This month, Sydney Spiesel explains and ventures an opinion about travel vaccines, computerized medical records, hand-washing, and a study on breast-feeding and nearsightedness. (Click here for the June roundup.)
Travel tips: Which shots do you need?
It's summer—vacation time. (Well, not for me: I went to a medical meeting in Santa Fe in May and, sadly, that's the end of it.) So, which shots to get for which trips? The Centers for Disease Control travel-tips Web site is a valuable resource and recommends immunizations based on destination, but I'd like to add a few comments (and some travel tips related to recent medical news).
Cholera. This month brings reports of a not-yet-available but promising new oral vaccine against this disease, which is so terrible that it was used as a curse in the old country ("may you be taken by a cholera"). This is a major stride forward, since the old vaccine was worthless, caused unpleasant side effects, and has been off the market for some time. If the new vaccine lives up to its promise, it will have some value for travelers and a great deal for poor people who live without sanitation.
Hepatitis A. This vaccine is excellent, providing a high level of protection against a common affliction that targets travelers to tropical paradises. Sure, hepatitis A isn't likely to kill you, but it's a shame for your holiday to be needlessly trashed by an illness that causes you to feel like death and to change color.
Polio. Once almost extinguished by immunization campaigns, this disease is oozing back, especially in central Africa and northern India. If these are your destinations, a booster dose of the current (higher potency) version of polio vaccine is probably a good idea, especially for adults who might have been immunized a long time ago.
Rabies. Last week, a British traveler who was bitten by a dog while vacationing in Goa died of rabies after she returned to England. The disease is uncommon in North America and Europe (though not as much so lately). It's prevalent in places where people are too poor to vaccinate dogs. Only some spelunkers, field biologists, and veterinarians need pretravel rabies shots, but any animal bite in most of the world should be taken seriously and treated immediately with a series of the shots.
Meningitis. The new meningococcus vaccine is a very good idea for travelers to sub-Saharan Africa, where meningococcal disease is endemic.
Computerized Medical Records: The curse and the promise.
There was a time (thankfully, long past) when I was a software developer. This enabled me to implement and use a computerized system for medical records, a system I've been using for more than 25 years. (Though, frankly, I don't trust computers as far as I can spit, so I keep a complete paper record as well.) The payoff has been quite good: I've been able to keep close track of my patients and their problems and to offload time-consuming and boring work, like filling in forms and writing prescriptions. That frees up a substantial amount of time, and I am old-fashioned enough to believe that the most important thing I have to give my patients is my time.
The Curse: But when my colleagues ask my advice about commercial software for medical records, I've mostly been stuck. For the most part, the software out there is horrible—poorly designed, clunky, rigid, and time-consuming to use. The vast number of systems offered for sale makes selection difficult. Also, they're all much too expensive; affordable only by high-earning specialists and large-scale practices. And once you've bought one, the upfront costs of learning to use it and of putting your patients' old records into it are so great you're doomed to be using it forever, no matter how bad it turns out to be.
The Promise: A solution may be on hand. Starting next month, the federal government will offer via Medicare a version of VistA, an electronic health-record system developed for the Department of Veterans Affairs, to any doctor who wants it—essentially for free. I haven't used VistA, but a number of my young medical associates have compared it favorably to some older systems. And because it is open-source (that is, the computer code is freely available), it should be possible to easily tack in the additional features that I think are indispensable. For instance, a feature of my record-keeping system that I particularly like is an automated in-depth review of every child's record before an appointment. This examination identifies deficiencies and abnormalities, some of which are easy to miss in the record as a whole, and suggests corrections. Stay tuned: I'm going to try VistA when it becomes available, and I'll give you a report.
Hand-washing: Do it.
State of the Science: Your mother always told you to wash your hands: Now her advice is supported by medical science. A recent study by Stephen Luby of the Centers for Disease Control and Mubina Agboatwalla of Health Oriented Preventative Education, a Pakistani nonprofit, describes what happened when these scientists distributed soap, along with information promoting hand-washing, to desperately poor squatters in Karachi. The control group in the study was made up of squatters who lived in nearby similar neighborhoods and were visited by study personnel but not given soap or the promotional materials. The soap and the encouragement had a profound effect: Among children younger than 5, washing cut the incidence of pneumonia in half. It also decreased by half the cases of diarrhea in children under the age of 15. Impetigo, a common skin infection that can occasionally lead to kidney or heart disease if untreated, was reduced by one third. Colds also decreased dramatically.
These are significant findings, since in the developing world diarrhea is the most common cause of death in the very young, along with pneumonia, killing about 3.5 million young children annually. The study report included no information on cost, but one can surmise that this must be a phenomenally cost-effective intervention. I don't know how expensive it would be to supply the desperately poor of the world with soap, but I'm pretty sure the annual amount spent on Botox in the United States would go a long way toward covering it.
Plus: An incidental finding of the study was that it made no difference if the soap included an antimicrobial ingredient or not. This finding is welcome for two reasons: Antimicrobials add to the cost of soap, and microbiologists strongly suspect that some of the common ones cause cross-resistance to antibiotics.
Lesson: Be good; wash your hands. And send your Botox money to some agency that distributes soap to poor families. If you do, your wrinkles will make you look better.
Breast-feeding and Nearsightedness: Not to worry.
State of the Science: There is a lot of evidence that myopic parents are more likely to have nearsighted children. Additional studies have made it clear that what eye experts call "near work"—frequent visual attention to objects in very near focus (for example, reading Harry Potter to children)—also plays a role, though a less-significant one. And now, a recent research letter in the Journal of the American Medical Association by Yap-Seng Chong of the National University of Singapore and his collaborators in Singapore, England, and the United States raises the possibility that another factor comes into play in the development of nearsightedness: breast-feeding, or rather the lack thereof. Chong's study of junior-high-school students in Singapore seems to show that children who were breast-fed are at somewhat less risk of developing myopia.
Caveat: Unfortunately (as acknowledged by the authors) the study is fraught with methodological problems. The most serious one is also almost universal: the thirst for a coherent narrative structure. Seemingly, we cannot wrench ourselves away from the belief that because one event follows another, the two must be causally related.
The association between lack of breast milk and nearsightedness in the Singapore study was not even very strong. In addition, it is likely that in Singapore, as in the United States, there are great socioeconomic and educational differences between families who choose to breast-feed and those who do not. But there is no reason to think that these differences are necessarily parallel between the two cultures. Families that breast-feed are often better-educated and have higher incomes than those who do not in the United States, but that same relationship may not hold for Singapore. In fact, the Chong study hints that the opposite may be true, since there is a higher risk for nearsightedness in the children of better-educated mothers in Singapore. There may well be other significant differences between Singaporean breast-feeding and formula-feeding mothers, and who knows which difference might play a role in the development of nearsightedness?
Lesson: The main thing to be learned from this study has nothing to do with breast-feeding and nearsightedness. Rather, it's about how skeptical we should be when we interpret research. It is all too easy to make unwarranted assumptions based on associations that are more apparent than real.