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:

 

 

 

All About Ear Infections – Prevention

Ear infections are all too common and cause a lot of distress for kids and their families. What can we do to help prevent them from happening?

This is part 3 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

What can be done to prevent ear infections?

Avoid all smoke exposure.

Tobacco smoke is known to predispose children to ear infections, upper respiratory infections and wheezing.

Do not bottle prop.

Keeping a baby’s head elevated a bit while bottle feeding can help prevent ear infections.

Breastfeed.

Breast milk is protective against many types of infection, including ear infections.

General infection prevention.

Avoid taking your infant to places where there are a lot of people during sick season.

Wash hands often. Teach kids to really wash their hands. Because they don’t do a great job much of the time.

Attempt to limit sharing of toys that young children mouth, and wash them between children.

If your child attends daycare, try to find one where there are fewer children per room.

Vaccinate.

One of the biggest causes of bacterial ear infections is pneumococcus. Your child will be vaccinated against this as part of the standard vaccine schedule.

Saline.

If you know me, you know I often recommend saline to the nose.

Saline drops for babies followed by suctioning.

Nasal saline rinses for kids over 2 years of age. (Nasopure has a great library to teach proper use and even videos to get kids used to the idea.)

Saline is a great way to clear the mucus from our nose, which can help prevent cough, sinus infections, and ear infections.

Keep the pacifier in the crib.

When kids play, they often drop their pacifier, which can encourage germs to accumulate on it before they put it back in their mouth.

Xylitol.

There are several studies that suggest chewing gum with xylitol as its sweetener helps prevent ear infections in children who can chew gum. For younger infants, there are nose sprays with xylitol. Xylitol is a naturally occurring substance that is used as a sweetener is many products, many of which are reviewed here. I do not endorse any of these, but do find this a helpful resource.

Treat acid reflux.

This can include dietary changes, positional changes, or medications. Talk to your doctor to see which is right for your child.

Treat allergies.

Treating allergies can help decrease mucus production and improve drainage.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines
Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age

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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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Help! I’m sick and I have a baby at home.

When we have newborns we don’t want them exposed to germs. We avoid large crowds, especially during the sick season. We won’t let anyone who hasn’t washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.

infection precautionsBut what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?

In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.

Wash

Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting.

Wash Baby’s hands after diaper changes too. Make this a habit even when you’re not sick… you never know when you’re shedding those first germs!

Wipe down surfaces

Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect.

Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area.

Avoid touching your face

Avoid touching your eyes, nose and mouth – these are the “doors” germs use to get in and out of your body.

Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.

Kiss the top of the head

Resist kissing Baby on the face, hands, and feet.

I know they’re cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too.

Cover your cough

I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs.

When you’re responsible for a baby, the baby’s head is often in your elbow, so I don’t recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren’t available.

Vaccinate

If you’re vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you’re less likely to bring those germs home. Encourage everyone around your baby to be vaccinated.

If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity.

See Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick? by Jody Segrave-Daly, RN, MS, IBCLC to better understand passive immunity.

Breastfeed

Breastfeed or give expressed breast milk if possible.

Mothers frequently fear that breastfeeding while sick isn’t good for Baby. The opposite is true – it’s very helpful to pass on fighter cells against the germs!

Again see Jody Segrave-Daly’s blog for wonderful explanation of how breast milk protects our babies.

Limit contact as much as possible

If possible, keep Baby in a separate area away from sick family members.

Wash hands after leaving the area of sick people.

If the primary caretaker is sick and there is no one available to help, wear a mask and wash hands after touching anything that might be contaminated.

Smoke-free

Insist on a smoke-free home and car.

Even if someone is smoking (or vaping) in another room or at another time, Baby can be exposed to the airborne particles that irritate airways and increase mucus production.

These toxic particles remain in a room or car long after smoking has stopped. If you must smoke or vape, go outdoors.

Change your shirt (or remove a coat) and wash your hands before holding Baby.

Final thoughts to avoid exposing Baby

It’s never easy being sick, and being a parent adds to the level of difficulty because you not only have to care for yourself, but someone else depends on you too.

As with everything, you must take care of yourself before you can help others.

Drink plenty of water and get rest!

Most of the time medicines don’t help us get better, since there aren’t great medicines for the common cold. Talk to your doctor to see if you might need anything.

Don’t be falsely reassured that you aren’t contagious if you’re on an antibiotic for a cough or cold. If you have a virus (which causes most cough and colds) the antibiotic does nothing.

You need to be vigilant against sharing the germs!

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