Today, the uptake of pertussis vaccine in the western world is similar to that for other vaccines, as the controversy is now largely forgotten. More than half of pregnant mothers are accepting the pertussis in mid-pregnancy to prevent early onset whooping cough in their newborn infant — the time of highest risk to children.
Unfortunately, in the process of reviewing our own vaccine safety, we exported the controversy to Third World countries, where mortality rates from pertussis were high and more benefit would have come from vaccine.
The MMR Vaccine: A Cause of Autism?
Autism is a lifelong neurodevelopmental disorder with a strong genetic component. In 1998, a study was published suggesting a link between MMR (measles, mumps, and rubella) and the onset of autism.
Various vaccine advocacy groups showed their concern, and soon the uptake of MMR vaccine fell off considerably. These illnesses then began to reappear in our homes and schools.
The profile of this controversy was highlighted by some very well known Hollywood figures — the best known of whom was Jenny McCarthy, an actress then in a relationship with Jim Carrey. Jenny firmly believed that her son’s autism was caused by MMR vaccine. Once again, very strong publicity resulted in the withdrawal of many thousands of people from the routine vaccination program.
It’s easy enough to see why parents might suspect a link between the two. MMR is given at 12 to 15 months, exactly the age that doctors begin to make pronouncements on a child’s development — particularly social development.
So suspecting a cause and effect is somewhat understandable — but not true. Recent studies across North America and Europe have failed to show any link between this vaccine and autism. Moreover, retrospective studies showed no increase in autism in the first ten years after the introduction of MMR in 1988.
Some of the theory propounded by the anti-vaccine advocacy groups related to the belief that the mercury in vaccines caused the autism. The mercury compound Thimerosal is used as a preservative in MMR. This compound has also been refuted as a cause of autism, but because of the number of new vaccines being given to children, it was deemed prudent to remove all mercury from vaccines after a recommendation by the American Academy of Pediatrics.
Concern has also arisen about the sheer number of shots that infants are being given in the first year of life. This too has been highlighted as a possible cause of autism, and again refuted by careful research studies.
So, largely because of these and other vaccines, we no longer need 800-bed hospitals — nor perhaps as many pediatricians either!
REFERENCES
Baker, J.P. The pertussis vaccine controversy in Great Britain, 1974–86. Science Direct March, Vaccine, vol. 21, 2003, pp. 4003–4010.
DeStefano, F. Vaccines and autism: Evidence does not support a causal association. Nature, vol. 82, no. 6, December 2007, pp. 756–759.
25 DIABETES AND THE INSULIN STORY: JUST TOO MUCH SUGAR?
THE DISCOVERY, ISOLATION, and manufacturing of insulin is one of the most Canadian of stories. Insulin research has probably altered medical outcomes more than any other medical research. An estimated 500 million people are afflicted with diabetes worldwide. Since the discovery and isolation of insulin in 1923, billions have had access to this hormone to control their blood sugar.
Although diabetes clinics are known to have existed in India in 4000 BC, before the discovery of insulin no treatment had targeted the cause of diabetes, namely insulin deficiency. It’s a source of great national pride in the Great White North that a relatively unknown surgeon, Frederick Banting, and an even lesser-known medical student, Charles Best, isolated this hormone from the pancreas of dogs. Their research, done in the University of Toronto, was awarded the Nobel Prize.
Banting discovered that removing the pancreas from a dog gave it symptoms of diabetes. After isolating pancreatic extract from a second dog, he was able to inject it into the diabetic dog and reverse the symptoms of high blood sugar. Dog 92, a collie, was the first live being to experience remission from symptoms of diabetes through use of the insulin hormone.
In the university hospital, Leonard Thompson, a 14-year-old boy, lay dying of Type 1 diabetes. When he was injected with insulin, he made a recovery and eventually went home.
One likes to think of dedicated researchers toiling over the research that will benefit humanity — and that certainly was the case with these two medics. However, when the Nobel Prize was announced, it was given to “Banting and MacLeod.” Professor MacLeod was head of physiology at the University of Toronto. He had given space to the researchers to conduct insulin extraction, but he had been sceptical about their research and played no part in the actual experiments.
A phone call came through to the University of Toronto requesting that Banting and MacLeod be present in Oslo 11 days later for the awards. Banting was furious — the university clearly was not going to allow a Nobel Prize to go to a mere medical student. He refused to travel to Oslo, and insisted that the prize be given to Banting and Best. He also contacted the Toronto Star and spoke to the reporter who had broken the story — a man called Ernest Hemingway. Hemingway had been working as a reporter for the Star for two years. He said he would love to publicize the cause of Charles Best, but he was leaving that week for a writing contract in the United States
Eventually, a compromise was reached: the prize would be shared with Best. Banting then accepted, believing the prize would be awarded to Banting and Best. However, although Best received 50 percent of the prize money, he was never recognized as a Nobel Prize winner. Instead the prize went to Banting and MacLeod. Such is the politics of medicine. Later in his career, Best was appointed professor of physiology at U of T and went on to claim MacLeod’s job.
Today in our Pediatric Diabetes Clinic in Kingston, Ontario, we have 150 young people who live amazingly productive lives while being dependent on insulin for their survival and well-being. I have enormous respect for these teens who live with these restrictions and yet achieve amazing academic, social, and athletic results. One of our lads is a competitive hockey player who lives away from home for training. He tests his blood sugar level six times daily, wears an insulin pump, and maintains average blood sugar in the normal range.
It wasn’t always this good. As a student, I recall that persons with Type 1 diabetes were only seen every six months. They had one blood sugar drawn by the laboratory, and visited a dietician to review their eating practices. It was impossible to know how these people were doing on a day-to-day basis. Some diabetics would be hospitalized because of poor control over their blood sugar levels, while some would have seizures from low blood sugar.
Technology has come to the aid of our clinic — in a big way. Up until the mid-1980s, we had no way of monitoring blood sugars on a daily basis. Then came glucometers. These are the portable meters that are able to test blood sugar levels from a tiny amount of blood, taken by finger pic from the side of the fingertip. By recording levels regularly, patterns emerge that allow us to adjust insulin according to the growth, diet, and lifestyle of the patient.
In the 1990s came insulin pumps and continuous glucose monitoring devices that allow hour-to-hour adjustment of insulin doses. An insulin pump acts like an artificial pancreas, delivering insulin under the skin at low doses all day, and increased doses at meal times.
Although it’s a common condition, there may be more misinformation than good information on this subject than any other in medicine. Myths abound ….
1 Diabetes is caused by eating too much sugar
This is pure myth. Everyone eats more sugar than they need. Many foods contain sugar — not just table sugar and candy. For instance, bread, fruit, and pasta contain carbohydrate sugars. If the pancreas is functioning, these sugars will be metabolized. However, diabetics do count their carbohydrates, to calculate how much insulin to give themselves.
2 Diabetes is a lifestyle disease
This is a misconception, based on inadequate information. There are
two types of diabetes, known as Type 1 and Type 2. These “types” are actually two separate diseases, with similar symptoms. The principal difference is that Type 1 patients are deficient in insulin, whereas Type 2 patients have plenty of insulin, but it doesn’t work to bring down blood sugar.
Insulin, produced by the pancreas, is the hormone that unlocks the cells to allow sugar to enter and be used as energy.
In Type 2 diabetes, patients tend to be heavier. But everyone who is overweight does not get Type 2 diabetes — being overweight is just a risk factor for Type 2. And while a reckless lifestyle will add to the negative prognosis, this could be said for most chronic diseases.
3 Diabetes is not very common
The best source for diabetes demographics is the United States, where figures are readily available: population, 350,000,000; diabetes incidence, 33,000,000. This ratio would equate to 3.5 million people with diabetes in Canada. So, close to one in ten people in the western world have diabetes, perhaps even more. Many people don’t realize they have it. Approximately 90 percent of these people have Type 2 diabetes.
The spread is different in adults and children. In children, 90 percent have Type 1 diabetes, while 10 percent have Type 2. In adults, 10 percent have Type 1, and 90 percent have Type 2.
Type 1 diabetes used to be called “Juvenile Diabetes” because of this demographic. Traditionally, children were not commonly seen with Type 2 diabetes. With the obesity epidemic in children, this situation is changing. Also, because of the genetic nature of diabetes, certain ethnic groups can experience Type 2 diabetes in adolescence. These groups in-clude Native American, Hispanic, Asian, and African-American children.
4 Long-term complications are inevitable
While it’s true that, if left undiagnosed and untreated, diabetes can lead to heart, stroke, and kidney problems, in addition to blindness, nerve damage, and amputation, this does not need to be the case, and the incidence of these complications is falling with treatment.
Prior to 1993, it was uncertain as to whether good control would actually lead to a healthier patient in later life. A landmark study from 1983 to 1993 called the DCCT (Diabetes Control and Complications Trial) showed that keeping the blood glucose level close to normal would slow the onset of the complications listed above. However, it is said that the arteries of someone with diabetes in midlife appear ten years older than normal.
Type 1 diabetes can strike at any age. A condition called DEND (Developmental Delay, Epilepsy, and Neonatal Diabetes) is fairly well known to those of us who treat children. Neither is it unusual to have a nine-month-old, or even nine-week-old, infant present with insulin dependent diabetes.
The logistics of caring for these children are very complex, but the principles are the same: keep blood sugars as close to normal as possible, without having them too low.
5 Young people don’t look after their diabetes
How often I hear this, mainly from those who know little about the world of young people who must learn to live with diabetes. True, before the discovery of insulin, mortality was inevitable. But try waking up on any given day and jabbing your finger to obtain a blood sugar reading before giving yourself two injections in your leg, and still being in good form for math class. Try fitting in at high school when other teens are gorging on submarine sandwiches, and you have to test blood and give yourself an injection — and try to be cool. Harder still, try injecting your two-year-old child and drawing blood from a tiny finger four to six times a day. Yes, there are those who fall short on their control from time to time. But could you or I do any better?
While it was somewhat uncommon in the past for persons with Type 1 diabetes to compete at professional level, Bobby Clarke (NHL) and Arthur Ashe (tennis) both had insulin dependent diabetes. In the future, it will be more common to see insulin-dependent athletes at a competitive level. This has come about because insulin pump therapy has allowed for an “artificial pancreas” to deliver insulin round the clock, and also to predict major falls in blood sugar levels and avoid them. Having an insulin pump can make our athletes with diabetes competitive with the general population.
Of our 150 patients in the Kingston pediatric diabetes clinic, I firmly believe that the majority are healthier and more functional than their peers in school.
6 You can’t drink if you have diabetes
This is not true. Persons with diabetes, on insulin, may enjoy a pint or two just like the rest of us. It’s just a matter of calculating the amount of carbohydrate sugar in the drink, and giving enough extra insulin to compensate for it, so the blood sugar doesn’t go too high. This is easier for those on an insulin pump, as it doesn’t require an extra needle.
However, any more alcohol than that and a new danger is introduced: low blood sugar next morning. Alcohol is metabolized in the liver and will block the release of sugar from the liver, causing a complication called hypoglycemia. This is a state of unconsciousness that can lead to a seizure. Rapid infusion of sugar is necessary to reverse it. We see this problem in teens who haven’t been educated in how to manage alcohol at parties.
7 Diabetes hurts your employment prospects
This, thankfully, is becoming a myth. An employer does not have the right to insist on disclosure of your medical file. However, if you don’t tell your employer about your condition, it’s hard to arrange time off to check blood sugar and take insulin or even to eat regularly. So most people are up front, and the rights of persons with disabilities ensure that you can’t be discriminated against because of your medical problem (3.5 million Canadians, after all).
But what of the danger to others? This is where good judgment needs to rule. In 2006, the RCMP ruled that if a criminal is allowed to have Type 1, then surely a police officer with Type 1 diabetes should be eligible to work on the force! Therefore, diabetes is no longer an impediment to joining the Mounties.
In the past, the medical profession was unable to provide sufficient reassurance regarding the risk of low blood sugar in persons working in dangerous positions. This is not so much the case anymore, although hypoglycemia is not 100 percent predictable. Truck drivers with diabetes, for instance, have strict protocols to follow: they must test blood sugars before driving and at regular intervals thereafter.
The Canadian and American armed forces are exempt from anti-discrimination laws. You cannot join the armed forces if you have insulin-dependent diabetes. If you develop Type 1 diabetes while you are serving, you will be discharged with a severance.
What about flying a plane? Well, this varies. The U.S. Federal Aviation Authority identifies insulin use as a disqualifying condition to receiving a medical certificate to fly an aircraft. However, it is possible to obtain a third class licence to fly a private recreational plane. Amazingly, Canada (2001) and the UK (2012) have been allowing pilots with Type 1 diabetes to fly aircrafts even in American airspace. The protocol for these pilots is a blood sugar test one hour before flight; test one hour into flight; test hourly during flight; and test 30 minutes before landing.
Unfortunately, Type 1 diabetes still precludes you from becoming an astronaut!
REFERENCES
Bliss, M. Banting: A biography, University of Toronto Press. March 1993.
Fox, L.A., L.M. Bucklow, S.D. Smith, T. Wysocki, N. Mauras. A randomised controlled trial of insulin pump therapy on diabetes control and family life in children 1–6 yrs old, with Type 1 diabetes. Diabetes Care, vol. 28, no. 6, June 2005, pp. 1277–1281.
26 SUBSTANCE ABUSE: A PROBLEM OF THE YOUNG?
IT’S NOT HARD TO SPOT someone who is abusing substances, especially if you are familiar with the person. The changes in behaviour, facial expression, speech, or cognition are usually clear.
However, our perception of a substance abuser is generally of a young person, high or otherwise intoxicated, perhaps associated with music or other entertainment. Celebrity personalities with substance-abuse problems do tend to belong to a younger generation. But is it a myth that older adults don�
��t use or abuse mood-altering substances?
Deteriorating function in an older person can be associated with progressive neurological disease or prescription drugs. However, these symptoms can also be caused by abuse of drugs and/or alcohol.
Traditionally, older adults have not shown high rates of substance abuse compared to younger people. But the Baby Boomer generation came of age at a time of great social change, with changing attitudes to drug (and alcohol) use not seen in previous generations. The prevalence of Substance Use Disorder (SUD) has remained high in this demographic as it ages. Today, Boomers (aged 50 to 69) make up around one-quarter of the population in Canada and the United States.
Consequently, the proportion of older people needing treatment for SUD will grow considerably. For example, SUD rates in persons over aged 50 are expected to double from 2006 to 2020.
Despite the cultural shift to mood-altering drugs in seniors, alcohol remains the most commonly abused substance in persons over 65. Although most older persons reduce their alcohol use as they age, the true incidence of AUD (alcohol use disorder) is skewed by underreporting. Current rates of binge drinking in over-65s is 19.6 percent for men and 6.3 percent for women.
Tobacco use is also quite prevalent in over-65s. Smoking cessation interventions are generally less successful in this age group because of physiological dependence on nicotine after a lifetime of smoking.
Illicit drug use is more prevalent among American seniors than those of any other country. Over one million reported using cocaine, methamphetamine, or heroin. In older adults cannabis use is more prevalent than the use of other drugs. Among adults over the age of 50, 4.6 million reported using cannabis in 2014. With the relaxation of marijuana laws and the passage of medical marijuana legislation, the prevalence of its use among this group may well increase, particularly if it is used to cope with the effects of illness.
One of the biggest sources of abused drugs is the medical profession. Older adults take more prescribed medications than younger people. Of persons aged 60 to 85, one-third are taking five medications concurrently!
Of Plagues and Vampires: Believable Myths and Unbelievable Facts from Medical Practice Page 7
