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By Jessica Snyder Sachs
religious about what really matters, you can take shortcuts with the rest.
Check out our guide to being a sensible slacker.
If you're religious about what really matters, you can take shortcuts with the rest. Check out our guide to being a sensible slacker.
1. Work Out 5 Days a Week?
It's not your imagination: Our bodies simply become higher maintenance after 40. Indulgences of food or drink are quicker to take revenge. Muscles require more maintenance. Screening tests become more important. So there's a lot to remember -- and yet the wellness precautions keep coming, with new dos and don'ts every passing year. Can anyone do it all?
Actually, no. And if you try, say experts, you may end up throwing in the towel on some of the essentials, as well as what's helpful but optional. So find out where you can settle for good enough and still enjoy great health.
Rule 1: Work out 30 to 60 minutes a day, five days a week.
The Midlife Shortcut: Catch up when you miss workouts.
To reduce the risk of heart disease, cancer, and osteoporosis -- all big concerns for women over 40 -- experts urge us to exercise at least 30 minutes a day, five days a week (and for maximum health benefits, make that an hour rather than half an hour). But daily workouts can be difficult to fit into a life crammed with work and family responsibilities. Then there's the knee and joint pain that many women experience after years of pounding their way through "healthful" exercise.
Why there's wiggle room: The cumulative hours -- the total time you clock each week -- is what really counts. In fact, the weekend warrior has gotten a bad rap, says exercise physiologist Jane Roy, PhD, of the University of Alabama at Birmingham. If you're too busy Monday through Friday, weekends are a great time for getting in two or more hours of enjoyable exercise a day. You can catch up by spending a weekend morning or afternoon playing tennis with girlfriends, taking back-to-back aerobic and Pilates classes, or going for a long walk or run.
Then, during the week, concentrate on interspersing sedentary activities such as computer work with small but frequent movement breaks, Roy adds.
2. Get a Pap Smear Yearly?
Rule 2: Get a Pap smear every year.
The Midlife Shortcut: Get tested every two to three years.
Sexually active women under 40 should be tested every year, but women over 40 can stretch it out to once every two to three years once they've had three or more normal results in a row, as long as they're in a long-term, mutually monogamous relationship or are not sexually active, and they're still getting annual pelvic exams.
Why there's wiggle room: When a woman is either not having sex or always has it with the same person (and that person is not having it with anyone else), she's not being exposed to new strains of the human papillomavirus, explains gynecologist Stacy Tessler Lindau, MD, of the University of Chicago Medical Center.
The majority of people who have ever been sexually active have been exposed to one or more strains of HPV. Most women clear the symptoms of the virus within a few months. But in a small minority, the infection causes cells to become precancerous over the course of several years. These are the abnormalities that show up on Pap tests.
What that means is the risk of precancerous changes (and ultimately cervical cancer) becomes very low once women pass through this latency period without being exposed anew by having sex with someone different. Even if you don't have a new partner, says Lindau, "You can be exposed to new sexual partners through your own sexual partner." That's why your relationship has to be mutually monogamous; if you're not sure it is, continue to be tested every year.
3. Eat 5 Servings of Veggies a Day?
Rule 3: Eat your veggies: five servings a day.
The Midlife Shortcut: Aim to include veggies in most meals.
Five servings a day add up to a heck of a lot of vegetables. Using USDA food guide serving sizes, you'd need to swallow up to 17 cups of salad or solid veggies a week to meet that goal -- that on top of the four daily servings of fruit you're supposed to get.
Admittedly, as the over-40 metabolism slows, substituting produce for higher-calorie foods and snacks can help with weight control. But as our lives grow exponentially busier, getting down all those veggies can become overwhelming.
"Five servings a day remains an admirable goal," says registered dietitian Christine Gerbstadt, MD, of the American Dietetic Association. And she argues that meeting it can be a lot easier than you think. "Potatoes count," she notes. "Just don't make it french fries every day." You can also add salsa, tomato sauce, or any kind of bean to the list.
But she's also willing to compromise. "A decent daily plan is to include some vegetables in most meals, then concentrate on rounding out the rest of your diet by pumping up the fibrous whole grains and healthy fats."
Why there's wiggle room: If you look at the big nutrition picture and aim for moderate goals, success may encourage you to surpass your quota. But if you don't hit the mark every single day, Gerbstadt says, you can get by with a daily multivitamin -- that will ensure you get the vitamins and minerals that are naturally abundant in fresh vegetables.
4. Brush After Every Meal?
Rule 4: Brush after every meal.
The Midlife Shortcut: Put down the toothbrush and grab some gum.
Or a toothpick. Or gum. Or a glass of water. It's not necessary to brush your teeth after every meal if you do something else to remove the food debris.
Why there's wiggle room: Brushing when you get up and before you go to bed is just fine, according to Edmond Hewlett, DDS, of the UCLA School of Dentistry. In fact, Hewlett says it's a bad idea to brush right after consuming acidic foods or beverages such as wine, orange juice, and most soft drinks. "The acidity slightly softens tooth enamel," he explains. So habitually brushing right after eating these foods can contribute to tooth sensitivity and cavities.
Chewing sugarless gum has other benefits besides removing food residue. It also increases saliva, which contains minerals that help replace the enamel lost to acidic food and acid-producing mouth bacteria. That's particularly important after age 40, when your natural saliva production starts to decrease. And if the gum contains xylitol, you'll get an added bonus: This sugar substitute inhibits the growth of cavity-causing tooth bacteria.
5. Sleep for 8 Hours?
Rule 5: Eight hours of sleep every night -- no sleeping in.
The Midlife Shortcut: Sleep late on weekends.
Yes, the human body does need eight hours of sound sleep each night, says Joanne Getsy, MD, of Drexel University College of Medicine, in Philadelphia. "It's a fallacy that you need less sleep as you get older," she says. "You don't need less; you simply get less." Anyone dealing with hot flashes and sleep disturbances knows this too well. But whereas many experts insist that "catch-up sleep" isn't as good as the real thing, Getsy says there's room for deviating from your normal wakeup and going-to-bed times.
Why there's wiggle room: "The aim should be to pay back your sleep debt as soon as you can," Getsy says. Specifically, she recommends scheduling twice-a-week catch-up nights. "Pick one weeknight and one weekend night, and don't plan anything on those evenings," she advises. "Let them be your nights to recover." Daytime napping is okay too, she adds: "Just keep it under an hour so it doesn't interfere with a solid night's sleep."
As for sleep-bingeing on weekends, Getsy advises staying in bed as late as you like on Saturday. Then on Sunday, split the difference between when you'd like to get up and when you have to get up on Monday. That will help ease you back into your weekday schedule.
Even better news: Getsy says that when it comes to sleep debt, it's okay to pay back less than you borrowed. Usually one full night's sleep is enough to make up for a couple of shortchanged ones, she says. "If you feel better in the morning, you've slept enough."
6. Lift Weights 3 Times a Week?
Rule 6: Lift weights three times a week.
The Midlife Shortcut: Try for one or two sessions a week.
On top of encouraging us to meet aerobic exercise quotas, the health gurus tell us to get to the gym and pump iron at least three days a week. Strength training is especially important after menopause, at which point a woman's body tends to lose both muscle mass and bone strength.
"When you make the muscle grow, you strengthen the bone that's attached to it," explains Felicia Cosman, MD, of the National Osteoporosis Foundation. Aerobic exercise such as jogging works only about 20 percent of muscle fibers, she says, while strength training with weights engages up to 90 percent.
Why there's wiggle room: There's no magic number as to how often you need to strength train. Aim for regularity, Cosman says, even if it's just twice a week. Nor do you have to schlep to a gym. "Weight machines and free weights are good," Cosman says, "but so are equipment-free Pilates and yoga moves, and push-ups."
7. Do a Breast Self-Exam?
Rule 7: Do a breast self-exam every month.
The Midlife Shortcut: Do it often enough to notice changes.
We came of age being trained to search for lumps every month. The mandate feels even more compelling now, given how greatly the incidence of breast cancer increases after 40.
As it turns out, however, there's little evidence that obsessively examining yourself really helps women catch more life-threatening lumps.
Why there's wiggle room: After years of urging women to perform monthly self-exams, the American Cancer Society recently deemed them optional. But what's still important, says ACS spokesperson Debbie Saslow, PhD, is that women become familiar with how their breasts feel and what's normal for them. "For a lot of women, that's still a monthly exam. For others, it's the occasional self-exam or simply paying attention when getting dressed or showering."
Where Not to Cheat
Here's where our health gurus draw the line. Follow these three rules, they say, as scrupulously as you can.
Yes, you get brownie points for working out on weekends, but you lose out on lots of benefits if you just sit in a chair the rest of the week, says Jane Roy, PhD, of the University of Alabama at Birmingham. So get up for a stretch break at least once an hour at work (you could walk down the hall to talk to a colleague instead of sending an e-mail), and a few times a day, catch some fresh air with a quick five-minute stroll outside.
If you need extra motivation, consider this: Five one-minute stretch breaks over the course of a day burn just 15 to 20 calories. But over the course of a year, that adds up to over two pounds of fat.
Mammogram Every Year
When cancer strikes women in their 40s, the tumors tend to be aggressive, which means fast-growing -- so the early detection offered by mammograms is crucial, says the American Cancer Society's Debbie Saslow. After menopause, women tend to have slower-growing cancers, she adds, but the incidence increases. "So going longer than a year just isn't worth the risk," she says.
Overweight women are more likely to develop heart disease, diabetes, and many types of cancer than normal-weight women are.
In fact, a recent analysis estimates that 20 percent of all cancer deaths in American women are linked to excess weight. In general, cancer rates increase when a woman's body mass index exceeds 25, says Colleen Doyle of the American Cancer Society. The risk rises more dramatically when the BMI passes 30. Abdominal fat appears to be closely associated with postmenopausal breast cancer and cancers of the colon and pancreas. And some experts say that the risk increases when a woman's waistline exceeds 32 inches.
Originally published in MORE magazine, February 2009.
Antibiotic-resistant germs are showing up in hospitals, playrooms, and gyms around the country. Here's how to keep you and your family safe
Snyder Sachs, as first appeared in PREVENTION
One summer morning in 2004, Susanne Petrosky, 37, of Perkasie, PA, woke up feeling feverish. It was a month after she'd given birth to her third child, and one touch of her left breast--hot, swollen, tender--told her it was infected. She knew the drill, having been through it with her second baby. She called her doctor, picked up a prescription for the antibiotic clindamycin, and took it faithfully for the full 7 days. No more breast infection.
Then the diarrhea started, with cramping so bad it made her recent labor pains seem mild. She made an appointment to see her doctor and got on the Internet. "I typed in clindamycin and side effects and it came right up--severe, sometimes fatal, diarrhea," she says. On the phone, her doctor was reassuring. That was on a Thursday. She spent much of the weekend lying on the bathroom floor; on Monday morning her sister drove her to the doctor. "He took one look at me," Petrosky says, "and told us to go straight to the emergency room."
Petrosky had picked up a dangerous new strain of an old bug: Clostridium difficile. The bacteria, which produces toxins in the intestine, is common--when people on antibiotics end up with diarrhea, C. difficile is often to blame. Generally, once they've finished taking the drugs, the diarrhea clears up on its own. But the new strain is much nastier than normal. It churns out 20 times the colon-damaging toxins as the older version, causing severe intestinal inflammation, or colitis, and is resistant to several important antibiotics. When Petrosky got sick, Canadian hospitals had already reported more than 200 deaths from C. difficile--toxins had eaten right through the walls of patients' colons. Many American hospitals were experiencing similar outbreaks, and the hypervirulent strain had begun to infect people in the general community. Since then, the situation has only gotten worse.
Experts have long warned against the overuse of antibiotics because of the possibility that bacteria would develop resistance to the drugs we use to kill them. Now, researchers say, some of their fears have come to pass. The CDC estimates that of the approximately 2 million bacterial infections Americans acquire in hospitals each year, 70% are resistant to at least one of the drugs commonly used against them. Why that's scaring the experts: If standard drugs don't work, doctors sometimes have to turn to more potent--and more toxic--alternatives. In some cases, those last-resort antibiotics have caused irreversible liver or kidney problems or lasting pain from nerve damage. In others, people have died for lack of an effective treatment. The CDC says that drug resistance kills 70,000 Americans each year--more than car accidents and homicides combined.
"The superbugs are here," says Martin J. Blaser, MD, president of the Infectious Diseases Society of America and the chair of New York University Medical School's department of medicine. "And it doesn't take a crystal ball to see that even more problems are coming."
Scientists are trying to develop new bacteria-fighting drugs, but that process takes decades. In the meantime, we have to defend ourselves. It's crucial to be able to recognize the warning signs of a superbug infection, or, even better, prevent one. Here are four of the most dangerous of these germs and how leading experts say you can protect yourself.
Superbug C. difficile: A Toxic Intestinal Bug
When Petrosky got to the hospital, doctors immediately put her on extrapowerful antibiotics. She improved, but her right arm went numb from medicine-induced nerve damage; when her physicians switched drugs, she relapsed. It took more than 9 weeks to get her out of danger. After her recovery, her 4-year-old son and a neighbor went through similar bouts of illness. The neighbor had to be hospitalized.
The number of new cases of C. difficile-associated colitis among US hospital patients has doubled over the past 5 to 10 years, to as many as 500,000 a year, reports CDC medical epidemiologist L. Clifford McDonald, MD. The infection rate outside hospitals appears to have increased many times over, as well. And the death rate has skyrocketed: from less than 2% to as high as 17%.
Avoid broad-spectrum antibiotics, if possible, when an illness requires an antibiotic. (Broad spectrum means they kill off good bacteria along with the bad.) The broad-spectrum antibiotics most associated with C. difficile infection are clindamycin (Cleocin), and the fluoroquinolones (Cipro, Floxin, and Levaquin).
Consider upping your intake of "friendly" bacteria, such as Lactobacillus and Bifidobacterium. They can be found in many brands of live-culture yogurt. Such a step can't hurt; research continues on whether it can help deny bad bugs a foothold in your system.
Contact your doctor if you have diarrhea or cramping and gas that lasts longer than a few days, and avoid antidiarrheal remedies, which can prevent your body from expelling C. difficile's tissue-damaging toxins. Instead, drink lots of fluids to stay hydrated and try the BRAT diet: bananas, rice, applesauce, and toast.
MRSA: Out of the Hospital and in your Community
On Christmas night, 2005, 14-month-old Bryce Smith had a stuffy nose and slight fever--his first cold, say his parents, Katie and Scott Smith of Santee, CA. Around midnight on New Year's Eve, Bryce began to struggle frighteningly for breath. The Smiths rushed him to the hospital, where a nurse checked his oxygen level. Within seconds, Katie recalls, at least 10 doctors and nurses had crowded around her baby, looking very scared.
X-rays and CT scans showed that Bryce's lungs were riddled with holes, and a team of surgeons hurried him into the operating room. Doctors told the Smiths that Bryce had the worst kind of lung infection, one caused by a particularly virulent variety of staph bacteria. Dubbed CA-MRSA, for community-acquired methicillin-resistant Staphylococcus aureus, the bacteria is resistant to penicillin, amoxicillin, and the other "cillins." And it produces poisons--which were chewing up Bryce's lungs.
Bryce lay in a medically induced coma for a month as doctors infused his body with a cocktail of antibiotics, sedatives, and other drugs. The medicines worked: After 40 days, the doctors brought him out of sedation and removed his tubes. But his parents have to be supervigilant now, because the treatment weakened his immune system, at least temporarily. "What would be an ordinary cold for us could prove deadly for him," his dad says.
Staph causes problems only when it slips past the body's defenses, through a cut or scratch or into lungs weakened by a viral infection. Close contact--on playing fields, in locker rooms and showers, and between children in day care and preschool--has been the key to many outbreaks. (Young children appear to be particularly at risk.)
MRSA made headlines in 2005 when Miami Dolphins Junior Seau and Charles Rodgers were hospitalized with limb-threatening skin infections and college football player Ricky Lannetti of Philadelphia died suddenly of MRSA pneumonia on the heels of the flu. And a study in the New England Journal of Medicine startled physicians by revealing that the bug now causes more than half of all skin infections treated in US emergency rooms. It's crucial, say researchers, for doctors to keep the possibility of MRSA in mind--the study found that most cases of MRSA were treated with drugs that don't work against the superbug.
How To Avoid MRSA
* Wash cuts and scrapes thoroughly with soap and water.
* Don't share personal items such as towels and razors, and just in case you have a scratch that would offer entry to MRSA, always keep your clothing or a towel between your skin and any shared surfaces such as workout equipment or locker-room benches. *
* Get vaccinated against the flu--the disease clearly raises the risk of the most severe kind of staph infections.
* Don't ignore an infected wound or a
pus-filled boil--not even a scratch, if it seems to worsen over the course of a
few days. MRSA skin infections tend to be very red, swollen, and painful,
sometimes with a raised bump resembling a spider bite. Getting the right
antibiotic is critical, so ask your doctor to consider the possibility of MRSA.
* Be particularly vigilant about any chest cold or flu that takes a sudden turn for the worse, or a fever that spikes over 102 degrees F. "Every major medical center is now on the alert for MRSA," says John Bradley, MD, chief of infectious disease at Rady Children's Hospital--San Diego, where Bryce was treated. "But there's still a problem with general practitioners and small community hospitals, where doctors may never have seen a case."
Superbug E. Coli: Food's Dangerous Hitchhiker
Frightening news stories recently about the damage done by tainted spinach made it horrifyingly clear: Produce, like meat, can harbor lethal germs. The culprit in spinach, E. coli 0157:H7, is not antibiotic resistant (in fact, antibiotics are not used to treat this infection), but is indisputably extratoxic; the poisons it produces can cause fatal kidney failure. Strains of other foodborne bugs, Salmonella and Campylobacter, turn out vicious toxins, as well--and these bugs shrug off many drugs that once could vanquish them. All told, these pathogens sicken 3 to 4 million Americans each year and kill several hundred.
Be scrupulous about washing hands after touching raw meat or eggs, and cook these foods thoroughly. (More than half of all cuts of raw supermarket chicken carry Salmonella and Campylobacter, studies show.)
Use hot, soapy water to wash cutting boards and other kitchen surfaces that come in contact with raw meat or eggs.
Rinse produce--even veggies and fruits with a thick rind, such as cantaloupe--with a strong spray of water. If produce is contaminated by irrigation water, as was the case with spinach, only thorough cooking will destroy the germs.
Wash your (and your kids') hands after handling pet rodents and reptiles or farm animals, which can spread Salmonella and Campylobacter.
Throw your kitchen sponges into the dishwasher daily and dishrags into the washing machine often; use hot water.
See a doctor for severe gastrointestinal distress that lasts more than a couple of days, especially if accompanied by fever. If your doctor prescribes an antibiotic, call back if symptoms worsen or don't get better within 24 hours.
Superbug UTI: Bladder Infections That Won't Quit
The first time Dena Kelley got a urinary tract infection, she ended up in the emergency room. It was the winter of 1999, and Kelley, now a 33-year-old store manager in Anchorage, was seeing what looked like tissue in the toilet bowl--the lining of her infected bladder. "It was unbelievably painful," she says, "and it scared the heck out of me."
The ER doc gave Kelley a powerful antibiotic--Cipro--to stop the infection fast, but 6 weeks later, Kelley got another UTI. Over the next year, she averaged an infection every 2 months. Finally, her doctors reluctantly turned to a drug to which she'd been allergic in childhood--amoxicillin, at four times the usual dose. Fortunately, Kelley had outgrown her sensitivity to the drug, which ended the agonizing bouts of UTIs. But she can no longer make it through the night without a trip to the bathroom. And her doctors have told her that permanent bladder damage may predispose her to chronic infections throughout her life.
Roughly half of all women get at least one UTI at some point in their lives. Until the late 1990s, doctors were able to treat the problem with trimethoprim-sulfamethoxazole (Bactrim), a narrowly targeted antibiotic with minimal side effects. But many UTIs have become resistant to Bactrim and other drugs. So doctors must use stronger antibiotics that can cause problems of their own.
"It's frustrating," says Gazala Siddiqui, MD, a urogynecologist at the University of Texas Medical School at Austin. "These powerful antibiotics increase the chances of a yeast infection, and also the chances that a woman's next bacterial infection--whether it's another UTI or pneumonia--will be drug resistant."
If a resistant UTI lingers, it can cause scarring--which predisposes a woman to even more UTIs. Some doctors try to stop the vicious cycle by keeping women on antibiotics for months at a time. But that virtually guarantees that any break-through infections will be impervious to antibiotics, says Siddiqui, who's sometimes had to admit patients to the hospital for intravenous treatment.
Prevent Antibiotic-Resistant Bladder Infections
Begin with good vaginal hygiene: Wipe from front to back after using the toilet and pee before and after sexual intercourse. Don't douche, and consider alternatives to spermicides; both can irritate the delicate tissue around the urethra, raising the odds of infection.
Discourage UTI-causing bacteria by making the urinary tract and vagina more acidic. "Cranberry juice is good at this. Cranberry capsules are better," says Siddiqui, who recommends two or three glasses or capsules a day for women who are prone to recurrent infection. Also helpful: acidifying vaginal jelly available by prescription (Acigel) or over the counter (RepHresh).
Try a low-estrogen vaginal cream if you're peri- or postmenopausal and getting lots of UTIs. It will keep the tissue of the urethra from thinning and becoming more vulnerable to infection.
If you suspect a UTI, ask your doc to send a urine sample for analysis. Start antibiotics, but call back for results. If it turns out not to be a bacterial infection, stop the drugs and work with your doc to find the true cause. If a bacteria is at fault, check to make sure the drug you're on is effective against the bug you have.
3 Stay-Healthy Moves To Make Right Now
1. Scrubbing with old-fashioned soap and hot water is the best way to keep germs at bay. Do it before eating, after using the toilet or handling animals, and before and after preparing food. Wash vigorously for 20 seconds, experts say--about the time it takes to sing "Yankee Doodle Dandy."
2. If a sink isn't handy, clean up with an alcohol hand sanitizer. Studies show that when someone is sick in a household, classroom, or workplace, using a gel (between hand washings) reduces the spread of disease-causing bacteria and viruses. Be sure to choose a product containing 60 to 95% alcohol--some contain less and can actually help spread germs. Use a generous gob--enough so that hands still feel damp after rubbing them together for 20 seconds.
3. Skip antibacterial soap. Household soaps and other products with antibacterial chemicals, such as triclosan and triclocarban, don't prevent infection any better than products without them, studies show. Worse, some experts worry that they may promote drug resistance. There's no proof yet that they do, admits resistance crusader Stuart B. Levy, MD, of Tufts University. "But why take the risk when they haven't been shown to be any more effective?"
Have A Healthy Hospital Stay
Ironically, "A hospital is not a good place to be when you're sick," says Curtis Donskey, MD, chief of infection control at the Cleveland VA Medical Center. Filled with the sickest patients on the strongest antibiotics, they're breeding grounds for superbugs. Unfortunately, many doctors neglect the steps that can reduce patients' risk of picking up nasty germs during their stay, says Donskey, who has spent a decade raising awareness among his colleagues. Enlist a friend or family member to help ensure that doctors and other medical personnel follow these guidelines.
* Ask your doctor to remove invasive devices such as catheters and IV lines as soon as it's safe--they provide a pathway into your body for dangerous bacteria.
* Request the most highly targeted antibiotic if you require one. Remind your doctor to take you off the drug as soon as possible.
* Demand to know more about infection rates. Few states now require hospitals to release this information, so it's next to impossible to "shop around" to avoid particularly risky facilities. That may be changing: New York recently passed a law requiring hospitals to make public their rates of hospital-acquired infection, and a number of other states are considering similar legislation.
Writer Jessica Snyder Sachs is the author of Good Germs, Bad Germs: Health & Survival in a Bacterial World (Hill&Wang/FSG) and Corpse: Nature, Forensics, and the Struggle to Pinpoint Time of Death (Perseus/Basic Books).
illustration by Gary Taxali
As first appeared in The New York Times,
Copyright JESSICA SNYDER SACHS
IT'S flu season, and health agencies have expanded their flu shot recommendations to include all children ages 6 months to 5 years in addition to adults over age 50, and anyone, child or adult, with a chronic condition like severe allergies, asthma or diabetes.
More parents than ever before - nearly 65 percent - intend to vaccinate their young children this year, according to a poll by the University of Michigan. But that leaves more than a third unenthusiastic about doing so. Their reluctance may reflect not only weariness with the increasing number of childhood immunizations but also the widespread sentiment that colds and flus are a "natural" part of childhood, even vital for toughening up a developing immune system.
Some parents have come to embrace colds and flus, and in recent years we've seen a resurgence of the chickenpox party, where parents deliberately expose their preschoolers to infected playmates on the theory that it's better to get the disease than to have the vaccine.
But the idea that illness is good for children - or anyone else - is wrong. In part, the idea of "good sickness" is a throwback to a now disproved version of the "hygiene hypothesis."
In 1989, an epidemiologist in Britain, David Strachan, observed that babies born into households with lots of siblings were less likely than other babies to develop allergies and asthma. The same proved true of babies who spent significant time in day care. Dr. Strachan hypothesized that the protection came from experiencing an abundance of childhood illnesses.
Dr. Strachan's original hygiene hypothesis got a lot of press, not only in the news media but in serious medical journals. Less publicized was the decade-long string of follow-up studies that disproved a link between illnesses and protection from inflammatory disorders like allergies and asthma. If anything, studies showed, early illness made matters worse.
Moreover, studies now show that the more infections a person has during childhood, the greater his or her chance of premature death from scourges of old age like heart disease and cancer. The link appears to be chronic inflammation, a kind of lingering collateral damage from the body's disease-fighting response.
Still, Dr. Strachan's original observation was confirmed - as a group, babies in large families and day care are less likely to develop allergies and asthma than are children born into smaller families and kept at home. The same protective effect can be seen in children born on farms and in areas without public sanitation.
But the link isn't disease-causing germs. It's early and ample exposure to harmless bacteria - especially the kinds encountered living close to the land and around livestock and other young children. In other words, dirt, dung and diapers. Just as disease-causing microbes clearly bring on inflammation, harmless microorganisms appear to exert a calming effect on the immune system.
A second misconception common among vaccine-shunning parents is that there's something "natural" about the 6 to 10 respiratory infections the typical American child gets every year (or even the two to four we adults experience). Common, yes; natural no, not if "natural" represents the forces that shaped the human immune system during all but the last sliver of our 250,000 years as Homo sapiens. Colds, flus and most other contagious diseases found a central place in our lives only after we and our domestic animals began crowding together in large settlements some 5,000 years ago.
Yet the most compelling reason to get a flu shot this year is a new and deadly threat - methicillin-resistant Staphylococcus aureus, or MRSA, a dangerous kind of staph that has been causing outbreaks of deadly pneumonia among the otherwise young and healthy, typically on the heels of the flu.
Unfortunately, we have no practical way to eradicate MRSA. About a third of us silently carry staph at any given time, and trying to eradicate MRSA or any other staph strain from a community of symptom-free carriers is difficult to impossible. Worse, the experts conclude, any widespread effort to do so is certain to breed greater drug resistance.
Flu shots don't guarantee protection from MRSA pneumonia. It can piggyback on other kinds of viral respiratory infections. But protecting yourself and your children from the flu may be the best way to reduce your family's risk.
Whether dealing with the flu, other "routine" infections or even the chickenpox, the message is the same: In a world abounding in harmless, even beneficial microbes, don't embrace the tiny fraction that can make you ill.
Jessica Snyder Sachs, the former managing editor of Science Digest, is the author of the forthcoming book "Good Germs, Bad Germs: Health and Survival in a Bacterial World."
Hospitals need to come clean about infections and what's causing them.
copyright Jessica Snyder Sachs, as originally appeared in The [Newark] Star-Ledger
Our neighborhoods are in a panic over news reports about MRSA, or methicillin resistant Staphylococcus aureus. There's no doubt that this nasty bug has moved into our communities and our schools. But the deadliest threat from MRSA--and an alphabet soup of other drug-resistant bacteria--remain behind the doors of our local hospitals. Eight-five percent of MRSA infections occur during or following a stay in a healthcare facility.
The sad truth is that our hospitals have become dangerous places to be sick. Even routine surgical procedures bring the risk of potentially deadly infections involving hospital-bred bacteria. Infections picked up in health-care settings kill an estimated 99,000 Americans each year, more than twice as many as die in car crashes. It's a problem that has grown dramatically worse by the decade, as our antibiotic-infused medical centers became breeding grounds for drug-resistant bacteria.
In addition to MRSA, other increasingly common hospital superbugs include a viciously toxic strain of Clostridium difficile, bred from the bacterium that commonly causes post-antibiotic diarrhea; vancomycin resistant enterococcus (VRE), a virtually untreatable bug bred from a harmless member of our intestinal microflora; and Actinobacter baumannii, another near-unstoppable microbe, this one recently introduced into our hospitals in the infected wounds of soldiers returning from Iraq, Afghanistan, and before that, Kuwait.
The good news is that a half century of dangerous secrecy is starting to come to an end. This year New Jersey joined New York and Connecticut in the ranks of at least 22 states with some sort of mandate for the reporting of hospitals infections. These laws represent a step in the right direction. But few ask hospitals to differentiate infections caused by "ordinary" bacteria and those caused by highly drug resistant superbugs. New Jersey is one of these exceptions, with a new law on the books requiring specific reporting of hospital MRSA.
The importance of such reporting laws goes beyond a consumer's desire to steer clear of a medical center plagued with abysmal infection control. Worse, fifty years of secrecy have left public health officials guessing as to the arrival and spread of deadly new strains of drug-resistant bacteria in our hospitals.
The current situation with C. difficile illustrates the problem. Since 2003, C. difficile deaths have dominated news in Canada and the United Kingdom. British tabloid headlines like "Toe Nail Surgery Nearly Killed Me" refer to the common scenario wherein someone checks into the hospital for a routine procedure, receives antibiotics, and promptly contracts this drug-resistant invader.
Public outcry in Canada and the UK produced tremendous political pressure to address the problem in those countries. Even today, British lawmakers are quick to call the government's health minister before Parliament for public castigation when quarterly hospital reports of either MRSA or C. difficile rates fail to show improvement.
Ironically, in 2005, medical detectives traced the origins of the toxic C. difficile strain wreaking havoc in Canada and the U.K. to the United States, where hospitals had been heedlessly experiencing deadly outbreaks for at least six years. "We had no idea what was going on," admitted the chief of infection control at the University of Pittsburgh Medical Center, which in 2005 belatedly reported that its own C. difficile death toll had begun a dramatic ascent in January 2000.
Once forced to examine and deal with their superbug problems, hospitals can make great strides. This month, a once-chastened University of Pittsburgh Medical Center reported that it has brought its C. difficile rates down by more than 70 percent with an aggressive combination of tactics that include requiring doctors to get permission from an antimicrobial management team before prescribing the kind of powerful antibiotics known to raze the body's good bacteria and, so, leave a patient vulnerable to C. difficile and other drug-resistant bacteria.
Once their dirty secrets are out, other medical centers can likewise begin sharing and comparing infection control efforts. To that end, the first round state laws requiring hospitals to report infections in a general way do not go far enough. Our state legislators need to ride the current wave of public concern about supergerms to pass further legislation requiring hospitals to report on infection problems on a bug by bug basis--starting with their most dangerous and drug-resistant bacteria.
Jessica Snyder Sachs, a contributing editor to Popular Science and Parenting magazines, is the author of Good Germs, Bad Germs: Health and Survival in a Bacterial World.[JUMP BACK TO HOME PAGE]
by Jessica Snyder Sachs, as first appeared in HEALTH magazine
How's your cholesterol? Here's a guess: If you're healthy, you probably have no idea. New surveys show women tend to be clueless about their risks of heart disease, especially when it comes to managing their cholesterol.
But this kind of ignorance is anything but bliss. The reason: The
artery clogging that makes heart disease the number-one killer of women
late in life begins much earlier--in your 20s, 30s, and 40s--and that's
when your cholesterol numbers may be sounding alarms. So, are you ready
to start paying attention? Here, the things all women need to know now.
1. High cholesterol is surprisingly common in premenopausal women.
Researchers with the Framingham Heart Study recently delivered a nasty surprise: Nearly a quarter of women in the study who are in their early 30s have borderline-high levels of bad cholesterol, as do more than a third in their early 40s and more than half in their early 50s. A third of women in all three age groups have low levels of good cholesterol.
Bad cholesterol, also known as low-density lipoprotein (LDL), contributes to heart disease by laying down artery-clogging plaque; good cholesterol, or high-density lipoprotein (HDL), helps clear it away. "The double whammy of high LDL and low HDL is particularly dangerous," says Framingham researcher Vasan Ramachandran, MD, of the Boston University School of Medicine.
2. Your doctor may miss the problem.
Though women are better than men about seeing a doctor regularly, the care they receive isn't as good when it comes to preventing and treating cardiovascular disease, according to new studies. "Perhaps doctors still haven't gotten the message that women need to control cholesterol," says Chloe Bird, PhD, author of one of these studies and a senior sociologist at the nonprofit RAND Corporation. Bird found that doctors are less likely to monitor and control cholesterol in women than in men, even when the women are at superhigh risk of heart attack.
Part of the problem, she says, may be that many women see only a gynecologist. This isn't to say that OB-GYNs can't be good primary care doctors, but you have to make sure the doc is willing to monitor your heart health, especially if you already have diabetes or a heart issue. That means she should order cholesterol checks as part of your regular blood work and discuss the results with you. What does "regular" mean? See "How Often Do I Need a Checkup?"
3. Your numbers may trick you.
Many people misunderstand the roles of so-called good and bad cholesterols, according to cardiologist and lipidologist Pamela Morris, MD, of the Medical University of South Carolina in Charleston. "What we've learned is that HDL and LDL are independent predictors of a woman's heart attack risk," she explains. "We see women with high HDLs having heart attacks when their LDL is also high, and we also see heart attacks in women with very low LDL but also low HDL."
What that means to you: It's important to keep track of both. A woman wants to keep her HDL above 60 (the level at which HDL helps prevent disease) and her LDL below 100. If your HDL drops below 50 or LDL rises above 160, you need to take immediate action. That may include an LDL-lowering drug such as a statin, and it definitely includes a commitment to a heart-healthy diet and lifestyle.
4. You may need an "inflammation" test.
The math used to estimate your heart disease risk is a little misleading. If your LDL rises above the danger line of 160 or your HDL drops below 50, the math says you have an elevated risk of a heart attack within 10 years. But that warning may actually underestimate your risks beyond 10 years, Morris says. So when she has a female patient with cholesterol numbers in the intermediate range--LDL above 130 or HDL under 60--she often takes a close look at the woman's whole-body inflammation level.
You can't see this kind of inflammation, but it's actually an independent measure of heart attack risk. You measure it by adding a test for high-sensitivity C-reactive protein (hs-CRP) to the usual cholesterol blood work. CRP, essentially a body chemical, usually rises anytime your body becomes inflamed. And since artery clogging is associated with inflammation, high CRP is viewed as a marker for clogged arteries. That means your C-reactive protein levels may help you and your doctor decide how aggressively you need to control borderline-high-cholesterol levels with drugs, diet, and exercise.
5. These foods are your best friends.
Certain classes of food chemicals can actively and powerfully lower a person's bad cholesterol. Two--soluble fiber and phytosterols--have so much science behind them that they've become part of standard medical prescriptions for treating high cholesterol. But dietitian Janet Brill, PhD, RD, author of Cholesterol Down, also recommends regularly eating almonds, ground flaxseed, apples, soy protein, and olive oil. Preliminary research suggests they all have cholesterol-lowering powers. "Each one works in a slightly different way," Brill says. "So together, you get a synergy that can dramatically lower cholesterol."
Almonds and olive oil are high in monounsaturated fats, which are thought to blend with LDL molecules in a way that speeds LDL's clearance from the blood by the liver. Flax is high in both soluble fiber, which lowers LDL by absorbing cholesterol from both food and bile inside the intestines, and omega-3 fatty acids, which studies show have anti-inflammatory effects. Other foods especially high in soluble fiber include oat bran, oatmeal, and apples. (Soluble fiber is different from insoluble fiber, the kind found in whole-grain bread and bran cereal. That's good for you, too, but it won't affect your cholesterol.) Soy may mimic natural estrogens in their LDL-clearing effects. Phytosterols are the plant version of animal sterols (a.k.a. cholesterol) and lower LDL by competing with it for absorption into the body. They're found in supplements or phytosterol-enhanced margarine such as Benecol.
You don't need any of these foods if your LDL is low, but experts still recommend them for everyone. What about steak, eggs, and cheese? They sure won't help your cholesterol, because they all contain a lot of it. But it's more important to focus on foods that lower your numbers rather than simply avoiding the bad stuff, experts say.
6. Good cholesterol may have a bad side.
The higher your HDL, the better, right? That's been the current thinking, due to HDL's protective effect. But here's a surprise you may have read about in some news reports: Studies are showing that HDL may actually have harmful proteins capable of boosting heart disease risks. A test to determine if your HDL has the harmful proteins may be available in a few years. In the meantime, if your HDL is lower than 60, it's still OK to raise it a little as long as you don't go overboard. How? Try getting a lot of omega-3s from fish or fish oil, exercising regularly, controlling your weight, and avoiding smoking.
7. Your heart loves long walks.
Walking 10 miles a week brings lasting improvements in your heart health, according to researchers at Duke University Medical Center. The funny thing is, if you jog those 10 miles, you won't get quite as much benefit. "Duration appears to be key," says Duke's Cris Slentz, PhD, an exercise physiologist. "Jogging or walking 10 miles both burned around 1,200 calories, but in our studies, one took about two hours and the other, three."
Longer stints of exercise, even moderate exercise, may burn more belly fat--the little rolls of skin near your navel and the fat deep inside your abdomen. The latter is linked to metabolic syndrome, a condition associated with a host of cardiovascular risk factors including low HDL, high blood pressure, and high triglycerides (a kind of blood fat that contributes to heart disease).
Should you aim for weight loss as well as long walks? If you're
overweight, absolutely. But understand that shedding a few pounds will
make only a small dent in your cholesterol. Canadian researchers
recently found that overweight women who lost about 25 pounds--no easy
task--saw their LDL drop about 10 percent and their HDL rise by the same
How Often Do I Need a Checkup?
Starting at age 19 and continuing until menopause, a cholesterol test once every five years is plenty--as long as your numbers fall in the healthy range:
HDL > 60
LDL < 100
Total cholesterol (HDL plus LDL) < 200.
But any time your numbers stray into unhealthy territory (and during and after menopause, when heart disease risk rises), get tested annually and work out an action plan with your doctor.Writer Jessica Snyder Sachs is the author of Good Germs, Bad Germs, out in paperback this fall.
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MRSA infects 94,000 Americans a year, and the superbug is no longer confined to hospitals. Here's what you need to know to protect yourself and your kids.
copyright Jessica Snyder Sachs, as first appeared in BEST LIFE magazine
It started one morning last June, when 14-year-old Max Yardley felt a little tenderness in his elbow. The arm looked fine, so Max's dad, Rockie, an explosives specialist with the Edmond, Oklahoma, police department, figured the problem was soreness left over from the lifeguard training Max had just completed. But that night, Max woke up his parents at 3 a.m. The pain had become excruciating.
"This is a kid who doesn't normally complain," says Yardley. "He'd been sick all of five days in his life." The Yardleys raced to the emergency room. Over the next 24 hours, Max's temperature soared to triple digits and his blood pressure plummeted. When doctors ran the usual laboratory tests, it came back positive for methicillin-resistant Staphylococcus aureus, or MRSA. A bacterial infection had infected the bone of Max's upper arm and was racing through his body, shredding up his lungs, liver, and spleen.
"One morning we had a perfectly healthy boy. Twenty-four hours later, the doctors were struggling to keep him alive long enough for the antibiotics to start working," recalls Yardley, who, as a former paramedic, understood enough about his son's vital signs to call the family's priest.
Unknown just 15 years ago, community MRSA (hospital MRSA's virulent sister) now accounts for more than half the serious staph infections showing up in the nation's emergency rooms. Some children's hospitals see it in more than 75 percent of the staph-infected children they treat.
"Once it arrives in a community, it just seems to take over," says Sheldon Kaplan, MD, chief of infectious diseases at Texas Children's Hospital, in Houston. Pediatric specialists fear that the superbug, which already accounts for 19,000 deaths in the United States each year, could soon become commonplace across the country. The vast majority of community MRSA cases are skin and soft-tissue infections, Dr. Kaplan explains.
But around 5 percent involve potentially deadly pneumonias and internal infections such as Max's. When this bug enters the bloodstream, it can cause severe and sometimes fatal disease, and many of those who survive bloodstream infections sustain severe organ damage, require limb amputation, or both. "A child's growing bones remain particularly vulnerable," says Dr. Kaplan, "because they are open to bacteria circulating in the bloodstream."
Max was one of the lucky ones. After a week on a respirator, he emerged without permanent organ damage. After another two weeks on intravenous antibiotics, he finally went home to complete his recovery and was symptom free after another seven weeks on antibiotics.
Each year, more and more kids aren't so fortunate. MRSA deaths among previously healthy kids began cropping up in the 1990s. "At first we assumed these children had some connection to a health-care setting in which MRSA infections had been confined," explains epidemiologist Jeffrey Hageman, a MRSA expert with the Centers for Disease Control and Prevention, "but it eventually became clear that something else was going on." Antibiotic use outside of hospitals may have bred strains of MRSA distinct from those in medical centers.
And although community MRSA isn't resistant to as many kinds of antibiotics as is hospital MRSA, what it lacks in multidrug resistance it appears to make up for in virulence. Medical experts are just working out how staph in general, and MRSA in particular, wreaks its damage. But new studies suggest that community MRSA strains have the ability to kill the kinds of immune cells that would normally eliminate such microbial invaders. This stubborn persistence, in turn, tends to trigger septic shock, a kind of immune-system meltdown in which body-wide inflammation leads to organ failure, massive blood clotting, and plummeting blood pressure.
Community MRSA has an aggressive tendency to enter through even the smallest of cuts and abrasions. For this reason, it often spreads in locker rooms and gyms, and between members of sports and dance teams, who have frequent skin contact with both other participants' skin and shared surfaces such as athletic equipment and benches, explains Hageman.
Ineed, if you have a child in school or day care, chances are you've received some version of the panic-but-don't-panic note, as in "Dear parents: A confirmed case of MRSA infection has been brought to our attention. Please be assured we are taking appropriate measures." Some schools go so far as to shut their doors for a massive, one-time disinfection--a move that may be as ineffectual as it is overdramatic.
A less overblown but diligent effort is key, say health experts. "Perhaps one of the biggest problems for parents, dads in particular, is deciding when to give your kid Tylenol and send him to bed and when to go straight to the emergency room," says Yardley. "For me, it was the urgency of Max's complaints that raised the red flag."
Here's what you need to know to protect your children from community MRSA:
1. Know When Risk is Greatest
Studies show some of the highest rates of MRSA in groups such as team athletes and those who have had a medical procedure or taken antibiotics within the past year. MRSA is what doctors call an "opportunistic pathogen," a microbe that takes advantage of breaches in the body's defenses. Young children are particularly susceptible because their immune systems aren't yet fully developed. "Staph. aureus can't be eradicated," explains MRSA expert Jeffrey Hageman, of the Centers for Disease Control and Prevention. "Overall, around one in a hundred Americans carries a resistant strain of this bug."
2. Avoid Unnecessary Antibiotics
MRSA infection rates are up to eight times higher among those who've taken antibiotics in the previous year. By eliminating the drug-susceptible competition, antibiotics promote the success of any microbe that can shrug off their effects. "Antibiotics tend to replace your body's protective bacteria with drug-resistant troublemakers," explains Tufts University's Stuart Levy, MD, author of The Antibiotic Paradox. When antibiotics are necessary, ask your doctor for the "narrowest spectrum" (most specifically targeted) antibiotics, which tend to be less disruptive of the body's good bacteria than are "broad spectrum" (big gun) antibiotics.
3. Wash Away the Bugs
"Teaching children good hygiene is the single most important thing you can do to protect them," says Hageman. Staph spreads primarily through skin-to-skin contact and frequently touched surfaces. Experts recommend frequent hand-washing with ordinary soap and water or, when that's not convenient, an alcohol-based hand gel. "Staph takes several hours to infect an abrasion," says Hageman, "so there's a window of time when it can be washed from the skin."
Drug-resistance experts such as Levy advise against using antibacterial soaps containing chemicals such as triclocarban and triclosan. They act like antibiotics and, in laboratory tests, promote the rise of drug-resistant bacteria.
4. Keep Exercise Areas Clean Encourage young athletes--or their coaches--to wipe down mats and sporting equipment with soap and water or bleach wipes between uses. Children can also use a personal towel or other barrier between their skin and shared exercise surfaces and equipment. Insist on daily disinfection of locker rooms and weight-room benches, wrestling mats, and other shared athletic equipment as well as the mats used by younger children for napping. The Environmental Protection Agency maintains a list of safe and effective MRSA disinfectants.
5. When in Doubt, Check It Out
MRSA infections don't always look scary. The skin may become red, swollen, and tender. An infected joint, bone, or muscle may look normal but feel painful. Sometimes symptoms include fever, nausea, or weakness, says Sheldon Kaplan, MD, of Texas Children's Hospital. That can make MRSA infection difficult to distinguish from muscle sprains or the flu.
6. Get a Flu Shot
When MRSA and the flu end up in the same body, the result can be life-threatening. "It's the perfect storm," says John Francis, MD, an infectious disease consultant at Yale University School of Medicine. Getting an annual flu shot may help protect against this deadly combination.
Jessica Snyder Sachs is the author of Good Germs, Bad Germs, out in paperback this fall.
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copyright Jessica Snyder Sachs, as first appeared in HEALTH magazine
Three months before she gave birth last year, Diana Simpson, a dental hygienist in Davison, Michigan, started coughing uncontrollably. The pain in her throat and chest was unbearable. "It brought me to tears," she remembers. Simpson's family doctor tested her for asthma, but she didn't have asthma. She had pertussis, a bacterial infection that usually goes by the name whooping cough because of its distinctive seal-like cough.
Most people are vaccinated against pertussis as kids. But here's a surprise: It's come roaring back since an all-time low in the 1970s, largely due to waning immunity in adults who received shots in early childhood. The Centers for Disease Control and Prevention (CDC) now recommends that all adults get a pertussis booster shot to strengthen their immunity, yet only 2 percent of adults have had their shots updated. Experts say that's just one of several vaccines you may need now. Here's the scoop.
The good news: If you get your regular tetanus-diptheria (Td) booster every 10 years, you won't need an extra jab for pertussis. Vaccine makers have added a pertussis component to that booster, so next time you're due for your Td booster request the Tdap. If you've lost track of your vaccines, ask your doc to contact your previous physicians. And there's no harm in getting the Tdap as long as two years have passed since your last Td booster. Better too soon than too late when a pertussis outbreak has hit your community.
Simpson was too late: She had passed the infection to her mother and her baby, too, landing the newborn in the hospital three weeks after he was born. That's when they all were diagnosed and received the antibiotic erythromycin to keep the infection from spreading further, though they all continued coughing for months. If pertussis isn't caught in the first few weeks, the infection may take three months to run its course. The greatest danger is to babies, who almost always catch it from unvaccinated adults. (The number of U.S. pertussis cases now ranks in the thousands each year, with deaths in the double digits, mostly due to related pneumonia.)
Simpson and her baby, along with her mother (and husband, too), eventually got the shot for future protection.
More than 90 percent of women in their childbearing years are immune to chicken pox because they had it as kids. The rest should be vaccinated before they try to get pregnant because catching the illness during pregnancy can lead to devastating birth defects. Once you get the vaccine (which was introduced in 1995), the CDC says you should delay trying to conceive for at least one month, due to the small risk that the fetus can get the virus from the vaccine. Chicken pox complications are much more frequent and severe in adults than children and can include life-threatening pneumonia and encephalitis (brain inflammation). And people who've had it are also at risk for shingles. Most insurers cover the chicken pox vaccine for adults.
If you've had chicken pox, you have a significant risk of developing shingles, a painful reawakening of the chicken pox virus. Worse, in nearly 50 percent of cases in adults in their 50s, shingles progresses to postherpetic neuralgia, an often agonizing form of nerve damage that can linger for years. (The risk increases with age.) But with the recent Food and Drug Administration (FDA) approval of the Zostavax vaccine, you can lower your risks dramatically. In a study of more than 38,000 adults over age 60, the vaccine cut the rate of shingles by over half and reduced the incidence of postherpetic neuralgia by two-thirds.
The vaccine was studied in and approved for people over the age of 60 because they have the highest rates of shingles, says William Schaffner, MD, head of preventive medicine at Vanderbilt University Medical Center. "The rates take off at age 50 and become more steep with each decade," he says. But around half of all shingles cases occur in younger adults.
Insurers won't currently pay for vaccination in people under 60, but that may change because studies in 50-and-overs are ongoing. Younger adults can pay out of pocket for this $150 to $200 shot. (Ask your doctor.) Researchers don't yet know whether the vaccine's protection will prove lifelong, though, so you may need a booster when you get older.
Vaccine: MMR booster
The measles-mumps-rubella (MMR) vaccine, a must for kids, is back in the adult-vaccine lineup, too. "Mumps is the problem," reports CDC epidemiologist Andrew Kroger, MD. The number of Americans who caught this viral disease jumped to 6,584 in 2006 from 300 or less in most years. A large mumps outbreak in the Midwest was responsible for most of these cases, and outbreaks continue in Canada and neighboring states such as Maine. The problem may be a spillover from countries like the United Kingdom and Japan, where lagging childhood immunization rates spurred a comeback.
Mumps can be painful and sometimes dangerous. There's the textbook swelling of salivary glands around the neck, but some women also suffer from inflammation of the ovaries. In rare instances, mumps can trigger life-threatening encephalitis.
The CDC encourages all adults to check their status: Do you know whether you were immunized or had the disease as a child? Those born before 1957 are presumed to have been infected or exposed, which provides lifelong immunity. The spottiest protection is among those born between 1957 and 1967, who are less likely to have had mumps or who may have received a less-effective vaccine. A single dose of the current MMR should bring your protection up to date, Kroger says, and it may be covered by your insurance.
Going on a cruise or an organized tour? Consider getting a flu shot, says Schaffner, who reports that influenza outbreaks frequently occur on cruise ships, even during summer voyages to northern destinations like Alaska. "Whenever people are jammed together, influenza is a risk," he explains.
In addition, visitors to Asia should talk to their doctors about vaccine protection against typhoid and Japanese encephalitis. Visitors to the "meningitis belt" of central Africa should get a meningococcal vaccine. And yellow fever vaccines are important for travelers to much of South America and parts of Africa.
Vaccine: Recombivax HB or Engerix-B
Both vaccines protect against the hepatitis B virus, which is spread through sexual contact or contaminated needles and blood. An infection can lead to dangerous liver disease. Each year, more than 78,000 Americans become infected and about 5,000 die of associated liver diseases, including cancer, yet few know that the CDC recommends the vaccine for all sexually active people who are not in long-term relationships.
Vaccine: Influenza shot or FluMist nasal vaccine
A dangerous bug known as methicillin-resistant Staph. aureus (MRSA) may aggressively attack flu-weakened lungs, according to William Schaffner, MD, head of preventive medicine at Vanderbilt University Medical Center. MRSA was previously confined to hospitals but is spreading into communities nationwide. The link is unclear, but there may be a connection in the way that flu weakens the immune system and MRSA attacks it. MRSA is often marked by nasty skin infections. The strains contracted outside the hospital are now associated with some 13,500 deaths in the United States each year, many involving flu sufferers. "If you need further motivation to get a flu shot," Schaffner says, "there it is."
Jessica Snyder Sachs is the author, most recently, of Good Germs, Bad Germs.
By Jessica Snyder Sachs, as originally published in PREVENTION
On a mid-August morning two summers ago, Debbie Twenge started coughing. Just a cold, thought the resident of Dundee, OR, now 56. But the body-racking cough got worse--much worse. Over the next 6 weeks, Twenge had to make two trips to the emergency room. One particularly frightening evening, her daughter called 911 when Twenge's throat closed up during a coughing fit. "I thought I was going to die," she recalls.
By the end of September, her doctor was suggesting tranquilizers--"as if I was just a nervous female," Twenge says with outrage. That's when her husband read about a local outbreak of whooping cough, aka pertussis. A test quickly revealed she had it, but it took 6 months for her to recover from the lingering inflammation and injury to her breathing passages.
So it was with great interest that Twenge recently learned that the CDC now recommends all adults get a booster shot to protect themselves against this "childhood" disease. Health officials estimate that the vaccine could prevent more than 8,000 adult infections and 30 to 40 deaths each year. "If I had known what pertussis was like, I would have jumped at the chance to be vaccinated," says Twenge.
Chances are, when you hit adulthood, you figured that you were pretty much done with vaccines, except for the occasional flu shot. But it's time to roll up your sleeve. Experts say the right vaccines can prevent pain and misery--and could even save your life.
Still hesitant? Worried about side effects? Don't be. Here's the lowdown on the shots you need and when--and why you want them.
Get It Now
Tdap booster: Prevents whooping cough, diphtheria, and tetanus
You probably got a pertussis shot as a child, or maybe even had a bout of whooping cough, and think you're immune. But experts now realize that neither immunization nor infection provides lifelong protection. In fact, immunity wanes within 10 years, explains Anne Schuchat, MD, director of the CDC's National Immunization Program. That's a big reason there's been a massive resurgence of pertussis over the past 20 years--more than 25,500 cases in the United States in 2005.
Protect yourself: The next time you're due for your 10-year tetanus-diphtheria shot (Td)--and yes, you should be getting a tetanus booster every decade--ask for the Tdap booster, which includes protection against pertussis. Get the shot now if you're in close contact with a baby or someone whose immune system has been weakened by age, chemotherapy, or HIV infection--they might not survive if you pass pertussis to them. (You can get a Tdap booster as soon as 2 years after a previous Td vaccine.)
MMR: Prevents mumps, measles, and rubella Just when we'd almost vanquished mumps, the viral infection is making a comeback. In a typical year, fewer than 300 Americans catch mumps, but in 2006, there were more than 5,800 cases! The reason may be found in England: Lagging childhood immunization rates there have led to a comeback of this disease, and tourists may have carried it here. In adults, mumps can be serious: 1 in 20 women develops swelling of the ovaries; 1 in 5 men, inflammation of the testes. Rarely, adult mumps can cause potentially deadly encephalitis (an infection of the brain).
If you were born between 1957 and 1967, you're particularly susceptible to catching mumps, because the version of the vaccine your pediatrician gave you wasn't effective enough to provide reliable lifelong protection.
Protect yourself: If you're not sure you had mumps or received two MMR doses after 1967, get this vaccine ASAP. (Kids need two shots 28 days apart; as an adult, you'll get only one.)
Flu Shots: Prevents influenza--and reduces risk of potentially deadly pneumonia. Late in 2003 and into 2004, doctors in the Baltimore area were helpless to save a previously healthy man in his 50s when he developed an antibiotic-resistant form of pneumonia on the heels of the flu. Three others--women in their 20s and 30s--nearly died the same way.
The bug behind those drug-resistant pneumonias is a new and nasty strain of Staphylococcus aureus, or MRSA--and researchers say flu raises the risk of catching it. There are plenty of other reasons to avoid the flu: 36,000 people die each year from flu-related complications. That's why the CDC now says that all adults should get an annual flu shot.
Protect yourself: This fall, get a flu shot or a spritz of the new nasal vaccine, FluMist (approved for adults up to age 50). It's best to get immunized in October or November, but immunization as late as January is still worthwhile--the flu often peaks as late as March.
Get It if You've Had Chickenpox
Zostavax: Prevents shingles and postherpetic neuralgia
One in four people who have had chickenpox eventually develops the blistering rash of shingles--caused when the chickenpox virus, Varicella zoster, is reactivated. Around 40% will go on to suffer what's been described as the worst kind of pain imaginable. Called postherpetic neuralgia (PHN), it is so agonizing that it's been known to lead some people to suicide.
Protect yourself: As soon as you hit 60, get a dose of Zostavax, approved by the FDA last year. Schuchat predicts that people in their 50s will eventually be urged to get the vaccine, too, if ongoing tests show that it's equally effective in their age group. You've never had chickenpox? Then definitely get the chickenpox vaccine, Varivax, as well. Adult chickenpox has a substantially higher risk of complications, such as pneumonia and potentially deadly encephalitis.
Get it if You're Dating
HPV vaccine (Gardasil): Prevents cervical cancer
The benefits of the HPV vaccine for women under 26 have been all over the news. But the headlines overlooked something important: Gardasil may also be lifesaving for older women, especially those who are divorced or in a nonmonogamous relationship. Younger women were studied first because they're more likely to be exposed to the cancer-causing human papillomavirus, but research is under way on women over age 26. The vaccine targets four of the viral strains most commonly associated with cervical cancer and genital warts and, says Schuchat, "the chance that any woman has been exposed to all four types is tiny. So the vaccine will probably benefit everyone who gets it."
Protect yourself: Consider getting the three-shot HPV series if you've been mutually monogamous--or abstinent--but are now dating again. (Think about getting a hepatitis B vaccine, too; that sexually transmitted virus sometimes causes liver cancer.) If you're over age 26, your insurance may not cover the $350 cost of the series, at least until Gardasil is approved for older women or a similar shot, called Cervarix, gets okayed (that vaccine was recently green-lighted in Australia for women up to age 45). However, one or both approvals may happen soon.
Vaccine Fears and Facts
Fact: A few years back, researchers raised the concern that people (especially babies) might accumulate a toxic dose of mercury from thimerosal, a vaccine preservative that consists largely of the metal. To be on the safe side, thimerosal was removed from many pediatric vaccines. But since then, studies have shown that the form of mercury found in the preservative, ethyl mercury, does not build up in the body.
Fear: Allergic reaction
Fact: These do occur, so tell your doctor if you have an allergy to egg (flu vaccine), gelatin (MMR vaccine), or yeast (HPV and hepatitis B vaccines). If you have an unexpected reaction, the doctor will give you an antihistamine, or a shot of epinephrine if your allergy is severe. It's worth noting, though, that vaccines cause only one death or serious reaction per million shots given--and save many more lives by preventing disease.
Fear: The flu vaccine actually causes the flu
Fact: The flu shot contains no live virus, while FluMist contains one that has been weakened so that it's incapable of causing infection. Neither can give you the flu, says Andrew Kroger, MD, a CDC epidemiologist and vaccine information specialist. But if you were exposed to the flu right before you were immunized, the protection may come too late to keep you from getting sick.
Copyright 2007, Prevention
Science writer Jessica Snyder Sachs is the author of Good Germs, Bad Germs: Health and Survival in a Bacterial World (Hill & Wang/FSG).
Last-chance surgery can mean enormous risks ... then again, it can inspire even higher hopes
By Jessica Snyder Sachs
(originally published in Longevity}
Like a shy schoolgirl, Donna Lavender curls her legs and feet together under her chair as she waits to see her doctor. This petite woman of 32 first met Jerrold Vitek, M.D., a year before. At the time, the 44-year-old Emory University neurologist advised against brain surgery. The risks far outweighed her pain and disability, he had said. And though the risks hadn't changed much since then, Lavender's pain and disability had.
The inward curl of Lavender's legs and feet is not for girlish effect; it's a symptom of dystonia, a brain disorder that causes severe and uncontrollable muscle spasms. In her case, the disease has locked her calves, ankles and feet in an excruciating, twisting cramp. "It's like a great charley horse that never ends," she explains in a rich Southern drawl.
In its various forms, dystonia affects some 300,000 people in North America alone. Its cause is not known, though there are many theories. Some dystonias start in childhood, and these may be related to gene defects. Others arise in adulthood and stem from injury. That may be the case with Lavender, who had been hit in the back and knocked unconscious by a runaway oil drum six years earlier while unloading an "18 wheeler" she and her husband had been driving. Two weeks after the accident, she lost all feeling in her legs and became bedridden. But the spunky young woman had fought back, progressing from bed to wheelchair to walker to unassisted walking. Then, six months after the accident, the dystonia began.
It came as a bad nighttime cramp in her right leg. "When I tried to get up in the morning, I couldn't stand," she remembers. "The cramping came with a burning pain like I'd never felt before." So severe was the pain that some mornings Lavender woke with her heart racing at 220 beats per minute--about three times the normal rate. Her doctors worried about heart damage. Her marriage ended in divorce. "My husband didn't want a cripple for a wife," she says, turning to hide the tears.
In 1994, Lavender married again, this time to a childhood sweetheart who had always been there for her. They settled in the small town of Millegeville, in the central hills of Georgia. But that same year, Lavender's dystonia spread to her left leg, with cramping even more painful than that in the right. An orthopedic surgeon tried to relieve the twisting of Lavender's feet by splitting and rearranging the ligaments in her anklesbut without success. So Lavender hobbled through the day on the outside edges of her curled-under feet, until the deep, burning pain would force her to lie down.
Her family doctor recommended exploring a type of brain surgery sometimes used to relieve severe case of dystonia. So she had met with Vitek at Emory. But early on in the conversation, they agreed there were too many risks involved in brain surgery including the risk of paralysis. "I knew what it was like being in a wheelchair," Lavender says. "I wasn't willing to take that chance." So she returned home to manage as best she could with bed rest and painkillers.
Unfortunately, the dystonia worsened. The spasming, which had originally come in "spells" lasting a few hours, became constant. Even worse, it began to spread to Lavender's thighs. She came to rely on narcotics to dull the pain. But the drugs dulled her mind as well, and made her depressed. She worried about the emotional toll she must be taking on her 12-year-old daughter and her new husband. The decision no longer seemed so clear cut.
"In my heart, I knew I had to [have the surgery]," Lavender tells a reporter on the day when she and her doctor are to meet to reassess their original decision. For his part, Vitek wants to make sure she understood the difficulties and risks involved, and had the resolve to face them out.
DAY OF DECISION
Despite her pain, Lavender flashes a broad smile when this man, who offers "one last hope," bounds into the room. A wiry, dark-haired researcher with an eager grin, Vitek is a pioneer in the mapping of the thalamus, a knob of gray matter the size of a walnut buried deep inside the brain. One of its functions is to serve as a relay station for movement and sensory messages traveling from the body to the cerebral cortex. The root of Lavender's dystonia may lie here, he explains, making a quick sketch.
In structure, a portion of the thalamus is like an onion, with each successive layer associated with a different body part: foot, leg, arm, shoulder, face, etc.
"At one time this are was your friend," Vitek says, pointing to the area associated with the leg. "But something has gone wrong; the cells there are now firing erratically, jamming other brain circuits and causing problems."
The "last hope" Vitek offers is a thalamotomy, an operation in which the problematic part of Lavender's thalamus would be lesionedburned away with an electrode. Thalamotomies had been performed in the 1970s, he explains, but the results were inconsistent. About half the patients with dystonia got some benefit, with a small subset getting full relief. But others came away from the surgery with weak or paralyzed limbs, slurred speech and thinking problems.
And Vitek thinks he knows why. He leans forward now, his hands spread, his eyebrows jumping in excitement. "In part, it may be that some surgeons were missing their mark," he says. The thalamus may be shaped differently in each person, and it's easy to get lost. Lesion the wrong area and ...
But Vitek has high hopes of improving thalamotomy's accuracy. He has spent five years studying the organization and cell-activity patterns of the normal thalamus in animal models. Building on this familiarity, he uses microelectrodes to probe the patient's thalamus and create a customized "map." Then, once he has isolated the problematic area, he steps aside, allowing a neurosurgeon to destroy it.
"So far we've had good results," he tells Lavender. "but we're on a learning curve." Should Lavender go through with the operation, she would be part of a study Vitek is conducting involving microelectrode-guided thalamotomies for 10 to 12 dystonia patients.
To make the decision thornier, Lavender's case will be especially difficult. The layer of the thalamus associated with the legs lies against a brain capsule filled with nerve fibers that control movement. So the surgery must be superbly precise--destroying as much of the leg-associated thalamus area as possible, without harming the adjacent fibers and possibly causing paralysis.
Vitek proposes that the team lesion only the leg area of Lavender's right thalamus. This should relieve the more painful dystonia in her left leg. And if the operation proves successful, they can later perform an operation to lesion the leg area of the left thalamus, relieving the right leg dystonia.
Despite all the risks and caveats, Donna is determined. "I know that even if this surgery doesn't help me, what you learn will help someone else in the future," she says. It's the answer that every medical researcher wants to hear. But Vitek needs to be sure. "It's going to be a tough day," he says.
While the "standard" thalamotomy can be done in as little as an hour or two, guiding it by microelectrode mapping can take the better part of a day. "And you'll have to stay awake throughout, telling me what you feel as I stimulate different areas.
"We'll have to move your leg," he continues, gently lifting Lavender's knee a fraction of an inch. She blanches with the pain, and he apologizes. "We'll try to give you medication to decrease the pain to a tolerable level, but if we sedate you too much, the cells will change their pattern of [electrical] activity, and we won't be able to map accurately." Lavender nods and smiles, and asks how much of her hair will need to be shaved. Vitek assures her that only a patch will be involved, and the surgery is set for the following Wednesday.
As she leaves the room, Vitek worries about Lavender's ability to cooperate during the operation. "She's a brave woman," he says. "But I have a feeling that pain's going to be a problem."
At home, Donna alternates between peaceful resolve and frightened doubt. But her decision is reinforced by her husband and a concerned circle of friends from the local church, who have educated themselves about Lavender's dystonia and the proposed surgery.
DAY OF DETERMINATION
Wednesday morning, 2 A.M. Lavender and her husband prepare for the drive to Atlanta. They are joined by their pastor and his wife. Together they pray, riding down the highway into dawn.
6 A.M. Lavender arrives at Emory University Hospital and is fitted with a "halo," a metal ring riveted to her skull with sharp posts. Technologists make a series of CT scans of her brain.
10 A.M. Lavender is wheeled into the operating room. The nurses cover her body with balloonlike "quilt" filled with a gentle flow of warm air. The rest of the room is kept at a chilly 63 degrees to minimize the risk of infection once Lavender's brain is exposed.
Enter neurosurgeon Roy Bakay, M.D., a no-nonsense bear of a man who takes complete command of the operating room. He positions Lavender's head in a second, calibrated ring, carefully matching its position to readings from the CT scans. "Scrub up," he directs Vitek and his neurology team. If all goes smoothly, they'll be finished in four or five hours.
11 A.M. Smooth is not to be. As Bakay attempts to inject a local anesthetic into Lavender's scalp, she jumps and writhes in pain, twisting her head inside the metal frame. "It hurts," she cries. "Hold still!" Bakay yells. Two nurses jump to restrain her. "Donna, you have to hold still," they plead. Lavender, groggy from painkillers and a sleepless night, moans with fright and discomfort.
Noon. Bakay has cut a triangle-shaped opening in Lavender's skull. Through it he has lowered the long, thin microelectrode that Vitek now uses to send and receive electrical pulses through Lavender's brain. The room fills with the amplified crackle and buzz of brain-cell activity. Green lines jump and wiggle across two monitors on a seven-foot-tall tower of electronic equipment. "Fiber at 52.5," reports Vitek to a team of assistants, who plot his readings on tables and graphs.
Vitek watches the green lines dance across the monitor, then closes his eyes to concentrate on the distinctive sound of each click, crackle and buzz. Drawing in his years of study, he lets the sounds guide him. "An injury here, not classic thalamus," he reports.
He brushes his hands softly across Lavender's left leg. He lifts it and shakes it, creating a storm of activity across the monitors. He sends a small current through the electrode and quizzes, "Donna, can you feel this?" A long pause, then a quiet murmur. "No."
2 P.M. After nearly two hours of mapping the neurology team confers in the corner of he operating room, trying to fit their graph of Lavender's brain-cell activity over an anatomical map of a "typical" brain. Angling their color-coded points this way and that, they try to make a fit that will reveal their exact location. They step back in puzzlement.
Vitek and Bakay confer. Lavender's writhing at the start of the surgery may have changed the position of her head in the surgeon's frame. Instead of hitting the thalamus, the electrode may be dead-center in the motor capsule. If so, lesioning here would prove disastrous. Hands on hips, Bakay shakes his head in frustration, then strides to the head of the operating table. He must expand the hold in Lavender's skull to move the electrode farther back in her brain. Lavender cries quietly as Bakay drills. Nurses hold her hands and whisper reassurances.
2:30 P.M. The team starts remapping from scratch. "Hear it? Hear it?" On the electrode's third pass through Lavender's brain, Vitek can hear the distinctive sound of thalamic cell activity. "This could be hip related," he says, rolling Lavender's leg to produce a burst of static. "I don't think we're quite there yet, but ..."
Bakay paces in the background. A nurse clutches a hot water bottle and drapes a blanket over her shoulders to ward off the operating room chill.
"There's the great toe; there's the ankle; there's the deep ankle," Vitek calls over several bursts of static. The mapping continues.
3:40 P.M. From the operating table, a weak, hoarse voice: "I want to stop."
Nearly six hours after being wheeled into the operating room, Lavender begs to move, to go home. Vitek stops, stunned, then steps close. "Donna, I know it hurts. I know you're tired. But we're close." He touches her left hand reassuringly. "I can't," she groans. Vitek steps back, confers with Bakay and returns. "Donna, we can give you something to help you relax," he says. "Let's just try."
4:15 P.M. The increased sedation has quieted the patient, but she lapses unresponsive. "Donna, do you feel this? Do you feel this?" Vitek asks, increasing the intensity of the stimulation to her brain. No answer.
4:50 P.M. The mapping continues, based more on electrical readings than on Lavender's feedback. But the crackle and buzz of brain activity is heard less often. Lavender's thalamus, like the rest of her, is flagging under the sedation. A small mercy: Lavender's leg and foot have visibly relaxed, uncurling for the first time in months. "We often see that during surgery," says Vitek. "But it won't last unless we lesion."
5 P.M. The nursing shift changes for the night. Vitek has yet to sit down.
6:15 P.M. The neurology team has pinpointed the "motor outflow tract" associated with Lavender's left leg. The mapping becomes more detailed, with Vitek stimulating Lavender's brain with smaller and smaller micro-voltages. "Can you feel this? Where do you feel this?" Lavender struggles to murmur her answer. "My my my ... foot."
7 P.M. The neurology team is confident they have found the area to be destroyed. But they advise against a large lesion: too risky, given Lavender's sedated responses. One more pass with the microelectrode to make sure of their bearings.
7:45 P.M. Lavender has been on the table more than nine hours. But now cooperation is absolutely crucial. Bakay begins to burn away brain tissue with a strong current through the electrode. Vitek grasps Lavender's hand and leans close. "Donna, this is it. I need to have you with me!" He asks her to smile broadly, purse her lips, stick out her tongue. Her responses tell him that no unwanted damage is occurring. "Now say the days of the week out loud. Come on, louder. Can you feel my cold fingers on your leg? Good, you can do it. Just five more minutes ..."
8 P.M. Bakay retracts the electrode. "Sedate her!" he calls, and the anesthesiologist puts Lavender into a mercifully deep sleep. The neurology staff stumbles out of the operating room. Bakay and his assisting surgeon cover the hold in Lavender's skull with a plastic plate.
Outside the surgical suite, the neurology team is cautious, but still hopeful. "A little disappointing," Vitek admits. "We'd hoped to be more aggressive [in destroying the problematic areas of the thalamus]. But the last thing we wanted to do is leave her with more problems."
DAYS OF WAITING
Some good news comes within a day. An MRI scan on Lavender's brain shows that the lesion is well placed. Recovering in her room, Lavender spends the morning moving her left leg and foot for the pure enjoyment of it. "I've got my leg back," she says.
But she hasn't forgotten the operating table. "It was so hard," she groans. "It hurt!"
Both Lavender and Vitek are cautious about considering further operations, either to enlarge the lesion if the dystonia in the left leg returns, or to restore the right leg if it doesn't. But as it turns out, a second surgery may not be necessary.
Seven weeks after surgery, Lavendar has recovered function and gained pain relief not only in her left leg and foot, but in the right ones as well. "I've got my life back!" she rejoices, as she makes plans to go to nursing school. "It was worth it."
Vitek can only guess at the reason for such a miraculous recovery on the right side. One possibility: Some neural "cross projections" from the right thalamus (affecting the left side of the body) had crossed into the left thalamus, where the team burned away cells. So the surgery may have ended up destroying the brain cells affecting both legs.
Alternatively, the pain and cramping Donna had been experiencing before the surgery may have been so severe as to produce a sort of negative feedback loop. The elimination of pain and cramping on one side may have been sufficient to break the feedback circuit and provide overall relief.
From past experience, surgeons and neurologists say that if the relief persists for three months after surgery, it's likely to be permanent. At press time, Donna Lavender was more than halfway home.
Jessica Snyder Sachs is the author of GOOD GERMS, BAD GERMS: Health & Survival in a Bacterial World (Hill & Wang/FSG October 2007).