Dr. Harley Rotbart’s GERMBlog™

Well, the retail stores are all having their “back-to-school” sales, so it must be time to remind you all of the strategies you should be taking to protect your kids from “back-to-school” germs!

Schools are truly “ground zero” for infectious disease transmission, because schools are both amplifiers of personal and community infections, as well as potential original sources of infections. There are many examples of both the amplifier and the originator roles that schools play in infectious diseases. Of the 3 great influenza pandemics of the 20th century (1918, 1957, and 1968 – I’m not counting the Swine Flu epidemic of 2009 because much has been written about that in my previous GERMBlog entries), the mildest of the 3 (1968) reached its peak during the winter break weeks of December. Because kids were not in school, the 1968 flu pandemic never really took hold in the U.S. to the extent that its forerunners did. In contrast, those two more severe pandemics (1918 and 1957) occurred just as kids were returning to school in Sept-Oct.  Kids in school rapidly became infected, and in turn infected their families and their communities. Influenza pandemics are examples of the amplifier role of schools in infectious diseases.  An infection enters the schools from the community and “explodes”, rapidly spreading among a highly susceptible and highly concentrated population of kids. Another extraordinary example of the critical role that schools play as germ amplifiers is smallpox.  It was mandatory school smallpox vaccination laws that were the ultimate key to eradicating that dread disease from this country – by protecting kids in schools, we saved millions of their lives as well as the lives of millions of others in the larger community.  Similar successes have been seen with mandatory polio, measles, mumps, meningitis, and other vaccines that are given to school kids and in so doing protect the country’s population as a whole.

In Sept-Oct, 2007, we saw examples of the potential for schools to also be the original source of infections.  MRSA (methicillin-resistant staphylococcus aureus – also known as “superbug”) outbreaks occurred in schools throughout the country (see Dr. Rotbart’s GERMBlog entries of October 17, 2007 and October 28, 2007). Although never proven to come from environmental contamination in the schools, the Centers for Disease Control and Prevention (CDC) and school districts across the country undertook rigorous measures to clean and disinfect schools.

At the forefront of the war against infectious diseases stand our school nurses.  In my talks to school nurses around the country, titled “Germ Proof Your Schools”, I emphasize the 3 core strategies that nurses must take to reduce school infections and reduce student absenteesim. The strategies are:

1. Reinforce students’ personal health and hygiene practices (including handwashing, wound care, vaccines, proper nutrition, adequate sleep, reduced stress, appropriate clothes to match the weather, and regular moderate excercise)

2. Adhere to health department exclusion and inclusion policies for infectious diseases (each state sets its own rules for which infections or symptoms warrant exclusion from school, and for how long).

3. Practice prudent environmental hygiene (strategic disinfecting policies, as well as meticulous attention to food safety).

There is no better group of professionals than our school nurses to undertake this crucial mission for the health of our kids and for the health of our country.

For much, much more about school health and protecting our kids from germs, see Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections (ASM Press, 2008) (www.germproofyourkids.com).

California is experiencing it’s worst outbreak of whooping cough (pertussis) in 50 years. The nearly 1000 cases reported so far this year is more than 4 times as many as during the same period last year, and more than 600 additional kids have “possible cases” that are being investigated. Five infants have died of the disease in California this year already.

Pertussis is caused by a bacterial infection with a germ called Bordetella pertussis that can be prevented with a safe and effective vaccine. Failure to vaccinate kids is associated with a significantly higher risk for developing the infection, and for spreading the highly contagious germ to others. Communities where vaccination rates have fallen off are well known to suffer higher rates of pertussis cases.

I’ve written much in this GERMBlog, as well as in my book, Germ Proof Your Kids – the Complete Guide to Protecting (without Overprotecting) Your Family from Infections (ASM Press, Washington, D.C., 2008; www.germproofyourkids.com ) regarding the safety and importance of vaccines. In the book there’s lots of information about pertussis and the pertussis vaccine for those of you wanting to learn more (see Chapters 3 and 7). The side effects of pertussis vaccine are generally mild, and the current “acellular” pertussis vaccines have dramatically reduced the chances of all side effects.

Make sure your kids’ vaccines are up to date before they head back to school!

There are few things that are certain in life, as the saying goes. Yes, death and taxes. But another certainty in life is that alcohol-based hand sanitizers prevent or reduce the transmission of infections. Both bacterial and viral germs are killed by the drying effect of alcohol, and hospitals routinely use alcohol-based hand sanitizers to reduce patient-to-patient and staff-to-patient (and patient-to-staff) transmission of dangerous infections. Reduction and prevention of infections are time-tested, proven benefits of alcohol-based hand sanitizers.

What about those hand sanitizing products that don’t contain alcohol, yet boast “kills 99.9% of germs”? Well, that’s the difference between a test tube result and a real life result. In the test tube, lots of substances (including alcohol) kill 99.9% of bacterial germs – but for the most part these products have not been proven to reduce or prevent the actual infections that those bacteria cause. And killing 99.9% of bacterial germs does not help prevent viral infections. Remember, viruses cause the vast, vast majority of infections that keep your kids home from school and you home from work.

So, how should you choose the proper hand sanitizer for your family? First of all, recall from previous posts, and from Chapter 9 of Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections (ASM Press, 2008), that good handwashing with simple soap and water also has been proven to reduce and prevent real life infections caused by bacterial and viral germs. But when you can’t get to a sink, hand sanitizers are very…handy! The non-alcohol choices include those that contain antibiotics (triclosan), other chemical disinfectants (e.g. benzylkonium chloride), organic substances that kill bacteria (e.g. thymol or citric acid), or a variety of healthy-sounding, pleasant-smelling herbs that may or may not kill germs. None of these products have been proven to reduce or prevent actual infections, bacterial and viral, as effectively as alcohol-based hand sanitizers.

If you are very opposed to alcohol because you believe it to be “toxic” or “flammable”, I might be able to console you that prudent use is very safe. That includes letting the alcohol dry completely before touching your face or mouth, and rinsing off the alcohol when you get home to a sink. Yes, kids may get hold of an alcohol hand sanizter bottle and drink the stuff – there have been a couple well-publicized cases – but that can happen with the other, fruitier smelling non-alcohol hand sanitizers as well. And just because something is “organic” or “natural” doesn’t mean it’s non-toxic. Indeed, some of the “all natural” products can be quite bad for kids if swallowed.

I’m comfortable using alcohol hand sanitizers for kids under the supervision of an adult – an adult should supervise use of non-alcohol sanitizers as well, for the reasons noted above. If you feel strongly that you’d rather have your kids use a non-alcohol hand sanitizer, it is absolutely better to use those products than not to wash your kids hands at all when there is no sink nearby. So, if your kids have just high-fived the opposing soccer team and you don’t want them to use alcohol-based hand sanitizers, give them a squirt of the non-alcohol product and have them rub their hands well for 15 or 20 seconds. The liquid and rubbing action, in addition to whatever killing of germs the non-alcohol product does accomplish, has to be better than having your kids eat their post-soccer game, post-high fiving snack with no attempt at cleaning their hands at all.

For lots more on hand sanitizers, alcohol and other, see Chapter 9 of Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections (ASM Press, 2008).

This is a very unusual time in the annals of influenza history. Usually by late January we are in full swing with “seasonal flu”, that annual ritual of sickness that typically begins in late October and lasts through late March (and sometimes well into April!). But a funny thing happened on the way to flu season this year – last April, a new strain, H1N1 (“swine flu”) entered the picture at the tail end of the 2009 seasonal flu period. Since that time, hundreds of thousands of cases of H1N1 (“swine flu”) have occurred worldwide with more than ten thousand deaths in two distinct “waves” of disease – one in Spring, 2009 and the other during the Fall and early Winter, 2009. In addition to many of us catching the flu during one of these waves, we also “caught a break” to some extent with this recent pandemic – it was not as severe as feared, causing the same or fewer numbers of serious cases and deaths as a typical seasonal flu might cause each year. That’s “lucky” since adequate doses of vaccine did not become available until just the past 3 months.

But now the weird part. H1N1 is disappearing, apparently having run its course (although everyone is still nervous that a “3^rd wave” may yet appear), perhaps in part due to aggressive vaccinations of high risk groups with the newly available H1N1 vaccine beginning in October. So, where is this year’s  ”seasonal flu?”. So far, the reliable annual appearance of seasonal flu appears to have been entirely edged out by the large H1N1 outbreak. Almost all cases of flu being reported across the country are still H1N1, albeit in much smaller numbers than a couple months ago. There have been essentially no cases of seasonal flu, and it’s the end of January!!?

So…what to do regarding vaccines? Since we are in uncharted waters, the recommendations remain to get your kids immunized against both seasonal flu (kids ages 6 months – 18 years) and to H1N1 (ages 6 months – 24 years). That way, if a late seasonal flu outbreak occurs the kids will be protected, and if a “3rd wave” of H1N1 (“swine flu”) occurs, they’ll also be protected.

For more on the unusual history of influenza, the significance of the infections, and strategies to prevent flu, please see Chapters 2,3,7, and 9 of Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections (ASM Press, Washington, D.C., 2008).

In the aftermath of every great natural disaster, infections make things worse – often, much worse. There are waves of infections, beginning with those that complicate wounds and bodily injuries. These germs are usually bacterial: staph, strep, and anaerobic organisms like tetanus and gangrene. The next wave of infections occurs as a result of the lack of clean water and the accumulation of dying victims. The germs in this second wave are typically gastrointestinal, and include both bacteria and viruses: cholera, enteric viruses, dysenteric bacteria. Finally, crowding and unsanitary conditions facilitate respiratory spread of infections, again both bacteria and viruses, resulting in pneumonia.

The key to interrupting the waves of infections is the rapid provision of clean drinking water and bathing water, as well as the removal of decaying material. Antibiotics must be delivered efficiently. Unfortunately, the chaos and disruption following a natural disaster impede all such efforts, and the underlying poverty and destitution in Haiti prior to the earthquake have made recovery operations even more challenging.

Our prayers are with the people of Haiti.