Vaping

What is it? Risks/Benefits?

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

January 2019

Devices to deliver heated solutions of liquid nicotine ("e-juice”), mixed usually in propylene glycol or glycerol, have become popular. They are in the form of "pens" which have a reservoir for the nicotine, a heating element to vaporize it, and a battery to do the heating. They thus produce a nicotine-saturated vapor, which is inhaled, hence "vaping". At least 13-15% of adults have now tried this new way to rapidly absorb nicotine into the blood stream, usually not to feed their nicotine addiction but to help them stop old fashioned "burn" cigarettes and thus avoid the 1000s of bioactive chemicals therein, which cause various cancers (lung, head and neck, bladder) as well as ischemic heart disease. Studies so far suggest that there may be some marginal health benefit when these devices are used alone to assist adult smoking cessation as long as they are not used with a few conventional cigarettes daily.  However, public health research shows that most people end up using the two together, and thus suffer the worst of both. Smoking cessation is more safely and reliably accomplished with nicotine patches, gum, or other proven medications, along with group or counselling support (see Vienna Newsletter, Feb-Mar, 2014: p6). Nobody yet knows if passive exposure from "nicotine vapers" is a significant risk to others nearby as it is for cigarettes. The adverse effects of vaping are only beginning to be understood, not surprisingly, since it took us 50 years to prove definitively the bad things smoking tobacco causes.

There are many proven as well as potential dangers to vaping. First, the rechargeable batteries can explode and burn, causing bad burns to the face or inside the pocket they are carried in. Nicotine causes faster heart beats and sometimes arrhythmias like atrial tachycardias or fibrillation. And nicotine itself is of course addicting and thus can prompt withdrawal symptoms, which often lead to higher use and/or use with regular cigarettes. Because the heat vaporized glycerol or propylene glycol liquid nicotine mix produces propylene oxide, formaldehyde, and acetylaldehyde, all known cancer-causing chemicals, most researchers expect that eventually we will see higher cancer rates in chronic or past users. Finally, some of the flavorings, especially sweet and cinnamon ones, added to attract new users to vaped nicotine mixes, break down, when heated, into diacetyl and benzaldehyde, compounds known to irritate the respiratory tract and thus can cause chronic bronchitis.

A second group of accidental or intentional users of vaped nicotine, are children and young adults respectively. The latter are now higher users than adults above age 25; surveys in 2015 reported that 15% of 11th graders had tried vaping nicotine. Nicotine impedes brain as well as global body development in the fetus if the pregnant mom uses either conventional tobacco or vaped nicotine. Accidental nicotine liquid exposure in young children from their eating, inhaling, or getting it on their skin or eyes, is just as bad as their eating real cigarettes; together both are responsible for 1000s of poison control center calls annually in the US. Over half of all such calls for nicotine liquid exposure are in this young age group; many are fatal. In teenagers and young adults up to age 25, studies show impaired judgment and other brain function maturation, and higher addiction rates to nicotine and other substances over time with chronic use. Unfortunately, there are few controls on use by these more vulnerable age groups. I went on Amazon today and could have bought all the equipment and supplies to get started myself for under $50. It's the wild west out there.

Finally, it's not just nicotine that can be used in these vaping devices. Inhaling caffeine and various vitamins this way, judging from the Amazon displays, is popular. Like the liquid nicotine, no one knows the long-term effects of sucking small particles of known and unknown substances into the lungs, but scarring and other damage seems likely over time. Lung replacements come hard. And, of course, liquid marijuana infusions can be taken this way too with rapid and extensive absorption; that too has similar bad effects on brain maturation in the young adult population.

So, my advice is: be cautious, read the surgeon general's report on vaping (https://e-cigarettes.surgeongeneral.gov/); don't vape when pregnant; keep nicotine out of reach of young children; talk about the potential dangers with your teenage and young-adult kids and grandkids. Only opiates and alcohol use present a greater danger to them. I'm sure that someday we'll look back and say, "why didn't people realize this could happen and do something!"

Immunizations in Children

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

April 2019

In these current times, some parental reluctance to immunize children is bringing back the old days a bit. There was a case of mumps in York county just last month. In Maine, during the first 3 months of 2019, there were 145 cases of whooping cough (pertussis) and 48 cases of chickenpox (varicella). And that’s not a one-off either; in 2018 there were a total of 446 cases of whooping cough and 252 cases of chickenpox! And right now, there are measles epidemics spreading across the country with nearly 500 cases reported this spring, the most since 1994; the closest cases are in Massachusetts. It’s a potentially a fatal disease in young and/or sickly children, especially in developing countries where it has a 2-10% mortality in kids and in rare cases can cause an encephalopathy 20 years later in adults who had cases as children.

What immunizations are currently required for children to attend public school in Maine? These immunizations, all of which, but for tetanus, are against communicable diseases, i.e. they are caught from those around us who are already infected and spreading the disease: 

•Required for kindergarten entry:

-5 DTaP (4 DTap if 4th is given on or after 4th birthday)*

-4 Polio (if 4th dose given before the 4th birthday, an additional age-appropriate inactive polio vaccine should be given

-4 MMR (measles, mumps, rubella)

-1 Varicella (chickenpox) or reliable history of having had the disease

•Required for 7th grade entry: 

• 1 Tdap

• 1 Meningococcal conjugate (MCV4)

•Required for 12 grade entry:

-2 Meningococcal conjugate vaccinations; only 1 dose, if 1st given after 16th birthday

* DPT, or DTaP, or Tdap are all immunizations against diphtheria, tetanus (lock jaw), and pertussis (whooping cough)

Fifteen years ago, I began seeing whooping cough cases for the first time in my professional life right here in Kennebec County. By being vaccinated against just diphtheria, tetanus (lock ja), pertussis (whooping cough), and small pox, my generation escaped diphtheria, whooping cough, and tetanus (which nearly killed an unimmunized farm boy in Oregon last year). When I was a boy, I recall adult neighbors pointing out houses where whole families were wiped out in a winter by diphtheria during the great depression in the 1930s; and as an intern in Seattle, I did, see some cases of it in unimmunized skid row residents. Small pox has been virtually eliminated now and we no longer immunize against it. Sure hope none of those come back!

Infants under age 2 are the most susceptible to whooping cough, especially under 3-6 months and if their mother’s immunity is low or absent. Those infants are too young to vaccinate and must rely entirely on either not being exposed, or breast milk and placental transfer of immunity. Half of those under 3 months with whooping cough require hospitalization and some die every year in the US. But even teenagers and adults suffer “the cough that lasts 100 days”. And they spread it to the unimmunized. Maine cases, usually fewer than 20-50/yr, have skyrocketed in the last few years (see first paragraph). 

Much of the concern of parents, who opt their children out of public school immunization requirements under the “philosophical” exemption, derives from a 20-year old controversy surrounding the MMR (measles, mumps, rubella) vaccinations; that controversy has been scientifically put to bed long ago (see below). But a change in Maine law 10 years ago allows parents to send children to school unimmunized if they have a “philosophical objection” to vaccines. Those children now constitute 4.6% of all children, while the religiously exempt remain under 0.4%, and the medically exempt (e.g. those with bad eczema, immune suppression, or other complicating conditions) about 0.3%. Maine’s opt out rate is one of the highest in the United States. In the best of circumstances, because of families moving in and out, it is impossible to get higher than 95% of children immunized at any one time, so an additional 4-5% opting out leads to a population barely 90% immunized and heading in the wrong direction. Most of these diseases, and clearly whooping cough, can continue and spread whenever 5-10% or more of the population is susceptible. The Maine legislature is debating tightening these rules again right now.

National data for 2018 not yet available

Things have changed a lot since “the good old days”. Kids get many more vaccinations and because of that, many fewer serious illnesses. A good thing, since we have many fewer children around. When I started practice in Maine in 1972, the state had 25,000 births per year. Smaller family size has cut that number to around 12,500 now. Many medical risks have been reduced over these decades. Child car seats and safer cars have dramatically reduced traumatic injury and death for adults and children. Sunblock now prevents severe sunburn and its consequences. Medical advances save many more children and adults, who would have died in the old days. All these improved survivals have allowed more and more people to reach their old age, a “squaring off of the survival curve”, as epidemiologists call it when the survival curves look more and more like a rectangle than a right triangle (compare 1900 with 1997 in the graph). 

A big part of this “squaring off” is due to improved immunizations against childhood diseases, eliminating that awful 20% mortality in the first 5 years of life one sees on the 1900 graph line. Diphtheria, whooping cough, tetanus shots (DPT) were first used in the military, then with school kids in the 1930s. So I, like others of my generation, didn’t catch those diseases but did suffer and survive mumps, chicken pox, German measles, and regular measles, still a major killer of young children in un-immunized developing countries. Mumps orchitis caused sterility in several of my male classmates in junior high. Chicken pox so scarred the lungs of a fellow medical intern when he was younger, that he never could walk upstairs without resting. And while German measles didn’t bother us kids much, it caused miscarriages and birth defects when mothers caught it for the first time when they were pregnant. Remember “rubella parties” to expose and thus immunize young teen girls? 

Then there were the really scary diseases, like polio; remember the March of Dimes? Public swimming pools would close when epidemics started, because it is spread by fecal (poop) contaminated water. Only 10% of the kids infected developed paralysis, but that was so devastating, all feared it. Also less well known but nearly as devastating were bacterial pneumococcal and Hemophilus influenzae infections of ears that then led to meningitis, pneumonias and abscesses. And most adults can probably still recall cases of meningococcal meningitis, killing young adults, especially those in high school or college or the military, mostly within just a few days. Bad stuff. All are now preventable with vaccinations; we docs almost never see these diseases anymore in this country.

Overall population resistance, or group immunity, is achieved when immunization levels exceed 90% and get closer to 95%. Why the reluctance of some parents to immunize? Many understandably also worry that the number of shots seems excessive. It certainly is more than our generation suffered. But the return in reduced illness and mortality is substantial. Other parents worry about the mercury preservative once used (thimerosal), but now removed from shots for those under 6, because it does cause more local reactions (sore arms). And an initial report in 1998 of 12 children who had autism after measles/mumps/rubella (German measles) shots, understandably frightened many. More extensive studies have since proved that connection wrong. The senior author of the 1998 paper was later sanctioned and his paper retracted when fraud, conflicts of interest, and data falsification emerged. Autism is a relatively newly recognized disease and continuing studies are attempting to identify its causes and treatments, but it seems pretty clear autism is not caused by vaccines. For instance, autism incidence has not declined despite the removal of mercury stabilizers. Further vaccine refinements have included changing the whooping cough vaccine to one devoid of any cellular material to reduce vaccine fevers. Many killed vaccines do still contain aluminum salts because they are benign and act as “adjuvants”, chemical enhancers of the immune response needed to protect.

So, how are our schools doing? Well, according to the Maine CDC, the Cape Cod Hill School’s kindergarten class in 2015-16 had 7% kindergarteners exempted without MMR vaccines, and 93% MMR immunized, whereas 3% of first graders were exempted. In 2018-2019, again 7% of kindergarteners were exempted and 93% MMR immunized (I can’t find first grade results). Small numbers, but worrisome trends. And our Franklin County is not doing so well as a whole (more on that next month). 

It has been a long road from the days of many serious common diseases, to the present where immunizations offer significant protections, but only imperfectly unless all participate. If we are to live, work, and play together, we cannot allow immunization opt-outs, any more than we can allow driving on the wrong side of the road. Parents falsely hoping to protect their own children by avoiding vaccinating them appropriately, jeopardize the health of all of our children and all of us. 

Outdoor Mental Health

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

October, 2019

I am sitting at my computer, having prepared for the patients I see tomorrow morning, looking out my window at a sunny, beautiful fall day. I’ve got to get out there and will shortly.

Such feelings are considered nearly universal and healthy by recent credible scientific publications. Even a few minutes in nature, let alone a few hours a day, have been correlated with people’s mood improvements.   Soul soothing by fields, trees and water, works. We are fortunate to live where we do. Despite disturbing news about local and national events, man-made and otherwise, we have many opportunities to treat ourselves this, Tom Ward’s metroplex. And those opportunities are increasing gradually by many local improvements and projects. Two come to mind immediately.

The 30 Mile River Watershed Association (30 Mile) (read about it at http://30mileriver.org/) purchased a bunch of kayaks with a grant last summer. The organization has been loaning them out for free to locals, kids and adults, this summer to help them “treat” themselves by kayaking our lakes and streams. The association hopes to help young and old experience the peace and fascination we all can find paddling around. The first selectwoman of Mt Vernon watches over the swim beach, and calls for help from 30 Mile’s Lidie Robbins, when she spots some reddish-brown stuff floating in the water there. 

Meanwhile, over on Parker Pond, 25 friends of the pond have put in hundreds of hours fixing the Loon Island cabin there, which needed extensive repair after nearly 100 years of use by the public. About 50 years ago, the Parker Pond islands were donated to the state of Maine’s Department of Conservation (DOC) by the Central Maine Power Company. Loon is one of four Parker islands with public, DOC campgrounds open to the public all year; the others are Spruce, Bill’s (named for local guide Bill Nurse), and Birch. Locals or visitors can stay for up to 2 weeks. Ice fishermen warm up over Loon’s wood stove. Fishermen staying there from New Jersey last year cut blow downs into firewood for future users. Each island also has a primitive toilet. The loon island camp has been permanently jacked up a couple feet to prevent sill rot. The porch has been re-floored, and rotten siding now being replaced and repainted. Check it out sometime. The Parker Pond Association web site (http://www.parkerpond.org/) has pictures.

And those are just a couple things that I know about that have been accomplished recently to improve access to the natural world around us; I’m confident there are many others. Enjoy a walk or paddle soon and often. You’ll be healthier for it.

Aging-In-Place and Its Limits

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

July, 2019

Last month I wrote about advance directives and promised to explore powers of attorney (POAs) this time, but I’m going to defer that for a month and instead address “aging-in-place”, its value and limitations. Mt Vernon is actively planning a laudable community-wide program to allow more people with physical and/or cognitive limitations to remain here with help. Vienna, given its twin city status in Tom Ward’s “metroplex”, would be a logical partner as well.

People who age and/or develop limiting disease conditions, don’t suddenly lose all their abilities. They usually retain and can still use many of their skills and community memories to contribute to our social network. But new limitations may make it impossible for them to live in our very rural towns on their own. So, the aging-in-place program goals must include the development of support systems that complement their deficits. Hence either town government or local organizations must look for ways to help, including many non-profits, like Mt Vernon rescue, the Mt Vernon Community Partnership Corporation and its Neighbors to Neighbors home maintenance program, Neighbors Driving Neighbors (NDN), the Vienna Grange, the Dr. Shaw Library, and many others. 

Short-term impairments usually are so transient that no organized help is feasible or necessary, unless no family is around to help. However, some impairments, like delirium following major illness or inadvertent medication intoxication, may last several months and can be amenable to help if short-term facility rehabilitation is not available. Permanent impairments of vision, cognition, or mobility (walking and driving) are, however, the most common. People who suffer macular degeneration may no longer be able to drive, but everything else works. Those with cognition impairment may lose some, but not all, their skills, doing what are medically called “Activities of Daily Living” (ADLs) and “Instrumental Activities of Daily Living” (iADLs). 

There are 6 ADLs: 

• Bathing
• Climbing stairs
• Walking indoors and out
• Feeding Self if food is prepared
• Dressing self
• Toileting self

And 8 iADLs:        

          iADLs Each may be helped by these>                          Alternative aids

• Using the telephone                                                      Medical alert systems
•  Shopping for food, clothes and repairs                        Grocery deliveries
•  Preparing food, including cooking                                Meals on wheels
•  Doing house work                                                        Neighbors to Neighbors
•  Doing laundry                                                               ditto
•  Driving (or using public transportation)                        Neighbors Driving Neighbors
•  Managing own medications                                         Visiting nurses
•  Managing own finances                                               Family or other POA

Generally, a person can manage in his/her own home (age-in-place) if they have all or almost all their activities of daily living, or perhaps all but stair climbing (depending on their house setup), and/or walking outdoors. Instrumental ADL impairments usually need to be covered less frequently than daily and may be amenable to family, purchased substitutes (for example, like substituting medical alert systems for emergency telephonic skills), or community support systems.

So, these limitations are helpful to bear in mind when choosing interventions that would be most helpful to supporting aging-in-place. Missed by this list are the interactive social supports that usually come with them and are, themselves very important. For instance, talking and interacting with the neighbor drivers themselves, rides to local events, hair dressers, , or to other social activities are at least as, if not more important than rides to medical visits. But aging-in-place in a person’s own home is likely not to work if the person is incontinent, wanders and gets lost, falls down a lot, can’t bathe, dress, or feed themselves much of the time.

A final issue, as programs are planned, is how to find people who need the help. We know Mt. Vernon has a population of about 1650; precise numbers by age group and other parameters won’t be available until the 2020 census comes out, but getting those a year or more from now is important to do. In the mean time we can presume at least 20% or 330 are over age 65 and 10% or 165 are over 75 by state-wide statistics. Those people are thus more vulnerable to the cognitive and physical deficits that may interfere with their ability to take care of themselves at home alone. NDN, as an example, struggles with how to reach out and offer services to people with transportation needs. Low income residents are particularly needy because of their shortage of financial resources. Those who are both over 65-75 and under federal poverty levels have greater and increasing need with age, but may also be the hardest to find. NDN is getting help from town offices to identify and distribute offers of help to these folks. Sharing these efforts with others trying to do complementary interventions would make sense. 

I hope Mt. Vernon will be successful and suggest including Vienna and perhaps other adjacent towns in some of the programs they develop. But all-in-all, there are benefits to be shared both by those we help and our communities, which benefit from the continued involvement of individuals like Betty White, who continues to help run the Mt. Vernon food bank.

 

Advance Directives 

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

July, 2019

OK, this isn’t a very popular topic, but it is important, especially for the chronically ill and/or those us over age 75. If you aren’t in those categories, you may, nevertheless, be called on to help family members or friends, construct advance directives. As a geriatric consultant, I talk with many people about how to prepare for and manage serious illnesses and the mortality risks those illnesses carry.

Advance directives are directions written out by a person ahead of time, most often when chronically ill or elderly, to lay out what kind of medical interventions they do or do not want, should they suffer a life-threatening event, like a heart stoppage (cardiac arrest), or other organ failure. They direct physicians to use or not use cardiopulmonary resuscitation (CPR), kidney dialysis, or lung intubation and ventilation on a respirator. The odds of such interventions succeeding decrease with age and/or frailty. For instance, the chance of CPR succeeding is small to non-existent over age 75. One can direct ambulance and hospital staff to forego such likely futile treatments. Otherwise nowadays, the default is to use extreme measures if there is no explicit direction not to do so in an advance directives document, signed by the patient.

Hospitals and doctors’ offices have forms with check boxes to indicate whether or not you desire feeding tubes, CPR, or any of what are often called “heroic” measures. Advance directives can spare prolonged intensive care unit stays and the associated suffering with low likelihood of success. Instead, they can permit comfort care, often labelled palliative or hospice care.

Because the default is to “do everything”, which for many, has little chance of successful return to normal function, you should prepare ahead of time by letting your primary care clinician, the ambulance service and your local hospital know your desires. Send them copies of your advance directive forms, and also share them with your family so they can monitor conformance to them when the time comes.

There are a number of similar form choices for creating your own advance directives1, several have been designed in Maine. You should feel free to add or modify yours beyond the check boxes to include some specific directions; I append my own in a footnote2.

1   Google Search: Advance directives

• 2If I am not mentally capable of participating in care decisions and facing any conditions listed below, please follow these guidelines as best you can.
• CPR up to age 75 unless I have a known terminal (under 1 yr) illness. No CPR over age 75 unless defibrillation possible within 3 minutes of loss of consciousness.
• No respirator support beyond 3 days, except in the case of trauma without brain injury.
• No IV maintenance fluids or feeding tubes unless recovery likely within 1 week and no terminal illness is present.
• Adequate pain control, preferably with a PCA system, or offer of pain meds regularly. But, if I am unable to request pain meds, I do not want others deciding to give them without direction from me. If I am medically paralyzed, then stop the paralyzing meds. If stroked out, work on ways to communicate with me (eye blinking etc.)
• If conditions don’t seem to conform to above situations and I am incapable of participating in care decisions, I authorize first my current POA, (NAME), and if he/she is not able to do so, then any or both of (NAMES), to use their best substituted judgment. My PCP (NAME), should, if possible, help them. If none of my named agents are reachable, my PCP himself can and should use his substituted judgment for me.

The June 2019 Union Hall Newsletter is here