August is Vaccine Awareness Month

In this post, which I am trying to keep as short as possible, I am providing a link to WebMD's vaccine information site.

August is the month we are all prepping our children to return to school (werent we just talking about summer camp?) and many children will be getting immunizations necessary for school entry, along with their "back-to-school" check ups, or pre-sports physicals. The number of vaccines available and recommended has increased markedly since my children were little, and many parents, even those who have accepted vaccination in general, wonder what benefit accrues from some of the newer vaccines.  While it is not possible for me to cover all the risks and benefits of every possible immunization, I encourage those of you who are wondering to follow the link I provided above, which enables you to obtain the recommended vaccines for every age group, a description of the disease it prevents, and a compendium of potential risks.

If you prefer to access the information in pdf format, please click on one of these links:  vaccine information , vaccine side effects or vaccine ingredients Remember, there is nothing that does not have at least some risk. Most vaccines can cause soreness at the site, fever and a day or two of irritability.  Rarely, there is the potential for more significant side effects. Those are described in the provided links.

One of the most recent questions I was asked by a reader was "why should I immunize my child against chickenpox, when so few children ever died from this disease?"

Its true, even before the varicella vaccine was available, only about 100 child deaths occured related to this infection each year.  However, there were about 10,000 hospital admissions for complications of the disease, such as pneumonia and encephalitis (infection of the brain), which sometimes required advanced techniques of life support in critical care units. Patients who were immunocompromised (such as patients with childhood cancers undergoing chemotherapy) were at much higher risk of complications, and chicken pox infection can spread rapidly in an immunocompromised population. I have personally witnessed the devastating effects of chickenpox in children with leukemia, and glad that I have not had to see this in recent years.  So why not just give the vaccine to kids who are at risk? Well, you don't usually plan for your your child to get leukemia, and once they have it their immune systems may not respond well to any vaccine, so the best protection for them is to not be exposed to it, which requires something we call "herd immunity."  This is a situation in which a large enough percentage of the population is immune to a particular disease that makes it hard for that disease to circulate in the population.

The other issue with chickenpox is that once the virus is in your system, even though you have recovered, it never goes away, but rather waits for an opportune time to cause another disease known as Shingles, or Varicella Zoster, which is caused by the same virus that causes chicken pox. The elderly are particularly prone to shingles, which is very painful, and may lead to significant complications, including death.  So, by having your child immunized against chickenpox, you are helping to protect them from shingles in their old age.

Other immunizations that were not available to my children are the HPV vaccine, rotavirus, meningococcal vaccine, and a few others. I urge my readers to follow the provided links and read about the vaccines that most interest you.

Feel free to post your questions about specific vaccines or their side effects in the comment section, and I will do my best to answer them.

I will try to be unbiased in my answers, but in the name of full disclosure I must admit that I am in general pro-vaccine, and that I personally worked on a vaccine that was the predecessor to the currently administered Hib vaccine which prevents a certain type of meningitis. The other reason for my bias is that working in pediatric critical care for so many years I have seen a large number of children admitted, and some of them die or become permanently disabled due to infections caused by preventable diseases.

My heart has broken many times, watching a patient and their family suffer needlessly from infections that are difficult or impossible to treat but are generally easily preventable.

Recent Comments

"As an aside, all vaccines that are currently recommended to be given together, or are manufactured to be administered together, have been tested and found to maintain the same or better degree of what is called immunogenicity (ability to induce the immune response) as when given separately."

That is so interesting. Thank you again, I know my questions are a bit involved. I wish I had known to ask them a few years ago.

Thank you for the chicken pox explanation. It makes sense.

1. If your children were younger, would you give them the HPV vaccine? Why or why not? Would you let them help with the decision, if they were old enough?

2. What do you think of delayed vaccinating (for the example, the Dr Sears alternative schedule) or doing only one vaccine at a time?

3. If a child has a difficult time with vaccines and has medications they have to take before and after the vaccine to prepare for it, and then has to be watched closely after the vaccine, and is very delayed in their vaccines because of this, are there any vaccines that are ok to skip (polio for example) in order to get in the ones that are more important?

Heather, Excellent questions. Not sure I have all the answers, but I will provide my opinions:

1. If my children were younger, yes I would immunize them with the HPV vaccine. HPV is the most common KNOWN factor leading to certain types of cervical cancer, and potentially some forms of throat cancer as well. While it cannot prevent against all forms of cervical cancer, the evidence suggests that immunizing before ANY sexual activity is most effective. So I would immunize my children (girls and boys) at a young age.

In general, I believe that once kids are old enough to understand not only short term implications of an action (this will hurt) but longer term implications of ANY health care intervention, they should be involved in the decision making. This is called patient ASSENT as opposed to CONSENT. We should try to obtain their agreement in whatever we are going to do to/for them, and immunizations are no exceptions. However, it is sometimes difficult to assess exactly how much a child at any age can understand, and so we can't automatically go with their decision.

2. Delayed vaccinations are very controversial. Many infections are most problematic for the youngest of children. Take pertussis, for example. The pertussis vaccine does not provide complete immunity until the entire series has been given, but having even one or two shots of the series can significantly decrease the severity of the disease. Very young infants are most at risk for the worst of the symptoms, such as apnea (failure to take a breath) and therefore most likely to end up in an ICU and on mechanical ventilation. So its definitely a trade-off. Pertussis is one of those diseases, like measles that is making a come back, due to falling levels of immunization in the general population. So older people may contract the disease, have a mild cough or some wheezing, and transmit it to an at-risk infant, who could potentially die from it. Over my career I have seen three infants die of pertussis, and countless others suffer through an ICU admission.

In terms of administering each component of a combined vaccine separately, that also has pluses and minuses. More separate shots are more painful (or at least your child will have to have more sticks) and will end up being more expensive, since there will be additional visits to the office and additional charges. Some of the components are hard to obtain separately these days, and the pediatrician may not have them immediately on hand. This might be especially the case for children who depend upon the Health Department (those on medical assistance or without insurance), since they can get the "routine" combination vaccines at no cost. The benefit is obviously if you are looking for side effects, and you have given only one component of a vaccine you can better assess which portion has caused the problem for your particular child. This is a situation that should be discussed with the child's health care provider, and an individual plan made that is acceptable to the physician and the parents and appropriate for the child's condition and risks.

3. This one is very hard for me to answer. Clearly, we would like to see kids get vaccines for the most common or most dangerous infections as a priority. The problem is that which infections fall into that category can change with time or with region of the country, as well as internationally. Polio is not a commonly seen disease any more, but is not eradicated (like smallpox) so there is still a small risk of coming in contact with it. A child with special needs, or who has intrinsic weakness could be completely devastated with permanent paralysis by polio, and so I cannot go "on the record" as advising that it would be OK to skip or significantly delay. On the other hand, the oral polio vaccine is often delayed because it is a live "attenuated" virus, and if the child has any kind of significant immune compromise (such as HIV) it is not given. In that case, the shot (containing the killed virus) is substituted. It is safer in that particular patient population, even though slightly less effective. Again, my suggestion is to have a serious discussion with your child's pediatrician.

If your care provider is unwilling or unable to engage in this discussion, find another provider who is more knowledgeable or accommodating.

Thanks. As far as the single shots...I meant more spacing them out, not dividing up the multi shots like MMR. So for example, do Hib. Four weeks later do Prevnar. Four weeks later do DTaP. Etc. So that way if there was a reaction, you would know which shot it was in relation to? I don't know how that would work with every insurance, but I know that for ours, if we go for a nurse visit just to get a shot, the shot is charged as part of the well visit (whenever that happened to be) and there is no charge for the nurse visit. So it is not any more expensive, just more trips to the doctor. But worth it?

Heather, your questions continue to be very detailed and important, as well as difficult to answer in a few sentences.

The success of any vaccine administration depends upon inducing the correct immune response that leads to production of antibodies, and timing of subsequent doses of vaccines are pretty important in terms of taking advantage of having an immune system that is appropriately "primed" to get a better response on subsequent doses. This is why, for example, we RARELY have a significant fever with the first of any vaccine series.

When the FDA licenses a vaccine that requires multiple doses, it requires data on the appropriate timing of those doses, and that is why you should give the doses at the specified interval, and NOT SOONER. During the peak time of making antibodies, usually between 2 and 6 weeks after the shot, there can actually be a period of decreased ability for the body to form antibodies to a new stimulus (the next shot), and this can sometimes suppress the ability to respond to OTHER vaccines as well.

So, my advice would be that if you want to spread them out you do it by at least 2 months (unless there is data to show that sooner is OK). This, of course can mean that the total series of all scheduled vaccines takes much longer than usual, but I believe would be the safest way to go. It is not the case for all vaccines, and so each one you plan to delay should be researched by your provider (or by him or her talking with an infectious disease or immunology specialist) since the body's responses to different stimuli can be so complicated.

As an aside, all vaccines that are currently recommended to be given together, or are manufactured to be administered together, have been tested and found to maintain the same or better degree of what is called immunogenicity (ability to induce the immune response) as when given separately.

Hope this helped.
There may be some docs lurking out there who have a different opinion, or want to add their commentary--PLEASE DO

Do you think it is ok for a boy to wait until he is sexually active before he gets the HPV Vaccine?

Dear Holly, Thanks for your question. I cannot tell you that it is OK. The best time to be protected from an infectious disease is BEFORE being exposed to it. While we would all hope that our offspring would always act in a responsible fashion, data shows that they don't always. In addition, kids may not always realize that the same risks of spreading HPV would be there if they engage in oral sex, which has been growing in popularity among teens.

So, all morality issues aside, I would recommend getting the vaccine BEFORE there is any chance of being sexually active. The CDC recommends it be given between the ages of 9 and 18. I would urge earlier in that range than later. It is not a REQUIRED vaccine at this point, and so whether or not to get it is up to you and your son, after conversation with his pediatrician or family medicine provider.

I had occasion just now to call one of your family practice offices and was put on hold. While on hold, I listene,d to this blah, blah blurb about getting the flu vaccine and how we should get it now. The exact nature of my call was to see if they were giving flu vaccines. When I finally got a "live" person, I asked if they were giving them, and I was told, "No not yet, but check back in a couple or three weeks!" If you are going to be running "blah, blahs" about getting the flu vaccine on your "hold recordings" then WHY don't you coordinate the "blah, blahs" with when you ACTUALLY have the flu vaccine and will give it and NOT in "two or three weeks?" Poor service, poor marketing, and poor public relations! I'm going to Walgreens or Krogers to get mine, since I cannot trust my own family practice clinic to have it available when I'm ready to take it. This is a "problem" that has been going for MULTIPLE YEARS", too, NOT just this year!

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About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.

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