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Vaccination for Adults

When you are a child, quite often you don’t have a choice. You have to get immunized against various disabling and life threatening illnesses. When you become an adult, you are too busy making a living and raising a family. You don’t think about immunization unless somebody reminds you or if you have to travel outside the country.

A website on immunization says, “Getting immunized is a lifelong, life-protecting job. You’re never too old to get immunized.”

There is a long list of adult immunization vaccines. Here is the list – influenza, Pneumococcal, tetanus, diphtheria, pertussis (Td, Tdap), hepatitis B (HepB), hepatitis A (HepA), human papillomavirus (HPV), measles, mumps, rubella (MMR), varicella (Chickenpox), meningococcal and zoster (shingles). For more information you should talk to somebody in the health unit or visit www.vaccineinformation.org

If you are planning to travel outside Canada, then your need for vaccination will depend on your destination and environmental conditions prevalent in that part of the world. The standard of hygiene, the quality of food and water will determine what kind of illness is prevalent in that country. At home or in foreign countries careful selection and handling of food and water will prevent many illnesses.

You should consult your local health unit three months before your date of travel to get all the information about your vaccination needs. This will give you enough time to complete the immunization schedule. A listing of travel clinics across Canada can be found at the Public Health Agency of Canada’s Travel Medicine Program at www.travelhealth.gc.ca.

It is estimated that two million Canadians will travel this year to developing countries. Many of these Canadians will be returning to their land of origin to meet friends and families. Many Canadians go overseas as volunteers to the world’s poorest people to help build houses or work in their hospitals or orphanages.

Studies have shown that 75 per cent of people who go abroad develop some kind of travel-related illnesses affecting their stomach or bowel, dengue fever, malaria and typhoid fever. These are just a few examples. It is also unfortunate that only 15 per cent of international travelers visit travel health clinics before they go abroad. Why?

Cost of vaccinations is one of the main reasons why many people avoid immunization. An article in the Canadian Medical Association Journal (CMAJ) says that a family of four going to a yellow fever zone in West Africa for one month would need to spend at least $1900 on vaccines alone. So what happens? Eighty five per cent of travelers avoid spending that kind of money. Hence they return to Canada with travel-related illnesses. The cost of treating these patients in our health care institutions costs millions of dollars. Would it be cheaper for provincial governments to provide vaccinations free? That is a question that needs to be considered by the provincial governments. In the mean time if you are planning to go abroad, make sure you budget for travel related vaccinations.

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Rabies – How Can You Prevent It?

If a dog bites me, the first thing I would think of would be rabies.

Why rabies? Because an animal infected with rabies bites, scratches or licks on a broken skin or mucous membrane of a human being, the risk of contracting rabies is high. Rabies can be transmitted through solid transplant organs as well.

Rabies is caused by a virus and is capable of infecting all mammals. An article in the Canadian Medical Association Journal (CMAJ) says that rabies is a disease entrenched in history, dating back to ancient Egypt.

In the world, rabies kills 50,000 people each year. About 20,000 people die of rabies in India and the remainder occur in Southeast Asia (particularly the Philippines), Oceania, Africa and Latin America, says the CMAJ article.

Rabies can be contracted from dogs, cats, raccoons, skunks, foxes and bats. The article says that in Canada, between 2000 and 2005, a total of 2238 cases of confirmed animal rabies were reported (about 373 per year). Skunks accounted for 40 per cent of the cases, bats for 26 per cent, foxes for 11 per cent and raccoons for eight per cent.

Since 1924, 23 Canadians have died from rabies. Since 1985, only two deaths have been reported in Canada, both from bat exposure.

It is not always easy to make a diagnosis of rabies in humans. The incubation period can be long with 20–60 days on an average. Initial symptoms can be vague. Eventually, the virus infects the lining of the brain (viral encephalitis) with classic symptoms of hydrophobia, aerophobia, hyperexcitability and autonomic dysfunction. Most patients with these symptoms die within a few days as there is no effective treatment.

Diagnostic tests require fresh samples of brain tissue. Tests are not easily or rapidly available.

Since there is no effective treatment for rabies, prevention of the disease is very important. A void contact with wild or stray animals. The CMAJ article says all stray dogs in foreign countries should be presumed to have rabies, even if the animal appears friendly. All contact with bats should be avoided, and bats should never be handled. In addition, monkeys should not be handled, and food should not be carried when visiting areas where monkeys congregate.

If you have been bitten, scratched, or licked on mucous membranes or an open wound by any animal (especially in a foreign country) then take the following actions:
-Immediately wash the wound thoroughly and vigorously with soap and water, and iodine
-Seek medical treatment immediately to receive post-exposure vaccination (five doses over 30 days for those who have not previously received pre-exposure vaccination) and human rabies immune globulin (a single dose within seven days of the first vaccine dose if not previously vaccinated).
-The incubation period for rabies is usually 20–60 days, but it may be prolonged (more than a year); therefore, it is never too late to receive treatment before symptoms develop.

Rabies vaccine is effective and substantially reduces the risk of infection when given before or after potential exposure.

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Genetic Risks – How Much Should You Know

When a physician or a nurse takes your medical history, he or she would like to know if there is a family history of any illness. You will have no clue how to answer this question if a physician, treating one of your family members, did not warn you about the illness and your risk of contracting the same illness.

An article in the Canadian Medical Association Journal (CMAJ) asks: What are the ethical and legal issues surrounding physicians’ duty to warn family members of genetic risk? This question has added importance in cases where a patient wants a physician to protect his or her privacy and not disclose the information to family members.

The article makes the point that common sense would dictate a physician to disclose such information without the patient’s consent if the physician thinks the risk is serious, imminent and preventable. But is this legally acceptable or is it just an ethical and moral obligation?

“The legal landscape around the duty to warn of genetic risk is unclear in Canada, but in some cases the benefits of disclosure may be so great as to outweigh the obligation to maintain confidentiality,” says the article.

The main reason to disclose genetic risk information is to avoid harm to other family members. The information will allow the family members to decide if they would like to undergo testing and take preventive measures. The information may help the family members make informed choices regarding marriage, career and having children who may be exposed to the same kinds of risks.

There may be some disadvantages to disclosing confidential genetic risk information without patient’s permission. The action would compromise physician-patient relationship and trust. It will violet patient’s autonomy and integrity and may cause mental and emotional distress to the patient and the family members.

In difficult situations, it would be best for the physician to explain to the patient the importance of sharing the information with the rest of the family. The article says, “Physicians fulfill their duty by informing patients of the importance of the information for family members and encouraging intrafamilial disclosure.” In my experience, in most situations, intrafamilial disclosure works the best. As a specialist, I have no information where all the family members reside. Contacting each one of them would be a huge undertaking.

Another option discussed in the article suggests that the physician should inform the patient that under certain circumstances they will disclose relevant genetic information to family members even if the patient refuses to do so.

Finally, in cases where withholding genetic risk information from other family members may cause imminent harm to the family then the physician has moral and ethical obligation to share the information with the rest of the family even if the patient refuses to do so. This may cause legal problems but preventing harm may be a good defense. It is comforting to know that a situation where there is a need for releasing confidential genetic information without the patient’s consent is pretty rare.

Do you know your family medical history and how it affects your and your children’s health?

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Statin Therapy for Your Heart

One more article on statin therapy? Yes, one more article. If you have had high cholesterol level then you know quite a bit about statin therapy. Statin therapy is extensively used for the management of high cholesterol level and in the management of coronary artery disease. One of the cholesterols is LDL (low-density lipoprotein cholesterol), also known as the “bad” cholesterol.

Recently, an article in the Canadian Medical Association Journal (CMAJ) discussed the efficacy and safety of intensive statin therapy in patients with high LDL cholesterol and coronary artery disease.

High LDL levels are associated with an increased risk for heart disease. Your doctor orders LDL testing as part of your routine check-up and it is often the first step in determining whether an individual is at risk for developing heart disease. In the management of high cholesterol level and coronary artery disease, LDL levels are often the major focus of cholesterol lowering diets and drugs.

The CMAJ article says high cholesterol level is the most important modifiable risk factor for myocardial infarction (heart attack) worldwide. High cholesterol level is directly related to high risk of dying from coronary artery disease. Studies have shown that reducing LDL cholesterol with statin therapy reduces events like heart attack by 21 per cent and death by 12 per cent.

Appropriate diet is the first line of treatment in the management of high cholesterol and high LDL. Avoid foods high in saturated fats and trans-fatty acids. Next line of treatment is cholesterol lowering medications. Commonest of these are statins. Statins reduce the bad cholesterol LDL by 30 to 50 per cent.

How low should the LDL blood level be to lower the risk of adverse events in patients with coronary artery disease? Current Canadian and American guidelines advocate LDL levels below 2.0 mmol/L in patients with coronary artery disease. Europeans guidelines differ a bit. They recommend LDL of 2.5 mmol/L in these patients.

Who should receive intensive statin therapy to lower the LDL blood level?

Analyses conducted by the authors of CMAJ article supports the use of more intensive statin regimens in patients with established coronary artery disease. What about patients who have LDL level higher than 2.0 mmol/L but have no coronary artery disease? The authors say there is insufficient evidence to advocate treating to particular LDL targets (i.e. 2.0 mmo/L) in patients without established coronary artery disease. What if these patients (the ones without coronary artery disease) have other risk factors making them prone to coronary artery disease? The authors say that there were too few clinical events in these trials to make definitive conclusions.

The authors of the article found more intensive statin therapy safe and well-tolerated. They also came to the conclusion that it helps in the prevention of heart attack and stroke in patients with known coronary artery disease, irrespective of their baseline LDL cholesterol levels. They said further research is needed to define:
-optimal LDL cholesterol targets (is 2.0 mmol/L the right target number?),
-the role of more intensive statin therapy in patients without coronary artery disease and
-the role of combination statin therapy (usually low LDL is achieved using two types of statins).

It would be a good idea to find out from your physician what your LDL level is every time you get your cholesterol level checked. If it is above 2.0 mmol/L then ask if you need statin therapy.

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