natural mold that can be trimmed or even safely consumed, moldy or questionably appearing products should be discarded.

Cleaning the refrigerator/freezer more regularly is important to avoid excess build up of bacteria. Clean spills as soon as they occur with a weak cleaning solution that will sanitize. Bananas, potatoes and onions should be stored in a cool dry place, not refrigerated. Store leftovers of any kind, in a clean airtight container. Food you prepare should be refrigerated within 2 hours after cooking to avoid spoilage and development of excess bacteria.


Enjoy cooking and family celebrations but stay safe. Remember when in doubt throw it out!

How to Tame Stress in the Workplace

For years incivility in the workplace has grown to worrisome proportions. The large majority of workers have fallen victim to rudeness and increased stress on the job. The impact on the business and individuals is measurable with potentially devastating economic and personal loss. It is widely accepted that it is linked to broader changes in our culture. The source of the rudeness was more commonly coworkers rather than clients. There are ways to encourage trust and respect in professional relationships at every level.

The definition of incivility is rude behavior lacking respect or politeness. We have long understood that cooperation is necessary in any relationship whether personal, professional, or family. All these relationships are built on trust and respect. Civility is simply how people work and live together cooperatively. Some would say that it has been key to the strength of our culture cutting across social class, economics and other forms of bias. Research shows that incivility occurs very frequently in the workplace. Low level negative behavior can be childish requests or accusations about lack of knowledge. More intense actions such as being left out of a key meeting, having your credibility undermined in front of others or extra work assigned because of inaction by others, even yelling or shouting are not uncommon. Unfortunately these behaviors are much more common than any violence in the workplace, yet can be very devastating.

How does this affect workers? The stress created in the workplace profoundly affects the overall productivity of any business and the health of individual workers. Increasing demands of the economy and technology have created increased productivity with less people. However the stress on the individual worker has increased. Most companies have overlooked the value and importance of professional civility. Much of the negative behavior occurs without organizational awareness. Some companies may even feel they don't have time "to be nice". The reality is they cannot afford to ignore effective communication cultivating professional relationships among their staff. The effects of stress on personal health have been widely accepted for over 50 years. The more stress a person experiences the more likely they are to get sick. The vulnerability to illness can last for a couple years after the stress has past. The unhealthy effects pertain to infectious diseases, chronic illness including mental and emotional side effects.

A model of workers who are valued for their effort and information yields greater productivity. When there is proper training in the specifics of the job, effective respectful communication, and encouraging value of all team members, the workplace is more comfortable and accomplishes more. Although people need to be compensated fairly the most common reason people leave a job is because of lack of respect and inappropriate treatment. With a better working atmosphere there is less turnover of staff and greater loyalty to the organization and its mission. Cultivating a professional atmosphere means trust that your coworkers are doing their best. Look for the strengths in each other and compliment those traits. Have and expect a clear process for communication and feedback available to everyone that is done in a manner with respect for all team members. No one person can accomplish the mission without the contributions of all the team members. Recognize someone for their help and support. Appreciation and validating the individual remains a very strong motivator at home or work. With a little help from our friends, we can lead healthy, happy, more productive lives.

Paid Sick Leave

Four in every ten workers have no paid sick leave. This single phenomenon has a major impact on public health. The Center for Disease Control (CDC) has identified paid sick leave as one of the three most important ways to reduce the spread of illness in the community along with hand washing and proper food handling. Paid time off from work allows an individual to seek medical attention, recover from injury or illness faster, and tend to a sick child or adult family member without threatening family economic security.

Paid sick leave promotes better public health by eliminating the spread of illness when sick workers are on the job. They are clearly less productive, make more mistakes and are incapable of sustaining high quality services. Research shows that illness is frequently spread by contact in the workplace from worker to worker throughout all industries. This is particularly poignant in service industries in particular food services where both workers and customers are at risk. One in six Americans get food related illnesses resulting in 125,000 hospitalizations and 3,000 deaths each year. At least 20% of these cases are traced back to a sick food worker.

Most people who do not have paid sick leave are in lower paid or part-time jobs where no benefits are provided. The short-term economic impact of time-loss from the job makes people come to work when they are sick. They cannot afford to take care of a sick child or get them to a health care provider. Children are more likely go to school sick creating additional negative health impacts in the community. There is an economic and social impact on family income, child's education and school performance. The CDC recommends keeping children home for 24 hours after a fever subsides in order to limit the spread of disease and allow adequate time for recovery. Research confirms that sick children improve faster with a parent present. Adults recover faster when they are able to get access to health care and adequate rest. Return to work in less time and lives that are more productive are the dividends.

Paid sick leave changes the dynamic in important ways. It promotes public health decreasing the spread of illness keeping workers and businesses healthy. The return on investment by any metric is a positive economic and social benefit that far outweighs the alternative. Three municipalities have passed mandatory sick leave standards including San Francisco, Milwaukee, and District of Columbia. After several years experience with minimum sick leave standards in place, two thirds of employers support them and tens of thousands of workers have benefited. Job growth has been enhanced in these same markets by having these benefit standards in place. National data shows workers who do have a sick leave benefit accrue on average 9 days a year, but only use 2 to 3 days a year. Fear that abuse of a sick leave benefit is simply unfounded. Companies that provide paid sick leave report higher morale, greater productivity and fewer employees who actually come to work sick.

The lack of paid sick leave is a serious public health problem with many economic and social implications. There are many existing models for sick leave and its associated benefits. Policies that promote a better balance between work and personal health result in better employee morale, less turnover and improved public health.

Update: Head Injuries Revisited

Head injuries in athletes resulting in concussions occur more frequently than previously thought.  We are learning more about the problem and the important consequences. Each year more than 300,000 athletes in the U.S. suffer some form of traumatic brain injury (TBI).  High school athletes comprise 60,000 of these injuries. The consequences vary a great deal but can be physical, emotional and intellectual.

TBI can result in short term symptoms as well as problems that are more serious which may not surface until several years later. What kind of problems develop depend on what portion of the brain is affected, the severity of the blow, the number of repeated blows to the head, preexisting conditions of the individual and personality traits of the injured person. The more blows to the head that occur, even small ones, increase the risk of for mental deficits. Significant head trauma to a football player occurs hundreds of times a week during practice and game experience. Exploring options for protective equipment in contact sports and teaching fundamental techniques in sports that can reduce head trauma are paramount to reducing the number of injuries and the serious consequences.

A 2000 study surveyed 1,090 former N.F.L. players and found more than 60 percent had suffered at least one concussion in their careers and 26 percent had three or more. Those who had concussions reported more problems with memory, concentration, speech impediments, headaches and other neurological problems than those who had not, the survey found. Considering these professional players spent many years coming up through the ranks as amateurs, the frequency of head trauma is likely under-reported. Other common problems are being discovered as we examine this challenge more closely. Depression, insomnia, attention deficit, personality changes occur more frequently among those who had even a single episode of head trauma. Long-term problems may take eight years or more to develop and become evident.

Immediate symptoms that require removal from sports activities include amnesia, poor balance, headaches, dizziness, or other neurologic deficits on exam regardless of how quickly they subside on the sidelines. It is widely accepted that symptoms of a concussion can reappear hours or days after the injury, indicating that the player had not healed from the initial blow. This requires strict guidelines that conservatively allow adequate time for healing to occur. This is challenging and unclear how much time is enough. A health care provider should be involved in examining and investigating these head injuries to insure the best outcome. Even one episode of head trauma makes the athlete at risk for serious consequences and more vulnerable for the next episode, which in many contact sports is inevitable.

Both professional and college sports authorities are changing their recommendations regarding contact sports. Reducing the numerous head blows by enforcing more practices where there is no contact. Research has shown the number of head blows during a college football season totals in the thousands to an individual player.  Many of these have forces comparable to driving a car into a concrete wall at 40 miles per hour. Teaching better techniques to reduce the head leading contact and providing better equipment can reduce the negative effects. Football helmet manufacturing and testing are not closely regulated. New helmet technology and better monitoring of equipment after repeated impact can reduce the consequences of head impact.

Repeated head trauma resulting in serious consequences of traumatic brain injury should be no surprise. We can do more to preserve and protect athletes of all ages. A concussion is a complicated problem that needs thorough initial evaluation. Seek medical attention for head injures even if they seem mild and no loss of consciousness. Severity of symptoms and initial imaging studies can detect serious problems early and be the reassuring basis for ongoing treatment.