Rounding up the Herd

As I have discussed in a previous post here, Pertussis, also known as whooping cough, is increasing in prevalence. There are outbreaks this year across the country, building on previous outbreaks last year and in 2010. In order to control these outbreaks, there are a number of strategies being suggested to increase immunization rates—from adding another adolescent dose of the vaccine, to increasing adult vaccination. However, one prominent population that has been a focal point in these outbreaks cannot currently be vaccinated: infants under 6 weeks of age, for whom the vaccine is not approved (pertussis vaccination starts with the routine shots at 2 months of age). How can we protect these infants?

A recent post on’s twitter feed linked to an article about the possible introduction of a newborn pertussis vaccine. This is a wonderful idea and could certainly help to address protection of infants from pertussis. However, either testing either the current DtaP vaccine or developing a newer version for use in this population are time-consuming propositions, both. On the order of years. And that will do nothing for people currently at risk from outbreaks currently in progress. There is another way to protect infants though, one that relies on the concept of herd immunity.

Herd immunity is the idea that by vaccinating a large enough number of individuals in a population–the “herd”–we will effectively halt transmission of the disease because there are not enough potential susceptible hosts. Thus the people who are unable to be vaccinated—infants in this case—will be protected by virtue of being surrounded by immune individuals. In the case of infants, this surround effect is rather evocatively called cocooning, with the idea of blanketing a baby with healthy, vaccinated people. This is accomplished in practice by vaccinating an infant’s mother, father, and caretakers. Previous efforts to accomplish this had relied on vaccinating the mother during pregnancy and encouraging others to be vaccinated during the same time period. But nearly every baby in the US is born in a hospital or similar facility and stays in the nursery for 2–4 days. Could the family be vaccinated then? The answer is a most emphatic yes!

Here in New York State, thanks to brilliant research and lobbying efforts of Shetal Shah, MD, a colleague of mine here at Stony Brook, this practice of cocooning— by encouraging vaccination of caretakers prior to the infant’s discharge home from the hospital—will now be law. Through work published in the journal Pediatrics in 2008, Dr Shah showed that the practice of vaccinating parers and caretakers prior to NICU discharge (Dr. Shah works in the neonatal intensive care unit) was well-tolerated, feasible, and effective. As the rather thorough press release explains, beginning January 2013, all parents and caregivers will be offered and encouraged to accept pertussis vaccination before taking their baby home from the hospital. The hope and aim is this will help to prevent pertussis cases in these infants in the event of an outbreak.

I for one am proud to live in a state so responsive to appropriate medical lobbying efforts, and so proactive in its vaccination practices. The next step is to broadly implement similar cocooning practices across the country and encourage similar laws in state legislatures elsewhere. Let’s get started!

“An Entirely Other Day: Bugged”

Just a quick post tonight. Anybody who has any awareness of or interest in the the Patient Protection and Affordable Care Act (PPACA) or “Obamacare”, which pretty much means anyone who has ever received medical care, hasn’t been living under a rock for the past 4 years, and/or has a pulse, should check out this blog post by Greg Knauss. A particularly choice passage, on why the PPACA was essential for him in allowing him to afford care for his son’s infected bug bite:

A bug bite cannot be the thing that draws the line between a middle-class life and poverty, between opportunity and the stagnant dead-end of could-have-been. Our friends, our neighbors, our children, the future of this country as a cohesive society — as an endeavor where we see each other as more than opponents, as more than competitors — depends on it.

Otherwise, we’re just waiting for the fever, and the rot, and for the bugs to pick the bones clean.

I encourage everyone to read the whole post.

It was also quoted, and greatly elaborated on, by Peter Cohen in a recent post on his personal blog. He had a similar but far worse situation of needing intense medical care for an infection; that care was only able to be provided due to a universal health care system being in place (in his case, that of Massacheusetts — “Romneycare”, on which the PPACA is largely based). My favorite passage:

I find it inconceivable that we’re still having a national discussion about health care as a privilege only for the wealthy or those lucky enough to work for an employer who offers affordable insurance. We need to recognize it as a fundamental human right if we’re to ever evolve as a compassionate society that actually wants to uplift its population to prosperity. We’ve heard a tremendous amount of lip service from the political right in this country about that, but their actions to dismantle the ACA and Medicare are completely counter to effort.

RomneyCare saved my life. And it kept our family out of bankruptcy.

The system worked.

‘Nuff said.

A Pediatrician’s Labor Day: What Really Matters

It can be all too easy for those of us who work in the medical field to forget why it is we do what we do for a living. And when we do remember why, it can feel difficult to understand how we face what we face on a daily basis. But during those moments, acutely, when you are really facing what matters in the medical care of children, it is not we that are impressive for doing the work at all.

I have worked in or studied medicine in some capacity for 13 years–from a volunteer in a pediatric ER in college through to medical school, training, etc. At first none of it phased me because I didn’t really comprehend what I was seeing, how it affected people. I was probably too young–here’s a good reason for medical training to remain longer, but I digress. Then as I moved further along in my training, seeing the sick children–oncology patients with hair falling out, ICU patients on ventilators, the list goes on–became difficult to take. It was hard to talk to parents, to see the children every day. It became even harder when, as a resident, I began having children of my own. I could not dream of facing the parents of a child the age of my son (quite obviously, a moving target as he aged) without tearing up. Even when the child was healthy and it was just the concerns or anxiety of the parents that were troublesome, I was able to relate almost too much and their fears would make me fearful, would undermine my confidence and make me doubt my own medical knowledge.

But at some point during my fellowship training, despite eventually having a second child—a girl—thus making nearly all of a children’s hospital identifiable as “this could be my kid”, something changed. I could talk to the sobbing parents of the bone marrow transplant patient who was dying; I could take care of a 4 year old with bacterial sepsis who had the same lisp as my son. Hell, it was really hard but I could and still can do it. Somehow I got over that hump of functioning, of doing my job in the face of some of the worst suffering and sorrow that mankind can conjure up: that of a parent facing the idea of harm to, or even death of, their child.

And we all do this. I make no claims to being somehow unique or superhuman in this regard. Every pediatrician, every family doctor, every pediatric nurse, every child life specialist—anyone who cares for sick children in any capacity—does this. We make ourselves able to go to work every day through some combination of denial (this can never happen to my kid), defense mechanisms (it can be very easy to put up an emotional wall if you practice enough), and even just sensory acclimation (who knew you could tune out screams and cries). The human mind is an amazing thing

And yet, for us, it isn’t. For we go home at the end of the day. Our patients and their families do not.

Right now, my wife is caring for a little girl only a bit older than our daughter who will probably die of a brain tumor. I recently took care of an infant who died from bacterial meningitis, who went from awake with a fever to dead in hours. These are obviously extreme examples, but they are real. The lives of their parents will be forever irrevocably altered. Some families of patients like this are broken and never fixed—they cannot overcome the death of a child; others are changed, bent by the force of such an event and must slowly rebound and reshape into a new normal, whatever that may be. And for the family, the example of the meningitis patient may even be somehow easier to cope with, as sick as I realize that sounds. But that death was quick, with nothing to discuss. For the parents of the patient slowly dying of a brain tumor there are decisions to be made: more chemo? more surgery? Do-Not-Resuscitate? “Full court press” or let her go quietly and peacefully? These are questions about another person nobody should have to answer, let alone about their own children.

As a parent, when I start to think of this, start to imagine what I would do, how I would act, I can’t continue. It’s too much; I know too much. When my wife and I have tried to imagine whether we would allow a DNR or push for more treatment in our own children, it is a thought experiment that even in that setting is too painful to continue. We retreat from it, shuddering. And yet the parents of our patients like this cannot and for the most part do not do that. They come to visit, to sit with their child, to talk to the staff. They are there, in the case of some families, every hour of every day of every week until their child leaves the hospital–either by car or by hearse. There is no break from being a parent or a loved one.

Every day, I go to work in the morning, work my day, and go home in the evening. Most of the time the day feels uneventful—if I take care of a sick child, as I said, it doesn’t faze me as much anymore. And even if it’s a horrible day and a patient is truly very sick or even dies, and I feel that pain and that weight on my trip home, that hurt and burden fairly rapidly diminishes. I kiss my wife, and delight in my own children, and the memories of someone else’s pain fade away to be replaced by my own thoughts of happiness and even relief, and then often a bit of guilt at that relief. And the same story can be told by many, many, many other pediatric practitioners. That story is not impressive. We are the lucky ones. Even those of us who have no family to come home to, we still leave our patients at the hospital.

So on this Labor Day, when we are supposed to think on the achievements of ourselves as workers, and then also when many take advantage of the day off to spend time with family and loved ones, think instead about the ones we pediatricians work for. For many, their time, today on this three-day-weekend, is spent not around a barbecue or picnic table but in the hospital with their son, or their daughter, watching them anxiously as they either get better or do not. They are the ones truly laboring, carrying this horrible load, while we flit in and out and around.

To the parents of sick children everywhere: I cannot possibly pretend to feel your pain, but I thank you for bearing it so graciously and allowing those of us who care for your children to witness the strength of humanity that you show. If there were some way we could fully carry your load for you, trust that we would. In lieu of that: Thank You.

Happy Labor Day; let’s try and make it count.

On Cows...

Today’s topic is vaccines and vaccination. And you thought I’d be writing about farm animals

From the Latin for “cow,” vaccination owes its name to the first virus used in a vaccine: Cowpox or Vaccinia virus. Edward Jenner first performed vaccination in 1796 when he successfully inoculated a young boy, James Phipps, with cowpox and thus protected him against smallpox. The term now applies much more broadly to the inoculation of a person with some or all of any infectious organism in order to induce immunity. It is one of the most incredible discoveries of modern medicine and widespread vaccination has transformed our world:

  • Infant mortality has greatly decreased, at least due to infectious causes, despite claims to the contrary.
  • Previously widespread childhood morbidity and death from infections like meningitis and pneumonia is decreasing.
  • Certain previously widespread cancers, like the subset of liver cancer caused by Hepatitis B, can now be prevented by vaccination against the causative agent.

However, vaccines and vaccine-preventable diseases have been in the news recently not because of our triumph over them, but for other reasons:

  • Measles, reported eliminated from the United States in 2000, has now been seeing a rise in cases. In 2011 there were 222 cases, 40% of which were imported from other countries, but many of the others were in under-vaccinated children.
    • One outbreak in Minnesota in particular affected 6 children whose parents had willfully withheld the MMR (measles-mumps-rubella) vaccine due to concerns over autism.
  • Pertussis cases have been rising overall for the past 2 decades, and outbreaks are becoming more frequent. With a 27,000 case outbreak in 2010, and despite a brief decline in 2011, Pertussis is on track to beat it’s recent peak–22,000 cases so far in 2012. Perhaps most horrible about this year’s outbreak is the 13 deaths–these all in infants too young to receive the vaccine.
    • It has been repeatedly reported that much of 2010’s outbreak was due to intentional undervaccination by parents; 2012’s outbreak in Washington State is similar.
    • See the chart below, courtesy of the CDC: pertussis chart.

And finally, on a more personal note, I will present the story of a young girl I cared for whose pediatrician had intentionally withheld the varicella vaccine–that’s the one against Chicken Pox. This shot is usually given at 12 months of age, but he withheld it until a planned visit at 15 months of age due to “too many shots” being given at the 12-month visit. The patient never needed her varicella vaccine.
At age 13 months she was admitted to the Pediatric Intensive Care Unit at my hospital with severe chicken pox and, more significantly, severe sepsis and neck muscle and soft tissue infection with Group A Strep. This bacteria is known to complicate chicken pox in this way, and the rate of this complication is in fact a reason for the vaccine in the first place. She survived, but only after a weeks-long ICU and hospital stay, intubated, on a ventilator, near death for the first few days of her course.

You tell me which is worse–one extra needle in the leg or the course of treatment above?

The reasons why people under vaccinate their children have been described to death by many others far smarter than I. Two excellent books on the subject are Autism's False Prophets and Deadly Choices. Dr. Paul Offit, the author of these books, also writes an excellent guide to parents called Vaccines and Your Child. I highly recommend all of these.

Similarly, the fact that none of the side effects and poor outcomes reported by those in the anti-vaccine movement have been held up by scientific evidence is now abundantly clear. Numerous strong epidemiological studies have shown no link with autism and Andrew Wakefield himself, the inventor of this myth, has been discredited and shown to be an outright fraud. Thimerosal is out of vaccines. Whole-cell pertussis vaccine is off the market. Every concern the anti-vaccine movement has raised that is even possibly scientifically valid (and many that aren’t) has been addressed through rigorous study or alteration of vaccines.

So you have science on the one hand and fixed false beliefs on the other. This duality has happened before with other issues in society. And I understand the hesitation of other facets of society, such as the media, to try to change individuals’ beliefs. We live in a country where freedom of thought and action is paramount. Except, however, when that action does demonstrable harm to others. Ignoring even for now the issue of their own children or patients, which I’ll address below, parents and doctors who withhold vaccines are harming other people’s children as well; children too young to be vaccinated regardless of parental wish, like those in the recent pertussis outbreaks. We’re beyond the choice of individuals like Jenny McCarthy and now the action of a minority has the potential, and is starting to hurt and even kill many, many others.

Ultimately, I should not have to write this.

The answer is simple: just give the damned shots.

Vaccines save lives. That fact is about as crystal clear as anything in science or medicine today. Many children died from these diseases before we could protect against them. Now that people don’t vaccinate again, children are dying again. These deaths are senseless, needless deaths that are entirely preventable. I understand vaccines represent a Big Black Box to most parents–they are an unknown. The immune system is an unknown. ‘Who can tell me that my child will not suffer after receiving this vaccine?’ Well, your pediatrician can. Medicine can. Science can. And it has done so repeatedly over the past 10–20 years since this issue came to the fore.

Vaccines are safe and have clear benefit. Withholding a vaccine from a child, either as a pediatrician or a parent, is potentially equivalent to withholding surgery from someone with appendicitis or withholding antibiotics from someone with strep throat. Sure, the kid without the vaccine may not get sick. The kid with strep throat also may not get rheumatic fever. But are you willing to take that chance with your child? With your patients? And if we aren’t for the other examples I gave, why are so many willing to gamble with vaccines?

Nowhere else in medicine is something with such clear benefit allowed to be a subject of debate. In fact, in many states, parents who try to take their hospitalized children out of the hospital against medical advice or withhold life-saving treatment can be prevented from doing so if there is clear benefit to the child. But we can’t force vaccines on our patients. The reason for this has never been clear to me. Hopefully, after reading this and clicking the links and learning more about what is now happening because of undervaccination, the reason will become unclear to you, the reader, as well.

Vaccinating saves lives. Undervaccinating hurts and even kills. It’s not too late for us make the choice ourselves. Or someone, someday, will make it for us.

Giving this Blogging Thing a Try

I had never really seen the point of blogging[1].

So why am I here, you ask?
I think it just comes down to it being the right time. Which is not to say it is the first time…

The internet is littered with the corpses of the blogs-of-yesteryear and I have certainly helped contribute to that waste, briefly writing some posts on Livejournal that are now long since deleted. My wife and I kept a blog for our son–a sort of ironic “look I’m a baby on the internet” thing. In the end we didn’t have the time for that. And while I’m on Twitter, as you can see I don’t post much, or haven’t until now. And so, while you wouldn’t know it from looking on the internet, it might surprise you to know that I enjoy writing!

While in medical school I took a course on Narrative Medicine and very much enjoyed it. We wrote short stories and read some fantastic illness narratives [2]. And I had planned on continuing writing through medical school, residency, and beyond. But then I got busy. And while I keep looking back longingly over my shoulder at that plan, I never went back to it. I’ve always made excuses and said I didn’t have the time.

Well, I’m making the time now. This is it. For real. At least once a week to start and hopefully more frequently, I will write a post of varying length on some ID (Infectious Diseases), and probably pediatric ID topic. And I may, if you’ll indulge me, from time to time exercise the side of me that enjoys doing more “literary” writing. There are many topics that touch on both the art and science of medicine, and those that are more “artful” often lend themselves to a more stylized approach. We’ll see if this works.

So after two posts on, essentially nothing, stay tuned. I need to find the right medical topic to really begin this blog with. And I think I have an idea that may almost write itself. As always, comment below or contact me on Twitter!

  1. Until now obviously…please don’t stop reading yet!  ↩

  2. Please go right now and buy The Cure for Grief by Nellie Hermann. She was one of the teachers in that course and is a wonderful writer. This book is heartbreaking and poignant and just fantastic.  ↩

Allow Myself to Introduce...Myself...

Call me old-fashioned, but I thought an introduction would be in order.

My name is Saul Hymes. I am currently an Assistant Professor of Pediatrics in the Division of Pediatric Infectious Disease at Stony Brook Long Island Children’s Hospital. I grew up in New York City, where I continue to live with my wife and two children. My professional training has taken me from the University of Chicago for college, to Columbia University’s College of Physicians and Surgeons for medical school, to Mount Sinai for pediatric residency, to NewYork-Presbyterian/Columbia for pediatric ID fellowship, and now to Stony Brook. So here I am.

My purpose in writing this blog is to have a place to discuss topical issues in medicine, especially those relating to pediatrics and infectious diseases. This includes everything from vaccines, to MRSA, to C diff, to Lyme disease (but not chronic Lyme disease), to Influenza, and everything in between. My hope is that, through comments here and social media like Twitter, this blog will become a focal point for discussion and education around these subjects and beyond.

The views expressed here and in all following blog posts are my own and do not represent the views of Stony Brook University, my employer, nor more broadly of the State of New York. What’s more, it is possible that the views I express here may be seen by some as controversial. Some may even disagree with them. Some may think I am a hateful, spiteful, evil, very bad man, and never want to bring their children to see me. All of that is fine; just please be polite, be respectful, and be adult in leaving comments. And I will do the same.

I hope you enjoy the blog!