Note:  As it turns out, the Model Emergency Health Powers Act is not to be passed by Congress, but by each state.  Go to  http://www.vaccinationnews.com/Recommended%20List/Bills.htm for a list of state bills thus far known to have been introduced. - SM

http://www.thedoctorwithin.com/newwest/index38.html

chapter 38                                                                                  www.thedoctorwithin.com

Hepatitis A - Creating a Market for Another Superfluous Vaccine

- Tim O'Shea

hey finally did it. After years of lobbying and angling, GlaxoSmithKline finally got their new vaccine for Hepatitis A tacked onto the mandated schedule as of Jan 2002, with no public fanfare. (www.aap.org) The vaccine is called Havrix, and is delineated on p.1544 of the 2002Physicians Desk Reference, which incidentally was printed much earlier last year. Merck also has a hepatitis A vaccine - Vaqta.

The CDC's mandated schedule is the brass ring that all vaccine manufacturers are going for- approval of a vaccine can mean annual revenues of $1 billion or more, which is about what Merck pulls in for their current Hepatitis B vaccine.

Hepatitis A vaccine appears in a brand new category on the mandated schedule called the 'high risk' category. The significance of this new category will soon become apparent. But before we get into that, let's take a look at Hepatitis A the disease and assess the necessity for a mandated vaccine.

WHAT IS HEPATITIS A?

As every doctor knows, Hepatitis A is an acute viral disease of the liver. Hepatitis A virus (HAV) has supposedly been isolated:

"a 27-nm RNA picornavirus (enterovirus) with only one serotype..."
-American Academy of Pediatrics, Dec 1996

The infectious agent is passed from human to human either through

- the oral - fecal route, waterborne, often from raw shellfish or dirty water

- blood and body secretions

Hepatitis A is a mild, self limiting disease, resolving on its own with no treatment in 4-8 weeks. Most infections are subclinical, meaning that most people who get the disease never even know it because they never manifest symptoms. (Merck Manual, p 377)The journal Pediatrics agrees:

"Most HAV infections in young children are asymptomatic... Clinical hepatitis occurs in fewer than 10% of infected children."

This disease is so mild that90%of kids who get hepatitis A never even know it. Even the National Institutes of Health states that:

"Most people who have Hepatitis A get well on their own after a few weeks."

- NIH Manual: What I Need To Know About Hepatitis A

Most cases of hepatitis A are found in Third World areas, outside the US. The question pops up: then why are we the only country in the world who recommends the vaccine on a mass scale?

That billion dollars hanging in the balance wouldn't be in the equation, now would it?

Diagnosis of hepatitis A is supposedly by IgM antibody. But more often, diagnosis is by symptoms alone.

SYMPTOMS OF HEPATITIS A

According to Merck Manual, the chief symptoms of hepatitis Aare

• loss of appetite
• NVD
• hives
• joint pain
• dark urine

- p 382

Hardly life-threatening situations. Jaundice may also occur, but it usually indicates the beginning of recovery. By the time these symptoms appear, the disease is no longer infectious.

Unlike hepatitis B, Type A hepatitis disappears completely after acute infection, and does not contribute to chronic liver disease or to cirrhosis. It is important to note that after the patient recovers, he has lifetime immunity. True immunity.

Hepatitis A is a disease of poor personal hygiene, bad sanitation, poverty, overcrowding - Third World scenario. Even well-groomed, well-fed junkies are not high risk for Hepatitis A. They're more apt to get Type B. Medline indicates the lack of sewers in Third World locales as the biggest contributor to Hepatitis A. Again from the journal Pediatrics we find that:

"The major method for prevention of HAV infections is improved sanitation and personal hygiene"

Bottom line here: Hepatitis A is not common in most of the United States.

OTHER CAUSES

It's shocking to discover that hepatitis can be caused by both hepatitis B and hepatitis C vaccines! This fact is found in a disclaimer that GlaxoSmithKlein makes about Havrix, that it can't cure the hepatitis caused by these other 2 vaccines. So can we infer from this that Havrix itself also causes hepatitis? We don't need to infer it. The manufacturer states it on p 1545 of the 2002 PDR: a possible side effect of Havrix is hepatitis!

Another source of hepatitis A for children is nososcomial infection. That means infants in hospital intensive care units pick it up there. We never hear about it because the new literature is leaving it out. (AAP Policy Statement, 1996)

SO THEN WHAT'S THE VACCINE FOR?

The question arises - did we really need another vaccine beyond the 40 already mandated for school kids, and specifically did we need a vaccine for a rare disease that resolves by itself in a few weeks?

To answer the first, we must ask were there any studies done which prove that the new vaccine is safe when Havrix is added to the other 40 mandated vaccines? No, there are none. This concept of the cumulative viral load is discussed at length in the 2002 edition of The Sanctity of Human Blood.

Secondly, to substantiate the necessity for any vaccine, we must look at two criteria:

incidence of disease
severity

HOW MANY CASES REALLY ARE THERE?

This is tricky - research roulette. In the 2002 PhysiciansDesk Reference, the manufacturer of Havrix cites 13-year old studies which supposedly show the incidence of hepatitis A and state that the case death rate is six-tenths of one per cent. (p 1545) This is claiming that about six out of a thousand who get hepatitis A die from hepatitis A. It seems like a rather high death rate until one realizes that these are not US figures, but global figures, meaning that they were taken primarily from Third World countries because that's where the majority of hepatitis A is found! So that means that these patients are trying to recover from a disease of poverty, filth, and malnutrition in an environment of poverty, filth, and malnutrition. Hardly applies in the rare instance of a patient in most of America. But these are the studies and figures that the vaccine manufacturer has used to convince the FDA that Hepatitis A is such a serious disease in the US that a vaccine is necessary.

Numbers, numbers, numbers. Different sources, different stats. From the American Academy of Pediatricians website we see only half the death rate reported by the PDR:

"Mortality is rare, especially in children. The case-fatality rate has been estimated as3 per 1000clinical cases in the United States.."

- http://www.aap.org/policy/01207.html

Looking at the true incidence of the Hepatitis A in the US is an academic artifice, a daunting challenge indeed. A standard government reference for epidemiology is Statistical Abstracts. On p 137 of the most recent edition (2000), we find that the overall incidence of Hepatitis A has been declining for the past 2 decades:

1980 --- 29.1 cases per 100,000
1998 --- 23.2 cases per100,000

This decline is good news, and of course has nothing to do with the vaccine. The vaccine just came out. But the figures still seem a little high, don't they? On closer inspection, getting out the magnifying glass and reading the microprint footnote on that same page, we read:

"Includes cases imported from outside the United States"

Huh? 'Cases imported from outside the United States'? We're not talking Pinot Noir here. No one doubts that the vast majority of hepatitis A cases are foreign. It's a disease of poverty, filth, and malnutrition. Unfortunately in a disease which only manifests symptoms less than 10% of the time, and with the immense amount of immigration and international travel going on, there is simply no way to separate foreign from domestic origin.

To further illustrate the low credibility of government figures for hepatitis A cases, we need only look at a CDC report which claimed more than 10 times higher incidence: 30,000 cases, which is about300 cases per 100,000. (Hepatitis Surveillance Report No. 55)

That's a little different from 23 cases per 100,000. So which study is right?

Who knows? Results depend on who funded it, who wrote it, and who was responsible for verification.

The truth is no one can really say with authority how many cases of hepatitis A occur in the US annually.

THE REAL NUMBER OF DEATHS

In an earlier part of that same reference -Statistical Abstracts, p 90 - we find that the total number of annual US deaths from all 3 types of viral hepatitis put together (Types A, B, and C) in 1998was only 4700.<BR
Remember this 4700 also includes complications of autoimmune diseases, terminal infectious diseases, and other serious illnesses, most in communities of poverty and malnutrition, alcoholics, drug addicts -individuals of this nature. This lowest common denominator of life supposedly represents the necessity of a vaccine for all.

Looking at the PDR's global figures above - a mortality of 6 out of 100,000 - we see the usual attempt by the vaccine manufacturers to grab the credit for saving us from an already declining disease. As we learned from the Michael Alderson figures cited in The Sanctity of Human Blood (p 45), virtually every infectious disease of the past century had almost disappeared by the time vaccines came on the market. This is the perfect time to make the same claim for Hepatitis A, before it disappears completely on its own. Masterful PR in action, a la The Doors of Perception- www.thedoctorwithin.com 

We may be sure that future studies on US hepatitis A incidence will show vast decreases, for which the vaccine will doubtless be given credit. Just remember the virtual impossibility of determining incidence at this time, when the vaccine is being introduced.

Stats game aside, almost all sources agree that children are not the group dying from hepatitis A:

"hepatitis with mortality occurs mostly in people with underlying conditions, such as chronic liver disease, and in older age groups"
- http://www.aap.org/policy/01207.html  

THE VACCINE ITSELF

This is fun. Hepatitis A vaccine is made from infected human connective tissue cells. Not kidding. Not from just one guy, but rather each batch of vaccine is made from an infected mass of cells which had 1000 donors. (Pediatrics) Imagine that party. They are infected with hepatitis A virus, the causative vector presumed to be present in every case of hepatitis A disease.

The agents are filtered, and attenuated with aluminum, formaldehyde, and phenoxyethanol - a synonym for ethylene glycol - a component in antifreeze.

Someday we're gonna pay for this.......

ALUMINUM AND FORMALDEHYDE

Just for the sake of argument, let's make the colossally irresponsible concession that the attenuated viral agent in this vaccine is necessary to stave off the "epidemic" of Hepatitis A about to sweep through our children's bloodstreams. All right, we'll concede that unlikely situation. So do the science wizards then want to explain the additional presence of one of the most potent of all human neurotoxins and also of a well known carcinogen in this supposed life-saving elixir? Of course I am now referring to the aluminum and formaldehyde which GlaxoSmithKline thought so vital to the composition of Havrix. (PDR, p 1544)

As Drs. Russell Blaylock and Theo Colburn have well explained, it is not just the connection with Alzheimer's that makes aluminum such a danger to human physiology. It's that aluminum can interfere with the formation, development and survival of virtually any human nerve tissue in an unpredictable fashion, beyond any timetables yet devised. (Excitotoxins, Our Stolen Future) We simply don't know.

As for formaldehyde, let's just ask how much danger of cancer is an acceptable risk in the pure, perfect blood of a newborn? Cancer occurs first in just one cell. So where are the studies that prove that this "trace" of formalin or antifreeze will not be sufficient to cause that first cell mutation that develops into cancer? Where are they?

As long as we're talking about scientific probability here, let's take the discussion one step further. This single causative viral agent that has been identified for hepatitis A is a presumption. Remember - diagnosis is often by symptoms and by the presence of IgM in the blood. Viral infections are not cultured for diagnosis - it's largely theoretical. So then doesn't the isolation, concentration, and dissemination of an infectious viral agent seem at least a little presumptuous if not enormously reckless, especially when we're talking about the unformed immune systems of the newborn infant population?

That seems like a reasonable question, doesn't it?

MASS DISSEMINATION OF AN UNPROVEN AGENT

Here's the key point -- is it really necessary to introduce an attenuated infectious vector into our entire population of children in order to theoretically prevent a disease which is extremely rare in the vast majority of US communities, and getting rarer? And is self limiting, does not contribute to chronic liver disease, and confers lifetime immunity to the ones who get it? What are we doing?

Even the manufacturer does not claim that the vaccine confers immunity, but only delay of the disease. Thus the need for boosters. Get the idea - if the vaccine worked, we wouldn't need boosters after 6 months or a year. Following this shaky logic, if the immunity only lasts a year, the child should get boosters every year for the rest of his life. Now, the booster shot and the first vaccination shot are identical. So why does the first shot supposedly last for a year but the last one is going to be effective for the rest of the patient's life?? Anybody ever think of that??

The other big issue is that the Hepatitis A virus is supposedly a specific agent that has been photographed, sequenced, and catalogued, and occurs the same in every case of the disease. Classical diagnosis is by symptoms and the presence of the antibody, remember? IgM. But acute viral liver infections can be of a variety of completely different agents and disease scenarios. To pretend that they can all be cured by the dissemination of one single type of attenuated viral agent is disingenuous at best and scientifically ludicrous, even criminal, at worst. Mass inoculation must be absolutely proven to be necessary, beneficial and free from side effects, or else it shouldn't even be considered. Havrix meets none of these criteria.

THE NEW HIGH RISK CATEGORY

The most disconcerting - make that horrifying - aspect of the new Mandated Vaccine Schedule that has just sneaked up on us will prove to be the creation of this new High Risk category, in my opinion. As we would expect, this ingenious addition was tacked onto the program with no fanfare, no general public attention. Suddenly the most vaccinated children in the history of the world are still not getting sufficient injections, even at 40 vaccines now mandated. So for further protection, the CDC has now created the new High Risk category which they'll christen with just 2 vaccines: Hepatitis A and influenza. Now folks, these extra shots aren't really part of the mandated schedule, but are intended for the child who needs that extra protection because he is what we doctors call 'high risk.' Which according to the American Pediatrics Association means any child who seems to have a tendency to get colds, asthma, allergies, the flu, or is generally sick.

What percentage of kids does that include? Like, all of them?

Step right up. It's such a slick set-up. The script will go something like, well, little Johnny and little Suzie just got their regular shots, so they should be fine. By the way, Mrs. Jones, do these children have a tendency to get allergies, colds, or the flu? Oh, they do? Well, then the newest recommendations, just to be on the safe side, are that for extra protection for Johnny and Suzie we should add just two more shots today, while they're here. And that's the new Hepatitis A shot and the flu shot. Yes, and then they should be good for a year. Yes, all the other kids are getting the 2 extra shots. You can't be too careful these days, you know.

Who's going to argue with a rap like that? Only the most informed.

SET-UP FOR FUTURE VACCINES

The most insidious consequence of the new High Risk category, however, is the door that it opens up for future vaccines. With all the hysteria surrounding bioterrorism and anthrax, we've certainly beeni nundated with beaucoup worries about coming vaccines:

anthrax
AIDS
smallpox

and a whole string of others waiting in the wings. That's where Hepatitis A vaccine was last year.

Don't miss the implication here: the High Risk Category is now providing the infrastructure for any new vaccine that has to be rushed to the population in a hurry because of supposed bioterrorist threats. This is the set-up for the administration of the edicts which may come down if the draconian Health Emergency Powers Act should ever pass through Congress.

(www.mercola.com/2001/dec/26/mehpa.htm)

As you may have read, by this Act the governor of any state would be given absolute, dictatorial powers to proclaim virtually any situation a terrorist emergency, and to summarily decree that all or any part of the population must submit to whatever health measures are deemed necessary, including experimental vaccines. Those who refuse may be quarantined, prosecuted, imprisoned, or forced to submit, and property may be burned or confiscated.

Why not toss in the guillotine?

It seems unlikely that legislation this extreme would ever pass through Congress. But just the fact that it is being considered at all should make us ask ourselves - who is behind these totalitarian proposals and at what point we might actually want to become involved in state politics... Given these two options, Nazis-R-Us or Terrorists Might Pop Up Here and There, give me the threat of terrorism any day of the week. We've seen how well the government can protect us from anything. The answer is obviously not to give them another bigger chance, in this writer's opinion.

THE ILLUSION OF HIGHRISK

The big trouble with the High Risk Category is that it doesn't target high risk groups - it hoses down everybody. In a semantic bait-and switch, typical of organized medicine, they will call the category High Risk, and then proceed to hustle every possible individual into it by the absurdly overbroad and indiscriminate criteria of anyone with a tendency towards

allergies
colds
the flu

Very selective. There are true high risk groups for hepatitis A, including those living in overcrowded, unhygienic surroundings, improper diet, and certain racial selections as well.But here's where politics controls science - imagine the furor that would emerge if the vaccine were mandated according to living environment and race. That would be interesting - trying to convince those groups that the vaccine was fort heir own good. But if the CDC recommends it for almost everybody, hey then everybody's equal - the American way, right? And no one whines.

PROPAGANDA VS. INFORMATION

With uncharacteristic foresight, in 2000 the National Institutes of Health published a booklet whose goal was to prepare the public for the addition of Hepatitis A vaccine to the 2002 Schedule. As a study in language alone, the book is a frightening representation of the NIH's presumptions about the public's intelligence, which are probably accurate. Written in Basic Retard, What I Need To Know About Hepatitis A spoonfeeds the ninth grade mentality some idiotically simplistic propaganda, dumbing them down in the most patronizing and condescending manner. Some excerpts:

"A vaccine is a drug that you take when you are healthy that keeps you from getting sick."

Really? First of all vaccines aren't drugs, nor do people "take" them. As for keeping people from getting sick, perhaps we should ask the hundreds of VAERS parents whose children have suffered fatal injury or permanent damage from vaccines about how well vaccines kept their child from getting sick. This is classic Edward L Bernays (Propaganda,1928)

Or this gem:

"Vaccines teach your body to attack certain viruses, like the hepatitis A virus."

This myth has survived intact since Jenner first propounded it in 1799. If it were true we would not have the ridiculous situation where the only cases of diseases for the last 35 years have occurred in the vaccinated population, as with smallpox and polio. (Salk, Sabin)

Here's another excerpt from the same NIH booklet:

"Children can get the vaccine after they turn 2. Children age 2-18 will need3 shots. The shots are spread out over a year.... Adults get 2 shots over 6 -12months. ... You need all of the shots to be protected."

Yes, 2 years is there commended age for the vaccine. And where are the studies showing the absolute safety of injecting aluminum and formaldehyde into the unformed neurophysiology of a 2 year old? Where?

CALL IT IN THE AIR

What is shocking about these statements is the cavalier, arbitrary fashion in which dosages are recommended. I mean, reading it like this, it seems so scientific, doesn't it, and you assume that an enormous amount of scientific study is behind this very sober recommendation for "3 shots over a one year period." So why is it that in the PDR, the manufacturer has a totally different dosage recommendation and the AAP still another?? (Policy Statement)

On p 1545 of the new PDR, the manufacturer of Havrix states that the child may get an initial dose, and then get one booster 6-12 months later.

What is this -Spin the Bottle?

Yes, actually it is. That's exactly what it is. These dose recommendations are just guesswork - not the result of clinical trials. A year from now they may change completely, as we just saw with other vaccines on the new schedule. That's why different sources recommend different dosages.

Nothing is more obvious is studying government publications than inconsistency and ignorance of the most fundamentally pertinent literature and policies of related health offices, even within the same office. The classic left hand and right hand thing. There's no real "oversight" which is a bureaucratic word that means "watching over" an entire field of inquiry. Each office just sort of says what it wants, and then the doctors or lawyers or health officials quote the parts they can use. There's really no such thing as objective science when it comes to legislated health policies. Either you know this or you don't. The unfortunate thing for those who don't is that they follow blindly what they assume to be health policies and decisions made with the physical welfare of the child in mind. Discovering their mistake too late, the consequences can be physically disastrous.

Some other arbitrary, unscientific recommendations by the AAP for the new experimental hepatitis A vaccine include just-in-case shots for

· travelers to practically any destination that doesn't have a US zipcode
· military personnel
· Persons living in or moving to areas that have a high rate of HAV infection.
· Persons who may be exposed to the hepatitis A virus repeatedly due to a high rate of hepatitis A disease, such as Alaskan Eskimos and Native Americans.
· Persons engaging in high-risk sexual activity, such as homosexual and bisexual males.
· Persons who use illegal injectable drugs.
· Persons living in a community experiencing an outbreak of hepatitis A.
· Persons working in facilities for the mentally retarded.
· Employees of child day-care centers.
· Persons who work with hepatitis A virus in the laboratory.
· Persons who handle primate animals.
·Persons with hemophilia.
· Food handlers.
· Persons with chronic liverdisease.

Again, this is just guesswork and does not have to make any particular sense. No special studies of these groups with the vaccine were done. If the vaccine doesn't confer true lasting immunity, then why would it be good for any of the above groups? If the disease itself is mild and self limiting and confers true lasting immunity, wouldn't it be better for that very low number of people just to get the disease and forego the addition of carcinogens and neurotoxins into their bloodstream?

Another questiona bout the persons using illegal injectable drugs - how would a virus know whether or not the injections were illegal? With all the serious side effects from prescription drugs and vaccines, legal - illegal: why would one be higher risk than the other? This is nonsense.

Why on earth would someone who already has chronic liver disease want to take a risky vaccine that only claims to protect him from a mild, temporary type of liver disease? Especially one which has a hepatitis as a possible side effect and one which is going to further stress the liver with toxic adjuvants?

Even though the above bullets are pure conjecture, they do represent groups that are being designated as High Risk. The question then becomes - why isn't the vaccine recommended ONLY for these groups instead of for the majority of the childhood population? What was that - one billion...?

PREGNANT? DON'T EVEN THINK ABOUT IT

Under no circumstances should Hepatitis A vaccine be given in pregnancy. The manufacturer states that pregnancy studies simply have not been done. (www.aap.org/policy/01207.html) So unless you want to be in the experimental group, when that doctor who has not read the manufacturer's insert tries to give you this vaccine "just to be on the safe side" - pass.

WRAP UP

So what have we learned? Well, there's a new vaccine for hepatitis A being recommended for most children over 2 years old, as part of a brand new category in the Vaccine Schedule. And the disease itself -hepatitis A is not a big problem because in the vast majority of cases the individual never even knows the disease is present. And even if he gets the disease, it almost always resolves in a few weeks with no permanent aftereffects whatsoever.

And there are a few problems with the vaccine:

• aluminum
• formaldehyde
• ethylene glycol
• many side effects, including hepatitis itself
• the dosages are best guesses
• the manufacturers can pull in a billion new dollars per year
• the vast majority of hepatitis A occurs outside the US, yet no other country has mass vaccines
• the mass dissemination of an infectious agent in to the childhood population
• adding to the cumulative viral load of the most vaccinated children in world history

Outside of that, everything should be fine.

SOMEWHERE MACHIAVELLI SMILES

Perhaps the darkest consequence of all the foregoing is that most of us have lost our confidence in the inner curative power of Nature - the body's inborn wisdom. A hundred media snippets a day, week after week, year after year, have undermined our ability to even consider the notion that 99.9% of infants may be perfect as they are. Or that their pure blood is the most sacred medium in the universe, the crucible in which the human genome itself was meant to be safeguarded and passed on from age to age. Or that the immune system can only develop to its full potential if left to its own devices, largely unknown to human science.

Such natural, vital postulates as these sound foreign to our ears, even fanatical, cultist. Clear, rational independent thinking has become so rare, so unwelcome, so feared in this world where Conventional Wisdom on all topics of consequence is locked down tight, top to bottom. Adrift in this gallery of manufactured illusion, no effort is spared to keep one idea from surfacing: that we have all but lost the ability to trust our own instincts, to find the truth, and then to act on it.


Copyright -- 2002

REFERENCES

NIH --- What I Need To Know About Hepatitis A --- 2000.

US Dept of Commerce --- Statistical Abstracts of the United States --- p 137 --- 2000.

Medical Economics --- Physicians Desk Reference --- 2002.

Beers&Berkow, MD --- The Merck Manual ---Centennial Edition --- 1999.

National Library of Medicine

http://www.nlm.nih.gov/medlineplus/druginfo/hepatitisavaccineinactivatedsy202902.html#Brands

Blaylock,R MD --- Excitotoxins: The Taste That Kills --- Health Press ---1997.

Colburn, T, PhD --- Our Stolen Future --- Plume ---1997.

O'Shea, T --- The Sanctity of Human Blood --- New West ---2002.

American Academy of Pediatrics --- Policy Statement: Prevention Of Hepatitis A Infections: Guidelines For Use Of Hepatitis A Vaccine And Immune Globulin Pediatrics --- vol 98 no 6 --- p 1207-1215 Dec ---1996.

Committee on Infectious Diseases --- Centers for Disease Control and Prevention. Hepatitis Surveillance Report No. 55. p 1-341994.

Bernays, E --- Propaganda --- Live right, New York1928.

Micromedex --- National Library of Medicine

Sabin, Albert MD--- La Stampa --- Torino Italia 8 Dec 1985.

Model Emergency Health Powers Act (MEHPA) Turns Governors into Dictators

http://www.mercola.com/2001/dec/26/mehpa.htm

Salk, Jonas, MDquoted in Science Abstracts 4 Apr 1977.

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Copyright 2002

ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.