Dr. Harley Rotbart’s GERMBlog™

Just this morning comes the report that the FDA opted not to ban cough and cold medicines for young children despite a recommendation to do so made nearly one year ago from a group of outside experts. The history of this issue is a bit complex and has been the subject of previous Dr. Rotbart’s GERMBlog posts (see October 19, 2007 and Jan 20, 2008). The over-the-counter cough and cold medicines for kids were approved by the FDA years ago under rules that are quite lax - many of the individual ingredients of the medicines have not been tested in kids to prove effectiveness or safety. More importantly, studies showing benefits of these medicines in kids under the age of 6 years are lacking. As a result, in January of 2008, the FDA ruled that the medicines should not be given to kids under 2 years - a vindication for pediatricians who have been urging this for years. But, anticipating FDA action and wanting to be out front in hopes of avoiding an outright ban, the manufacturers of the medicines had already voluntarily removed kids under age 2 from packaging and marketing of the products.

It was hoped by many of us that the FDA would then follow through with an official recommendation against the medicine for kids under the age of 6, per the outside panel of experts’ suggestions. However, the FDA instead decided that banning the medicines would drive parents to use adult formulations of the over-the-counter medicines for their kids, a potentially worse outcome.

Why shouldn’t these medicines be in your household with young kids? Because they don’t work (see Chapter 8, Germ Proof Your Kids - The Complete Guide to Protecting (without Overprotecting) Your Family from Infections (ASM Press, Washington, D.C., 2008), they have undesirable side effects, and thousands of accidental overdoses are reported each year (the medicines are pleasant-tasting and have appealing colors - very tempting for young kids).

Tis’ the season for colds and flu. There are lots non-medicinal ways to ease your kids through these illnesses once they get sick (including honey for coughs in kids older than 15 months - see Dr. Rotbart’s GERMBlog, December 9, 2007 post), and lots of good advice for reducing the number of episodes your kids and you get this winter (see Chapter 11, Germ Proof Your Kids - The Complete Guide to Protecting (without Overprotecting) Your Family from Infections.

Skip the cold and cough medicines for your kids.

I certainly forgive you if you missed the story last week that measles vaccine does not (DOES NOT!) cause autism. There were no celebrities touting the results. No Larry King specials. Just a small piece in the back pages of the bigger newspapers. Yet, this was a really big story for everyone who has been laboring for a decade to undo the harm caused by a poorly done British study.

     The initial concerns regarding a possible link between MMR and autism (see Chapter 7, Germ Proof Your Kids - The Complete Guide to Protecting (without Overprotecting) Your Family from Infections ASM Press, Washington, D.C. 2008) were generated by a report in 1998 of 12 children in England who developed autism within a few weeks of receiving the MMR; these children also had intestinal symptoms. The investigators hypothesized that the measles virus in the live, but weakened MMR vaccine damaged the intestines, allowing toxins to escape from the intestines into the blood, reach the brain, and cause the developmental problems of autism. A subsequent study by the same investigators identified evidence of measles virus in more intestinal biopsies taken from kids with autism than from kids without autism. These published reports generated enormous media attention, and an instant, and persistent, controversy was born.  As with most controversies, new perspectives emerged with time and data were more critically assessed. Many other experts reviewing those two initial studies identified numerous and serious flaws with the way in which those investigations were conducted and with the interpretation of the results.  

In addition to finding flaws with the original studies and results, many lines of evidence have since accumulated to refute the association between measles vaccine and autism. These include a study from Denmark of more than 500,000 kids comparing those who did, with those who did not, receive MMR vaccine – the occurrence rate of autism in the two groups of kids was identical regardless of vaccine status. Other studies have looked at large numbers of “home movies” made of kids prior to their diagnosis of autism and prior to their MMR vaccine, as well as home movies of other kids matched for age and other factors who didn’t ultimately get diagnosed with autism. Expert autism investigators who didn’t know whether the kids they were watching on the home movies went on to be identified as autistic or not were able to very accurately predict by the kids’ behaviors on the movies which kids would, and which would not be diagnosed with autism – and all of those telltale behaviors occurred before MMR was given to any of the kids. Thus, if a child received the MMR vaccine a month after the home movie was taken, and was diagnosed with autism two months after the home movie, there might be concern that the vaccine had something to do with the development of autism  – but the movies prove that the signs of autism in those kids preceded the vaccine and preceded the actual time of diagnosis of the disorder. Finally, studies of identical twins and of toxic exposures that occur during pregnancy that are known to cause autism all suggest that autism is a condition that develops prior to birth and is subsequently diagnosed when kids’ behaviors are more easily assessed – often around the time that vaccines are coincidentally given.  All of that evidence prompted the National Academy of Science’s Institute of Medicine (http://www.iom.edu/?ID=4705) and the American Academy of Pediatrics to conclude that the vaccine does not cause autism or autism spectrum disorder.

And then, there was last week’s non-headline - investigators repeated the exact experiments that were done 10 years ago, and found absolutely no evidence for the virus in kids with autism. None.

End of story - measles vaccine doesn’t cause autism. Well, not quite the end of the story. The study done 10 years ago resulted in a dramatic drop in the number of measles vaccinations that have been given because parents have been frightened. Fewer immunizations mean more cases of natural measles, and 2008 marks the highest number of cases of naturally-occurring measles in the U.S. since 1996. There is no scientific controversy about the dangers of measles - it can be a deadly infection.

Immunize your kids.

Antibiotics have been added to soaps, shampoos, laundry products, deodorants, and many other personal care products that manufacturers then label as “antibacterial” and increase the price. The most frequently used antibiotic is Triclosan. Although triclosan reduces germ counts in the laboratory more than simple soap, there are no studies demonstrating that triclosan-containing products actually reduce personal or household infections. The majority of household illnesses are due to viruses which are not affected by antibiotics. Indeed, a recent study of households randomly assigned to either antibacterial or non-antibacterial hand washing, cleaning, and laundry products showed no difference over a 1 year period in the occurrence of symptoms typically attributable to viral illnesses.  But the absence of a benefit in reducing viral symptoms likely predicts that overall household health will not be greatly benefited by the use of antiseptic products, because viral illnesses are so much more common than those due to bacteria. Despite the fact that triclosan benefits in reducing actual infections are theoretical and based on laboratory germ counts, the antibiotic can now be found in as many as three-quarters of all liquid soaps marketed to households in the U.S.  

        Whenever widespread exposure to antibiotics is considered, so too must the development of antibiotic resistance be considered (see Chapter 5, Germ Proof Your Kids - The Complete Guide to Protecting (without Overprotecting) Your Family from Infections (ASM Press, Washington, D.C., 2008). Resistance results from the conditioning or acclimating of resident germs to their environments. When anti-microbial substances are part of that environment, germs that are naturally or mutationally resistant to those substances have a selective advantage and outgrow the sensitive bugs. Initial concerns regarding triclosan, in particular, have been largely resolved regarding resistance – it does not appear that the use of triclosan in the household, even continuously for a year, results in the emergence of resistant germs. However, recall, that it is also not proven that triclosan-containing products are in any way advantageous over non-antibiotic cleaning products in reducing personal or household infections.

The absence of evidence suggesting an advantage of antiseptic soaps, and the theoretical risks of increasing resistance (although also not actually observed to date), prompted an FDA Advisory Panel to recommend in October of 2005 against these products for home use, in favor of simple soap.

But now for the really silly part. Triclosan has now been incorporated into dozens (DOZENS!) of inanimate objects like floor tiling, countertops, toys, clothes, combs, brushes, and, of course toilet seats. On the school supply aisle, you can now find antibiotic impregnated scissosrs, rulers, protractors, and compasses! No one has yet explained to me (or anyone else) how the antibiotic on the protractor and the compass gets out to kill the geometry germs that land on it, or whether any reduction in germs occurs at all - and certainly no one has shown any decrease in infections from antibiotic-laced scissors. But…the plastic scissors without the antibiotic cost $0.99 while the antibiotic-impregnated plastic scissors are $2.49. And that, my friends, apparently is motive enough to put antibiotics into everything that we touch.

What’s the solution? Don’t put antibiotics into anything. Rather, effectively clean surfaces that tend to accumulate germs - that’s a proven technique for reducinig actual infections and keeping households healthier (see Dr. Rotbart’s GERMBlog entry of August 3, 2008 for Home Hot Zones and effective surface disinfecting; and see Chapter 9 of Germ Proof Your Kids - The Complete Guide to Protecting (without Overprotecting) Your Family from Infections). 

I recently had the honor of speaking to the School Nurses Organization of Oklahoma - a wonderful group of committed health care professionals, truly on the front lines of keeping our kids healthy.  I have had the opportunity to present my seminar, “Germ Proof Your Schools - Reduce the Spread of Infections, Reduce Absenteeism” to many statewide school nurse organization meetings around the country. School nurses are unsung heroes.

As part of the Oklahoma appearance, I did a three-part interview with Tulsa’s KRMG radio host Joe Kelley. That series begins running this week and you can hear it at: http://krmg.com/blogs/the_krmg_morning_news_blog/2008/08/krmg-series-germ-proof-your-ki.html  (You may have to disarm your “pop-up blocker” to hear this series - on most computers ,you simply hold down the “control” key while clicking on the link).

For more about the Germ Proof seminar series, as well as the book on which it’s based (Germ Proof Your Kids - The Complete Guide to Protecting (without Overprotecting) Your Family from Infections - ASM Press, Washington, D.C., 2008), see: www.germproofyourkids.com

Now that the FDA has identified the precise origins (peppers imported from a single farm in Mexico) of the recent nationwide Salmonella outbreak that sickened more than 1300 people (see previoius GERMBlog entries), let’s expose an even greater risk factor for Salmonella infections – your kitchen!!

Of the more than 75 million cases of infection-related food poisoning that occur in the U.S. each year (including the recent 1300 cases of Salmonella imported from Mexico), one-fifth occur in our homes – and the kitchen and bathroom are prime breeding grounds. In particular, 90% of all Salmonella infections occur at home – 90% !!  In a house with one Salmonella-infected individual, two-thirds of other household members will become infected. Similarly, E. coli and Campylobacter infections, also causes of potentially severe gastrointestinal diseases, frequently originate and/or are spread in our homes (for much more on household hygiene see: Chapter 9 in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections (ASM Press, Washington, D.C., 2008).

Although we are trained to think of public places – restrooms, restaurants, day care centers, and schools – as likely sources of infection, and they are, our perception of home as a clean refuge is fantasy. Taking a culture swab to surfaces at home has been the subject of many a child’s school science fair project – and the results are always startling. In particular, the kitchen, bathroom, play room, sick room, and even the laundry can be vast reservoirs of lurking germs. Items that you think of as allies in the war on bugs – dish rags, sponges, and mops may, in fact, be double agents, spreading germs faster than they eliminate them. Recognizing where germs lurk will help you to keep your kids healthy. There is no law that says that when one family member is sick, everyone has to get sick with the same germ. Here are some clues to stopping the spread of germs like Salmonella in your homes.

Home Hot Zones

Kitchen

Germs like moisture. The highest counts of bacteria in the kitchen are found in the sink, dish rags, mops, and sponges. When dish rags are also used to wipe down counter tops, the germs from the sink are spread to new surfaces. Salmonella has been found in 15% of sponges and dish rags in homes like yours. Raw and undercooked meat, poultry, and fish harbor dangerous germs like E. coli O157:H7, Salmonella, and Campylobacter, which get on the hands of the chef (you!) and then spread to cutting boards, faucets, countertops, and to your family.

Bathroom

Bathroom wetlands are fertile areas for bacteria, virus, and fungus growth. Toilets, toilet seats, and the rim under the recess of the toilet bowl all harbor germs in households where a family member is infected. Rotaviruses, the leading viral cause of gastroenteritis in young children, can survive for days to weeks on moist environmental surfaces including the toilet bowl, faucets, bath toys, diaper changing and disposal areas, and sinks!

Bedroom/sick room

Respiratory viruses are spread by hand contact with infected secretions and by airborne infected droplets. In a household study of colds, infection spread to 71% of adults holding and playing with a sick infant, and to 40% of adults merely touching surfaces in the baby’s room; no adults became ill if they just sat in the room next to the crib without touching anything. Hand washing after holding an infected baby protects the adults from getting sick.

Laundry room

Another moisture haven, the laundry room nurtures germs. Cooler temperature wash cycles, smaller water loads, and permanent press clothes help germs survive on clothing. Most bacteria survive a typical wash cycle; adding a rinse reduces but does not eliminate the germs. In contrast, using hot water with bleach and complete drying cycles reduces viral and bacterial contamination of clothes by 98-100%.

Infection Prevention

There is an important difference between cleaning and disinfecting; cleaning refers to mechanically removing dirt, whereas disinfecting means the incapacitation of germs. Common detergents, for example those containing baking soda, vinegar, and water alone are used for cleaning and do not kill germs. In contrast, chemical compounds with anti-microbial properties, such as those containing bleach, ammonia, alcohol, antibiotics, and phenols are disinfecting. Cleaning is a good start when the dirt is visible – like the mud on the floor or the grease and grime on the stovetop. But, disinfecting is more important in preventing infections because it actually kills the germs on surfaces that are likely to come in contact with your kids’ hands and mouths. Household cleaning and disinfecting products come in many flavors. Disinfectants, containing the chemical compounds above, kill most of the bacterial germs you should be worried about. Products containing bleach also kill many common viruses that can cause colds, flu, and stomach flu (gastroenteritis); viruses are the most common causes of childhood (and adulthood) infections, making bleach-containing products preferable to other disinfectants. 

Care and common sense in cleaning is essential: only use kitchen dish rags for one day before laundering; don’t use the dishrags that you’ve used to wash or wipe dishes to clean counter or stovetops, and vice versa; don’t store mops in a wet bucket – remember, germs like moisture; thoroughly wash mops, in bleach-containing disinfectant or in the washing machine with bleach-containing detergent, after each use.

Establishing and adhering to a consistent schedule for cleaning and disinfecting each room of the house is probably the most important thing you can do to protect your family from germs.  A reasonable regimen is to disinfect kitchen sinks and countertops daily; bathroom sinks, countertops and flush handles 3-4 times each week; toilets and kitchen and bathroom floors weekly. The bedroom and playroom of a sick child should be disinfected twice a day. Disinfecting sprays and wipes are very convenient for bedroom and sick room surfaces like crib railings, door knobs, light switches, and diaper pails. Adding bleach to your regular laundry routine will kill the leftover germs on clothes, towels and linens.