Men's Health

Presentation at What Ails Males
Oct. 2006

Healthy Aging – For Men

From an Infectious Diseases Standpoint - by Dr. Donald Skllman

Four Eternal Truths:

• Prevention is preferable to treatment.
• Germs never sleep.
• Fever is our friend.
• Time stops for no man.

Prevention of Infections:

• Vaccines
• Prophylactic antibiotics
• Healthy Living
• Don’t be stupid

Vaccines:

Influenza Vaccine:

• From 1990 – 1999: approximately 36,000 deaths per year in the USA.
• Rates of serious illness and death are highest
  • Among persons aged > 65 years
  • Children aged < 2 years
  • Persons of any age who have medical conditions that place them at increased risk for complications from influenza.

The Advisory Committee on Immunization Practices (ACIP) updated their guidelines for antiviral treatment and vaccination for influenza for the 2006 season:

Annual influenza vaccination is recommended for:

• adults and children with chronic cardiovascular, pulmonary, or metabolic illnesses
• nursing home residents
• those who care for patients at high risk for influenza.
• children aged 6 to 59 months
• women who will be pregnant during the influenza season
• persons older than 50 years
• children and adolescents receiving long-term aspirin therapy and at risk for Reye syndrome

There are different types of vaccines:

• Live attenuated influenza vaccine
• Inactivated influenza vaccine

The live attenuated influenza vaccine is recommended for:

• ·healthy household contacts and caregivers of those at risk and healthcare workers.

 The live attenuated influenza vaccine is contraindicated in:

• persons older than 50 years
• people with asthma, reactive airway disease or other chronic conditions of the pulmonary and cardiovascular systems
• children or adults receiving aspirin
• persons with a history of Guillian Barré syndrome
• those with hypersensitivity to eggs.
• persons younger than 5 years
• pregnant women

Inactivated influenza vaccine is recommended for:

• adults and children with chronic metabolic, pulmonary, or cardiovascular disorders or other medical conditions predisposing to influenza, including asthma but not hypertension.
• Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases, including diabetes mellitus, renal dysfunction, hemoglobinopathies, or immunodeficiency, (including immunodeficiency caused by medications or by HIV)
• Adults and children with any condition that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration, including cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders
• Residents of nursing homes and other chronic-care facilities for persons of any age who have chronic medical conditions
• Persons aged older than 65 years
• children aged 6 to 23 months
• children and adolescents aged 6 months to 18 years receiving long-term aspirin therapy and might therefore be at risk for Reye syndrome after influenza virus infection.
• women who will be pregnant during the influenza season

The inactivated influenza vaccine is contraindicated in those with anaphylactic sensitivity to eggs and acute febrile illness.

Updates to 2005 ACIP recommendations:

• Healthy children aged 24 to 59 months and their household contacts and out-of-home caregivers should be vaccinated against influenza.
• All children aged 6 months to 9 years not previously vaccinated at any time with influenza vaccine should received 2 doses of vaccine. Those who receive inactivated vaccine should receive a booster at 1 or more months after the first dose. Those aged 5 to 9 years who receive live attenuated influenza vaccine should have a second dose 6 to 10 weeks after the initial dose.
• Doses of influenza vaccine required for this year in the United States are projected to be 100 million. State and public health agencies should expand outreach and develop contingency plans for prioritization of vaccine administration.
• Influenza vaccine should continue to be offered throughout the influenza season even after infection has been documented in the community.
• Clinics that serve target vaccine groups are encouraged and should schedule at least 1 vaccination clinic in December.
• Neither amantadine nor rimantadine should be used for treatment or chemoprophylaxis of influenza A in the United States because of recent evidence of widespread resistance.
• Ostelamivir or zanamivir can be prescribed if antiviral treatment is indicated. Ostelamivir is indicated for persons older than 1 year and zanamivir for persons older than 7 years. Both can be used for chemoprophylaxis of influenza.
• The 2006-2007 trivalent vaccine virus strains are A/New Caledonia/20/1999 (H1N1), A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens.

Influenza Treatment and Prophylaxis

Treatment should follow an accurate diagnosis, and the common cold should not be treated with anti-influenza medications.

If antiviral treatment of influenza is indicated, oseltamivir or zanamivir can be prescribed. They demonstrate activity against both influenza A and B viruses.

• Oseltamivir is approved for treatment of persons older than 1 year
• Zanamivir is approved for treatment of persons older than 7 years.
• For chemoprophylaxis of influenza, oseltamivir is licensed for use in persons aged older than 1 year, and zanamivir is licensed for use in persons aged older than 5 years.

Neuraminidase Inhibitors

Influenza types A and B are RNA viruses with two glycoproteins, hemagglutinin (H) and neuraminidase (N), projecting from the viral surface. The influenza neuraminidase cleaves sialic acid from cellular and viral glycoconjugates, preventing viral aggregation and allowing the release of progeny virus from an infected cell.

Zanamivir  (Relenza^TM)

Zanamivir (Relenza) is an inhaled drug, which requires careful patient education for proper use and has been reported to cause bronchospasm in people with asthma.

Prophylaxis studies show it to be 67 - 82% effective in preventing laboratory evidence of disease and 84 - 95% effective in preventing febrile illness. In treatment of influenza studies, zanamivir reduced the time to alleviation of major symptoms by 1 – 1.5 days (4 days vs. 5 days) compared with placebo. Those who initiate therapy sooner (no later than 30 hours after symptom onset) and those with more pronounced illness may exhibit greater benefit (e.g., a 3-day decrease in symptom duration). High-risk patients receiving zanamivir had significantly fewer complications than those receiving placebo and needed fewer courses of antibiotic medications.

Zanamivir is well tolerated. The most common adverse events are related to the respiratory tract (7% to 11%) or gastrointestinal tract (5% to 9%) and were similar for zanamivir and placebo. High-risk patients receiving zanamivir experienced fewer adverse events (such as asthma and bronchitis) than those receiving placebo. Because of the risk for serious adverse respiratory events and because efficacy has not been demonstrated in patients with underlying airway disease, zanamivir is not recommended for treatment of this population.

      For prophylaxis: 10 mg once a day with the Diskhaler device

      For treatment: 10 mg twice a day for five days with the Diskhaler device

Oseltamivir (Tamiflu^TM)

      An oral inhibitor of influenza A and B neuraminidase. It is effective in the long-term prophylaxis of natural influenza infection, with a protective efficacy of 74 – 84%. Treatment trials showed that it reduces the duration of illness by 1.3 days and the duration of cough is reduced by 24 hours.

      The oral drug is well tolerated. The most common adverse event is gastrointestinal symptoms that are mild and transient. Taking the drug with food prevents these side effects and improves bioavailability. Some subjects in the early trials with this drug developed antibodies against influenza, indicating that they had a subclinical infection but still gained protective immunity.

      For prophylaxis: 75 mg once a day

      For treatment: 75 mg twice a day for five days

Viral resistance to adamantane drugs (Amantadine and Rimantadine) can emerge rapidly during treatment because a single point mutation can result in cross-resistance to both amantadine and rimantadine.  During treatment with either of these agents, drug-resistant viruses can emerge in approximately one third of patients.  In contrast, development of viral resistance to zanamivir and oseltamivir during treatment has been identified but does not appear to be frequent.

Diagnostic tests available for influenza include viral culture, serology, rapid antigen testing, polymerase chain reaction, and immunofluorescence assays.  The sensitivity and specificity of these tests may vary based on the laboratory that performs the test, the type of test used, the type of specimen tested, and the timing of specimen collection.  Nasopharyngeal specimens are typically more effective than throat swab specimens for viral isolation or rapid detection.  As with other diagnostic test, the findings should be evaluated in the context of other available clinical and epidemiologic information.

Prevention of Upper Respiratory Infections  (Colds)

Persons with URI symptoms and people in contact with them should wash their hands frequently to reduce common cold transmission.

Echinacea and vitamin supplements have not been proven as a means of prevention in most patients.

Prophylactic vitamin C is not recommended for the general community, but can be considered for marathon runners, skiers, and soldiers exposed to significant cold or physical stress.

Pneumococcal Vaccine

Pneumococcal 23-valent polysaccharide vaccine is recommended for all adults 65 years of age or older who have not previously received the vaccine, or who received the vaccine more than 5 years earlier.

• Also is indicated in all younger adults who are at increased risk for pneumococcal disease or its complications.
• Adults with chronic diseases such as cardiovascular disease (e.g., congestive heart failure, cardiomyopathies), pulmonary disease (e.g., chronic obstructive pulmonary disease or emphysema, but not asthma), diabetes mellitus, alcoholism, liver disease (e.g., cirrhosis), or cochlear implants or CSF leaks
• Adults with functional or anatomic asplenia (e.g., sickle cell disease, splenectomy)
• Adults living in certain environments or social settings (e.g., Native Americans)
• Adults who are immunocompromised
  • HIV infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, solid organ or bone marrow transplantation, or those receiving immunosuppressive therapy
• All adults should be evaluated at 50 years of age to determine their vaccination status and need for pneumococcal 23-valent polysaccharide vaccine.
• This provides an opportunity to determine whether a patient has one or more risk factors indicating a need for pneumococcal 23-valent polysaccharide vaccine and provides an opportunity to administer a booster dose of tetanus and diphtheria toxoids absorbed (Td) (for adult use).

Pneumococcal and influenza vaccines can be administered concurrently at different sites without increasing side effects.

Hepatitis A

• Transmitted by contaminated water or food.
• Not much of a problem in the USA.
• But, when you travel to exotic places, you should get the vaccine before you go.
  • It’s a two-dose vaccine, given several months apart.
  • So, plan early!

Hepatitis B

Hepatitis B is transmitted by blood, IV drug use, birth, or sex.

Hepatitis B Vaccine is recommended for:

• All newborn infants
• All unvaccinated children under age 11.
• High-risk adolescents.
• High-risk adults.
• Vaccine and HBIg are needed for postexposure prophylaxis:
  • inadvertent percutaneous or permucosal exposure to HBsAg-positive blood
  • sexual exposure to a HBsAg-positive person
  • household exposure to a person with acute hepatitis B.
• Hepatitis B vaccine is considered for all patients with chronic hepatitis C and other forms of chronic liver disease.

Hepatitis C

Prevention

Don’t use illicit drugs!

• Enter a substance-abuse treatment program
• Obtain hepatitis A and B vaccination
• Consider participating in a needle-exchange program

Don’t engage in high-risk sexual practices!

• Multiple sex partners are “bad”.
• Getting sexually transmitted diseases is bad.
• If you must engage in high-risk sexual practices, use condoms to protect yourself and your partners.

Tattoos or body piercings can be risky.

• Single-use equipment and appropriate sterilization is imperative.

Employment or volunteer work may put you at risk of exposure to infection.

• Health care, public safety (first responders), emergency medical services, or home health infusion therapy.
  • Needle-stick accidents from infected patients may result in transmission of HCV in up to 10% of victims
  • Barrier precautions are important (splash accidents that result in mucous membrane contamination have been suggested as a risk factor)
  • Don’t recap needles!

Prophylactic Antibiotics

• In the operating room
• When immunocompromised
• During an epidemic or outbreak
  • Influenza
  • Anthrax
  • Meningitis
• Self-treatment
  • Herpes – to stop an outbreak or reduce transmission risk
  • Traveler’s Diarrhea
  • Prevention of malaria
  • Endocarditis Prophylaxis
    • Dental work
    • Lots of other “dirty” procedures

Healthy Living

• Exercise
• Follow your doctor’s instructions
• Eat “right”
• Don’t get old

Don’t be stupid

• Avoid risky behavior
• Listen to your body
  • Fever, blood, pus, pain, rash
• Don’t go to New Guinea or the Amazon without adequate preparation!
• Don’t eat scrawny elk!

GERMS NEVER SLEEP  (but doctors do!)

• Most of them want to live with you peacefully
• Others just want to use you to propagate themselves
• If you had any idea of what is living in your own mouth, you’d never kiss anybody.
  • the mouth is just the front end of that long continuous tube we call the Gastro-Intestinal Tract – and you know where the other end is.
• Many germs are continually adapting to get around our defenses
• Resistant staphylococcus, streptococcus, etc
• There is no such thing as “ordinary” staphylococcus – it’s all evil and very dangerous
• And we sometimes destroy our own defenses
  • Chemotherapy
  • Organ transplantation
  • Alcoholism
• New things are discovered all the time
  • Lyme disease
  • AIDS
  • Hanta Virus
  • Toxic Shock Syndrome
  • Erlichiosis
  • “Flesh-Eating” Bacteria
  • Avian Influenza
  • ????

• Evil people can use germs to attack us
  • Anthrax
  • Small pox
  • Salmonella
  • Ebola, mutated killer viruses

3.  Fever is our friend

• A sure sign of badness
• Pay attention
  • It’s your body’s “Early Warning System”
  • Tell your doctor if you’ve taken something to “hide” your fever.
    • Tylenol, Motrin, Naprosyn, etc

4.  Time stops for no man

• We’d stop for a moment of silence to mourn this fact, but then we’d just be a moment closer to being dead, so let’s not.
• hey say the first five minutes of life are very dangerous and risky.  Well, the last five aren’t so great either.

In the next 1 minute, 97 people will die:

• 40 will die from infection
• 19 will die from diseases of the circulatory system
• 11 will die from cancer
• 5 people will be killed by tuberculosis
• 4 people will be killed by malaria
• 2 people will be killed by hepatitis B

In the next one minute:

• 761 people will acquire malaria
• 19 people will be disabled by polio
• 4 people will acquire HIV infection
• 1 person will acquire leprosy

Older people have weaker immune systems

• Vaccines don’t work as well
• Ordinary mild infections can get out of control
• Collateral damage suffered during the rigors of a normal life make us more susceptible to infection.
  • 15-60% of elderly people have bacteria in their urine
  • Artificial joints, heart valves
  • Liver, Kidney, and other organ damage
  • Diabetes, cholesterol, poor circulation
  • Surgical adventures
  • Forgetfulness
    • May not finish the course of antibiotics
    • May not get around to getting the flu shot
  • Disgruntled family members may choose to punish you
    • Angry wives
    • Angrier ex-wives
    • Ungrateful children