Alphabet Soup of Meningitis Vaccines: A, C, W, Y, B… What does it mean?

In my previous post I discussed the many different types of meningitis and most of the vaccines used to prevent them. Meningococcal meningitis deserves its own post because there are different strains of meningococcus and different vaccines to cover those strains. We’re familiar with the recommended vaccine schedule, but one type of meningitis vaccine falls into a lesser known category, so it’s very confusing. Here I’ll discuss the two main types of meningitis vaccines that protect against meningococcal meningitis as well as the recommendations for their use.

Meningococcal meningitis can refer to any meningitis caused by the type of bacteria called Neisseria meningitidis, but there are many different types of N. meningitidis. We have vaccines to protect against types A, C, W, Y, and B.

Who gets N. meningitis?

Infants, teens, and young adults are most likely to get meningococcal meningitis. You can see from the graph that infants have the highest risk, followed by the elderly, but there is a bump in the adolescent years. Among the adolescents, 16-23 years of age is the highest risk.

Meningococcal disease incidence by age.
Source: CDC

People at increased risk

Like most infectious diseases, risk increases if there are a lot of people living in close quarters. This is why college outbreaks occur, but even teens and young adults not in college are at a higher risk.

People who have weak immune systems or a damaged or missing spleen are at higher risk.

Sub-Saharan Africa is called the meningitis belt. People who live or visit there are at risk.

Living in or visiting areas of a current or recent outbreak of course elevates the risk.

Working in a lab that handles N. meningitidis bacteria is considered high risk.

Anyone at higher risk should talk to their doctor about when they are eligible for meningitis vaccines. These recommendations differ from the standard vaccine recommendations.

Rates of meningitis are falling

Rates of meningococcal disease have been falling in the US since the 1990s, mostly due to the routine use of meningococcal vaccines. Among 11 through 19 year olds, the rate of meningococcal disease caused by serogroups C, W and Y has decreased 80% since tweens and teens were first recommended to get a meningococcal conjugate vaccine.

Interestingly, serogroup B meningococcal disease has declined even though vaccines were not available to help protect against it until the end of 2014.

It is difficult to measure the impact of these vaccines because the overall incidence of the disease is so low. It takes large numbers of vaccines over time to measure effectiveness because the disease is so rare. It’s easier to notice change when something is frequent. The less common something is, the harder it is to follow trends and measure incidence.

Vaccines to prevent meningococcal meningitis

In the United States there are two types of meningococcal vaccines, quadrivalent and serogroup B.

Quadrivalent Conjugate Vaccines (MCV4)

Menactra and Menveo are different brands of meningococcal conjugate vaccine. These protect against serogroups A, C, W, and Y. Because there are four serogroups, it is called quadrivalent, shortened MCV4 – meningococcal conjugate vaccine 4.

Between 80-90% of tweens and teens vaccinated with Menactra show immune protection one month after completing the series. This protection drops to 70-90% of adults vaccinated with Menactra.

Between 70-90% of tweens, teens, and adults vaccinated with Menveo show immune protection 1 month after completing the series of vaccine.

The immunity from the MCV4 vaccines seems to fall after about 5 years.

Side effects from the vaccines are generally mild and self resolve within a few days. These side effects include redness and pain in the area of the injection as well as fever. More serious reactions, such as an allergic response, are possible but rare.

Any vaccine (or use of a needle for a blood draw) can lead to fainting in tweens and teens. It is recommended that they sit for 15 minutes after all vaccines and blood draws. This can help to prevent a head injury if they fall when they faint.

Routine recommendations

MCV4 is usually first given when kids are 11 to 12 years of age, followed by a booster at age 16 years.

The vaccine’s protection falls over time, so two doses are necessary. For most US children, getting the vaccine at 11 years protects through the early period of increased risk and the booster at 16 years covers the late teen and young adult years.

High risk groups

Children between 2 months and 10 years who are considered high risk based on the risk categories above should be vaccinated earlier.

Adults should get the MCV4 vaccine if they have the risk factors noted above.

Serogroup B Vaccines

Bexsero and Trumenba are meningococcal vaccines that protect against serogroup B. These vaccines are commonly called Meningitis B vaccines, or MenB. These vaccines are significantly different from one another, so if the series of vaccines is started, it needs to be completed with the same brand. They are not interchangeable, as are most vaccine brands. There is no preference of one brand over another.

Bexsero is a 2 dose series. Doses should be 1 month apart. Between 60-90% of people show immune response 1 month after completing the 2 dose series.

Trumenba is a 3 dose series. It should be given at 0, 1-2, and 6 months. If the 2nd dose is delayed beyond 6 months, only 2 doses are required. Eighty percent of people show a protective immune response one month after completing the series.

Side effects to MenB vaccines are generally mild. They include soreness, redness and swelling of the injection area, fatigue, headache, muscle or joint pains, fever, nausea, and diarrhea. If these symptoms occur, they generally self resolve within a week. More serious reactions, such as an allergic reaction, are possible but rare.

Again, it is recommended that tweens and teens sit for 15 minutes after all vaccines and blood draws due to the risk of fainting.

High risk people

MenB vaccines are recommended for people at high risk between 10 and 25 years of age.

Healthy, low risk people

The tricky part is that Men B vaccine is only given permissive use for most 16-23 year olds.

The CDC’s Advisory Committee on Immunization Practices (ACIP) makes recommendations for vaccine use based on all the data that is collected. Members of the Committee felt that the data available did not support the routine use of MenB vaccines, so it is not on the list of recommended vaccines.

What is permissive use?

Permissive use means it is approved for use, but it isn’t one of the standardly recommended vaccines.

This category is given because the vaccine is felt to be safe, but there is not sufficient evidence to recommend that it be given routinely.

Is it ever required for healthy people?

Some colleges require it. This is often due to a recent local outbreak so they are considered high risk.

Does insurance cover it if it’s not recommended?

Most often insurance does cover the MenB vaccine, but this is one of the concerns raised by the groups who argued that it should be routinely recommended. They argued that some insurance companies might not cover it if it is not recommended.

If you plan to get the vaccine, you should check with your insurance carrier to see if it is covered.

Why isn’t it recommended for everyone?

The meningitis A,C,W,Y vaccine is recommended for everyone at 11 and 16 years of age, so why isn’t the meningitis B vaccine recommended for all?

MenB vaccines protect against the majority of currently circulating strains of meningococcal B, but not all. The MenB vaccine also gives only a short duration of protection.

It is expensive to vaccinate, and since there is a relatively low incidence of meningitis B disease, it would take a lot of money to prevent a single case. While no price can be put on the value of human life, the overall risk remains low to individuals, even when they are not vaccinated. All of these factors led to the committee’s decision.

Dr. Vincent Iannelli discusses the risks and benefits in more detail at Understanding the Recommendations to Get a Men B Vaccine if you want more details.

Where can you get MenB if you choose to get it?

Physician offices, student health care centers, pharmacies, and county health departments might offer the MenB vaccine. Since it is not on the standard schedule, they might opt to not carry it. If you desire it, you should ask if it’s available.

My office offered the MenB vaccine last summer, but we did not have enough patients want it after discussing the current recommendations. Much of our stock went unused and had to be wasted.

We did not feel that we could push it strongly despite the fact that we were losing money on unused stock.

I know this might surprise some who believe that doctors are just pharmaceutical shills. (Shills is a term used to imply that doctors offer vaccines only to make money despite knowing about their dangers.)

My partners and I didn’t push this vaccine because we didn’t believe strongly in it. We bought it to be able to offer it to patients who desired it, but since we couldn’t honestly say we recommended getting it, we had few want it.

In the end we decided to not re-order it. We no longer offer MenB vaccine.

We strongly believe in giving the vaccines that are recommended. Recommended vaccines have been shown to not only be safe, but also effective in preventing disease. They can make a big impact on our health as individuals and as a community.

Final MenB Vaccine Thoughts

Unfortunately, the MenB vaccine has failed to show sufficient effectiveness to support the cost of vaccinating everyone.

Putting value on one person’s life is not possible, so if my patients want this vaccine, I suggest they go to the health department, a pharmacy, or student health on their college campus.

I do not think it is wrong to get the vaccine. I simply can’t say that everyone should get it.

Some students must get it due to their school’s requirement. If a school requires it, that should not be argued. The schools with MCV4 requirements often have had a recent outbreak and are considered high risk. In that case, protect yourself!

Meningitis Basics: What you need to know.

Meningitis occurs when a virus or bacteria causes inflammation of our brain or spinal cord. We use several different vaccines to prevent a few types of meningitis, but it’s all very confusing. Recent commercials have raised questions about what these vaccines are and if they’re needed.

Today we’ll go over what meningitis is and what types of germs cause it. Next time I’ll discuss some of the new meningitis vaccines in more detail.

What is meningitis?

Symptoms of MeningitisBoth viruses and bacteria can cause meningitis, but not everyone with these germs gets meningitis. Most people have less severe symptoms when they get these infections.

Not everyone gets all the symptoms listed below when they have meningitis. Some of these symptoms are common to many less serious infections, but if your child has these symptoms and appears more sick than normal, he or she should be evaluated immediately.

Symptoms of meningitis include:
  • fever
  • stiff neck
  • body aches and pains
  • sensitivity to light
  • mental status changes
  • irritability
  • confusion
  • nausea
  • vomiting
  • seizures
  • rash
  • poor feeding

Viral meningitis

Viruses are the most common cause of meningitis. Thankfully viral meningitis tends to be less severe than bacterial meningitis.

Most people recover on their own from viral meningitis. As with many infections, young infants and people who have immune deficiencies are most at risk.

There are many types of viruses that can cause meningitis. It’s likely that you’ve had many of these or have been vaccinated against them.

Non-polio enterovirus

The most common virus to cause meningitis is one from the non-polio enterovirus family.

Fever, runny nose, cough, rash, and blisters in the mouth are all symptoms that kids can get from this type of virus.

Most kids are infected with this type of virus at some point. Adults are less susceptible, and can even have the virus without symptoms.

There is no routine vaccine given for non-polio virus strains.

MM(R)V

Measles, mumps and chicken pox viruses can cause meningitis.

We vaccinate against these typically at 12-15 months of age, so it is uncommon to see these diseases. The MMR and varicella vaccines can be given separately or as MMRV. (Rubella is the “R” and can lead to brain damage in a fetus, but does not cause meningitis.)

Influenza

Influenza can cause meningitis, which is one of the reasons we recommend vaccinating yearly against flu starting at 6 months of age.

Herpesviruses

Herpesviruses can cause meningitis. Despite the name, most of these are not sexually transmitted.

This family of viruses includes Epstein-Barr virus,which leads to mono most commonly. Cold sores from herpes simplex viruses are also in this group. Chicken pox (or varicella-zoster virus) is another of these blistering viruses.

Bacterial meningitis

Bacteria that lead to meningitis can quickly kill, so prompt treatment is important. If you’ve been exposed to bacterial meningitis, you may be treated as well, but remember that most people who get these bacteria do not get meningitis.

Most people who get bacterial meningitis recover, but some have lasting damage. Hearing loss, brain damage, learning disabilities, and loss of limbs can result from various types of meningitis.

Causes of bacterial meningitis vary by age group:

Newborns

Newborns can be infected during pregnancy and delivery as well as after birth. They tend to get really sick very quickly, so this is one age group we take any increased risk of infection very seriously.

Bacteria that tend to infect newborns include Group B Streptococcus, Streptococcus pneumoniae, Listeria monocytogenes, and Escherichia coli.

Mothers are routinely screened for Group B Strep during the last trimester of pregnancy. They are not treated until delivery because this bacteria does not cause the mother any problems and is so common that it could recur before delivery if it’s treated earlier. This could expose the baby at the time of delivery. If a mother does not get adequately treated with antibiotics before the baby is born, the baby may have tests run to look for signs of infection or might be monitored in the hospital a bit more closely.

Once the mother’s water breaks, we time how long it has been because this opens the womb up for germs to infect the baby. If the baby isn’t born during the safe timeframe, your delivering physician or midwife might suggest antibiotics. After delivery your baby might have tests done to look for signs of infection or might be monitored more closely in the nursery.

It is very important that sick people stay away from newborns as much as possible. Everyone should wash their hands well before handling a newborn.

Babies and children

As children leave the newborn period, their risks change. Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib) are the bacteria that cause disease in this age group.

Thankfully we have vaccines against many of these bacteria. Infants should be vaccinated against S. pneumoniae and H. influenzae starting at 2 months of age. (Note: H. influenzae is not related at all to the influenza virus.)

Vaccines against N. meningitidis are available, but are not routinely given to infants at this time. High risk children should receive the vaccine starting at 2 months of age, but it is generally given at 11 years of age in the US.

Teens and young adults

Neisseria meningitidis and Streptococcus pneumoniae are the risks in this age group.

Thankfully most teens in the US have gotten the S. pneumoniae vaccine as infants so that risk is lower than in years past.

Tweens and are routinely given a vaccine against A, C, W, and Y strains of N. meningitis. A vaccine against meningitis B is recommended for high risk people and can be given to lower risk teens. This will be discussed further in my next blog.

Older adults

Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), group B Streptococcus and Listeria monocytogenes affect the elderly

Talk to your parents to be sure they’re vaccinated and follow the vaccine recommendations for yourself too. Vaccines are not just for kids!

‘NI, Leptomeningitis purulenta cerebralis. Alfred Kast’ . Credit: Wellcome Collection. CC BY

 

When vaccines are given too soon

Sometimes vaccines are given too soon to count toward the required vaccine schedule. This can easily happen if there are changes to the standard vaccine schedule for any reason, but what does that mean for the child? Are they in danger? Do they need extra shots? Is that even safe???

Early vaccines don’t count.

Don’t try to sneak in early before a recommended age.

It’s not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in every state. State laws can dictate a grace period in which vaccines can be given earlier than the standard schedule, but not all do.

This is an issue with some children moving from a more lenient state to one with a lesser (or no) grace period.

In some states they can get their MMR a couple days before their first birthday.

Does this protect them against measles, mumps, and rubella?

~ Probably. (Nothing’s 100%.)

Does every school count it?

~No. If they move to a state that doesn’t, they need to repeat it.

International travel changes things.

It is recommended for international travelers over 6 months to get an MMR early due to worldwide measles outbreaks.

This dose does not count toward the 2 doses typically given after the 1st birthday because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Most babies are protected against measles for 6-12 months after birth.

If the MMR vaccine is given when they are already protected, the vaccine doesn’t work.

We don’t know if a 6-12 month old is safe or not, so when the risks increase, as with international travel, it is recommended to give a shot to help if needed.

But that shot might not work, so it should be repeated after the 1st birthday.

Minimal intervals are important.

Most vaccines are given as a series, and each vaccine within a series needs to be separated by a minimal interval.

Before vaccine logic was built into our electronic health record, it could be difficult to know which vaccines were recommended if people got off the standard schedule.

Not all EHRs have smart vaccine logic, so if you’re off schedule, be sure to discuss intervals before giving vaccines.

The hepatitis vaccines are more commonly given off an appropriate schedule than other vaccines. I’ll touch on each of them and why they’re problematic.

Hepatitis A vaccine interval problems.

My office routinely gives the first Hepatitis A vaccine at 12 months and the second at 18 months. The CDC schedule states:

Hepatitis A (HepA) vaccine. (minimum age: 12 months)

Routine vaccination:

  • 2 doses, separated by 6–18 months, between the 1st and 2nd birthdays. (A series begun before the 2nd birthday should be completed even if the child turns 2 before the 2nd dose is given.)

Despite warning parents to schedule the 18 month visit 6 months or more from the 1 year visit, sometimes they don’t have the correct spacing. This generally happens when they do the 1 year visit several weeks after the birthday but then try to “get back on track” and do the 18 month exam on time.

The good news is our smart EHR tracks minimal intervals and doesn’t suggest the vaccine if it’s too early.

I typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine if it is too early at the 18 month visit, but I ask the family to come in just before the 2nd birthday. This allows the child gets the vaccine before 24 months of age and fit the main recommendation of getting both doses between the 1st and 2nd birthdays.

Sidenote about HEDIS

A delay to wait until the 2 year well visit follows the CDC recommendation to have the doses separated by 6-12 months.

Despite following the CDC guidelines, it fails to meet HEDIS benchmarks.

If a child gets the Hepatitis A vaccine after the 2nd birthday, the physician loses quality points.

These points help rank physicians for insurance company purposes.

As long as it doesn’t happen often, it’s not an issue.

But if schedules are off too often, a physician’s contracts with insurance companies could be at risk because they are seen as not high quality, regardless of why the vaccine is given after the 2nd birthday.

If you want to keep your favorite physician and use your insurance, please help them meet the standards of care for all metrics. This includes coming in for annual well visits and having regular follow up for chronic issues. It also means taking the recommended medications, such as preventative medicines for asthma and doing certain labs, such as lipid panels, or screenings, such as depression screenings.

Sidenote about vaccine shills

There are many groups sounding alarms about physicians getting paid huge amounts of money to vaccinate from Big Pharma. I wish this was true, but it’s not.

Don’t confuse the HEDIS measures and insurance contracts with this Big Pharma farce. First off, we pay pharmaceutical companies to buy their vaccines. They don’t pay us. Sometimes they buy a lunch for our staff so they can have our attention when they talk about their products, but there is no big money to be made from vaccine companies.

Insurance companies pay us for the vaccine and the costs associated with giving vaccines. These costs are not only for syringes and band aides. We must carry insurance for the vaccine inventory. There must be a dedicated refrigerator and freezer to safely store vaccines. We should use a refrigerator alarm system to alert us if the temperature is too warm or too cold. We pay staff to keep logs about refrigerator temperatures and inventory. All of these costs add up.

Trust me, no one gets rich off of vaccines.

Some insurance companies offer bonuses if we meet HEDIS measures, but more often I think they just pay less if we don’t meet measures.

Why do they pay more if we give vaccines?

Because the insurance company comes out ahead if we vaccinate. Vaccine preventable diseases cost them much more than vaccines. They want to encourage us to vaccinate to save them money.

Hepatitis B Interval problems.

Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.

There are vaccines that just have hepatitis B protection (monovalent vaccines) that can be given starting at birth. They can be used for all three doses.

There are other vaccines that combine the hepatitis B vaccine with other vaccines (combination vaccines). The combination vaccines are given at different intervals, depending on what is in the vaccine. They cannot be given under 6 weeks of age, but it’s still recommended to give the first dose within 24 hours of birth.

Yes, it’s confusing.

From the CDC guidelines:
  • A complete series is 3 doses at 0, 1–2, and 6–18 months. (Monovalent HepB vaccine should be used for doses given before age 6 weeks.)
  • Infants who did not receive a birth dose should begin the series as soon as feasible.
  • Administration of 4 doses is permitted when a combination vaccine containing HepB is used after the birth dose.
  • Minimum age for the final (3rd or 4th) dose: 24 weeks.
  • Minimum intervals: Dose 1 to Dose 2: 4 weeks / Dose 2 to Dose 3: 8 weeks / Dose 1 to Dose 3: 16 weeks. (When 4 doses are given, substitute “Dose 4” for “Dose 3” in these calculations.)

There are even additional recommendations if the mother is a known Hepatitis B carrier or if her status is unknown.

If any of the doses are given too early, they need to be given again. This is considered safe.

Live viruses need special attention.

Live viruses must be given either at the same time or at least 28 days apart. If they are given at a shorter interval, the second vaccine is presumed to not be effective and must be repeated.

This is another great reason to not alter the standard vaccine schedule your provider uses. If your child gets off track, you run the risk of him or her needing additional vaccines.

Common live virus vaccines include MMR, Varicella, MMRV, and Flumist.

Some vaccines, like the oral typhoid vaccine, cannot be given at the same time as antibiotics.

Quiz yourself!

See if you know what vaccines your child needs.

To avoid vaccines that are given too soon:

  • Be sure that whoever is giving vaccines knows any recent vaccines and medicines your child has had recently.
  • Try to stay within the recommended vaccine schedule as much as possible to avoid needing extra doses.

Vaccine schedules for children birth – 6 years and 7-18 years:

 

 

 

Top Reasons to Follow the Recommended Vaccine Schedule

Every once in a while we see a child whose school nurse says the child’s vaccines didn’t count and need to be repeated. This can be due to many things, usually inappropriate timing of vaccines. Some electronic health records now have intelligent vaccine recommendation abilities. These smart vaccine logic systems are catching kids who had incorrect spacing before this technology. Staying on the routine vaccine schedule and keeping all records in one place can help avoid extra doses due to inappropriately spaced vaccines.

One thing to remember if your child needs extra doses: you don’t need to worry. They’re safe!

What’s in this post?

First you’ll need to understand about the different types of vaccines to know why they are scheduled like they are. Some are given in a series to boost the initial response, but others need to be repeated to cover those who weren’t protected with a first dose.

Then we’ll do a quick review of the risk of the diseases to remind us why we vaccinate in the first place.

Hopefully after learning some basics, you’ll see why the timing of vaccines is so important and why we should all follow the recommended vaccine schedule.

What’s not in this post?

If you want to know what to do if a recommended vaccine has been delayed, see What happens if a vaccine booster is delayed?

Dr. Vincent Iannelli has a list that includes some issues not discussed in this post, such as improper storage.

How vaccines work

Vaccines are made in different ways and the body responds to them in different ways.

Live attenuated vaccines

Live attenuated vaccines are made from weakened virus that teaches the body to recognize the real virus but doesn’t cause the symptoms of the virus in healthy people.

Those with weak immune systems should talk to their physician before receiving a live virus vaccine. The amount of immune compromise and specific vaccine must be taken into account on an individual basis.

It’s usually okay to be vaccinated with a live virus vaccine if you’ll be around an immunocompromised person, but again, let your physician know the risk of exposure.

Examples of live virus vaccine:
  • rotavirus
  • measles
  • mumps
  • rubella
  • varicella
  • nasal flu vaccine (NOT the injectable flu vaccine)

Many people respond sufficiently to the first dose of these, but repeat doses are given to help those who missed the response the first time.

The second dose doesn’t boost the first, but it gives a person a second chance at making immunity.

Spacing between doses:

Because of the way these vaccines work, they must follow special separation rules. More than one live virus vaccine can be given on the same day, but they cannot be given on separate days that are closer than 4 weeks apart.

If one live virus vaccine is given, you must wait a minimum of 28 days to give another. If they’re given too close together, the body doesn’t make immunity as well to the second one given. This second vaccine wouldn’t count.

As an example, if the FluMist (nasal flu vaccine) is given on January 1 and the Varicella vaccine is given January 15 of the same year, the Varicella vaccine will not count and must be repeated.

Live virus vaccines are the only vaccines that are subject to this 28 day rule. If another vaccine type is needed, it is okay to give in a shorter time frame.

For example, if a child has the MMR at his 4 year well visit, it is okay to do an injectable flu vaccine at a flu clinic later that same month. (Note: the nasal flu vaccine is a live virus vaccine, so it is NOT okay to give the FluMist within the month before or after the MMR.)

If there is less than 28 days between live virus vaccines, the one that was given second must be repeated.

I see this quite frequently in kids who move to the US from other countries. It seems quite common elsewhere for kids to get the varicella (chicken pox) vaccine about 2 weeks after the MMR. When this happens, another varicella vaccine is needed.

Live virus vaccines aren’t recommended under 1 year… usually

Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.

Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.

Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.

If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.

By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.

International travel increases risks

If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection. Many parts of the world have high measles rates so fit into this recommendation.

If the antibody levels are still high, the vaccine won’t work, but the baby should still be protected against the disease from mom’s antibodies.

At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.

The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.

Yes, I realize there are some measles outbreaks in the US, but the experts have not said to start giving that extra dose to babies who are staying here yet. If you’re worried, talk to your doctor.

Inactivated virus vaccines

Inactivated virus vaccines are made by killing the virus and using it to make the vaccine.

They aren’t as effective as live virus vaccines, so several doses are needed to build immunity to these.

Examples of inactivated virus vaccines:
  • inactivated polio vaccine
  • injectable flu vaccines
  • hepatitis A vaccine

Subunit, recombinant, polysaccharide, and conjugate vaccines

Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces of a virus or bacteria to make a vaccine.

Because these vaccines use only specific antigens, they give a very strong immune response that’s specific to the infectious particle and side effects are less common.

This type of vaccine is safe for nearly everyone, including people with weak immune systems.

One limitation of these vaccines is that you may need booster shots to get ongoing protection against diseases.

Subunit, recombinant, polysaccharide, and conjugate vaccines include:
  • Hib (Haemophilus influenzae type b) – not related to influenza vaccine at all
  • Hepatitis B
  • HPV
  • whooping cough
  • pneumoccal disease
  • meningococcal disease

Toxoid vaccines

Toxoid vaccines prevent diseases caused by bacteria that produce toxins in the body.

The toxins are weakened into toxoids so they cannot cause illness and are used to make the vaccine.

When the immune system receives a vaccine containing a toxoid, it learns how to fight off the natural toxin.

Example of toxoid vaccine:
  • diphtheria and tetanus portions of the DTaP vaccine

Several shots are needed to build and continue immunity over time.

Passive immunization

Passive immunization is a bit different than any of the above.

Either catching a disease or getting any of the above vaccines stimulates your immune system to make memory cells to fight of that specific germ if it comes in contact with it.

Passive immunity results when a person is given someone else’s antibodies.

The protection offered by passive immunization is short-lived, usually lasting only a few weeks or months, but it helps protect right away.

Example of a passive vaccine:
  • Synagis (RSV) vaccine

Why are vaccines repeatedly given?

Vaccines interact with the T and B cells of our immune system to make memory cells.

If you want to learn more, see How Vaccines Work. It’s a really cool slide show from The College of Physicians of Philadelphia.

Some vaccines need several doses to help the body develop a strong immunity against the germs. Later boosters are required to maintain that level of protection.

Other vaccines require more than one dose to insure that most people develop the protection.

Age at time of vaccine matters

The CDC Immunization schedule allows for age ranges for many vaccines to be given. Many states allow a grace period around those ages, but not all do.

Some vaccines have been shown to work best at certain ages. Our vaccine schedule reflects the best ages to give vaccines so that they are safe and effective.

If a child receives a vaccine within the grace period of their current state, it might “count.” But if that child moves to another state, the vaccine might not count per the new state’s laws.

My office only gives the routine MMR, Varicella, and Hepatitis A vaccines on or after the first birthday to help prevent a child from moving to a location that does not have a grace period. This is despite the fact that Kansas does have a 4 day grace period.

We will give the MMR earlier under certain circumstances as discussed above, but it does not count toward the two needed after the 1st birthday.

Spacing matters

Many vaccines need to be separated by a minimum timeframe, often 4 weeks, but sometimes longer. The Hepatitis A vaccine has a minimum timeframe of 6 months between doses, for example.

If the vaccine doses are not separated by a minimum time, one or more will need to be repeated.

For spacing rules, see the CDC vaccine schedule at the bottom of this post. Click on “footnotes” to see the details for each vaccine.

Why not space them out further?

Many parents have come to believe the “too many too soon” theory. They believe this despite the overwhelming evidence that vaccines are safe and effective when given according to the CDC schedule.

The risks to waiting to give vaccines are many.

Increasing vaccine preventable disease rates

Young adults of today have grown up without seeing the suffering of vaccine preventable diseases. But we’re seeing an increase in these diseases where vaccine rates have fallen.

Infants who aren’t vaccinated are at risk of diseases that can lead to death. They are among the most vulnerable and need protection.

More trips = more exposure

Not only are underimmunized children more at risk for vaccine preventable diseases, but bringing them to a clinic more frequently to do one vaccine a time increases risk. Each time they visit the clinic, they’re exposed to all the common viruses. Why risk bringing them back again and again to get more exposures?

Giving the vaccines together has been shown to be safe and effective.

More visits = more stress

There are studies that show less overall stress to the body if vaccines are given together.

Studies have shown that the first injection causes a stress response measured by elevated heart rate, blood pressure, cortisol levels, and cry. Subsequent injections given at the same time do not increase as significantly the stress when compared to returning on different days to get further injections.

The immune system can handle it

Are you worried about “too many too soon” and that vaccines will overwhelm the immune system? Stop worrying. These fears are simply unfounded.

As Paul Offit summarized in Addressing Parents’ Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant’s Immune System?:

Current studies do not support the hypothesis that multiple vaccines overwhelm, weaken, or “use up” the immune system. On the contrary, young infants have an enormous capacity to respond to multiple vaccines, as well as to the many other challenges present in the environment. By providing protection against a number of bacterial and viral pathogens, vaccines prevent the “weakening” of the immune system and consequent secondary bacterial infections occasionally caused by natural infection.

Keep your child’s vaccine record handy

I see many kids who transfer to my office but I don’t have access to their vaccine records at the time of the visit. This makes it difficult to know which (if any) vaccines are needed.

Hopefully as we use Electronic Health Records with portals and vaccine registry databases more this will become a non-issue. At this time it’s still a problem.

This is one of the many reasons I prefer for all vaccines to be given at the same clinic. If you’re changing primary care providers, be sure records are transferred before your first visit.

Flu vaccines are especially troublesome.

Flu vaccines are commonly given in many locations: your primary care provider (PCP) office, a parent’s workplace, a local pharmacy, at a school flu vaccine drive. They need to be repeated yearly, so it’s easy to forget if each of your kids has had it this year.

It’s common for one parent to not know if their child got a flu vaccine already this season. That leads to a missed opportunity or vaccines given unnecessarily.

I have seen a few kids who couldn’t get their kindergarten vaccines at their well visit because they recently had a FluMist elsewhere. That requires another trip to the office for the family.

I have seen a few kids who did get the kindergarten vaccines inappropriately because the parent didn’t realize the other parent had taken them for a FluMist elsewhere. They needed to repeat the MMR and varicella vaccines, which didn’t make the kids happy!

FluMist is coming back to the US for the 2018-2019 flu vaccine season. It is not the preferred vaccine by many experts due to continued concerns about its effectiveness, but it will be preferred by many kids who hate needles. If your kids worry about shots, learn how to make them less painful.

Be sure to keep track if your kids get a FluMist – especially if they’re getting kindergarten vaccines around the same time!

Learn more about vaccine preventable diseases:

This comic book can teach kids and adults about viruses and how science works:

Dr. Paul Offit is one of the leading experts on vaccines. His many books can show how vaccines work and why they’re needed. He delves into the anti-vaccine movement in many of his books. He shows how delayed vaccine schedules are not effective or necessary in most of his books. I have many of these at my office available for patient families to check out. Just ask if you’re in my office. Otherwise, read about each on the links to see what best fits your needs.


Note: As an Amazon Affiliate Member, I will get a small percentage for the sale of the books if purchased from these links. This is at no additional cost to you.

Vaccine Resources for Kids and Teens is a great list of resources from the Children’s Hospital of Philadelphia.

15 Common Anti-Vaccine Arguments and Why They are a Load of Crap

How Math (and Vaccines) Keep You Safe From the Flu Simple (or not so simple) math shows how herd immunity works. Widespread vaccination can disrupt the exponential spread of disease and prevent epidemics.

Simulation of how herd immunity works. Is a free online simulation. Try it!

The CDC schedule:

 

 

What happens if a vaccine booster is delayed?

A lot of parents question the timing of vaccines. What happens if a vaccine booster is delayed? Does the series need to be restarted? Is it even worth it if it’s late?

There are so many questions about delayed vaccines…

This is not about a delayed schedule.

Intentionally delaying vaccines, especially during the infant schedule, puts kids at risk for catching a disease.

I always recommend giving vaccines according the standard vaccine schedule. This helps protect our children and our communities.

A bit about insurance…

There also might be insurance issues if vaccines are given out of the standard age range. Details of coverage should be in the fine print of your individual contract with your insurance company and your physician will not know coverage specifics. You should talk to your insurance company to see if there are limitations on vaccine coverage if you are vaccinating outside the standard vaccine schedule.

Most insurance companies cover the infant series until 2 years of age. I recommend getting those done prior to the 2nd birthday if at all possible, not only for the protection of your child, but also potential increased costs to you if your insurance company has age restrictions.

The “kindergarten” vaccines are given between 4 and 6 years of age and then there are “tween/teen” vaccines at 11-12 and 16 years. These also might fall into age restrictions of your insurance company, so talk to an insurance company representative if you have questions on payment.

Life happens, and sometimes there are inadvertent delays in vaccinating.

The typical question I’m asked regarding what happens if a vaccine booster is delayed is along the lines of one of these questions:

“He is due for his kindergarten shots on July 5th, but we’re on vacation then. Is it okay to wait until the end of July?”

or

“Tweeny is getting her first HPV vaccine today, but she has a big out of town tournament the week she is due for the 2nd dose. Can she come later?”

The answer to both questions: yes.

Vaccines are recommended with minimal intervals. If there’s a delay for whatever reason (missed appointments, scheduling conflicts, temporary immune compromise-such as cancer) it’s usually recommended to catch up as soon as possible.

Vaccine series do not need to be restarted if the interval has been longer than recommended. You give the next required dose and make sure successive doses fit minimal intervals and age limitations.

Minimal intervals will be discussed in a future post.

Exceptions to completing the series

There are a few vaccines that should not be given if too much time has passed.

Rotavirus vaccine

Rotavirus vaccine is very specific as to when it can be given.

There are two types of rotavirus vaccine. One is typically given at 2, 4, and 6 months. The other is given at 2 and 4 months. Either is considered acceptable. It is recommended to use the same type to complete the series, but they can be interchanged if needed.

The minimum age for the first dose is 6 weeks and the maximum age for dose #1 is 14 weeks 6 days.

Vaccination should not be started for infants age 15 weeks or older due to safety concerns in older infants. If an infant of 15 weeks 1 day or older has not started the rotavirus vaccine, they should not start it.

The maximum age for the last dose of rotavirus vaccine is 8 months and 0 days. If an older infant has not completed the series, it is not recommended to do a catch up.

Hib vaccine

The Hib vaccine also has different versions and a variable schedule due to vaccine types and combination vaccines. It is either a 3 or 4 dose series. The earliest it can be given is 6 weeks, but it standardly starts at 2 months.

At least one dose is recommended after the first birthday for children under 5 years of age.

It is not recommend to give Hib vaccine after 5 years of age to healthy children. Some high risk people should continue to get the vaccine beyond their 5th birthday.

Pneumococcal vaccine

Again, there are various types of pneumoccal vaccine, but the one routinely given to infants is the PCV13.

The youngest an infant can receive this vaccine is 6 weeks, but it’s typically given at 2, 4, 6 and 12-15 months. If a child misses doses, they should do catch up vaccines at least 28 days apart and at least one dose after the first birthday, unless they are over 5 years of age.

Only children with underlying health risks require catch up doses if they’re over 5 years of age.

Some schools require at least one dose, so children over 5 years who have never had this vaccine may be required to be vaccinated despite the CDC guidelines. While this is safe, it may not be covered by insurance. (Another great reason to stay on the routine schedule as much as possible!)

DTaP and Tdap (D and d = diptheria, T = tetanus, P and p = pertussis/whooping cough)

The DTaP vaccine is typically given at 2, 4, 6 months and then boosters at 15-18 months and 4-6 years of age. If the full series hasn’t been given, it is okay to complete it up until the 7th birthday with the DTaP.

If the child is over age 7, the Tdap should be given instead of the Dtap. These cover the same diseases, but the Dtap has a higher diphtheria component than the Tdap (as indicated by the capital letters).

The Tdap is the booster that is usually given at 11-12 years of age, but can be used as early as 7 years if the Dtap series was not completed or if there is a wound requiring a tetanus booster.

If additional doses are needed after one Tdap, Td boosters can be used to complete the primary series.

Tetanus boosters are recommended every 10 years and with each pregnancy. The Td vaccine is recommended for most of these boosters. Exceptions are that the Tdap  should be used during pregnancy and can be used if the Td is not available.

Polio

In the US, the standard polio vaccine schedule is 4 doses at 2, 4, 6-18 months and 4-6 years.

In other countries it is given soon after birth and there are additional doses. Even if a child has had more than 4 doses, if one was not given after the 4th birthday, an additional dose is needed.

Conversely, if the 3rd dose was given after the 4th birthday and 6 months or more after the previous dose, a 4th dose is not needed.

Typhoid

The typhoid vaccine is not on the standard US vaccine schedule. It’s recommended for many travelers and it might involve at-home compliance, so I decided to include it.

The injectable typhoid vaccine is recommended for 2 years of age and up and can be repeated every 2 years. Talk to your doctor to see where it is available, since they may or may not keep it in stock.

The oral typhoid vaccine is the one that can be complicated. It can be given to children over 6 years of age through adult years. It is boosted every 5 years. Even though it is a vaccine, it is given in pill form by mouth. It should be given on an empty stomach every other day for a total of 4 doses. The pills should be kept in the refrigerator, which can make them hard to remember. Because they are a live virus vaccine, they should not be taken with antibiotics. If antibiotics are required during the week of administration, the vaccine won’t be as effective and doses might need to be repeated. If there are forgotten doses, talk to your physician to be sure the series does not need to be repeated.

So… What happens if a vaccine booster is delayed?

Talk to your pediatrician (or the people where you get your vaccines) to make a plan to catch up on immunizations.

Good news! The CDC has a catch-up schedule that gives a timeline of when to give various vaccines if you’re off the typical schedule.

What happens if a vaccine booster is delayed
Source: https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf#page=3

There’s even a cool vaccine scheduler that you can use to estimate what vaccines your child needs.

Talk to your physician to help decide how to catch your family up on their vaccines.

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Measles Outbreaks: What can you do to protect your family?

Any area can be affected by measles. My county is in the middle of an measles outbreak right now. This is despite relatively high MMR vaccine rates above 95% for at least 1 MMR by 3 years of age. There are a lot of questions about measles outbreaks, so I thought I’d tackle a few. Like most pediatricians, I’ve never seen measles and I hope to not miss it if I do. We all need to be aware of its symptoms so we can recognize it when we see it!

What is measles?

Measles is a viral illness that includes fever, cough, fatigue, red eyes, and a characteristic rash. The rash spreads from head to trunk to lower extremities.

Measles rash PHIL 4497 lores
Source: https://commons.wikimedia.org/wiki/File%3AMeasles_rash_PHIL_4497_lores.jpg

RougeoleDP
Source: https://commons.wikimedia.org/wiki/File%3ARougeoleDP.jpg
Measles is usually a mild or moderately severe illness. It can lead to pneumonia, encephalitis, and even death (risk of 2-3 per 1000).

One rare complication of measles infection that occurs many years after the illness appears to resolve is subacute sclerosing panencephalitis (SSPE). It is a fatal disease of the central nervous system that usually develops 7–10 years after infection.

 

 

 

Koplik spots, measles 6111 lores
Source: https://commons.wikimedia.org/wiki/File%3AKoplik_spots%2C_measles_6111_lores.jpg
Koplik spots are a specific rash seen in the inner cheek. Koplik spots are visible from 1 – 2 days before the measles rash and disappears to 1 – 2 days later. They look like white spots with a blue center on the bright red background of the cheek. They can easily be missed because they are not present for long, but if seen are classic for measles.

What is the timeline of symptoms after exposure?

Measles is highly infectious. It is primarily transmitted by large respiratory droplets in the air, so handwashing doesn’t help prevent exposure.

An area remains at risk for up to 2 hours after a person with measles was there. This is why it is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician. DO NOT go to a walk in clinic or your doctor’s office unannounced. You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

More than 90% of susceptible people develop measles when they’re exposed.

The average incubation period for measles is 11–12 days. It takes 7–21 days for the rash to show. It is due to this long time for the characteristic rash that susceptible people who were exposed are put in isolation for up to 21 days.

Most people are contagious from about 4 days before they show the rash until 4 days after the rash develops. If a person has measles and the rash resolves, they can leave isolation when cleared by their physician and/or the health department.

What is a measles outbreak?

Measles outbreaks are defined as 3 or more measles cases linked in time and space.

How do outbreaks start?

I know the big question on everyone’s mind during an outbreak is, “Where did it start?”

Often an unimmunized traveler brings the measles virus into the US. Countries in Europe, Africa, Asia, and the Pacific continue to have outbreaks. Travelers who visit those countries can return to the US and share the virus for a few days before symptoms are recognized. Anyone who was in the same area as an infected person for up to 2 hours after that person left the area could be exposed.

In case you’ve heard that vaccines can lead to outbreaks: that’s not the case. Measles shedding from the MMR does not cause disease.

What happens during an outbreak?

Measles Outbreaks: What can you do to protect your family?During an identified outbreak of any reportable infectious disease, the health department directs what to do. They attempt to identify and notify all people who are at risk.

Our current outbreak involves several infants from the same unnamed daycare in addition to people not associated with the daycare. I know many families are worried that their child was at that daycare. Families at that daycare will have been notified by the health department already. The health department will track all known contacts of those families.

Local health departments also will notify the public of known locations of potential contact with the virus. The above linked article lists the known locations that infected people visited during their contagious period.

Why are infants at risk?

Infants are at particular risk because they are not typically vaccinated against measles until 1 year of age.

When the virus is in a setting with infants, such as a daycare, it can easily spread.

Infants under 2 years of age who are infected also tend to have more complications from the disease than older children and adults. This is one of the biggest reasons to not wait until 2 years to start immunizations, as some anti-vaccine groups suggest.

If you think you were exposed to or have symptoms of measles

It is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician.

DO NOT go to a walk in clinic or your doctor’s office unannounced.

You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

Do not go to the pharmacy to pick up medications. Don’t go to the grocery store for food.

Do not leave your home unless it is to a medical facility that knows you’re coming and is prepared.

(Yes, I know I repeated myself for much of this section, but it’s that important!)

The MMR vaccine can help stop the spread

The MMR vaccine is recommended routinely at 12-15 months and again at 4-6 years of age. Vaccines not only help the vaccinated, but provide herd immunity to those too young to be immunized and to those who are immunocompromised.

Please be sure your family is up to date on all their vaccines. All children over 1 year of age should have at least 1 MMR vaccine. All school aged children and adults should have 2 MMRs. By vaccinating your family, you not only protect them, but also those around you!

Why is a second dose given?

The second dose is used to provide immunity to the approximately 5% of people who did not develop immunity with the first dose. It is not a booster because it doesn’t boost the effect of the first dose.

The second MMR helps some people develop immunity if the first vaccine did not work effectively.

This second dose can be given as early as 28 days after the first.

Why don’t we start the vaccine series earlier?

Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.

Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.

Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.

If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.

By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.

Sometimes we do vaccinate earlier

If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection.

Many parts of the world have high measles rates so fit into this recommendation. When infants between 6 and 12 months travel internationally, they should receive one dose of MMR vaccine prior to travel.

Sometimes during US outbreaks it is recommended to vaccinate infants 6-12 months. The local health department helps to determine which infants should be immunized in this situation.

If the maternal antibody levels are still high in the infant, the vaccine won’t work. In this situation the baby should still be protected against the disease from mom’s antibodies. That is why this early vaccine does not “count” toward the two needed after the first birthday.

At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.

The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.

What if someone who hasn’t been vaccinated is exposed?

measles outbreaks, what can you do to protect your family
Source: http://www.immunize.org/photos/measles-photos.asp

The MMR vaccine may be effective if given within the first 3 days (72 hours) after exposure to measles. This is why the local health department is so aggressive in identifying cases during an outbreak.

Immune globulin (IGIM, a type of immunity that doesn’t require a person to make their own immunity) may be effective for as long as 6 days after exposure. IGIM should be given to all infants younger than 6-12 months who have been exposed to measles. The MMR vaccine can be given instead of IGIM to infants age 6 through 11 months, if it can be given within 72 hours of exposure.

Are boosters of the MMR needed?

are mmr boosters needed
From my practice Facebook page. Note: In this reply I was going off of my experience many years ago. At that time the advice was only 1 additional MMR, but my research for this blog shows otherwise!

Those of us who work in healthcare must have titers checked to verify immunity to many of the vaccine preventable diseases.

Healthcare workers come into contact with sick patients and patients with weak immune systems, so this is one way to help control disease spread.

From Immunize.org:
Adults with no evidence of immunity (defined as documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957) should get 1 dose of MMR unless the adult is in a high-risk group. High-risk people need 2 doses and include healthcare personnel, international travelers, students at post-high school educational institutions, people exposed to measles in an outbreak setting, and those previously vaccinated with killed measles vaccine or with an unknown type of measles vaccine during 1963 through 1967.

Most people don’t know their immune status, and it’s not recommended at this time to check it for the general population.

During an outbreak exposed people might be asked to be tested to help identify risk factors and track disease patterns.

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Common risks from shots: real and perceived

Parents want to keep their kids as healthy as possible, but with the overwhelming amount of information found on media these days, it’s hard to know what is safe and what risks really are when it comes to vaccines. What are the common risks from shots?

Nothing we do is without risk.

risks from vaccines
There are many unfounded fears about vaccines. What are the real risks?

The most risky thing most of us do daily is to get in a car and drive somewhere.

We can minimize the risk by wearing a seatbelt and putting our kids in the proper sized car seat, obeying the traffic laws, and adjusting our driving to the road and weather conditions, but there is always the chance of an accident.

For most of us, the risk of an accident is outweighed by the benefits of getting to where you need to go.

 

Some people want you to think we give kids green toxin-laden vaccines from huge syringes (at least if you look at the photos like I show above). But no, vaccines don’t look green, and we don’t inject them like most stock photos show.

Vaccines have risks, but more benefits.

The benefits are many, including preventing early death from infection. The risks are often overblown, but do exist.

What about package inserts?

You might have read somewhere that you should read the package insert of vaccines before allowing your child to get a vaccine, like there’s some big secret everyone’s trying to hide.

No one’s hiding anything. They’re available online.

The problem isn’t hidden information, it’s people mistaking what is written for something that it’s not.

The package insert has a lot of information, but it’s designed for legal reasons, not consumer information sharing.

Some groups who try to warn people about vaccines encourage the reading of package inserts to learn risks of the vaccines.

This can lead to undue fear and confusion because not all problems recorded in the adverse reactions section of the package insert are due to the vaccine.

If someone fell out of a tree and broke his leg after a vaccine and reported it during vaccine trials, “broken leg” could be listed as a reaction. It does not mean that the vaccine broke the leg or caused the broken leg in any way, but it is reported in a way that can make it look like there is a cause and effect relationship.

More realistically, it is common for people to have headaches or congestion, so these types of things get reported for most medicines in their package inserts. It does not mean the medicine caused the headache or congestion, just that people had those symptoms during the study period.

For a more detailed description of package inserts, see Package Inserts – Understanding What They Do (and Don’t) Say.

Common Risks from shots that are known

The risks of all vaccines are similar. Specific risks can be found on the Vaccine Information Sheets, which are designed to educate consumers about risks and benefits.
These risks include:
Pain with injection

This is very subjective.

Most babies cry, but typically as soon as they are cuddled by a parent they quickly calm down.

Toddlers are more prone to longer crying times, but that often starts unrelated to the vaccine and is not solely due to pain. It’s often due to their frustration and/or fear of being in the doctor’s office.

Older kids often will say the pain was less than they feared, but some do complain for several minutes. Moving the arms or legs that were injected can help ease this pain.

You can do many things to help kids tolerate the shots with less pain.

Fever

A mild fever can occur for a day or two after many vaccines.

Most kids do not need any fever reducers for this. The fever reducers might even reduce some of the effectiveness of the vaccine, so are not routinely recommended after vaccines.

If the temperature is over 102F or the child is very fussy with the fever, it is okay to use a fever reducer. These higher fevers are not common after vaccines, but are possible.

Fussiness or feeling mildly ill

Infants can be fussy for a few days and older kids might say they feel tired or have a headache.

Some kids (and adults) will feel like they’re getting sick, but it never evolves into an illness and it stays mild.

Extra sleep would be beneficial, but typically no treatment is needed.

Non-stop crying

While unusual, it is possible that an infant will cry for hours after one or more vaccines.

If this occurs, you can try a pain reliever.

If the crying doesn’t stop, have your child examined to identify if something significant is causing the crying.

Seizure

It is not common to have a seizure after a vaccine, but whenever a child under 5-6 years of age has a fever, it’s possible to have a fever seizure.

Most fever seizures are from viral illnesses, some of which are prevented by vaccines.

Vaccines rarely cause fever seizures, but if the temperature increases rapidly after a vaccine in a susceptible child, it’s possible.

If a child has a fever seizure, it is scary to watch but does not lead to permanent brain damage.

Interestingly, studies show that delaying the MMR past 15 months increases the risk of seizures.

Any child who has a first time seizure should be evaluated for potential causes and treatments.

Pain, tenderness and swelling
vaccine side effect redness
This is my arm 2 days after a Tdap. The area was swollen, warm and red. The redness has irregular borders, looking lacy in appearance, which is common in shot reactions. I didn’t need any pain relievers. The muscle was sore from the tetanus, but the redness wasn’t uncomfortable.

Some vaccines, such as DTaP and Tdap, are more prone to swelling and redness than others.

The most swelling tends to happen after several doses of these vaccines, such as with kindergarteners, tweens, or adults.

My son’s arm was so swollen after kindergarten shots that he couldn’t fit into some of his shirts with narrow sleeves, but it was a normal shot reaction.

With a shot reaction the inflammation begins a few hours after vaccination, peaks 24 to 48 hours afterward and resolves within one week.

Tenderness is usually at its worst during the first few hours and resolves as the reaction enlarges.

The amount of swelling and redness is more significant than pain or tenderness with a classical vaccine reaction.

Infection of the injection site

Very rarely the area can become infected (cellulitis) but this is exceedingly rare now that most childhood vaccines come in single dose syringes.

Cellulitis can evolve rapidly — often within 12 to 24 hours.

Diagnosis is based on the symptoms of redness, pain, swelling and warmth, usually with fever and ill appearance.

Most redness and swelling is a normal shot reaction and not a sign of infection. If your child seems ill along with a painful red and swollen area where the vaccine was injected, it might be wise to have your doctor take a look at it.

Risk vs Benefit

The risks above must be weighed against the benefits of vaccinating.

In my family, we vaccinate against all recommended vaccine preventable diseases by following the standard schedule.

I advise that most people do the same. There are those who cannot receive vaccines due to age or health status, and they depend on us all to vaccinate.



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The flu shot doesn’t work

I’ve seen a few kids this season who have influenza despite the fact that they had the vaccine. When the family hears that the flu test is positive (or that symptoms are consistent with influenza and testing isn’t done), they often say they won’t do the flu shot again because it didn’t work.

flu shot ineffectiveHow do they know it isn’t working?

Influenza can be deadly.

Most of the kids I’ve seen with flu who have had the shot aren’t that sick. Yes, they have a fever and cough. They aren’t well.

But they’re not in the hospital.

They’re not dying.

They tend to get better faster than those who have unvaccinated influenza.

Some kids still get very sick with influenza despite the vaccine.

That’s why there’s surveillance to see how it’s working.

When FluMist was determined to not be effective, it was removed from the market.

Studies are underway to make a new type of flu vaccine that should be more effective.

We know the shot isn’t perfect, but it’s better than nothing.

Maybe if you weren’t vaccinated you’d be a lot sicker.

Maybe you were exposed to another strain of flu and didn’t get sick at all.

I think it’s still worth it to get vaccinated each year (until they come up with a vaccine that lasts several seasons).

If everyone who’s eligible gets vaccinated against the flu, herd immunity kicks in and it doesn’t spread as easily. Historically only around 40% of people are vaccinated each year against influenza. We know that to get herd immunity we need much higher numbers.

Shot fears…

If your kids are scared of shots, check out Vaccines Don’t Have to Hurt As Much As Some Fear.

Don’t rely on Tamiflu to treat flu symptoms once you’ve gotten sick.

Tamiflu really isn’t that great of a treatment. It hasn’t been shown to decrease hospitalization or complication rates. It shortens the course by about a day. It has side effects and can be expensive. During flu outbreaks it can be hard to find.

Prevention’s the best medicine.

Learn 12 TIMELY TIPS FOR COLD AND FLU VIRUS PREVENTION.

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It’s not the flu!

I was at the gym today and an otherwise great instructor who seems to know a lot about health was sharing incorrect information about the flu with the class of about 40 people. She said that she had received several texts from other instructors asking her to cover their classes because they were vomiting. Then she went on to say that many at first thought it was food poisoning, but it’s spreading like illness, so it’s the flu, not food poisoning. She made a big deal that the flu is here. Is vomiting from the flu?

She’s only partially right.

Yes…

There’s a stomach bug going around.

It’s not food poisoning.

Influenza is in town.

But this extreme vomiting is not “the flu”

vomiting from the flu
Vomiting can be associated with influenza, but is not the main symptom.

The flu causes predominantly fever, cough, sore throat, and body aches for many days. It can cause vomiting and diarrhea, but those aren’t usually the predominant symptoms. And the flu doesn’t cause just a few hours of extreme vomiting like we’re seeing these days.

Why do I care if people call this stomach bug “flu”?

Runny nose is one of the symptoms of influenza.

The biggest reason I care is that it leads people to make other incorrect assumptions and to get the wrong treatments.

I hear all the time that people had the flu the year they got a flu shot, so they don’t want to get it anymore.

When probed about their illness, it’s usually not consistent with the flu. It was either a cold and cough or a stomach virus.

If they think a common cold or vomiting is from the flu, they’re mistaken.

They need to know that this isn’t the flu.
Cough is one of the most common symptoms of influenza, along with fever, sore throat, and body aches.

Common colds and vomiting are not prevented with the flu shot.

The flu shot has nothing to do with protecting against most cases of vomiting and diarrhea or most upper respiratory tract infections.

Of course there are people who got the flu shot (or FluMist when it was available) who did come down with the flu. They had a positive flu test and symptoms were consistent with the flu. But if they get influenza after the vaccine they tend to have milder symptoms. They tend to not end up in the hospital or dead if they’ve had the vaccine. Yes, even healthy young people can end up very sick from influenza. They can even die. (The FluMist didn’t protect well and was removed from the market due to this.)

We forget about all the times people did get the vaccine and they didn’t catch the flu even with likely exposure. Lack of disease is easy to fail to acknowledge.

We know the flu vaccine is imperfect. But if the majority of people get vaccinated, we can slow the rate of spread and protect us all against influenza most effectively.

We don’t have great treatments for influenza, so vaccinating and using other precautions is important!

7 Vitamin K Myths Busted

Social media has allowed the sharing of misinformation about many things, especially medically related things. When the specifics of something are unknown to a person, pretty much anything that’s said can sound reasonable, so people believe what they hear. This happens with many things, such as vaccine risks, chelation, and vitamin K. I want to tackle 7 Vitamin K Myths.

Refusing Vitamin K

I am especially frustrated when parents refuse to give their newborns vitamin K after birth. Since 1961, the American Academy of Pediatrics has recommended giving every newborn a single shot of vitamin K given at birth. This is a life saving treatment to prevent bleeding.

Life.

Saving.

Life saving.

Vitamin K works to help our blood clot. Insufficient levels can lead to bleeding in the brain or other vital organs. Vitamin K deficiency bleeding or VKDB, can occur any time in the first 6 months of life. There are three types of VKDB, based on the age of the baby when the bleeding problems start: early, classical and late. Unfortunately there are usually no warning signs that a baby will have significant bleeding, so when the bleeding happens, it’s too late to do anything about it. Why parents don’t want to give this preventative life saving treatment is usually based on incorrect information.

This is a matter of a fairly low risk of bleeding if you don’t give vitamin K: 250-1700 per 100,000 within the first week, and 4-7 per 100,000 between 2 and 12 weeks. You might notice that the number is variable – it’s hard to study since the large majority of babies have gotten vitamin K over the years and the risk is low even without vitamin K. However, when there is bleeding it has significant consequences: lifelong disability or death. And we also know that there’s very low risk from the vitamin K and it works very well to prevent bleeding. So why take the chance of not giving it?

Conspiracy Theories, Misunderstandings, and Science

This is not a governmental conspiracy to somehow kill children. It’s a world wide attempt to help children survive and thrive.

The World Health Organization (WHO) guidelines:

All newborns should be given 1 mg of vitamin K intramuscularly [IM] after birth [after the first hour during which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated]. (Strong recommendation, moderate quality evidence)

Science is hard to understand

Most people look at scientific information and can’t make heads or tails of what it means.

Photo Source: Hemorrhagic Disease of the Newborn

That coupled with the fact that things we read that make us react emotionally (such as fear that something will harm our child) makes us remember and associate with the information that created the emotion, whether it is right or wrong. This can lead parents to make dangerous decisions for their children while trying to do the right thing.

Myth Busting

I’m going to attempt to de-bunk the most common concerns I’ve heard because the best way to combat misinformation is to help explain the facts as we know them.

1. If every baby’s born with too little vitamin K, that’s the way we’re supposed to be.

Babies are born with very little vitamin K in their body. If they don’t get it with a shot, they need to either eat it or make it. Breast milk has very little vitamin K and babies won’t be eating leafy greens for quite awhile. Formula does have it, but it takes several days for vitamin K to rise to protective levels with formula and the highest risk of bleeding is during that first week of life. (Of course if you’re using this argument because you want babies to be all natural, you probably won’t be giving formula at this point.)

Bacteria help us make vitamin K, but babies aren’t colonized at birth with these gut bacteria.

Just because they’re born that way doesn’t mean they’re supposed to stay that way. Inside the mother the baby is in a very different situation. They don’t breathe air. A fetus doesn’t eat. They don’t have gut bacteria. Their heart has a bypass tract to avoid pumping blood to the lungs. This all works well in utero, but must change once they leave the womb. Change takes time, and during this time they are at risk. Why not minimize the risk if we know a safe way to do it?

2. The package insert has a big warning at the top that it can kill.

There are many reasons why we should not use the package insert of a medicine or vaccine to make healthcare decisions. These have been discussed before so I won’t go into all the details but please see these great blogs on how to read and use package inserts:

It is true that there is a black box warning on the top of the vitamin K package insert. This has scared some parents from wanting to get the vitamin K shot for their newborn.

Screen Shot from Package Insert 

Reactions to IV (intravenous) vitamin K are much more common than IM (intramuscular) injections. The difference is anything given by IV goes directly into the bloodstream and back to the heart. But we don’t give vitamin K by IV to newborns.

IM injections go into the muscle, allowing very slow absorption of the medicine. This not only decreases reactions to the injected vitamin, but also helps the level of vitamin K stay elevated for a prolonged time after a single injection.

I only found one report of a newborn with a significant reaction to vitamin K. The authors of the paper did note that IM vitamin K has been given for many years to babies all over the world without significant reactions and could not explain why the one infant had such a significant reaction.

Since we must always look at risk vs benefit, the very, very low risk of a serious reaction from receiving vitamin K IM is preferable to the benefit of the prevention of VKDB.

Another great resource on this topic is Dr. Vincent Iannelli’s That Black Box Warning on Vitamin K Shots. He doesn’t want you to skip the Vitamin K shot either.

3. Vitamin K causes cancer.

Many years ago there was a small study that suggested vitamin K led to childhood cancers. This issue has been extensively studied since then and no link has been found.

Vitamin K does not cause cancer.

Rates of cancer have not increased in the years since vitamin K has been given to the large majority of newborns worldwide. This is reported in the Vitamin K Ad Hoc Task Force of the American Academy of Pediatrics report Controversies Concerning Vitamin K and the Newborn.

4. Bleeding from vitamin K deficiency is rare or mild.

In the US bleeding from vitamin K deficiency is rare because most babies get the vitamin K shot soon after birth. In countries where vitamin K is not used routinely, bleeding is not rare at all. Some communities of the US where vitamin K is being refused by parents are seeing an increase in newborn bleeding.

Early VKDB occurs within 24 hours of birth and is almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include anticonvulsants, anti-tuberculosis drugs, some antibiotics (cephalosporins) and blood thinners to prevent clots. Early VKDB is typically severe bleeding in the brain or gut.

Classic VKDB typically occurs during the first week of life. The incidence of classic VKDB ranges from 0.25-1.7 cases per 100 births.

Late onset VKDB occurs between 2 and 12 weeks usually, but is possible up to 6 months after birth. Late VKDB has fallen from 4.4-7.2 cases per 100,000 births to 1.4-6.4 cases per 100,000 births in reports from Asia and Europe after routine prophylaxis was started.

One out of five babies with VKDB dies.

Of the infants who have late VKDB, about half have bleeding into their brains, which can lead to permanent brain damage if they survive. Others bleed in their stomach or intestines, or other vital organs. Many need blood transfusions or surgeries to help correct the problems from the bleeding.

5. It’s just as good to use oral vitamin K.

Early onset VKDB is prevented well with the oral vitamin K in countries that have oral vitamin K available, but late onset VKDB is an issue.

Children with liver or gall bladder problems will not absorb oral vitamin K well. These problems might be undiagnosed early in life, putting these kids at risk for VKDB if they are on an oral vitamin K regimen.

Getting the oral form isn’t easy

There is no liquid form of vitamin K that is proven to be effective for babies in the US.

That is a huge issue.

Some families will order vitamin K online, but it’s not guaranteed to be safe or even what it claims to be. This is an unregulated industry. It is possible to use the vitamin K solution that is typically given intramuscularly by mouth, but this requires a prescription and the taste is questionable, so baby might not take the full dose.

It would be an off-label use so physicians might not feel comfortable writing a prescription. The other issue that might worry physicians is with compliance in remembering to give the oral vitamin K as directed, since most studies include babies with late onset bleeding who had missed doses.

Vitamin K in food

Most of us get vitamin K from gut bacteria and eating leafy green vegetables.

Newborns don’t have the gut bacteria established yet so they won’t make any vitamin K themselves. They may get vitamin K through their diet, but breastmilk is very low in vitamin K. Unless baby is getting formula, they will not get enough vitamin K without a supplement.

It is possible for mothers who breastfeed to increase their vitamin K intake to increase the amount in breast milk, but not to sufficient levels to protect the baby without additional vitamin K.

What do other countries do?

Many countries that have used an oral vitamin K protocol, such as Denmark and Holland, have changed to an intramuscular regimen because the oral vitamin K that was previously used became no longer available.

There are various oral vitamin K dosing strategies that can be reviewed in the linked abstract.

  •  Australia and Germany: 3 oral doses of 1 mg vitamin K are less effective than a single IM vitamin K dose. (In 1994 Australia changed to a single IM dose and their rate went to zero after the change.)
  • Netherlands: A 1mg oral dose after birth followed by a daily oral dose of 25 mcg vitamin K1 may be as effective as parenteral vitamin K prophylaxis.
  • Sweden: (a later study) 2 mg of mixed micellar VK given orally at birth, 4 days, and 1 month has a failure rate of one case of early and four cases of late VKDB out of 458,184 babies. Of the failures, 4 had an undiagnosed liver issue, one baby’s parents forgot the last dose.
Oral Vitamin K vs injectable (IM) Vitamin K

When vitamin K is given IM, the chance of late VKDB is near zero.

Oral vitamin K simply doesn’t prevent both early and late bleeding as well. This is especially true if there is an unknown malabsorption disorder, regardless of which dosing regimen is used.

6. My baby’s birth was not traumatic, so he doesn’t need the vitamin K.

Birth trauma can certainly lead to bleeding, but the absence of trauma does not exclude it.

Late vitamin K deficient bleeding (VKDB) cannot be explained by any birth traumas since they can occur months later.

7. We’re delaying cord clamping to help prevent anemia and bleeding. Isn’t that enough?

Delayed cord clamping can have benefits, but decreasing the risk of bleeding is not one of them.

There is very little vitamin K in the placenta or newborn. Delaying the cord clamping cannot allow more vitamin K into the baby.

Still not convinced?

Read stories about babies whose parents chose to not give vitamin K:

For More Information:

Evidence on: The Vitamin K Shot in Newborns (Evidenced Based Birth)