A public health nurse gives an immunization injection.

As reported here on May 16, schools across Pennsylvania were forced to ban students from attending as part of an effort to catch up on required immunizations and record keeping. Reports suggest that the effort payed off in many school districts. It took eight months plus two weeks, and the exclusion of hundreds of students to reach that end.

Pennsylvania, like all states, has a list of immunizations that it requires students in public schools to have in order to attend school. The state allows a medical exemption, as well as a religious / personal belief exemption.

(b) Religious exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief.

Pennsylvania school districts, by law, cannot admit a student without proof of exemption or immunization. They have been, in the thousands.

The Republic:
Scranton School District – 139 students out of compliance on May 15
Bethlehem Area School District – 3,000 students out of compliance at start of school
Erie – 350 students on may 15
Lancaster – several dozen barred on May 17
Allentown – 3,000 unvaccinated in January
Philadelphia – 16% of student not in compliance in early spring

Tribune-Review:
Laurel Highlands School District – 17 students banned on May 14
Belle Vernon Area School District – 300 out of compliance in January / February
Southmoreland School District – 10 students excluded

Reading Eagle:
Reading School District – 40 students kept out of class

Lancaster Online:

As recently as two weeks ago, more than 2,000 county public school students lacked documentation that they had received the vaccines.

WJAC TV:

The Citizens’ Voice reports the Wilkes-Barre and Wyoming Valley West districts each have more than 200 students who are not up-to-date on their shots. Officials say those students are still attending school but will be excluded next year without immunizations.

Pennsylvania school districts allowed thousands of students to attend school without proof of immunization or an exemption.

The Minnesota Department of Health reports 670 cases of whooping cough in the state for the year through May 15. The cases are largely centered in and around the Minneapolis / St. Paul metro area.

Counties in Minnesota reporting pertussis cases in 2012 through May 15. Click for a larger image.

All 19 of the 2012 reports have shown Minnesota as having no pertussis cases. Media reports contradict that data.

Kristen from the CDC called with an explanation. The state of Minnesota is trying to implement a new electronic reporting system and they have reported nothing for the year as yet.

Claudia Miller from the Minnesota Department of Health verified that statement. The DoH is struggling to bring the system on-line. The deadline for reporting final case counts for 2011 to the CDC is coming up, so the DoH is concentrating on reporting the 2011 data first. Ms. Miller believes that the 2012 data will be reported by the end of June, 2012, and be reported weekly after that.

PLEASE NOTE:
The 670 pertussis cases in Minnesota in 2012 do not appear in the CDC’s data. Our reporting, until now, was based on that faulty data. The missing cases represent an additional 7.5 percent increase in the national case count.

Pie chart showing top states reporting pertussis in 2012. Click for a larger image.

The number of pertussis cases in the United States for 2012 through May 12 is 9,586. That represents 62 percent more cases of whooping cough than for the same 19 weeks in 2011. Minnesota ranks fourth nationally in cases.

A public health nurse gives an immunization injection.

When the school year began last September, large numbers of Pennsylvania school children lacked immunizations or the proof that they had received those immunizations. The Pennsylvania Department of Health notified families that they would have eight months to obtain immunizations, file the correct paperwork or provide the paperwork giving their student an exemption for medical, religious or philosophical reasons. The deadline passed and was extended for two weeks. Yesterday was it.

It was up to the district superintendents to ban students or not ban students for lack of immunizations. Some schools are permitting unvaccinated students to attend classes while others have refused and banned them from the building. The push to obtain immunizations and correct records has been successful in other districts.

The Pocono Record reports that some local schools have full compliance with the immunization policy. Two local schools were banning some students. The East Stroudsburg Area School District has reduced its backlog from 650 student to 70, and they were going to be banned. Pocono Mountain had gone from 300 to 50 by Tuesday’s deadline, and these students were set to be banned.

Wilkes-Barre Area and Wyoming Valley West are taking the opposite tack. The Times-Leader reports that Wilkes-Barre has about 300 students without all their immunizations. They are being allowed to finish the school year but will not be permitted to attend in the fall if the situation has not been corrected. WNEP-16 reports the same policy at Western Wayne, with the number of non-compliant students in that district at 67.

In Erie, 350 students were not allowed in class on Tuesday. By day’s end the number had been reduced to 206, as reported by GoErie.com.

In the Scranton area, the Times-Tribune surveyed local school districts. Many had full compliance while others reported very low numbers of students that would be banned. The Scranton district had about 300 students needing immunizations at the lend of last week and 155 students were banned on Tuesday.

Pennsylvania is one of twenty states that permit parents to exempt their children from immunizations based on a philosophical belief. The statute describes it as “a strong moral or ethical conviction similar to a religious belief”. The state has reported nearly 500 cases of pertussis, whooping cough, in 2012 and ranks fifth nationally in the number of reported cases.

An annual Mother’s Day event at a Buddhist monastery in rural Putnam County, NY, was interrupted yesterday afternoon as participants began suffering gastrointestinal symptoms like vomiting and diarrhea. The event drew hundreds to the Chuang Yen Monastery, and delawareonline.com states that about 500 arrived by bus from New York City’s Chinatown. Food for the event was provided by volunteers, similar to a pot luck supper.

Illness
Susan Hoffner, a spokesperson for the Putnam County Health Department, states that approximately 150 people were taken ill. Symptoms of the illness include vomiting, diarrhea, nausea and dehydration. Many became ill after they left the event. By evening, the Times Herald-Record states that local emergency services had received reports of dozens of cases of illness in travelers between the monastery and New York City. The outbreak is believed to be caused by some form of food poisoning.



Police Response
The Kent, NY, police department responded to the incident. Detective Gerald Locasio, a spokesman for the department, said that four officers from Kent and assistance from the Woodbury Police Department, responded. Fifteen patients were transported by ambulance from the area of the monastery. While there were some language barriers, Locasio said, there were enough English speaking individuals who could translate. The monastery shut down food service when notified of the problem. Detective Locasio states that there is no current indication that the incident was criminal in nature or that there was terrorist involvement. The investigators are working closely with the Putnam County Health Department.

Medical Response
The Putnam County News and Recorder reports that several fire and ambulance agencies from the region responded to the monastery as calls flooded the Putnam County 911 center. Triage was performed by EMS personnel on site and some patients were taken to nearby hospitals.

In Orange County, buses transporting people from the event stopped at a local shopping mall, where some of the travelers became ill. About two dozen patients were taken to local hospitals from this location. A spokesman for the Orange County Regional Medical Center, located in Middletown, estimated that around a dozen patients were treated and released from their facility. St. Luke’s Hospital in Cornwall reports that it treated eight from the incident. All were released. Good Samaritan Hospital in Suffern also treated and released several patients.

Health Department Response
The Putnam County Health Department will be working with experts from the New York State Health Department to investigate the outbreak. Peter Constantakes, spokesman for the NYS Department of Health, said that the DoH has personnel on the ground in Putnam County at this time working with the county health department. The followup with patients is requiring the DoH to translate the standard questionnaire into Chinese. They will also need to translate the answers when they are received. Constantakes stated that any outbreak follow up in Chinatown would be conducted by the New York City Department of Health and Mental Hygiene. If there is any indication that the illnesses resulted from a food product sold commercially, the Centers for Disease Control would be advised of the situation.

Attendees to the opening ceremony of the Kandahar Nursing and Midwifery Institute participate in the ribbon cutting May 9, 2012 in Kandahar, Afghanistan. The Kandahar Nursing and Midwifery will be able to train up to 800 students, both male and female, a year in nursing, midwifery, pharmacy, lab and dental services. Photo by Staff Sgt. Timothy Chacon

DVIDS
Story by Staff Sgt. Timothy Chacon

The Kandahar Nursing and Midwifery Institute held a ribbon cutting ceremony May 9,2012. The Nursing and Midwifery facility is one of only eight similar facilities in the country and will be able to train up to 800 students, both male and female, per year. The facility will teach students nursing, midwifery, pharmacy, lab, and dental services, with an emphasis on improving maternal and infant mortality rates in Kandahar, as well as surrounding provinces.

The May 9, 2012 ribbon cutting ceremony for Kandahar Nursing and Midwifery Institute marked a big step in the improvement of medical facilities in Afghanistan. The Director of Public Health, Dr. A.Q. Pokhla, Provincial Governor, Toryalai Wesa, and the Minister of Public Health, Dr. Suraya Dalil attended the ceremony along with many of the U.S. military and civilian partners who assisted in the project.

The speakers spoke about the importance of the facility and what it will mean for Afghanistan.

“Today we celebrate the transition to Afghan authority,” said Minister Dalil. “We should stand on our own feet to deliver services for our people.”

The Nursing and Midwifery facility is one of only eight similar facilities in the country and will be able to train up to 800 students, both male and female, per year. The facility will teach students nursing, midwifery, pharmacy, lab, and dental services, with an emphasis on improving maternal and infant mortality rates in Kandahar, as well as surrounding provinces. The compound consists of male and female dormitories, a dining hall, a schoolhouse, mosque, recreation field and administrative buildings.

The new facility will greatly increase the institute’s capabilities from those provided at the former site at Mirwais hospital.

“The nursing and midwifery facility will provide students with a better learning and living environment.” said U.S. Navy Lt. j.g Kimberly Gaines, Kandahar Provincial Reconstruction Team senior medical officer. “As well facilitate the growth of a multitude of health services in Kandahar City.”

U.S. Navy Lt. j.g. Kimberly Gaines, Kandahar Provincial Reconstruction Team, listens to a translated speech through a headset during the Kandahar Nursing and Midwifery Institute grand opening ceremony May 9, 2012 in Kandahar, Afghanistan. Kandahar PRT is a joint team of U.S. Air Force, Army, Navy service members and civilians deployed to the Kandahar province of Afghanistan to assist in the effort to rebuild and stabilize the local government and infrastructure. Photo by Staff Sgt. Timothy Chacon

Local Afghan contractors conducted the building of the facility with the assistance of the Kandahar Provincial Reconstruction Team. The Kandahar PRT is a joint team of U.S. Air Force, Army, Navy and civilians assigned to the Kandahar province to assist with the effort to rebuild and stabilize the local government and infrastructure.

Sailors with the Preventive Medicine Unit, 2nd Marine Logistics Group, place traps along a tree line aboard Camp Lejeune, N.C., May 8, 2012. Throughout the year, PMU performs many tasks to keep the living conditions on base at a high standard. The unit is now working hard as the summer months approach to catch and test mosquitoes from across the base for malaria. U.S. Marine Corps photo by Pfc. Franklin E. Mercado

DVIDS
Story by Pfc. Franklin Mercado

According to the Center for Disease Control, in 2010 an estimated 216 million cases of malaria occurred worldwide and 655,000 people died from the disease.

Sailors with Preventative Medicine Unit, 2nd Marine Logistics Group are working diligently to ensure diseases, such as malaria, do not threaten Marines and sailors aboard Camp Lejeune, N.C.

Throughout the year, PMU performs many tasks to keep the living conditions on base at a high standard. They inspect chow halls, barracks and working facilities for health hazards.

Complaints about pests are constant with the warm weather and rising number of insects. The heavily wooded and wet areas aboard the base are also conducive to a thriving mosquito population.

On May 8, Sailors with PMU ventured across the base to plant traps and conduct their research of the installation’s mosquito population.

There haven’t been many outbreaks of malaria in the U.S. compared to other stricken places, but it doesn’t stop the unit from doing all they can to keep it that way.

“We don’t have any cases in the area,” said Petty Officer 3rd Class Charles A. Hill, a preventive medicine technician with PMU. “We still do regular trapping and testing of mosquitoes from around the base.”

Camp Lejeune has a large quantity of grassy and moist areas, which is why it is important for traps to be spread out across the vast installation, explained Hill.

Sailors with the Preventive Medicine Unit, 2nd Marine Logistics Group, place traps along a tree line aboard Camp Lejeune, N.C., May 8, 2012. Throughout the year, PMU performs many tasks to keep the living conditions on base at a high standard. The unit is now working hard as the summer months approach to catch and test mosquitoes from across the base for malaria. U.S. Marine Corps photo by Pfc. Franklin E. Mercado

“We spread the traps out as far as we can,” he said. “We put them on Midway Park, Onslow Beach, around the Naval Hospital, and a lot more places on the base, so we can get a wide variety of mosquitoes.”

There are many types of mosquitoes – with the most common breeds being Culex and Aedes mosquitoes – and the trapping process gives PMU a chance to test a large number of them. In the peak mosquito season, traps are regularly found with 300 to 400 mosquitoes each, said Hill.

“When we get the traps back, we get a good idea of which mosquitoes are in the area,” said Petty Officer 3rd Class Justin Munger, a preventive medicine specialist with PMU. “We can better identify the ones that are harmful to people, and conduct population control.”

The traps are collected 24 hours after they are set out. They set the traps with carbon dioxide and lights, which attract approximately 80 percent more mosquitoes, said Hill.

“We don’t only rely on how many traps we lay out, we rely on the carbon dioxide and lights to help almost double the amount of bugs,” Hill said. “Malaria is a serious disease, so we need to do the best we can to keep it away from the people on base.”

The traps are rarely seen by personnel on base; sailors with the PMU do their best at hiding them in the tree line. If a person happens to run into the mosquito trap, the PMU strongly encourages people to leave them alone.

Registered nurse 2nd Lt. Rebeccah Collins vaccinates Alexia Woods, 12, for chicken pox and meningitis during the Carl R. Darnall Army Medical Center School Physicals and Immunization Clinic at Fort Hood, Texas. Photo by Jeri Chappelle, CRDAMC Public Affairs

Every state mandates a set of immunizations in order for a child to enter public school. Some also require immunizations as the student gets older. The list varies slightly but a pertussis (whooping cough) immunization is required in all states.

Not every student in public will have all their immunizations. Every state also provides for conditions of exemption from one or more of the mandated immunizations.

The medical exemption is the easiest to understand. A physician certifies that the student has had the illness, or that there are medical reasons for the child being unable to receive the immunization. An allergy to one of the vaccine’s ingredients would be an example of the latter.

Most states also provide for a religious exemption. The method of requesting this sort of exemption and the proof required varies by state. The exemption is granted to students whose religious beliefs do not allow immunizations. There are very few organized religions that hold this belief.

Twenty states allow a third type of exemption from immunization. It is called a philosophical or personal exemption. The request and the proof varies by state. In general, the state requires the parents or guardians to assert that they have a personal or philosophical objection to immunization. Several of these states have modified their laws recently to provide that the parents be counseled by a physician to the benefits and risks of immunizations in order to receive the exemption.

The states permitting some sort of personal or philosophical exemption from immunizations are: Arizona, Arkansas, California, Colorado, Idaho, Louisiana, Maine, Michigan, Minnesota, Missouri, New Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, Texas, Utah, Vermont, Washington and Wisconsin.

The Centers for Disease Control (CDC) collect and publish data on a number of reportable illnesses in the United States. The finalized data is available on line for 1996 to 2008. The preliminary data for these illnesses is available from 2009 to 2011, and monthly data for 2012 through May. Since pertussis (whooping cough) is in the news, the CDC pertussis case counts provide a basis for analyzing the effects of personal exemptions on case counts for the years 2005 through 2011.

• From 2005 to 2011, the average number of yearly pertussis cases in the United States was 17,801.
• The twenty states that allow the personal / philosophical exemption reported an average of 11,192 pertussis cases per year. That is 63 percent of the national average.
• Exemption states ranked first, second and third in pertussis case counts for the years 2005,2008, 2009 and 2010.
• In 2007, exemption states accounted for 54 percent of the total pertussis cases reported in the United States. This is the lowest percentage in the period studied.
• In 2010, exemption states accounted for 72 percent of the total reported cases. This is the highest percentage in the period studied.
• In the four years where exemption states reported the top three pertussis case counts, they account for 27 to 42 percent of the national total.
• Texas holds the most top three rankings, ranking in five out of seven years.
• California had the most reported cases of pertussis in four of the seven years. All four years, the state reported the highest number of cases in the nation.
• Minnesota ranked in the top three for three of the seven years.

Pertussis cases are surging in 2012. Year to date, the number of reported cases is up 44 percent from the same period in 2011.

The last year with this level of illness was 2010. In that year, California had a whooping cough epidemic. The states of Washington, Texas Ohio and Michigan also had large numbers of cases.

Data analyzed at that time indicated that the pertussis outbreaks in those states were centered in counties where the residents were above average in income. Many were also home to major universities and large academic communities.

• California
• Michigan, centered in the wealthy Detroit suburbs and around Ann Arbor
• Ohio, centered around Columbus
• Texas, centered around Austin

Prepared by Charles Simmins from CDC data. Click for a larger image.

In 2012, through May 5, 2012, six of the nine states reporting over 200 cases of whooping cough are exemption states. They account for fifty percent of all pertussis cases nationwide. The CDC reports that through week 18, ending May 5, there were 8,159 pertussis cases reported in 2012. That is a 44 percent increase over the same period in 2011.

Airman 1st Class Andrew McCutchen receives an immunization. U.S. Air Force photo/Staff Sgt. Nathan Bevier

Parents are asked to approve a variety of immunizations for their children. The various recommended vaccines are given beginning within a few months of birth and continue for the next dozen years and more. Some parents believe, without a scientific basis, that vaccines routinely harm children and that children are better off unvaccinated.

The United States Army has some experience with infectious disease. They keep records. The historical data for some diseases which we now prevent with a vaccine is available on line. Here are just some of the costs to the Army and the troops.

All four of these illnesses are preventable through immunization. The Army varied in number during those years but never exceeded three million men.

Registered nurse 2nd Lt. Rebeccah Collins vaccinates Alexia Woods, 12, for chicken pox and meningitis during the Carl R. Darnall Army Medical Center School Physicals and Immunization Clinic at Fort Hood, Texas. Photo by Jeri Chappelle, CRDAMC Public Affairs

The United States population is estimated to be 313,515,695 as of May 10, 2012. Let’s look at the case counts for these illnesses for the year 2011, the last full year.

Diphtheria – 0 No reported cases in the U.S. since 2003.
Measles – 222 cases
Mumps – 370 cases
Smallpox – 0 No reported cases since 1949.

Look at the difference that routine immunizations make. Each case of mumps, for example, cost the Army 17 days back during World War I. The 2011 case count for mumps is 0.16 percent of the Army total. The savings in days out of work due to mumps is clear.

Add in the people who did not die from diphtheria or smallpox. Add in the reduction in illness related disabilities. Immunization for vaccine preventable diseases saves lives and money.

Enrique Ruiz was very sick when he went to the emergency room at New York City’s Lincoln Hospital in April. He was diagnosed with pneumonia and bronchitis. Less than a week later, he was being treated for second degree burns on his neck and chest.

Sunday’s New York Post reported on the ordeal by fire that Enrique Ruiz suffered at Lincoln Hospital in the Bronx. As doctors were trying to insert a breathing tube, Ruiz caught fire. The pain was severe enough that he woke up from sedation. An electronic scalpel being used to cut an opening in his neck combined with the oxygen he was being given causing a flash fire around the surgical site.

Surgical Fires

Mark Bruley, vice-president of investigations for the ECRI Institute, stated in the Post article that 500 to 600 surgical fires occur in the United States each year. The results can be serious or fatal. A spokesperson for the New York State Health Department (NYSDoH) states that the fire was originally reported as minor but additional information has now been provided. All injuries to patients are required to be reported to the DoH.

Causes of Surgical Fires

A fire needs oxygen, an ignitions source and fuel – something that will burn. The Food and Drug Administration (FDA) points out that all of the requirements for a fire are routinely found in a surgical environment. The patient is supplied with oxygen. Alcohol skin preparations, anesthetics and surgical draping are among the fuels present. Ignition is provided by electronic surgical tools such as scalpels and lasers.

Other Surgical Fire Cases

Kira Reed was undergoing a cesarean-section in March 2010, according to the Syracuse, NY, Post-Standard. She was awake and smelled something burning. She was on fire. Her baby was delivered without injury but she suffered third degree burns to her side. An alcohol-based antiseptic skin preparation is being blamed.

In September 2009, Janice McCall died some six days after being burned by a fire on the operating table, MSNBC reports. While her death was ruled accidental, her family is pursuing legal action against Heartland Regional Medical Center in Marion, Il.

In early December, 2011, two separate fires left two patients with severe burns to the face. ABC reports that Kim Grice was burned while undergoing an outpatient procedure in Crestview, Fl. Seattle’s qFox 13 has the story of Tommy Beams, who also suffered facial burns after a fire at Grays Harbor Community Hospital.

These fires are preventable, according to Mark Bruley in the Post. The FDA has a website with information for both patients and medical professionals on how to prevent surgical fires. The agency has no mandatory reporting requirement but does ask that voluntary reports of surgical fires be submitted.

Defense Department:

Lt. Christopher E. Mosko, 28, of Pittsford, N.Y., died April 26 while conducting combat operations in Nawa district, Ghazni province, Afghanistan. Mosko was assigned as a Navy Explosive Ordnance Disposal (EOD) Platoon Commander to Combined Joint Special Operations Task Force, Afghanistan. Mosko was stationed at EOD Mobile Unit 3, San Diego, Calif.

Lt. Mosko lived in Pittsford, a suburb of Rochester, NY, for several years. His father, on his blog, has corrected some of the media reporting.

Mosko spent his high school years in Eu Clarie, Wisconsin. He attended Drexel University in Philadelphia 2002 to 2007 and received his Navy commission through their ROTC unit there. Drexel awarded him a B.S. degree in Finance and Engineering.

From 2007 to 2008 he was at the Navy’s Explosive Ordnance Disposal school at Eglin AFB in Florida. He then served as an Assistant Operations Officer until May 2009 when he received his first command assignment.

At the time of his death he was serving as a platoon commander in Explosive Ordnance Disposal Mobile Unit 3 (EODMU 3). The unit is stationed in San Diego.

He leaves behind a wife, Amanda, who is also a Navy officer. He is also survived by his father and mother, John and Gayle Mosko and a sister Meredith.

Chris Mosko on LinkedIn
John Mosko’s moving letter to his son upon graduating
John Mosko’s blog

News Media Reports
Superior Telegram – Sailor killed in Afghanistan was ECM HS grad
WEAU 13 – Friends remember Memorial High School grad killed in combat
Leader-Telegram – Memorial High graduate killed in Afghanistan

The nurse depicted in this 2006 image was administering an intramuscular vaccination in the left shoulder muscle to a young girl. The nurse immobilized the girl’s arm by clutching it tightly, while the girl held up her sleeve in order to facilitate the procedure. CDC/ Judy Schmidt

Two deadly childhood illnesses are back in the news. The Centers for Disease Control (CDC) raised all sorts of flags over the number of measles cases in the United States last year. The number of pertussis cases, also called whooping cough, is also rising rapidly across the nation.

The CDC publishes the Morbidity and Mortality Weekly Report every week. In that report is the data from the National Notifiable Diseases Surveillance System. The latest report is for week 16, ending April 21, 2012.

Through week 16, the CDC has received 28 reports of measles case. For all of 2011, the number of cases was 222. There were seventeen outbreaks. The CDC held a press conference about the number, which was a spike from the historical median of sixty cases and four outbreaks. 200 of the measles cases were contracted overseas.

Measles (rubeola) is very contagious and is a serious respiratory illness. It is preventable through a series of immunizations. With 90 percent of the measles cases in 2011 having originated outside the United States, it is unclear what the reason is for the alarm. The Customs Service states that they have a program to prevent travelers with an illness from entering the country.

What was the legal status of the 200 patients who caught measles outside the U.S. but were diagnosed here?

Changing gears, the opponents to immunization place children at risk by avoiding necessary vaccinations. The same MMWR reports that the number of cases of pertussis, whooping cough, is up 29 percent over the same time last year. Eight of the top ten states in case counts allow parents to exempt children from immunizations based upon some sort of personal or philosophic objection. 59 percent of all the pertussis cases reported in 2012 originate in the 20 states that allow such objections.

Using the MMWR data, the highest number of cases of whooping cough reported in 2012 is from Wisconsin. They have reported 1,006 pertussis cases. Illustrative of the situation is a report from Fox 6 in Milwaukee. 30 students at the St. Matthias Catholic School in the Wisconsin city have whooping cough. The article quotes the school principal as saying that the cases are throughout the elementary and junior high grades.

Coming in second, with a declared pertussis epidemic, is Washington with 863 pertussis cases. Minnesota and Oklahoma are the only states reporting no cases in 2012. Here is a list of reported cases of whooping cough from the top ten states in 2012.

Only New York and Illinois do not allow a personal exemption. Also of note is the sharp drop in cases counts from New York to Pennsylvania.

Washington, on its Health Department website, reports more cases than the CDC, 1,008 pertussis cases. This is common and reflects reporting delays at the state or local level.

It is unclear why New York is reporting so many cases. In theory, without a religious or medical exemption, every student in New York ought to be immunized for pertussis. It is the law. The State Health Department has an office that audits public schools for their compliance with this issue and their record keeping on immunizations in general. Inquires to that office have not received a response.

Is it possible that some New York public schools schools do not comply with the law? The audits are not punitive and there is no punishment for not complying, so far as can be determined. It is a monumental record keeping task and schools can ill afford the loss of state revenues based on attendance. Barring large numbers of students would put one more financial strain on already tight budgets.

USA in the UK

The Summer Olympics will take place in London From July 27 to August 12, 2012. Hundreds of thousands of Americans will travel to England to see the show and they will be bringing lots of souvenirs home with them. Without precautions, those souvenirs may include mumps or measles.

The United Kingdom has been struggles with large numbers of cases of these two illnesses for a decade. Much of the British public lost faith in childhood vaccines in the late 1990′s when the now debunked Wakefield paper on a link between the MMR vaccine and autism was published. An 2009-20010 outbreak of mumps in the New York City region that grew to almost 2,000 patients was traced to one tourist who had traveled to England.

Number of laboratory confirmed cases of measles in England and Wales by month of onset: January 2007 – January 2012, Health Protection Agency

Case counts for measles and mumps in England and Wales remain high. Both illnesses are highly contagious. Both are preventable by immunization. The Centers for Disease Control suggest that travelers to the United Kingdom ensure that their immunizations are up to date.

The CDC on measles:

The only vaccines available in the United States are the measles-mumps-rubella (MMR) and the measles-mumps-rubella-varicella (MMRV) vaccines. MMR has been used safely and effectively since the 1970s. A few people experience mild, temporary adverse reactions, such as joint pain, from the vaccine, but serious side effects are extremely rare. There is no link between MMR and autism.

Information and the latest data on the outbreak of measles and the outbreak of mumps in England can be found at the UK Health Protection Agency pages for those illnesses.

The United States embassey in London has lots of information for Americans who may want to attend the 2012 Olympics. The Centers for Disease Control have a comprehensive site covering the topics of illness or injury abroad. For Americans traveling to the United Kingdom, the State Department has this reminder:

While medical services are widely available, free care under the National Health System (NHS) is allowed only for UK residents and certain EU nationals. Tourists and short-term visitors will be charged for medical treatment in the United Kingdom. Charges may be significantly higher than those assessed in the United States. Travelers to the United Kingdom should ensure they have adequate medical insurance to cover the cost of any treatment received – please see additional insurance information below…

You can’t assume your insurance will go with you when you travel. It’s very important to find out BEFORE you leave whether or not your medical insurance will cover you overseas. You need to ask your insurance company two questions:

Does my policy apply when I’m out of the United States?
Will it cover emergencies like a trip to a foreign hospital or a medical evacuation?

In many places, doctors and hospitals still expect payment in cash at the time of service. Your regular U.S. health insurance may not cover doctors’ and hospital visits in other countries. If your policy doesn’t go with you when you travel, it’s a very good idea to take out another one for your trip. For more information, please see our medical insurance overseas page.

Cpl. Tristan I. Hobson checks the trunk of a patrol car for supplies on Camp Foster March 28. Hobson saved a local community member's life on Camp Kinser Feb. 18 with the aid of an automated external defibrillator. Hobson is a military policeman with Headquarters and Service Battalion, Marine Corps Base Camp Butler. Marine Corps photo by Lance Cpl. Kasey Peacock

The life of a military policeman encompasses many different tasks. One might assume a typical day would include patrolling, issuing citations, interacting with service members, and making arrests.

What one may not assume is that MPs can be called for anything, at any time, sometimes even placing them first on scene at a medical emergency.

The morning of Feb. 18, Cpl. Tristan I. Hobson, a military policeman with Headquarters and Service Battalion, Marine Corps Base Camp Butler, Marine Corps Installations Pacific, received one of those calls.

When Hobson received the call that an employee at the Camp Kinser Mess Hall, had collapsed and was not breathing, he immediately shouted to his partner, Lance Cpl. Leonard J. Kim, that it was time to go. The two geared up for the unknown and later found out that the key to the victim’s survival lay unused in the trunk of Hobson’s patrol car.

“When I arrived on scene, I could tell immediately the victim was not breathing,” said Hobson. “I began conducting (cardiopulmonary resuscitation), but it wasn’t working.”

That is when Hobson grabbed an automated external defibrillator.

An AED is a portable electronic device that diagnoses potentially life-threatening cardiopulmonary conditions in a patient and guides the first responder through the life-saving process.

Hobson and his partner connected the AED to the victim and began following the instructions.

“I can remember the machine telling me to continue chest compressions and then telling me to administer the shock,” said Hobson. “At that time, I advised everyone to back away and did what I was supposed to do. I used the shock.”

After repeating this process for several minutes, emergency technicians arrived. Hobson had given the fifth shock, which restored the victim’s heart rhythm and proved to be the shock that saved her life.

“MPs are fully capable of responding to a crisis, and we are thankful for their training,” said Petty Officer 3rd Class Jason M. Turgeon, a preventive medicine technician with Combat Logistics Regiment 37, 3rd Marine Logistics Group, III Marine Expeditionary Force. “It’s important for properly trained personnel to make sure the scene is safe and secure for the emergency medical providers.”

Military policemen conduct a variety of annual training scenarios refreshing their CPR and basic first-aid capabilities.

“Our MPs train for anything that could possibly be thrown at us,” said Staff Sgt. Thomas D. Sanford, a military policeman with the battalion. “Hobson and Kim showed great leadership skills by taking action and responding accordingly to the crisis.”

Hobson later found out from the victim’s brother, who was on the scene, that without his quick actions with the AED, she may not be here.

“When I heard the news that she was alive I was very relieved,” said Hobson. “I remember giving all that I had while performing CPR because I realized her life was at stake.”

Hobson responded to a similar situation a few months prior. These two incidents have proven this piece of equipment is vital for responding to life-threatening situations, according to Hobson.

U.S. Army Staff Sgt. Laura Comacho, of New Braunfels, Texas, the non-commissioned officer-in-charge of the new mild traumatic brain injury recovery clinic on Forward Operating Base Sharana, stands next to the as yet to be mounted sign for the new facility March 21. Photo by Sgt. Ken Scar

DVIDS
Story by Sgt. Ken Scar

The Department of Defense estimates that 22 percent of all combat casualties from Operation Enduring Freedom are brain injuries. Of those, the majority are mild traumatic brain injuries. Victims of MTBIs don’t have the extreme symptoms of the more serious TBI, but even mild damage to the brain can last a lifetime. Fortunately, sufferers of MTBI have an excellent chance at making a full recovery if the injury is treated properly within the first 72 hours, so treating MTBI has become increasingly important to health care professionals in the field.

The medical treatment facility at Forward Operating Base Sharana now has a posh new facility to treat those casualties during the most crucial time in their recovery, the first 24 hours.

“Within the first 24 hours is when the brain is going to heal the most, so we’ve tried to give them a simple place that’s quiet to sleep,” said U.S. Army Staff Sgt. Laura Camacho, from New Braunfels, Texas, the non-commisioned officer-in-charge of the facility. “The brain is healing when they’re sleeping. If they’re thinking, reading, writing, playing a computer game – the brain is working. We don’t want any stimulation – just stillness. I hate to say it, but we almost offer a spa-like retreat.”

Comacho explains the careful planning put into every detail of the new facility as she leads a tour through the immaculate rooms of the center, all simply decorated with comfortable beds and chairs, dimly lit with strings of Christmas lights, and walls painted with a muted burnt umber color which, she explains, helps to prevent headaches.

Creating this refuge for injured soldiers has been a labor of love for the soldiers of Company C, 122nd Aviation Support Battalion, Task Force Blackhawk, who currently operate the Sharana Medical Treatment Facility.

“Our soldiers have worked really hard to make this place better than when we received it,” said Staff Sgt. Lucas White, of Coffeyville, Kan., who is the NCOIC of the Sharana MTF. “There was nothing wrong with how we received it, but you always want to make a mark where you’ve been.

“We’ve seen approximately 140 MTBI’s since we’ve been here,” he said, noting that the unit is about nine months into their one-year deployment. “We return the large majority of them to duty after 72 hours.”

“83 percent are returned to duty,” said Comacho. “We are giving them the best place we can to recover, and that’s pretty important.”

The new facility is a vast improvement from the last building they used, which was the typical FOB plywood structure with no separate rooms and little temperature control, Comacho said. The new MTBI recovery center has separate, centrally heated and cooled accommodations for up to 10 patients.

“This is a huge, huge improvement because if you don’t give them a comfortable environment, they’ll do whatever it takes to get out of here,” Comacho added. “They may not be 100 percent, but tell you that they are because they just want to get out. With this place, they’ll wait until they are well and we feel good letting them go.”

“Now we can provide a nice, quiet, comfortable environment that will allow their brain to rest,” said Capt. Cindy Dean, from Fort Belvoir, Va., the officer in-charge of the new center.

“It’s so inclusive and comfortable in here sometimes it’s hard to walk outside into the light,” she added, laughing.

PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. According to the National Institute for Mental Health, there are five diagnostic criteria that must be met for this to be a valid diagnosis.

1. Presence of Obsessive-compulsive disorder and/or a tic disorder
2. Pediatric onset of symptoms (age 3 years to puberty)
3. Episodic course of symptom severity
4. Association with group A Beta-hemolytic streptococcal infection (a positive throat culture for strep. or history of Scarlet Fever.)
5. Association with neurological abnormalities (motoric hyperactivity, or adventitious movements, such as choreiform movements)

By definition, PANDAS is a pediatric disorder. It is possible that adolescents and adults may have immune mediated OCD, but this is not known. The research studies at the NIMH are restricted to children.

Case discussion from the American Journal of Psychiatry Am J Psychiatry 1998;155:1592-1598

PANDAS is not a diagnostic label, but an acronym designating a subgroup of children with OCD and tic disorders whose symptoms appear to be triggered by streptococcal infections.

The fourth criterion, temporal association between GABHS infections and symptom exacerbations, is the most important one for determining whether or not a child should be included in the PANDAS subgroup. The relationship between symptom exacerbations and GABHS infections must be established by demonstrating that the symptoms worsen in association with streptococcal pharyngitis and remit when the child is free of GABHS.

From Pediatrics Vol. 113 No. 4 April 1, 2004 pp. 883 -886

Therapy
What treatment should be considered for patients who present with the manifestations associated with the PANDAS constellation of symptoms?

Neuropsychiatric Drugs
Children with disabling tics or OCD should receive appropriate treatment for their symptoms, including medications (eg, tic suppressants such as ?-agonists, classical or atypical antipsychotics, or antiobsessional drugs such as selective serotonin-reuptake inhibitors) or nonpharmacologic approaches (eg, cognitive behavioral therapy for OCD).24

Antibiotics to Prevent Strep Infections
The only published clinical trial of prophylactic penicillin in children with this syndrome revealed no conclusive evidence that the antibiotic reduced clinical exacerbations.25 Admittedly, the duration of that study was too short to allow definite conclusions. A later report suggesting improvement of new-onset or acute exacerbations of symptoms in such children with antibiotics provides inadequate support for such an approach, because treatment was not placebo-controlled and was unblinded.26 It is well known in treatment studies of TS that there is a substantial placebo effect; the natural course of TS and OCD is such that exacerbations are followed by remissions. This latter phenomenon of “reversion to the mean” implies that virtually any intervention at the time of peak symptoms may seem successful. Only a double-blind, placebo-controlled study can identify a true therapeutic effect.

Another reason to feel comfortable with avoiding antibiotic treatment for these patients is that, to date, no cases have been reported to develop any rheumatic carditis as occurs in patients with Sydenham’s chorea. This is a very important point to remember, because some have attempted to relate this syndrome to rheumatic fever. It is recognized that as many as one third of patients with Sydenham’s chorea ultimately will have evidence of rheumatic valvular heart disease.27 This issue requires additional investigation, because the lack of heart disease strongly argues against a relationship between PANDAS and Sydenham’s chorea or other forms of rheumatic fever.

PANDAS references:
National Institute of Mental Health
NYS Department of Health report released February 3, 2012
Peter D. Springberg, M.D., FACP
International OCD Foundation PANDAS Fact Sheet
What every psychiatrist should know about PANDAS: a review Clinical Practice and Epidemiology in Mental Health 2008, 4:13
PANDAS – PITAND Awareness & Research Support
International PANDAS Foundation
PANDAS Resource Network