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Does It Make Sense To Delay Children’s Vaccines?

When Elyse Imamura’s son was an infant, she and her husband, Robert, chose to spread out his vaccinations at a more gradual pace than the official schedule recommended.

“I was thinking, ‘OK, we’re going to do this,’” says Imamura, 39, of Torrance, Calif. “‘But we’re going to do it slower so your body gets acclimated and doesn’t face six different things all of a sudden.’”

Seven years later, Imamura says her son, Amaru, is a “very healthy,” active boy who loves to play sports.

But delaying vaccines is risky. Many pediatricians will tell you a more gradual approach to vaccinations is better than no vaccinations at all, but they offer some hard advice to parents who are considering it.

“Every day you are eligible to get a vaccine that you don’t get one, the chance of an invasive disease remains,” says Dr. Charles Golden, executive medical director of the Primary Care Network at Children’s Hospital of Orange County.

Recent outbreaks of measles, mumps and whooping cough have once again reignited a war of words over vaccinations.

The squabble is often painted as two-sided: in one camp, the medical establishment, backed by science, strongly promoting the vaccination of children against 14 childhood diseases by age 2. In the other, a small but vocal minority — the so-called anti-vaxxers — shunning the shots, believing the risks of vaccines outweigh the dangers of the diseases.

The notion that there are two opposing sides obscures a large middle ground occupied by up to one-quarter of parents, who believe in vaccinating their children but, like the Imamuras, choose to do so more gradually. They worry about the health impact of so many shots in so short a period, and in some cases they forgo certain vaccines entirely.

Alternative vaccine schedules have been around for years, promoted by a few doctors and touted by celebrities such as Jenny McCarthy. Donald Trump endorsed the idea during a 2015 Republican presidential debate.

The concept gained a large following more than a decade ago, when Robert W. Sears, an Orange County, Calif., pediatrician, published “The Vaccine Book,” in which he included two alternative schedules. Both delay vaccines, and one of them also allows parents to skip shots for measles, mumps and rubella (MMR), chickenpox, hepatitis A and polio.

Sears’ book became the vaccination bible for thousands of parents, who visited their pediatricians with it in tow. But his ideas have been widely rejected by the medical establishment and he was punished by the Medical Board of California last year after it accused him of improperly exempting a 2-year-old from all future vaccinations. He declined to be interviewed for this column.

Imamura, who describes herself as “definitely not an anti-vaxxer,” says she and her husband “followed Sears to a T.” They limited the number of vaccines for their son to no more than two per appointment, compared with up to six in the official schedule. And they skipped the shot for chickenpox.

She concedes, however: “If there’d been outbreaks like now, it would have affected my thinking about delaying vaccines.”

Elyse and Robert Imamura with their son, Amaru (Courtesy of Elyse Imamura)

The ideas promoted by Sears and others have contributed to parents’ worries that front-loading shots could overwhelm their babies’ immune systems or expose them to toxic levels of chemicals such as mercury, aluminum and formaldehyde.

But scientific evidence does not support that. Infectious-disease doctors and public health officials say everyday life presents far greater challenges to children’s immune systems.

“Touching another human being, crawling around the house, they are exposed to so many things all the time on a daily basis, so these vaccines don’t add much to that,” says Dr. Pia Pannaraj, a pediatric infectious-diseases specialist at Children’s Hospital Los Angeles.

The same is true of some of the metals and chemicals contained in vaccines, which vaccination skeptics blame for autism despite numerous studies finding no link — the most recent published earlier this month.

In the first six months of life, babies get far more aluminum from breast milk and infant formula than from vaccines, public health experts say.

“When you look at babies that have received aluminum-containing vaccines, you can’t even tell the level has gone up,” says Paul Offit, professor of pediatrics at Children’s Hospital of Philadelphia (CHOP) and director of the hospital’s Vaccine Education Center. The same is true of formaldehyde and mercury, he adds.

(Offit co-invented Merck’s RotaTeq vaccine for rotavirus, and CHOP sold the royalty rights to it for $182 million in 2008. CHOP declined to comment on what Offit’s share was.)

Parents who are concerned about mercury, aluminum or other vaccine ingredients should avoid information shared on social media, which can be misleading. Instead, check out the Vaccine Education Center on CHOP’s website at www.chop.edu by clicking on the “Departments” tab.

The Centers for Disease Control and Prevention also provides a detailed breakdown of the ingredients in every vaccine at http://www.cdc.gov/vaccines.

If your child has a condition you fear might be incompatible with vaccinations, discuss it with your pediatrician. The CDC gives very specific guidelines on who should not receive vaccines, including kids who have immune system deficiencies or are getting chemotherapy or taking certain medications.

If your children are not among them, vaccinate them. That will help prevent outbreaks, protecting those who, for medical reasons, have not received the shots.

When parents resist, Pannaraj says, she emphasizes that the potential harm from infections is far more severe than the risks of the vaccines. She notes, for example, that the risk of getting encephalitis from the measles is about 1,000 times greater than from the vaccine.

Still, side effects do occur. Most are mild, but severe cases — though rare — are not unheard of. To learn about the potential side effects of vaccines, look on the CDC website or discuss it with your pediatrician.

Emily Lawrence Mendoza, 35, says that after her second child, Elsie, got her first measles, mumps and rubella (MMR) shot at 12 months of age, she spiked a fever and developed a full body rash that looked like a mild version of the disease.

It took three visits to urgent care before a doctor acknowledged that Elsie, now almost 5, could have had a mild reaction to the vaccine. After that, Mendoza, of Orange, Calif., decided to adopt a more gradual vaccination schedule for her third child.

Yet Mendoza says Elsie’s adverse reaction made her realize the importance of vaccinations: “What if she’d been exposed to a full-blown case of the measles?”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Students With Disabilities Call College Admissions Cheating ‘Big Slap In The Face’

For Savannah Treviño-Casias, this week’s news about the college admissions cheating scandal was galling, considering how much red tape the Arizona State University senior went through to get disability accommodations when she took the SAT.

“It felt like such a big slap in the face,” said Treviño-Casias, 23, who was diagnosed in sixth grade with dyscalculia, a disability that makes it more difficult to learn and do math. “I was pretty disgusted. It just makes it harder for people who actually have a diagnosed learning disability to be believed.”

Federal prosecutors have charged 50 people, including actresses Felicity Huffman and Lori Loughlin, in a nationwide bribery and fraud scheme to admit underperforming students to elite colleges. Some of the parents charged, the FBI said, paid to have their children diagnosed with bogus learning disabilities so they could get special accommodations on the SAT and ACT college entrance exams. Such accommodations can include giving students extra time on the tests or allowing them to take their exam in a room alone with a proctor to limit distractions. Prosecutors allege ringleaders in the scandal arranged for proctors in on the scam to correct students’ answers during or after the exam, or had someone else take the test for them.

Now, families and advocates are worried about a backlash that could make it harder for students with legitimate disabilities to get the accommodations they need to succeed.

“There are already too many hoops and hurdles disabled students must navigate in order to vindicate their civil right to higher education,” said Matthew Cortland, a lawyer and disability activist based in Boston. “My fear is that these celebrity fraudsters will incite a crackdown on accommodations. Schools and testing companies will make it even more burdensome for disabled students to get the accommodations that allow them to realize their civil right to access higher education.”

Federal law requires colleges and college testing companies to provide accommodations for students with documented disabilities, including learning disabilities. But in practice, it can be difficult for students — particularly low-income students — to get those accommodations. Students diagnosed in grade school may have to provide updated evaluations documenting their need for special accommodations — testing that can cost thousands of dollars.

Students with legitimate disabilities constantly have to fight the perception that they’re gaming the system, said Lindsay Jones, CEO of the National Center for Learning Disabilities.

Savannah Treviño-Casias, a senior at Arizona State University, worries about the backlash against educational accommodations for students with legitimate learning disabilities. She was diagnosed in sixth grade with dyscalculia, a math learning disability. (Courtesy of Savannah Treviño-Casias)

“Many people in our society assume accommodations give you an advantage. They assume, ‘I, too, would have done better,’ which is a fundamental misunderstanding,” Jones said. “But these individuals are already facing skepticism. The college admissions scandal is incredibly damaging to a population that’s already fighting to prove that they are amazing and can achieve incredible things.”

The FBI did not charge any medical professionals who might have provided a fraudulent diagnosis.

Diane Blair-Sherlock, a real estate attorney in the Chicago suburb of Villa Park, didn’t have any trouble getting entrance exam accommodations for her daughter, who is deaf, although it took three months for the College Board, which administers the SAT, to approve a sign-language interpreter.

Her son, diagnosed with Asperger’s syndrome, a form of autism, was another story. Blair-Sherlock said the College Board turned down her son’s application for accommodations on the SAT despite his having provided documentation of his disability. She finally succeeded after appealing the denial, and her son was granted extra time, breaks and an isolated area in which to take the test. He is now a student at the University of Illinois-Chicago — getting A’s and B’s, she said proudly — and Blair-Sherlock helps other parents facing similar difficulties.

“I’m looking for a level playing field,” Blair-Sherlock said. “You’re playing with kids’ lives here.”

The College Board, which also administers Advanced Placement (AP) tests, has said that requests for accommodations have increased in recent years as more students opt to take the exams, but didn’t respond to questions about specifics from KHN. Such requests rose from 80,000 in 2010-11 to 160,000 in 2015-16, and about 85 percent of requests for accommodation were approved, according to recent news reports.

In 2017, under pressure from disability advocates and amid inquiries from the U.S. Department of Justice, the company said it would streamline applications for accommodations; students who had been granted existing accommodations at their high schools — extra time on tests, for example — would have the same accommodations automatically approved for exams such as the SAT.

When documentation is requested, the College Board requires that a diagnosis be made by “someone with appropriate professional credentials” and that a diagnosis be current. For example, for students with a diagnosis of attention deficit hyperactivity disorder, or ADHD, evaluations should be no more than five years old. The College Board said it combats organized cheating by banning cellphones, analyzing test-taker behaviors and enhancing security measures at test centers, among other actions, though it failed in a number of the cases the FBI investigated.

The ACT organization, which administers the test by the same name, also requires students to have a professionally diagnosed disability and generally to already be getting accommodations in their school classrooms. It may require additional documentation, depending on the type of disability. Students reporting mood or anxiety disorders, for example, would have to provide information on the psychological tests used, as well as a history of medication and treatment. Documentation of a psychiatric disorder must be current within the past year. The ACT declined to comment on whether the number of students granted accommodations has gone up in recent years, citing the ongoing investigation.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

‘Medieval’ Diseases Flare As Unsanitary Living Conditions Proliferate

Jennifer Millar keeps trash bags and hand sanitizer near her tent, and she regularly pours water mixed with hydrogen peroxide on the sidewalk nearby. Keeping herself and the patch of concrete she calls home clean is a top priority.

But this homeless encampment off a Hollywood freeway ramp is often littered with needles and trash, and soaked in urine. Rats occasionally scamper through, and Millar fears the consequences.

“I worry about all those diseases,” said Millar, 43, who said she has been homeless most of her life.

Infectious diseases — some that ravaged populations in the Middle Ages — are resurging in California and around the country, and are hitting homeless populations especially hard.

Los Angeles recently experienced an outbreak of typhus — a disease spread by infected fleas on rats and other animals — in downtown streets. Officials briefly closed part of City Hall after reporting that rodents had invaded the building.

People in Washington state have been infected with Shigella bacteria, which is spread through feces and causes the diarrheal disease shigellosis, as well as Bartonella quintana, which spreads through body lice and causes trench fever.

Hepatitis A, also spread primarily through feces, infected more than 1,000 people in Southern California in the past two years. The disease also has erupted in New Mexico, Ohio and Kentucky, primarily among people who are homeless or use drugs.

Public health officials and politicians are using terms like “disaster” and “public health crisis” to describe the outbreaks, and they warn that these diseases can easily jump beyond the homeless population.

“Our homeless crisis is increasingly becoming a public health crisis,” California Gov. Gavin Newsom said in his State of the State speech in February, citing outbreaks of hepatitis A in San Diego County, syphilis in Sonoma County and typhus in Los Angeles County.

“Typhus,” he said. “A medieval disease. In California. In 2019.”

The diseases have flared as the nation’s homeless population has grown in the past two years: About 553,000 people were homeless at the end of 2018, and nearly one-quarter of homeless people live in California.

The diseases spread quickly and widely among people living outside or in shelters, fueled by sidewalks contaminated with human feces, crowded living conditions, weakened immune systems and limited access to health care.

“The hygiene situation is just horrendous” for people living on the streets, said Dr. Glenn Lopez, a physician with St. John’s Well Child & Family Center, who treats homeless patients in Los Angeles County. “It becomes just like a Third World environment where their human feces contaminate the areas where they are eating and sleeping.”

Those infectious diseases are not limited to homeless populations, Lopez warned. “Even someone who believes they are protected from these infections are not.”

Infectious diseases are resurging in California and around the country, hitting homeless populations especially hard. (Heidi de Marco/KHN)

At least one Los Angeles city staffer said she contracted typhus in City Hall last fall. And San Diego County officials warned in 2017 that diners at a well-known restaurant were at risk of hepatitis A.

There were 167 cases of typhus from Jan. 1, 2018, through Feb. 1 of this year, up from 125 in 2013 and 13 in 2008, according to the California Public Health Department.

Typhus is a bacterial infection that can cause a high fever, stomach pain and chills but can be treated with antibiotics. Outbreaks are more common in overcrowded and trash-filled areas that attract rats.

The recent typhus outbreak began last fall, when health officials reported clusters of the flea-borne disease in downtown Los Angeles and Compton. They also have occurred in Pasadena, where the problems are likely due to people feeding stray cats carrying fleas.

Last month, the county announced another outbreak in downtown Los Angeles that infected nine people, six of whom were homeless. After city workers said they saw rodent droppings in City Hall, Los Angeles City Council President Herb Wesson briefly shut down his office to rip up the rugs, and he also called for an investigation and more cleaning.

Hepatitis A is caused by a virus usually transmitted when people come in contact with feces of infected people. Most people recover on their own, but the disease can be very serious for those with underlying liver conditions. There were 948 cases of hepatitis A in 2017 and 178 in 2018 and 2019, the state public health department said. Twenty-one people have died as a result of the 2017-18 outbreak.

Typhus. A medieval disease. In California. In 2019.

Gov. Gavin Newsom

The infections around the country are not a surprise, given the lack of attention to housing and health care for the homeless and the dearth of bathrooms and places to wash hands, said Dr. Jeffrey Duchin, the health officer for Seattle and King County, Wash.

“It’s a public health disaster,” he said.

In his area, Duchin said, he has seen shigellosis, trench fever and skin infections among homeless populations.

In New York City, where more of the homeless population lives in shelters rather than on the streets, there have not been the same outbreaks of hepatitis A and typhus, said Dr. Kelly Doran, an emergency medicine physician and assistant professor at NYU School of Medicine. But Doran said different infections occur in shelters, including tuberculosis, a disease that spreads through the air and typically infects the lungs.

The diseases sometimes get the “medieval” moniker because people in that era lived in squalid conditions without clean water or sewage treatment, said Dr. Jeffrey Klausner, a professor of medicine and public health at UCLA.

People living on the streets or in homeless shelters are vulnerable to such outbreaks because their weakened immune systems are worsened by stress, malnutrition and sleep deprivation. Many also have mental illness and substance abuse disorders, which can make it harder for them to stay healthy or get health care.

Saban Community Clinic physician assistant Negeen Farmand checks Millar at a homeless encampment near a Hollywood freeway one morning.(Heidi de Marco/KHN)

“To get these people to come into a clinic is a big thing,” Farmand said. “A lot of them are distrustful of the health care system.”(Heidi de Marco/KHN)

One recent February afternoon, Saban Community Clinic physician assistant Negeen Farmand walked through homeless encampments in Hollywood carrying a backpack with medical supplies. She stopped to talk to a man sweeping the sidewalks. He said he sees “everything and anything” in the gutters and hopes he doesn’t get sick.

She introduced herself to a few others and asked if they had any health issues that needed checking. When she saw Millar, Farmand checked her blood pressure, asked about her asthma and urged her to come see a doctor for treatment of her hepatitis C, a viral infection spread through contaminated blood that can lead to serious liver damage.

“To get these people to come into a clinic is a big thing,” she said. “A lot of them are distrustful of the health care system.”

On another day, 53-year-old Karen Mitchell waited to get treated for a persistent cough by St. John’s Well Child & Family Center’s mobile health clinic. She also needed a tuberculosis test, as required by the shelter where she was living in Bellflower, Calif.

Mitchell, who said she developed alcoholism after a career in pharmaceutical sales, said she has contracted pneumonia from germs from other shelter residents. “Everyone is always sick, no matter what precautions they take.”

During the hepatitis A outbreak, public health officials administered widespread vaccinations, cleaned the streets with bleach and water and installed hand-washing stations and portable toilets near high concentrations of homeless people.

But health officials and homeless advocates said more needs to be done, including helping people access medical and behavioral health care and affordable housing.

“It really is unconscionable,” said Bobby Watts, CEO of the National Health Care for the Homeless Council, a policy and advocacy organization. “These are all preventable diseases.”

Sweetgreen Makes Healthful Fast Food — But Can You Afford It?

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Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.

Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.Credit Jason Henry for The New York Times

Healthful, fast and affordable food is the holy grail of the public health and nutrition community. A popular restaurant chain shows just how much of a challenge that is.

It began when three Georgetown University students were frustrated that they could not find a healthy fast-food restaurant near their campus. With money raised from family and friends, they started their own, renting a small storefront on M Street in Georgetown. The result was Sweetgreen, a restaurant that offered organic salads, wraps and frozen yogurt. Pretty soon, the daily line of lunchtime customers stretched out the door and around the corner.

Ten years later, the line is still there, but Sweetgreen has grown into a nationwide salad chain, with more than 40 locations. Sweetgreen is part of a small but growing breed of farm-to-table fast-food chains – like Chopt Creative Salad Company on the East Coast and Tender Greens in California – that are giving fast-food restaurants a plant-based makeover. Their mission: to fix fast food, which has long been fattening and heavily processed.

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At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.

At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.Credit Jason Henry for The New York Times

Sweetgreen’s owners say their goal is to offer customers foods made with nutritious, sustainable and locally grown ingredients. The company has decentralized its food sourcing and production. Fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site. They don’t sell soda or use refined sugar.
Sweetgreen expects to open another 20 stores in major cities around the country this year, and eventually to expand to places where experts say healthy, delicious fast food is needed most — low-income neighborhoods.

But while the chain has proven there is a big appetite for more healthful fast food, the goal of taking this concept to poor areas may be a distant reality. The company and other chains like it operate almost exclusively in affluent communities, far from the low-income food deserts where obesity is rampant and farmers’ markets and healthy food stores are scarce. And with salads that typically cost between $9 and $14, some question whether a healthful fast-food chain like Sweetgreen can ever be affordable for average Americans.

Maegan George, a Columbia University student who lives near a Sweetgreen, calculated that for the price of one Sweetgreen salad, she could buy the same ingredients in bulk at a local market and make several similar salads at home.

“I’m a first-generation student and I’m on full financial aid,” she said. “Sweetgreen is delicious and I enjoy it. But there’s no way I could afford to eat there on a regular basis.”

Jackie Hajdenberg, another Columbia student, wrote about the restaurant for the campus newspaper, The Spectator, earlier this year, lamenting that on a per calorie basis, a salad at Sweetgreen was three times the price of a Big Mac at McDonald’s.

“Sweetgreen has not only made it easier for people to make healthy decisions – it has also illustrated the unequal socioeconomic landscape of the world in which we live,” she wrote.

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Salad options at Sweetgreen change often, depending on what is available at local farms.

Salad options at Sweetgreen change often, depending on what is available at local farms.Credit Jason Henry for The New York Times

Sweetgreen says it prices its food so that it can compensate its suppliers and employees fairly, and that it expects nutritious fast food to become more affordable as the healthy food movement grows. Nicolas Jammet, a co-founder of Sweetgreen, said the company wants to serve lower-income customers, and has long-term plans to expand to low-income communities.

To get there, he said, the company will have to overcome hurdles involving its supply chain, the minimum wage and greater nutrition awareness and education among the public. For the past six years the company has been running a nutrition education program in schools that teaches children about healthier eating and locally grown food.

“It’s a long-term goal for us to be part of this larger systematic change that needs to happen,” he said. “But there are so many parts of this problem that need to be addressed.”

Mr. Jammet notes that the company was among the first to show that fast-food chains don’t need profits from soda and sugary drinks to succeed. He believes chains like Sweetgreen have caused a ripple effect throughout the fast-food industry.

In January, for example, Chick-fil-A unveiled a new kale, broccolini and nut “superfood” salad, responding to customer demands for “new tastes and healthier ways to eat in our restaurants.” McDonald’s is experimenting with kale salads, and Wendy’s is testing a spinach, chicken and quinoa salad.

“Companies like McDonald’s have more power to change the way that people eat than we do,” Mr. Jammet said. “We don’t see these companies as the enemy. We just have to force change on them.”

Public health experts say that such changes cannot come soon enough. A University of Toronto study recently showed that people have a higher risk of developing diabetes if they live in “food swamps” – an area with three or more fast-food restaurants and no healthy dining options.

Another study published in JAMA in June found that the percentage of Americans eating an unhealthy diet — high in sugar, refined grains, soft drinks and processed foods and low in fruits and vegetables — was on the decline, but the improvements in diet were much smaller for lower-income Americans.

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Customers wait in line at Sweetgreen in Berkeley, Calif.

Customers wait in line at Sweetgreen in Berkeley, Calif.Credit Jason Henry for The New York Times

Overall about twice as many people from poor households have poor diets compared to those at higher income levels.
Why is traditional fast food so cheap? One reason is the underlying infrastructure of the industry. Many of the ingredients, like the soy that’s turned into oil for deep fryers, or the the corn that’s fed to animals and used to make high-fructose corn syrup, begin with crops that are heavily subsidized by the government. To make their food economical, many traditional fast-food chains mass-produce their food in large factories, often stripping it of fiber and other nutrients that decrease its shelf life, while adding salt, sugar and other flavorings and preservatives.

Then they freeze and ship the processed components, like burger patties, bread, pickles and sauce, to their restaurants. There they are reheated and assembled, often with minimal effort, ensuring that a Big Mac in Seattle looks and tastes the same as a Big Mac in Charlotte, N.C.

By comparison, every Sweetgreen location has a chalkboard that lists the farms where its organic arugula, peaches, yogurt or blueberries are produced. As a result, the menus vary by location and by season. In Boston, Sweetgreen stores use New England Hubbard squash. In Los Angeles, the menu features a different variety of squash grown locally in California.

Those differences mean fresher, more nutritious ingredients, but ultimately costlier food for customers — one of the obstacles that Sweetgreen and other chains like it will have to overcome if they hope to make their food more accessible to all income brackets.
Marion Nestle, a professor of nutrition, food studies and public health at New York University and the author of “Food Politics,’’ says restaurants like Sweetgreen offer an encouraging, but imperfect, model for making fast food more healthful.

“What’s not to like?” she asks. “The cost, maybe, but for people who can afford it the quality is worth it. Next step: Moving the concept into low-income areas.”

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