Town Meeting Questions: Drinking Water vs Beach Water Testing, and Hepatitis Immunization Questions

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

March, 2017

Mark Rains and Roger Reveille asked me a set of questions at our March 11 town meeting this year that others may also be wondering, so I'll expand my answers to them here.

At the meeting, Roger asked if testing the Flying Pond beach just once a year was sufficient protection and I responded that I thought it was. What I didn't say in the meeting but explained later to Roger, was that the $60 the town voted is sufficient for two tests if needed. At least a couple times in the past, I've had a borderline test and gone back to re-test a week or two later. The standard test for a swim beach is a measurement of how many fecal (poop) bacteria (Escherichia coli or Enterobacter) are in one cubic centimeter (cc) of the water. The standard swim beach test is for the E. coli. In drinking water any such contamination would be unacceptable, but for swim areas, standards are lower because people, even children, actually swallow very little water when swimming, or as the Environmental Protection Agency calls it, "recreating" there. Instead, the standard is set so that there would be fewer than 35 fecal illness episodes in 1000 people who swam there, whereas the drinking water standard would be none. I usually get 1-12 bacteria per cc of lake water; once I did get 249, but repeats were way back down. I had taken the sample just after some heavy rains, which may have temporarily washed some animal poop off the shore. I had worried about a septic system leak, but subsequent normal tests made that highly unlikely.

After the meeting, Mark asked why we didn't test as often and extensively as the Grange does the Kimball Pond spring. I explained that in Maine, lake water standards are different in the ways I just outlined above, because lakes must only be safe for swimming and fishing, not for drinking unless the water is treated (with chlorination). That's why most camp owners, who draw pond water, use it for bathing, laundry and toilets, but use bottled water for drinking and cooking.

Finally, Roger later asked me about hepatitis. The rescue/firefighters are immunized with a 3-shot immunization series against Hepatitis B. He asked when they should get boosters. The answer to that is that in immunocompetent people, like most of us and certainly firefighters, the initial series of shots leads to more than 15 years of measurable antibody levels against Hepatitis B in over 95%. And even after that, research has found that immunologic "memory" is retained and will quickly produce more antibody if challenged by a Hepatitis B invasion. This could change as new studies follow people for decades. But for now, no re-immunization or even antibody measurement is recommended. Healthcare workers, potentially exposed on a daily basis to blood, might be an exception and probably should be re-immunized after 10-15 years with a single vaccination. He also asked whether Hepatitis C too can be prevented by a vaccine. The answer to that one is no. Hepatitis C is a viral liver disease like Hepatitis A and B but almost always transmitted by intravenous drug use through needle sharing. Thus it is best prevented by not using IV drugs. There is now relatively effective treatment with shots after it is diagnosed; but that's not so good that it can be counted on to work always.

Maybe we could have more town meetings to get more public health questions and discussion?

Gun Violence in Maine, and Beyond

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

November, 2017

I am writing this on March 25, the day after huge marches to demand action to reduce gun violence were held locally and all over the country, along with some counter marches. Those marches and a recent dialog I had with Mt. Vernon's most prominent sportsman, George Smith, (see his Bangor Daily News blog) lead me to want to expand the discussion of gun violence to other related and alarmingly bad public health transformations we seem to be suffering.

In our published dialog, I said to George: " Gun violence is on the rise, as school and other mass shootings are becoming more and more commonplace. Several instances have been thankfully prevented recently in Maine. Domestic violence against women and children in Maine has been and continues to be a perennial cause of injury and death, the latter often perpetrated with guns (over 12 each year, half of all Maine homicides, and half are children under 13). And finally, suicide by guns (half of all Maine suicides) is also a major risk and increasing here in Maine. All three examples are especially impacting teenagers and young adults, and thus dramatically increase the 'years of potential life lost,' as the 'public healthies' like me use to measure the payoff of a public health issue intervention."

The mass shootings have prompted outrage and demonstrations. They have increased dramatically after the 1994 ban on assault weapons was reversed in 2004. Fixing or moderating such high-risk gun use needs doing. I've hunted all my life, as have most rural people; but these aren't hunting guns we are talking about. Access to any weapon that carries significant risks to others is no more a right than is driving on the wrong side of the road or drunk!

But it ain't just guns that are playing an increasing role in premature deaths here in Maine and the nation. So too are other deaths now classified as "unintentional deaths," like the rising number of narcotic overdoses, car crashes, falls and other accidents often associated with alcohol use, as well as diseases like hepatitis (from needle transmitted hepatitis, alcohol, and/or diabetes), and lung cancer and emphysema from smoking. Unlike mass shootings, these deaths, as well as clear suicides, seem to be rapidly increasing most in rural areas, disproportionately afflicting the white households with lower incomes and education levels, to the point that their overall age-adjusted mortalities are worsening or at least not improving overall unlike the other segments of our US population, as illustrated in sub-groups in the graphs below,. I urge you to go to the Washington Post reference #2 below, which allows you to look at those subgroups in various combinations, like urban vs rural, males vs females, White/Black/Hispanic, region of the country, and by 5-year age groups.

Most of these potential causes seem likely caused by increasing risky behaviors in the subgroups, perhaps related to the increasing income disparities in the US among segments of the population over the past 50 years, even though all have improved over their historical averages. Perhaps what matters more than one's own situation compared to that of one's parents, is how one now compares to one's peers and neighbors. When social safety nets are trimmed or dismantled, like the Affordable Care Act, MaineCare , and food stamps, we see more illness and downright despair and thus suicide, murder, accidental overdoses of opiates, and death through recklessness and/or depression.

Other research, like ours I frequently cite done in Franklin County Maine over the past 50 years, shows that community-wide engagement in preventive activities like education and social pressure can counteract some of these bad outcomes, despite socio-economic impediments. The ability to initiate and maintain community interventions seems to hinge on how much "Social Capital" the community has or can muster. In other words, can and does the community exhibit altruistic interactions and programs open to all.

Demonstrators are now demanding more gun controls since mass shootings have become commonplace. It may be that such shootings have now extended such unintentional harms from the poorest, least politically powerful of our society, into the middle classes. Our schools especially are melting pots of all classes. Their unfortunate vulnerability now may increase the likelihood of real change in gun laws and perhaps eventually even some of the income disparities, which may be causal. I certainly hope so!

Still, I think we need concerted efforts to develop and sustain local community-wide programs to reduce the despair and risk-taking among those most at risk, and to provide compassionate outreach, and evidence-based interventions to turn this nearly two-decade-long spiral of worsening mortality in our populations. Mt. Vernon and Vienna do a lot of that already through volunteers who organize community center and church dinners, Neighbors Driving Neighbors, the Grange, our churches, the food bank, the Mt. Vernon Community Partnership, and our library, and probably more I am forgetting, in addition to the many individual acts of human kindness and support we see here every day. We need to keep it up and recruit even more to participate. Kindness and caring not only enrich a community, but also save lives.

Arsenic in Our Water

The Vienna Kimball Pond Road Spring

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

June, 2017

Contaminants in our home water supplies are a perennial concern to health officials, especially here in Maine where fewer than half of our citizens use town water sources. The use of multiple, and often single-family wells and springs make it difficult to ensure everybody’s water is safe. Of course, no one in Mt. Vernon or Vienna is on a public (town) water supply. And many use the old spring on Vienna’s Kimball Pond Road as a drinking water source because it carries on a nearly 200-year-old local tradition -- and it tastes good.

By far, the most common contaminant in Maine wells and springs is fecal matter (poop) from humans, or more commonly, domestic animals. Fecal matter can cause various kinds of gastrointestinal illness. But in some areas, like our towns, arsenic contamination is also common. About 30% of Mt Vernon and 5% of Vienna wells, if tested, will show elevated, potentially dangerous levels of arsenic, a “heavy metal” element, closely related to lead, cadmium, mercury and chromium on the chemical periodic table.

Arsenic can interfere with cellular metabolism by blocking the burning of sugar in our subcellular engines, known as mitochondria. It has been recognized as a poison since ancient times, while today it is most commonly used to make herbicides and pesticides. Think of New Sweden Maine 20 years ago, where a potato farmer, apparently upset at his fellow parishioners, added an arsenic-based herbicide to their post-Sunday service coffee, killing a couple and sickening several others.

Over the past decade, new scientific findings have led to greater concern about arsenic in our drinking water. The research has shown that even lower levels of chronic arsenic exposure can cause disease. For this reason, in 2012, the definition of a “safe level” of arsenic was reduced from 50 parts per billion or micrograms/liter, to 10. Chronic use of water with above 10 levels, especially over 20, for many months and years, can cause fatigue, blood in urine and kidney damage (mostly in children), painful nerve irritation, rashes and white lines in the nails, increased cancer rates (in bladder, lung, kidney, and liver), and dementia. Exposure to levels over 50 parts per billion in drinking and cooking water, within a month of regular use, can cause acute symptoms, including vomiting, bloody diarrhea, blood in the urine and pain in the upper abdomen, heart failure and irregular pulse.

There are three ways to report arsenic levels in water: as milligrams/liter, as parts/billion, or as micrograms/liter. The upper limit of tolerable levels now is 0.010 milligram/liter, or 10 micrograms/liter (which, said another way, is parts/billion). The Maine state lab reports in micrograms/liter, whereas many private labs use milligrams/liter.

The Historical Society acquired the Kimball Pond Road spring many years ago and conscientiously maintains it with fencing, clean pipes and regular water testing most often for fecal contamination, done several times a year by Vienna’s Jim Gajarski. This year he tested again for arsenic and found the level to be 10.9 – up from 2011’s reading of 10, (not flagged because the tolerable maximum then was 50). I consulted with state toxicologist, Dr. Andrew Smith, in the water quality/environmental protection division of Maine Center of Disease Control. Smith recommended retesting every three months for a year since their cutoff for public water sources is an average of less than 10.5 on several readings, three months apart. If that is not achieved, then the water source is closed until fixed, if it can be.

In the meantime, at his suggestion, the Historical Society has posted these results at the spring and in the Vienna Post Office, with warnings that pregnant women and children may be particularly vulnerable. All users are advised to use it at their own risk. Jim plans to retest the water several times over this next year.

The Kimball Pond spring arsenic levels are not high enough to cause acute poisoning. If regular users of the spring think they have any of the chronic symptoms, they should see their doctor to decide if they might need further testing. Blood levels can be confusing. We live in an area with lots of granite bedrock that contain inorganic type arsenic. That is in contrast to the organic type found in lobsters and other seafood. Arsenic poisoning by inorganic arsenic is a cause of premature dementia (a condition that appears like Alzheimer’s disease). Several times I’ve found an elevated total arsenic level in a patient only to find on further testing that it was the organic type from their diet, and not in their coffee water.

It is a little surprising that this spring has any levels of arsenic. Springs, in contrast to deep wells into the bedrock, usually do not. It may be that the greater amount of snow and rain we’ve had this year caused more water to well up through the granite.. Another possible, though unlikely, explanation, Dr. Smith told me, is that a Civil War soldier might be buried above the spring. Civil War dead were heavily treated with an arsenic preservative before being shipped home for burial.

What can we conclude about all this? First, we should all get our own water tested every 3-5 years either by the state lab (https://www.informe.org/cgi-bin/shopping/cart.pl?catalogPage=pageTwo) or by one of the several private water testing laboratories  http://www.informe.org/hetl/). It costs about $20 to test just for arsenic, but for $70, you can test for the full panel of potential contaminants here in Maine.

In the meantime, let’s hope that further tests at Kimball Pond Road site show a decrease in arsenic so that people can continue to drink from the spring, as they have for centuries

Measuring and Fixing the Disturbingly Strong Link between Health and Economic Status in Maine Counties

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

September, 2017

My mission as town health officer is to promote the health of all town residents. That can be done in several different ways: educate individuals about how to better care for themselves, find and evaluate environmental risks in town, and promote ways the health care infrastructure can be improved. The last can get a little political, because it involves state-wide public policies. But it is important for all of us to appreciate those policy impacts. One policy issue with the greatest impact on health is insurance. I think it’s important for voters, as they are asked to vote on proposals to improve health disparities, to understand the powerful correlations between county populations' health and their socio-economic status (SES) in Maine and elsewhere.

The data to estimate the effect of household economics on health come from two principle sources. The US Census Bureau collects most socioeconomic status (SES) data by county, with the same methodology, throughout the nation. In our state, like most, the Maine Center for Disease Control (CDC) collects health data and passes them on to the national CDC. A county’s socioeconomic status correlates tightly with its good or bad health outcome differences, including death rates.

Research using these data shows that the poorer a county’s socioeconomic status, measured any number of ways, the worse the county’s health, also measured in any of a number of ways (see table). I include a graph below the table showing this correlation using the first row examples above.

Maine County SES vs Outcome measures

Over the last 50 years, the link between economic status and health statistics appears stronger than ever. In the 1960s, only 15% of the variation among Maine county mortality rates was explained by income variation. By 2010, that percentage had risen to 80% as shown by the R2 value of .81. This makes sense to me from the patients I see. Poorer patients have higher rates of smoking, lower levels of exercise, and poorer diets, as well as much more difficult access to health care when they are sick because of no or very spotty health insurance. They also have less reliable transportation, and inadequate funds to pay for prescriptions after heat, food and car expenses.

Our studies in Franklin County have shown that improving access to health care and to programs that reduce risk factors, can compensate for lower economic resources. Improved access and reduced risk factors can improve outcomes of those county populations back to or even better than those of the more affluent counties. Sadly, our most recent data show that Franklin, after 45 years of being better than average, has now regressed back to average for a county with its socioeconomic status. We held a conference in Farmington last week to analyze the possible reasons why. Diminished leadership in these areas and a failure to monitor the success of existing programs to guide improvements were major reasons cited there.

When possible, our communities should strive to affect these powerful factors, by encouraging healthy behaviors and improving access to regular medical care for all. The local Neighbors Driving Neighbors transportation project is one example. Another way to help would be by expanding MaineCare, as allowed by the Affordable Care Act, to include the working near-poor. I know from our local research and my medical practice, that such a program gets everybody on the same level playing field to do the best they can with their lives, both adults and especially kids. Right now half the children in Maine are living in impoverished households. Last year I supported MaineCare expansion by gathering signatures on election day in Vienna. That referendum was approved and will now be on the ballot in November and would be a powerful improvement for a group of people needing better health care access.

HEY, ABOUT THE INFLUENZA EPIDEMIC, MANY OF YOU NEED TO LISTEN UP TO HELP YOURSELVES, YOUR FAMILY AND THE REST OF THECOMMUNITY MORE RIGHT NOW!

HERE’S HOW!

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

February, 2018

People, people, people, many of you I meet are not listening, and are giving up about surviving the influenza epidemic we are in the midst of right now. That’s crazy; please don't!  We’ve got several kinds of arrows in our quiver to help us and ours survive if we are smart enough to use multiple strategies at once, as we do with other complicated challenges. Listen up! Here’s how.

Please start by going back and reading my piece last November, 2017 in the town newsletter, Medical Probabilities Exemplified in Influenza and Car Crashes. It is on p10 though the index in front says p9; go back and read those details; they are important. I explain the presence and impact of probabilities of influenza vaccine on the spread and effect of a “flu” epidemic in our community. It never is all or nothing!  I hate the way the media emphasize one artificial number, “the effectiveness”of the vaccine. I am not even sure how they compound that one number, but it ain’t the whole story and it sure seems to encourage people to give up. The number they are disseminating now is "30% effective". That should mean that of 100 people, who are exposed to the flu by breathing the viruses into their nose and lungs, 70 will get the flu while 30 won’t. But those aren’t bad odds to start with. We take what we can get and then go from there. So if you got a flu shot, you are right now that far ahead of your neighbor who didn’t. What they don’t tell you clearly enough, is that of the 70 who get the flu, those who have had a flu shot, nearly all have a better time of it with less severe illness, fewer complications, and not being so sick they are hospitalized or die. Yea, influenza can be a fatal disease and is proving itself to be right now in Maine! Listen up!

Yesterday I talked about influenza with 3 people. One, a 70s year old friend and carpenter, told me he never got flu shots, didn’t believe in them, and wasn’t getting one despite having had severe pneumonia last year in that milder flu epidemic even though he still had left over lung damage and shortness of breath from it. He, of all people, needs a leg up on this year; I begged him to get the shot. Then there was a young woman grocery clerk with a clearly sputum-producing cough, repeatedly turning to cough away from her customers. Now it could be she just had bronchitis from being a smoker, but that would be unusual at her age and in the midst of a flu epidemic. I bet she had an early influenza infection and will get sicker. Coughing in the other direction simply spread the virus more widely; she should be taught how to effectively cover her mouth with her elbow and/or wear an effective mask, or go home until better. Her employer has a responsibility to have effective education to make this happen. Unfortunately the Maine Center for Disease Control (CDC), which tries to do that education, has been budget cut to the bone; and the US congress let the national CDC shut down over the budget fight. So we may be on our own, guys. The 3rd example was a mother of a 1-year old who didn’t “believe in” flu shots for her kid. My God folks, this isn’t a belief issue; it’s the science that got us to the moon, dropped mortality rates in this country so most of us get to see age 75 now, and redesigned cars and roads so motor vehicle deaths have plummeted over the last 50 years!

First you’ve got to understand and recognize two things:

•What influenza is and what it is not. It is not simply a cold with sore throat and temperature under 100 degrees and the person still able to function. Nor is it predominantly nausea, vomiting and diarrhea from gut germs, and which we also call “flu”. Rather, it is a specific viral infection of the lung itself, caused by several related influenza viruses which characteristically change their protein coats as they rip through the population each year. That way people, who have previously been infected, have less resistance because the blue coat antibody (antibodies are the swords our blood cell soldiers use) their body produced by infection with the blue coats last year don’t work as well against the red and purple coats the little devils have switched to. Still, they do work some in slowing down the severity of the resulting illness.

•The vaccine actually immunizes against 4 different types of influenza viruses this year (that’s what “quadrivalent” means) because these sneaky devils run in packs. Each of those shot elements have varying efficacy. But again, you take what help you can get, and shouldn't let the perfect be the enemy of the good.

•We have designer vaccines with higher doses for older people, many times also now on immune-suppressant drugs for our chronic diseases like me, and who are harder to make immune, so we need double doses of the vaccine at a time. Childhood vaccines under age 2 are similarly specific to that age group. Get a flu shot now, if you haven’t already this fall or this month. This epidemic is going to go on until spring, April or even May, guaranteed. They all peak in late March with the maximal snow depth no matter the year.

Second, recognize and know about the 3 ways people get sick with the flu and how to take care of them.

•Super sick fast patients: these are usually young people over 4 but under 40, mostly teenagers and young adults with young families of their own, kids often bring it home from school, who haven’t seen as many winters as us oldies and thus have a narrower spectrum of past body experience with the shifting devils. They get sick one night with chills, sometimes but not always have a fever over 101, become prostrate within hours, always have cough, which may not produce sputum; their lungs “white out” (fill with fluid) by xray, they often get confused, turn blue and will/can die within hours, often overnight. Get thee to an emergency room ASAP, do not delay!! Rare but extremely dangerous, the ones you hear about on TV right here in Maine now.

•Then there is another other group with delayed badness, especially in the young and old patients, who get the flu with fever over 101, productive cough, feel rotten all over, may have some vomiting, rarely diarrhea, who are having bad influenza that then allows a secondary bacterial pneumonia to grow in the lung mess the flu made. They start to get better after 3-5 days then relapse back with high fever, get sicker again, with more cough, more sputum, if they are strong enough to produce it, and can die in a few more days if not diagnosed and treated with bacterial antibiotics. They go to the ER as soon as that bounce back to bad happens

•Finally for the rest of the population, with sore throat, fever chills the next day, feel lousy, try to work still, which exposes more friends and neighbors, then gradually improve over a week and get back in the saddle.

Thirdly there are effective medical interventions that work and help those in the 2nd and 3rd bullet groups. You can prepare for using them by asking your doctor or nurse to consider giving you a written prescription for oseltamivir (Tamiflu) 75 mg to have on hand to fill if you get sick,  taken twice a day for 14 days and started within the first 48 hours of classic symptoms of the real flu; many clinicians will want to test a throat swab before prescribing Tamiflu but when the epidemic gets bad, most will figure hoof beats mean horses and do it even over the phone if your case sounds good enough. Also, by taking Tamiflu when you have been exposed to someone living in your house with influenza, one pill a day for 7 days can decrease the likelihood you get it and certainly reduce the rate of complications.

And finally, think of your family, friends and neighbors. Don’t work or visit with them if you can help it, when you are sick. Not 100% effective because you are spreading the virus a couple days before you get really sick, but still can help others.

That’s all (yea right!)!  Get a flu shot now if you have not. Avoid people sick with the real flu if you can. Know the 3 different patterns of illness when you or family get it. And be prepared to soften the blow with Tamiflu.

Shingles: What is it and how vaccinations may help

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

June, 2018

Several townspeople have asked my opinion about the new herpes zoster immunization now available, so here goes!

Herpes zoster or shingles is a fairly common disease (in my full time practice of primary care, I'd see 8-10 cases a year) caused by the recrudescence of the herpes varicella/chickenpox virus years after typical childhood chickenpox with fever, painful rash and pustules. The name shingles comes from Latin and French words for belt, or girdle, from the appearance of the skin rash on the torso. Since the introduction of childhood chickenpox vaccination in the mid 1990s, many fewer children now get it. But that leaves nearly everyone born before then with the potential to develop shingles later in their lives and especially if they become immunocompromised with immunosuppressant medications like steroids or anti-cancer drugs, or from diabetes, cancer itself, or other serious illness.

Strangely, the chickenpox virus hides in the body's sensory nerves, and can much later cause a recurrence of the chickenpox-like rash with pain/itching, redness and pustules confined to the anatomic distribution of the nerve in which it had been lurking undetected and innocuously for many years. So it manifests as a day or two of pain or itching and then a relatively unimpressive rash in a patch of body skin, often the trunk or an arm, or even and dangerously the face when an eye is involved. It is almost always on one side of the body, not symmetrical. The duration of the rash is usually several weeks, worst in the first and then gradually healing; it is shortened by antiviral antibiotics if given within the first 2-3 days. However, in about 5-10% of people, the pain persists despite the rash healing, a condition called post-herpetic neuralgia. This can be devastating; these poor people have skin hypersensitivity in the now-healed skin, so even the touch of clothing causes severe pain and suffering. I had an older patient once who had had shingles on her right chest wall; she took to wearing a small dishpan under her clothes, over the neuralgic skin patch, to prevent spasms of pain caused from clothing bumping it. Her pain lasted years and never went completely away.

If adults weren't immunized as children and never had chickenpox, they can still catch it from children or even from someone with an active case of shingles. Those cases are much more serious than in children, with fatalities from viral pneumonia. There is no evidence for immunizing these adults protectively with the childhood or zoster vaccines helps.

So most people over age 30, who have had chickenpox (the vast majority), can develop shingles at any time, most commonly over age 50, with a further higher incidence progressively with aging. To prevent shingles and the rarer incidence of severe post-herpetic neuralgia, two vaccines have been developed:

1) Zostavax in the early 2000s, a live attenuated Herpes varicella virus (like less virulent cow-pox virus vaccination was used to prevent small pox). It is given in a single shot, costing about $200, over age 60 and prevents over 50% of new shingles cases and 60% of post herpetic neuralgia over the first 3 years. Thereafter that efficacy diminishes gradually over time.

2) Shingrix just recently; contains inert pieces ("recombinant subunits" produced in test tubes) of the varicella virus. It requires two shots, a month apart, costing $300, and has many more side effects of local redness, swelling and pain as well more frequent systemic fever reactions, than Zostavax. But it appears to be moderately more effective over the first 3 years studied, especially in people over age 70. And studies have shown benefit even starting at age 50. We don't know how long the protection provided by this new vaccine will last or whether it is effective in people after they have had a first episode of shingles, unlike Zostavax, which clearly does.

There are many unanswered questions here:

1) Should I get one of these vaccinations?

Answer: Yes, maybe, if you have had known chicken pox and/or are older than 30 and immunocompromised, or over 50-60.

2) Which should I get and when?

Answer: Harder question, but probably depends on your age; get one of the two vaccines by age 69-70, when your immune system is still intact, because that is when your likelihood of developing shingles later starts to rise dramatically. The new vaccine might be better if you are immunocompromised by medication-treated diabetes or other conditions since it is effective from age 50 on.

3) What if I've already had shingles once; can I get it again and if so would the vaccines help?

Answer: Yes, you can get it again, although the episode of shingles you had jazzes up your immunity for at least a year. So get one vaccine or the other about a year after your shingles to prevent more episodes.

4) Should I get a booster shot of one or the other after some years go by?

Answer: So far, research has not shown that benefit for either vaccine, probably because you've gotten older and the vaccine is less effective in people over 70-75.

5) Is it worth it?

Answer: It depends on your attitude about the odds. Since the major complication worth preventing, post herpetic neuralgia, is fairly rare, about 200 people would have to be immunized with either of these vaccines to prevent one such bad case over the first 3 years post vaccination. That's a lot of money and immunization site pain and soreness for the other 199, and #200 never knows he was the lucky one.

6) So how do I sort all this out? What would you do?

Answer: I had chicken pox as a child, memorably! So I know I've got the little buggers hiding in my pain-sensing nerves. I got a Zostavax shot 15 years ago at age 60. I may leave it at that, despite, my being on steroids for another problem, though that may impair my immunity beyond normal. Tough call, but two shots of Shingrix with some likely local pain and suffering, especially with the 2nd one, dissuade me for now. And the effectiveness of a booster with either vaccine is unclear. If I did decide to go ahead, I would choose Shingrix because it clearly is more effective in older people despite no data past the 3-year mark yet.

A good but dense summary of all these issues with medical references can be found at: http://www.rxfiles.ca/rxfiles/uploads/documents/Shingrix_QandA.pdf

Medical Probabilities Exemplified in Influenza and Car Crashes

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

November, 2017

A relative told me last week that she was not going to immunize her daughter because she had read on the internet that the immunization didn't always work and had complications. Her husband, my nephew, is an anthropologist and so trained in scientific probabilities. It astounded me that he could tolerate such oversimplification of the probabilities involved here. I thought of these issues again yesterday as I got my annual influenza shot. What if I asked the medical assistant if it would work and what the complications were; what would she likely say?

Medicine, especially public health, and life for that matter, are all about probabilities carefully measured. Their accurate measurement by scientific methods are the core charge of medical research; and part of that method is the replication of results by multiple different researchers to see if those results agree consistently.

If challenged, the medical assistant giving me my flu shot (technically an influenza shot) might have answered that, yes, it would help prevent the flu, or if in a hurry, perhaps just yes. The "help prevent the flu" is the more honest answer, which at least alludes to the probabilities behind the full answer. That full answer is that a flu shot reduces the likelihood of my having a major complication of flu, especially hospitalization, secondary pneumonia, or death, not to 0% but perhaps to half or 1/4 the risk I would run had I not had the shot. Medical treatment and prevention actions are never 100% effective, but if they prevent, ameliorate or cure disease even about 10% of the time, they are usually considered worth it. In my case, I have an increased risk of flu complication because of my age (as do kids over 6 months but under 5), and so am a particularly important target for flu immunization programs. So the crucial questions, when someone tells you that they had had the shot "but still got the flu", are: "was it really the flu, not just a cold?", and most importantly, "did the flu kill you?", because half the immunized people exposed to someone with the flu still get it, but in a much milder form.

And both I and a 2-year old have special types of vaccine just for us; in the case of the 2-year old, it is a 2-shot series with split viral particles to enhance the "take" to produce more antibody; and in my case it is a 4-virus (quadrivalent with two types of A, and two types of B influenza) in contrast to the usual trivalent version, and at a double concentration because people my age respond more sluggishly to the standard dose. More than you wanted to know, but the strategy is to tailor the vaccines to the age groups to get the biggest bang for the buck.

And what about my nephew's wife's concerned about complications and adverse effects? Well, like the benefits, they are always there as a possibility. What matters is what they are and at what probability. In the case of the flu shot, the benefits are pretty good, from my perspective, if my chances of dying when I get the flu are reduced by 50% from 10% to 5% with similar reductions in the disease severity and other complications. The only real side effect is a sore arm (in about 20%) from the double dose of flu shot, which is a pretty mild downside. It is harder on patients with a rare previous neurologic infection called Guillain-Barré Syndrome. But that ain't me. So I got the shot. Other vaccines have some very rare side effects, but beware of extremist internet sites, especially those concerning the childhood vaccines, like measles, mumps, rubella, polio, chickenpox, etc. I remember all those diseases (see my " Vaccination Ruminations" piece in the newsletter, Oct-Nov, 2014); they aren't pretty, and they are dangerous.

Yet another factor in deciding about flu shots or other infectious disease immunization, is the community. If you don't get the flu (most flu shot regimens prevent flu with at least a 50% success), then you are decreasing the likelihood of spreading it to your family and friends. That's why all medical personnel are required to get the flu shot every year; they will kick me out of the hospital if I don't.

So what about the car crashes mentioned in my title? Well, look at the graph below. It shows deaths from car crashes in this country from 1900 to the present. Guess why the dramatic drop from the 1930s to now. The reduction reflects improved car and road engineering as cars evolved from wagons with motors to safety pods that travel on much safer roads at 2-3 times the speed of those early vehicles. The graph for influenza and other communicable diseases looks almost exactly the same.

Improving vaccines and motor safety methods improve outcomes, not by 100%, but by a lot, if done scientifically. It all depends on the balance between the probabilities of benefits vs the harms and the costs.

MaineCare Expansion; Signing up

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

August 1, 2018

A bit of history first. The Federal Medicaid Program (called MaineCare here in Maine) was created when its enabling legislation was passed along with the better known Medicare Program in 1968, just as I was graduating from medical school. Before then, all the low-income patients I cared for as a medical student at Boston City Hospital, were dependent for free medical care at city- or county-run hospitals and their clinics, like Boston City, or community hospitals like those around us here in Mt. Vernon, all of which were committed to providing free care to those patients by acceptance of hospital construction monies dispensed through the Federal Hill-Burton program. All 3 Federal programs continue to this day.

More recently, the Federal Affordable Care Act (politicized by calling it "Obama Care", by many), created two new programs: an expansion of Medicaid to include adults under 65 with current annual incomes of less than $16,754 for individuals, $22,715 for couples, and $34,638 for families of 4 (see full tables below), and a "Market Place" where low-income individuals and families with incomes above those and up to 175% of poverty levels could buy Federally subsidized (discounted premiums) full insurance coverage. Over 70,000 people in Maine are getting their insurance through the latter program now but, because the governor has repeatedly vetoed the Medicaid expansion proposals in the name of saving Maine's 10% cost to do so, Maine people who would be eligible, are now left without access to MaineCare coverage. Nearly 2/3 states in the US are participating. Right now Maine income tax dollars are going for supporting the program in those other states but not here.

Annual Income Federal poverty upper limits

Monthly Income Federal poverty upper limits

Having cared for low-income families and studied the impact on their health if they are without insurance (see Mt Vernon Newsletter, October 2017, p5)) for my entire professional life as well as my work as president of Neighbors Driving Neighbors and as town health officer for Mt. Vernon/Vienna, I know how crucial such coverage is if these folks are to be able to find work, care for their children, and remain productive members of our communities. The children are particularly important. 15-20% of children in Maine are now born into such low-income families! The future of Maine will depend on these kids being healthy and succeeding. They can't do that very easily without their and their parents' health! I don't see anything controversial about such a position. As health officer for the town, I want to do anything I can to help that hole in our population's health insurance coverage for those under 65 who are between 100-138% of Federal poverty guidelines.

Maine passed the Medicaid expansion referendum last November with over 60% of the vote. I helped get signatures to support that. Now I'd like to help any Mt. Vernon resident who fits in that category to sign up for Maine Medicaid (MaineCare). If you are not sure, ask me to help you figure it out. As many may know, the legal team at Maine Equal Justice Partners (MEJP) has taken the governor to court to implement the law as passed. It is going to happen sometime within the next year. Those who apply now will get coverage for medical expenses retroactive to the date of their application. So applying now makes sense. In the meantime, those with other insurance coverage should not cancel that insurance until this comes through.

To learn if you are eligible and how to enroll, go to MEJP at: http://mejp.org/content/medicaid-mainecare-expansion-guide, or call 1-866-626-7059.

Or contact me at dkonion@gmail.com, or 293-2076.

About the Influenza Epidemic: Many of You Need to Help Yourselves, Your Family and the Community Right Now. Here’s How.

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

February 2018

People, people, people, many of you I meet are giving up about surviving the influenza epidemic we are in the midst of right now. That’s crazy; please don't!  We’ve got several kinds of arrows in our quiver to help us and ours survive if we are smart enough to use multiple strategies at once, as we do with other complicated challenges.

Please start by going back and reading my piece last November 2017 in the town newsletter, Medical Probabilities Exemplified in Influenza and Car Crashes. It is on p10 though the index in front says p9; go back and read those details; they are important. I explain the presence and impact of probabilities of influenza vaccine on the spread and effect of a “flu” epidemic in our community. It never is all or nothing!  I hate the way the media emphasize one artificial number, “the effectiveness” of the vaccine. I am not even sure how they compute that one number, but it isn’t the whole story and it seems to encourage people to give up. The number they are disseminating now is "30% effective". That should mean that of 100 people, who are exposed to the flu by breathing the viruses into their nose and lungs, 70 will get the flu while 30 won’t. But those aren’t bad odds to start with. We take what we can get and then go from there. So, if you got a flu shot, you are right now that far ahead of your neighbor who didn’t. What they don’t tell you clearly enough, is that of the 70 who get the flu, those who have had a flu shot, nearly all have a better time of it with less severe illness, fewer complications, and not being so sick they are hospitalized or die. Yes, influenza can be a fatal disease and is proving itself to be right now in Maine!

Yesterday I talked about influenza with three people. One, a 70-something friend and carpenter, told me he never got flu shots, didn’t believe in them, and wasn’t getting one despite having had severe pneumonia last year in that milder flu epidemic even though he still had left over lung damage and shortness of breath from it. He, of all people, needs a leg up on this year; I begged him to get the shot. Then there was a young woman grocery clerk with a clearly sputum-producing cough, repeatedly turning to cough away from her customers. Now it could be she just had bronchitis from being a smoker, but that would be unusual at her age and in the midst of a flu epidemic. I bet she had an early influenza infection and will get sicker. Coughing in the other direction simply spread the virus more widely; she should be taught how to effectively cover her mouth with her elbow and/or wear an effective mask, or go home until better. Her employer has a responsibility to have effective education to make this happen. Unfortunately, the Maine Center for Disease Control (CDC), which tries to do that education, has had its budget cut to the bone; and Congress let the national CDC shut down during the budget fight. So we may be on our own. The 3rd example was a mother of a 1-year old who didn’t “believe in” flu shots for her kid. My God folks, this isn’t a belief issue; it’s the science that got us to the moon, dropped mortality rates in this country so most of us get to see age 75 now, and redesigned cars and roads so motor vehicle deaths have plummeted over the last 50 years!

First, you’ve got to understand and recognize two things:

•What influenza is and what it is not. It is not simply a cold with sore throat and temperature under 100 degrees and the person still able to function. Nor is it predominantly nausea, vomiting and diarrhea from gut germs, and which we also call “flu.” Rather, it is a specific viral infection of the lung itself, caused by several related influenza viruses which characteristically change their protein coats as they rip through the population each year. That way people, who have previously been infected, have less resistance because the blue coat antibody (antibodies are the swords our blood cell soldiers use) their body produced by infection with the blue coats last year don’t work as well against the red and purple coats the little devils have switched to. Still, they do work some in slowing down the severity of the resulting illness.

•The vaccine immunizes against 4 different types of influenza viruses this year (that’s what “quadrivalent” means) because these sneaky devils run in packs. Each of those shot elements have varying efficacy. But again, you take what help you can get, and shouldn't let the perfect be the enemy of the good. We have designer vaccines with higher doses for older people, many times also now on immune-suppressant drugs for our chronic diseases like me, and who are harder to make immune, so we need double doses of the vaccine at a time. Childhood vaccines under age 2 are similarly specific to that age group. Get a flu shot now, if you haven’t already this fall or this month. This epidemic is going to go on until spring, April or even May, guaranteed. They all peak in late March with the maximal snow depth no matter the year.

Second, recognize and know about the 3 ways people get sick with the flu and how to take care of them.

•Super sick fast patients: these are usually young people over 4 but under 40, mostly teenagers and young adults with young families of their own, kids often bring it home from school, who haven’t seen as many winters as us oldies and thus have a narrower spectrum of past body experience with the shifting devils. They get sick one night with chills, sometimes but not always have a fever over 101, become prostrate within hours, always have cough, which may not produce sputum; their lungs “white out” (fill with fluid) by X-ray, they often get confused, turn blue and will/can die within hours, often overnight. If you see these signs, get to an emergency room ASAP, do not delay!! Rare but extremely dangerous, the ones you hear about on TV right here in Maine now.

•Then there is another other group with delayed symptoms, especially in the young and old patients, who get the flu with fever over 101, productive cough, feel rotten all over, may have some vomiting, rarely diarrhea, who are having bad influenza that then allows a secondary bacterial pneumonia to grow in the lung mess the flu made. They start to get better after 3-5 days then relapse back with high fever, get sicker again, with more cough, more sputum, if they are strong enough to produce it, and can die in a few more days if not diagnosed and treated with bacterial antibiotics. They go to the ER as soon as that bounce back to bad happens

•Finally, for the rest of the population, with sore throat, fever chills the next day, feel lousy, try to work still, which exposes more friends and neighbors, then gradually improve over a week and get back in the saddle.

Third, there are effective medical interventions that work and help those in the 2nd and 3rd bullet groups. You can prepare for using them by asking your doctor or nurse to consider giving you a written prescription for oseltamivir (Tamiflu) 75 mg to have on hand to fill if you get sick.  You take this twice a day for 14 days and start within the first 48 hours of classic symptoms of the real flu. Many clinicians will want to test a throat swab before prescribing Tamiflu but when the epidemic gets bad, most will figure hoof beats mean horses and do it even over the phone if your case sounds good enough. Also, by taking Tamiflu when you have been exposed to someone living in your house with influenza, one pill a day for 7 days can decrease the likelihood you get it and certainly reduce the rate of complications.

And finally, think of your family, friends and neighbors. Don’t work or visit with them if you can help it, when you are sick. Not 100% effective because you are spreading the virus a couple days before you get really sick, but still can help others.

That’s all: Get a flu shot now if you have not. Avoid people sick with the real flu if you can. Know the 3 different patterns of illness when you or family get it. And be prepared to soften the blow with Tamiflu.

Aging In Place

from

September, 2018

by George Smith and Dan Onion

Dan: George, I know from your recent columns that you are very interested in “aging-in-place” issues for both personal and public reasons. I’d like to hear a little more about why and how because as the health officer for both your and my adjacent towns and a boarded geriatric physician, I too have been been working on ways to help seniors stay here in their homes and among their friends and acquaintances. Tell me what you’ve been doing.

George: Our rural communities are full of old folks, so that is a new and important focus for many of us, including those of us working on a new comprehensive plan for Mount Vernon. A group recently formed a committee to work on initiatives for the elderly. Townspeople appropriated $1000 at the June town meeting for this new initiative. A few of us attended an AARP seminar on their programs for the elderly and were very impressed. Mount Vernon will be applying to join the AARP project soon. 200 towns are already participating in the AARP initiative that is called Building an Age-Friendly Community.

Dan: I’ve been working for the past 3 ½ years to establish a volunteer transportation system in our 2 towns and 3 contiguous ones. Four years ago, Sandy Wright and I happened to have coffee together at the Mt Vernon community center, where she told me that transportation solutions for seniors, who had had to retire from driving were the number one concern of a senior gathering at the local school. From there, she and I recruited a group of interested townsfolk, studied the issue, did some surveys of our seniors, and obtained a Maine Community Foundation 1-year planning grant. That grant let us pull together some focus groups to define the problem and explore some possible solutions, as well as hire Jo Cooper and a colleague from Ellsworth to consult with us about our plan. Jo has been a running service there for nearly 20 years. And, by the way, you probably know her brother Matt Dunlap, the secretary of state, who thereby is in charge of the Bureau of Motor Vehicles. Having served as chair of the BMV medical advisory committee for 5 years in the recent past, I know how interested they are in finding ways to help those whose health requires them to retire from driving themselves.

  Out of that planning arose Neighbors Driving Neighbors, our 5-town volunteer driving service, which has now, after 2 ½ years has given over 1000 rides to local residents, mostly seniors who can no longer drive. Starting with about 20 drivers, we now have over 45 volunteer drivers. A couple startup grants from the Bingham Betterment Fund and the Bingham Program got us going and we now seem able to survive with donations and charitable contributions from individuals and local businesses. Two part-time, very modestly paid local contracted coordinators field the ride requests and find driver matches. We are now giving about 40 rides a month, and last summer gave over 60. Initially most rides were for medical appointments, but we’ve been able to grow the percentage for other social activities up to nearly 50%.  Both are important, we think.

George: Neighbors Driving Neighbors is a great project, and I thank all who are participating, especially you and Sandy. And yes, Matt Dunlap is a good friend of mine. AARP offers community challenge grants to create vibrant public places, and we hope to get a grant for our library, where we hope the addition will become just that – a vibrant public place – for all members of our towns, from kids to senior citizens.

Dan: I never realized, until I got old myself, how complicated it is to plan for contingencies. When will I need driving help. When with housecleaning? When with plowing? When with meals. Can I stay in my house, etc.? And how do I keep up with friends and find new ones as others pass on or move away? I admire your planning and think your example and explicit reporting are helpful to many. In the old days, and occasionally still, multiple generations living in the same or nearby houses made all these choices much easier, but such arrangements are getting rarer, with smaller families, and adult children having to move out of state to find work. Strong, innovative communities seem to find a way to broaden support beyond immediate family members, as I see with Neighbors Driving Neighbors. Ours is one such community to be proud of.

George: One project that we need to tackle comes from the Red Cross. A local volunteer comes to your home to check on your smoke detectors, and they replace them if that is needed.  Both Wayne and Readfield participate in AARP’s program. I have friends who volunteer for Readfield’s Handy Helpers project, ready to help with things like moving furniture or taking things down from high shelves. With my illness of ALS, I must say it is wonderful to live in such a caring community, where many have volunteered to help Linda and me whenever we need help. Four friends came all winter to help Linda shovel. We are blessed.

From Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com