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Wellness tips from Dr. Mays

Informed Consent: Pneumoncoccal conjugate

Pneumococcal Conjugate Vaccine (PCV13)

What is this disease?

Pneumococcal disease is an infection by Streptococcus pneumoniae bacteria, aka “pneumococcus”. Although the name of this bacteria suggests that is the cause of pneumonia, pneumonia can be caused by many different things. S. pneumoniae is the most common cause of bacterial pneumonia. The most common cause of pneumonia in children under 5 years is viral; viral pneumonia cannot be treated with antibiotics and this vaccine does not prevent it. Viral pneumonia is typically mild. Many people (up to 90%) are carriers of S. pneumoniae and are not infected by the bacteria. Most infections of this bacteria are mild that may prompt the child to see a doctor if a fever is involved. This bacteria has been known to cause ear infections (about half of cases), sinus infections, pneumonia, meningitis, and blood infections.

This bacteria is spread through respiratory fluids, although it is uncommon for someone to contract an infection from an infected individual. This disease seems to be more prevalent in the winter and early spring. Children that are more susceptible to S. pneumoniae infection include those that are: missing spleen function, immunocompromised, in childcare and under the age of 2, have cochlear implants, and from these groups-Alaska Native, African American, American Indian (Navajo and White Mountain Apache).

Statistics

In the US, 90% of serious cases, and >95% of the deadly S. pneumoniae infection are in adults.

Annual Burden of Pneumococcal Disease in in US Children*

Syndrome Cases
Bacteremia 13,000
Meningitis 700
Death 200 cases
Otitis media 5,000,000 cases

*Prior to routine use of pneumococcal conjugate vaccine

The first vaccine for S. pneumoniae in US was cleared in 1977. The first conjugate vaccine in the US was in 2000, PCV7. The current vaccine PCV13 was cleared by the FDA in 2010, it vaccinates against 13 types rather than 7 but is otherwise the very much the same vaccine. The blue bars in the graph below are for invasive infections from all strains of the bacteria, the gray bars are those covered by the PCV13 vaccine.

In 2000, there were 14.5 million pneumococcal cases worldwide, in children under 5 years. 735,000 of those were fatal. The following maps depict the distribution of these cases.

How do you treat this disease?

Most mild cases will resolve without treatment. If infection with S. pneumoniae is suspected as sample will be taken to confirm infection. Treatment will be initiated with antibiotics once the infection is diagnosed from the sample, usually these will be taken by mouth and care is in the home. Antibiotic resistance is present in 3/10 of S. pneumoniae strains and specific antibiotics will be able to be chosen to fight these tougher infections from a sample. Antibiotic resistance is a serious problem we are facing today. Always finish a course of antibiotics prescribed to you. Do not pressure a physician to prescribe antibiotics as they are not appropriate for all infections, including viral infections.

Preventative measures include breastfeeding for up to two years of age, keeping your child out of big daycare centers, good hygiene & health habits, and avoiding smoking in the home.

How effective is this vaccine?

A large clinical trial comparing vaccinated and unvaccinated children showed that PCV7 reduced invasive infection by 97%, pneumonia by 20%, and ear infections by 7%. See the above bar graph.

Side-effects of vaccine

Children that have reacted to prior doses of this vaccine or the DTaP vaccine should not receive this vaccine. (Diphtheria toxoid is part of this vaccine.) If your child is ill, you should reschedule any vaccination appointment.

Adverse reactions to the conjugate vaccine: apnea (more common in premature infants), hypersensitivity reaction including facial edema, dyspnea, bronchospasm, anaphylactic/anaphylactoid reaction including shock, angioneurotic edema, erythema multiforme, injection-site dermatitis, injection-site pruritus, injection-site urticaria, and lymphadenopathy localized to the region of the injection site. These severe reactions occur at a rate of 8%.

In general, reactions tend to be more intense with subsequent boosters of the injection. Local reactions occur in up to half of children (e.g. swelling, redness, tenderness). Fever and body aches occur in a quarter to a third of children. Decreased appetite and/or irritability occur in 80% of children. Febrile seizures occur in up to 14% of children with this vaccine alone; however, in combination with the flu vaccine this increases to nearly 50%. (I am in general making no recommendations for/against vaccination in these blog posts as they are only intended for educational, informed consent purposes. However, given this data, if you choose to vaccinate your child against S. pneumoniae AND influenza my recommendation is to not have these vaccines administered to your child on the same visit).

Vaccine injuries listed by the National Vaccine Injury Compensation Program include: shoulder injury and fainting. To date (current July 2017), 7 cases have been compensated in vaccine injury court.

Vaccine Schedule

Standard US schedule is: 2 months, 4 months, 6 months, and 12-15 months.

Canadian schedules are by province/territory, most are 2, 4, and 12 months; some have the last dose at 18 months, and two have a 4 dose schedule much like the US.

Alternative schedules place this vaccine in a separate month as other aluminum containing vaccines and therefore recommend it be given at 3, 5, 7, and 12-15 months.

As with any decision to give your child a drug, you should read the insert to this vaccine before having it administered. There is only one version of this vaccine, Prevnar 13, made by Wyeth/Pfizer. You can find it before your appointment with a simple internet search. Do not give your child Tylenol before this vaccine as it can decrease the antibody response, which is the primary measure of effectiveness to vaccines.

References:

CDC Website

Mayo Clinic Website

National Vaccine Injury Compensation Data accessed 7/17/17.

Pediatrician websites (alternative schedule data only)

Prevnar 13 Insert, FDA website

Public Health Agency of Canada

WHO Website

Informed Consent: HIB

Haemophilus influenzae type b (Hib)

What is this disease?

Haemophilus influenzae is a bacteria. There are several types (a-f) and many untypable varieties. These bacteria have been found in the microbiome of humans. They can be benign or cause infection. Infection occurs almost exclusively in children under the age of 5 (85% of infections). It is a spread from respiratory tracts of infected people coughing or sneezing near susceptible people which then breathe in the bacteria. The bacteria does not survive in the environment. Peaks of the disease are September-December and again in March-May.

Infections include mild ear infections right up to serious infections called ‘invasive infections’. The most common non-invasive infections are ear infections and bronchitis.

An invasive infection is one that is in an area that is in an area where bacteria should not exist in your body such as your bloodstream, pleura (space around your lungs), or spinal cord. The most common invasive infections for Haemophilus influenzae are: pneumonia (lung; only invasive if infecting pleura or blood), bacteremia (blood), meningitis (brain & spinal cord), epiglotitis (throat), cellulitis (skin), and infectious arthritis (joint). Symptoms of the disease vary by organ that is infected. All will typically include fever.

Recurrent infections can occur in those under the age of 2. Those over 2 who have been exposed to Hib will likely develop immunity.

Morbidity & Mortality Stats

Fatal cases of Hib infection are at 3-6% in the United States. In 2015, the CDC estimates that the US had 1,600 cases of invasive infection in children under 5 years. In 2015, 1,015 deaths were attributed to Hib in children under the age of 5. Of note, these statistics are much better than the 2020 goal. Non-b and nontypable cases and deaths were higher than type-b in 2015. There were 23.9 million children in the US under the age of 5 in 2015.

Pre-vaccine incidence of Hib meningitis under the age of 5 in the majority of the US was approximately 50-60/100,000 per year, except in the southwest closer to 90/100,000 and in Alaska over 100/100,000. Pre-vaccination northern Canada, Alaska, and northern and central Australia had some of the highest rates worldwide. Pre-vaccination there was a 5% case fatality rate. Before vaccination (stats from 1985), it was estimated that there were 20,000 cases of invasive HIB infections in children 5 years and younger annually in the US. The U.S. population from 0-5 years in 1985 was 21.4 million children. Two-thirds of those children with invasive infections were meningitis cases. 15-30% of those meningitis cases had permanent effects from the infection and 4% of the cases were fatal. Other causes of bacterial meningitis in this age group include Group B Streptococcus, Streptococcus pneumoniae, Listeria monocytogenes, Escherichia coli, and Neisseria meningitidis. Vaccinations began in 1986 in the US. Vaccines at that time was a version known as the PRP which was shown in a trial in the 70s to have no efficacy in kids under 18 months.

Conjugate vaccines (which is used today) started in 1991. The conjugate vaccine job is to prevent nasopharyngeal Hib colonization. Before these vaccines, Hib could be isolated in 0.5-3.0% of all infants and children. Pre-conjugate vaccination it is estimated that there were 88 cases/100,000 children under 5 per year. Post-conjugate vaccination 1.6 cases/100,000 children under 5 per year.

How do you treat this disease?

Diagnosis is accomplished by testing the appropriate body fluid. It is treated with antibiotics, typically a 7-10 day course. Non-invasive cases may not require antibiotic treatment. Invasive infections are treated with antibiotics and typically require hospitalisation. Invasive infections can result in serious complications such as loss of limbs with blood infections and with meningitis loss of hearing and brain damage, even as severe as death. Successful treatment of meningitis leaves approximately 30% of children with some sort of permanent challenge, usually hearing loss.

Because fever is the only sign that is common in all of the invasive infections, here is a good review on how to manage fever. Most of the time fever (body temperature over 100.4 degrees Fahrenheit) is a healthy response that shows your child’s immune system is working properly to fight infection. Rectal thermometers are the best kind. Use these in smaller children. Use oral thermometers in older kids if rectal is not tolerated after they have not had anything to eat/drink for a while. Seek care if any of the following apply to your child:

  • Your child’s behavior changes dramatically, they have no interest in usual things such as food and play. In a baby they cry excessively and cannot be soothed.
  • Baby under 3 months rectal temperature is over 100.4 degrees Fahrenheit
  • Baby under 2 years with a fever lasting more than 24 hours
  • Child is over 2 and the fever lasts more than 3 days
  • Child of any age repeatedly spikes over 100.4 degrees Fahrenheit

Treat fevers in children at home with hydration, taking off their clothes/blankets, & giving them lukewarm baths. If any of the above apply, please call your healthcare provider.

How do you prevent meningitis infection?

The CDC recommends prevention by avoiding cigarette smoke, getting plenty of rest, and avoiding close contact with sick people in addition to the vaccination according to their standard schedule. They state on their site that the healthy lifestyle factors are especially important for young children, the elderly, those with weak immune systems, and those without a functioning spleen.

How do you prevent Hib invasive infections?

Current thinking is that a respiratory infection from a virus or a mycoplasma preceding the Hib infection may predispose a child to an invasive infection.

Breastfeeding is protective.

Pre-vaccination most children acquired immunity by age 5-6 from an asymptomatic infection of Hib.

How effective is this vaccine?

Since vaccination has been standard with the conjugate vaccine cases have dropped 99%. Clinical efficacy is stated to be 95-100%.

However, 36% of confirmed cases of invasive Hib infection in children aged 6 months-5 years, the child is fully vaccinated. The cause for this is unknown.

Side-effects and adverse events from of vaccine

Redness & swelling

Shoulder injury

Vasovagal syncope (fainting)

To date (6/26/17) 41 injury cases and 3 death cases have been filed with VAERS.

As always, before administering this or any vaccine to your child, please read the current insert of the particular version your child will be receiving. This can be obtained from the healthcare provider or the internet, different versions of the vaccine may be more appropriate for your child than others.

Different versions of this vaccine

PRP-T versions require 3 doses at 2, 4, and 6 months. These include: ActHIB, Pentacel, Hiberix, & MenHibrix

PRP-OMP versions require only 2 doses at 2 & 4 months. These include: PedvaxHIB & COMVAX.

Hib vaccines should never be given to a child under 6 weeks, a child who is currently ill, or a child who has had a reaction to a previous injection of Hib vaccine.

Boosters are also given at 12-15 months.

Alternative Schedules

Canadian schedule is 4 doses at 2, 4, 6, and 18 months.

In Europe 2-3 doses are given.

Alternative schedule A) 2,4,6,& 12 months with the ActHIB version recommended

Alternative schedule B) Aluminum-free version recommended at 3, 5, 7, & 15 months.

References:

  • CDC Website
  • Heikki Peltola. 2000. Worldwide Haemophilus influenzae Type b Disease at the Beginning of the 21st Century: Global Analysis of the Disease Burden 25 Years after the Use of the Polysaccharide Vaccine and a Decade after the Advent of Conjugates. Clin Microbiol Rev. 2000 Apr; 13(2): 302–317.
  • Hopkinsmedicine.org
  • Immunize.org
  • Pediatrician Websites for alternative schedule information.
  • Vaccine Injury Compensation data, accessed 6/26/17.
  • WHO website

Informed Consent: DTaP

In my efforts to help expedite your research on pediatric vaccines, here is one of the month 2 vaccines.

DTaP:  Diphtheria, Tetanus, & acellular Pertussis

Diphtheria

Diphtheria is a bacterial infection caused by Corynebacterium diphtheriae.  Once attached to the respiratory lining, the bacteria produces a toxin which kills healthy tissue.  This creates a gray buildup of dead tissue that create a pseudomembrane within 2-3 days that can block the throat or other passageways making breathing and/or swallowing difficult.  Toxin can also get into the bloodstream and cause problems with the heart, kidneys, and nerves.  Other symptoms include:  weakness, sore throat, fever, swollen glands.  Severe cases lead to coma, paralysis, and death.

Diphtheria is spread via the air (cough/sneeze) or contact (toy/clothes/wound).  It is typically spread in the winter and spring months.  Without treatment, the person is contagious for 2-6 weeks.  Risk factors for susceptibility to the disease are:  overcrowding, poor health, substandard living conditions, incomplete immunization, and immunocompromised people.  Infants are not typically susceptible to diphtheria as they care some immunity from in utero for 6-12 months, at which point this natural immunity wanes.  

Tetanus

Tetanus is a bacterial infection caused by Clostridium tetani.  The bacteria enters your body as a spore through a deep wound, incubation is 3-21 days (average of 10 days).  The wound can be a puncture wound, burn, etc.  This bacteria produces a toxin that bonds to your nerve endings and causes body wide muscle spasming.  The toxin cannot be removed from your nerve endings and you need to grow new ones which can take several months.  Complications of this disease are broken bones, pulmonary embolism, respiratory failure, and death.  

Tetanus is found in soil, dust, and manure and is not spread from person to person.  Although the bacteria is found world-wide, it is most prevalent in densely populated regions in hot, damp climates with soils rich in organic matter.  

Pertussis

Pertussis is a highly contagious bacterial infection caused by Bordetella pertussis.  The bacteria enters your body from contact with another person or respiratory droplets.  An infected person is contagious for about 2 weeks after the cough begins.  Even vaccinated people may be infected.  Incubation is 5 days to 3 weeks.  This bacteria produce a toxin that damages the cilia and cause airway swelling.  

This disease looks very similar to a cold.  In babies, the disease can cause apnea, or a pause in their breathing.  This disease can be serious in babies and 50% of those that catch it will need to be hospitalized.  After two weeks of infection that looks like a cold, the next 1-10 weeks are filled with terrible coughs that may be worse at night, make you have a ‘whooping’ inhale due empty lungs, vomiting and exhaustion are common after coughing fits.  After this stage, there is a 2-4 week ‘recovery’ stage where there is less severe coughing and the symptoms are cold-like again; during this final stage people may be more susceptible to other respiratory infections.  Primary natural immunity gained through infection lasts 4-20 years.

Statistics

Diphtheria

Before treatment and prevention methods were available, 50% of those infected died.  In 1921, there were 206,000 cases and 15,520 deaths.  Currently the case-fatality rate is 5-10%, up to 20% in those under 5 and over 40.  Between 2004-2015 there were thankfully only 2 cases in the US.  Worldwide, there were 4,778 cases in 2015.  Since 1980, there has been no greater than 5 cases in the US annually.  In recent times there have been outbreaks of the disease in eastern Europe and Russia.

Vaccination began in the 1920s in the US.

Tetanus

29 US reported cases 1996-2009.    Tetanus is more of a problem in undeveloped areas of the world.  

Vaccination began in the 1940s in the US.  

US Tetanus cases and deaths from 1900.

tetanus-incidence-1900-2009

US Tetanus cases and deaths from 1947 per million people.

tetanus-incidence

Pertussis

According to WHO, pertussis is a world-wide problem for infants, especially those in developing countries.  Worldwide,  they estimated 16 million cases in 2008, 95% were in developing countries.  In 2008, 195,000 children died from pertussis.  In 2008, 82% of world infants had 3 vaccinations for pertussis; the WHO goal is 90%.  WHO states that “Although vaccination can prevent pertussis in adolescents and adults, there is insufficient evidence to support the addition of vaccine boosters in these age groups for achieving the primary goal of reducing severe pertussis in infants.”

Pertussis incidence was on a steady decline from the time reporting was mandatory in 1922.  In recent times there has been an increase of pertussis in the US.  Globally, there has also been a modern increase in incidence.  The following figure illustrates this as well as when various versions of the vaccine were introduced.   In 2014, there were 32,971 cases reported in the US.

pertussis-1922-incidence

The following graph illustrates the modern increase by age group in the US.

pertussis-1990-incidence

How do you treat this disease?

Diphtheria

Even with treatment, diphtheria currently kills 3% of those that contract it.  This rate is higher in those under age 15.  Treatment typically involves ICU care and involves antitoxin and antibiotic treatments as well as possible removal of pseudomembrane blockages to the airways.  

Tetanus

There is no cure for this disease.  It is managed by injecting an anti-toxin which can block un-bonded toxin from binding to nerves.  Antitoxins were discovered in the late 1800s and used in World War I.  Antibiotics will be given to kill the bacteria.  Sedatives and other drugs are given to decrease the spasming.  Lengthy ICU stays are common and necessary to provide supportive care.

In 1984 there was a study in Bangladesh that utilized 1 gram of IV ascorbic acid (Vitamin C) in tetanus treatment, which was effective.  There have been no follow-up studies on this.

Prevention is possible by thorough cleaning of wounds and leaving deep wounds open to the air.  Tetanus thrives in an anaerobic environment.  Neonatal tetanus is possible if birth occurs in a dirty environment.  Neonatal tetanus is typically fatal.  

Pertussis

Pertussis can be treated with antibiotics, but if you have been infected for over 3 weeks, they will not be helpful as a normal immune system will have already eliminated the bacteria from your body.  Aside from following prescribed antibiotic directions, there are several things you can do to aid recovery:  avoid airborne irritants such as smoke, chemical fumes, and dust, use a cool mist vaporizer, hydration, and good sanitary practices.

If a child is hospitalized, they may be given antibiotics and/or IV fluids.  Keeping the airways clear and the child well-oxygenated is the key goal of hospital treatment.

How effective is this vaccine?

Since vaccination began in the 1920’s, diphtheria has significantly lessened the impact of the disease in the US and worldwide.  A case-control study (conducted in 1993) in Russia during an outbreak demonstrated that 3 or more doses of the vaccine were 97% (94.3%-98.4%) effective.  This same study showed 5-6 doses to be 99.0% (97.7%-99.6%) effective compared to unvaccinated children.  

To date, there have been no studies done on the effectiveness of the tetanus vaccination.  

The effectiveness of the pertussis vaccine is short-lived in most.  A recent Canadian study on the acellular vaccine shows that those that are up-to-date with the pertussis vaccination have an 80% (71-86%) effectiveness within one year.  From 1-3 years post vaccination (when up-to-date) the vaccine is 84% (77-89%) effective.  After that, effectiveness drops dramatically as time passes.  In those that are partially vaccinated, effectiveness is even lower.  

Contraindications, Complications & Side-effects of DTaP vaccine

The CDC recommends postponing vaccination if your child is ill until after they recover from a current infection.  

Children who have had a serious side effect or allergic reaction to a previous DTaP should not have another dose.  

Any child who suffered a brain or nervous system disease within a week of prior vaccination should not be given further DTaP.  

Special consideration should be taken before booster shots if with a previous DTaP injection, the child had a seizure, collapsed, cried non-stop for 3 hours, or had a fever over 105 degrees.  For those children, having a version without pertussis may be better.

Side effects of the DTaP vaccine include: fever (25% of kids), redness/swelling in injection site (25% of kids), soreness at injection site (25% of kids).  Swelling of entire extremity happens in later doses in 14% of kids.  Other problems:  fussiness (33% of kids) fatigue/anorexia (10% of kids), vomiting 2% of kids.  All of these problems are common and occur within 1-3 days of the shot.

Other, more uncommon though more serious problems:  seizures, 3 hours or more of constant crying, fever over 105 degrees, serious allergic reaction.  Rare, severe long-term problems that have been reported include long-term seizures, lowered consciousness, coma, and permanent brain damage.

You are encouraged to go to the FDA site and read the inserts for the DTaP vaccine your child will be receiving.  

Vaccine Injury Data:  October 3, 2016  

Data for DTaP only, not other versions or combination vaccines.  Please go to http://www.hrsa.gov/vaccinecompensation/data/index.html for current data on various vaccines.

Claims filed:  494

Deaths: 80

Compensation Awarded:  205

Of note:  to date, 39% of all compensated claims for vaccine injury were for versions of diphtheria, tetanus, and pertussis vaccines, including combination vaccines.

Adverse Reaction and reporting interval for VAERS:

  • Anaphylaxis or anaphylactic shock (7 days)
  • Brachial neuritis (28 days)
  • Encephalopathy or encephalitis (7 days)
  • Any acute complications or sequelae (including death) of above events (interval – not applicable)
  • Events described in manufacturer’s package insert as contraindications to additional doses of vaccine (interval – see package insert)

Different versions of this vaccine

There are 6 branded versions of this vaccine and one generic.  I will list the two that are actually DTaP here, the others add in other vaccines.  The generic does not protect against pertussis.  

Daptacel from Sanofi Pasteur.  This version contains less aluminum and formaldehyde than the Infanrix.

Infanrix from GlaxoSmithKline.  

I highly recommend you read the inserts of these on the CDC’s website when choosing the appropriate version for your child:  http://www.cdc.gov/vaccinesafety/vaccines/dtap-tdap-vaccine.html

Timing of vaccination

The US recommended schedule is 5 doses at:  2 months, 4 months, 6 months, 15-18 months, and 4-6 years.

The Canadian recommended timeline varies among provinces, and includes 6 doses.  They also use several different combo vaccines at different times.  Children in Canada are recommended to have their doses at 2, 4, & 6 months, 18 months, age 4-6, and in 7-11th grade.

Alternative schedules:  

2,4,& 6 months, 18 months, 4-6 years for DTap and then Tdap at age 10 with boosters every 5-10 years.

OR

2, 4, & 6 months, a Tetanus booster at age 7, and another Tetanus booster at age 17.

References:

Bisgard, KM, et al.  2000.  Diphtheria toxoid vaccine effectiveness:  a case-control study in Russia.  The journal of infectious diseases, 181:  S184-S187.

CDC

Clark, TA.  2014.  Changing pertussis epidemiology:  everything old is new again.  Journal of infectious diseases, 209:  978-981.

Jahan, K, et al.  1984.  Effect of ascorbic acid in the treatment of tetanus.  Bangladesh Medical Resource Council Bulletin, 10: 24-28.

Mayo Clinic

Medscape summary of Diphtheria, by Bruce Lo et. al.

Schwartz, K.L.  2016.  Effectiveness of pertussis vaccination and duration of immunity.  CMAJ, published online September 2016, early release.

WHO

Alternative schedule information from pediatrician websites.

Informed Consent: Rotavirus

There are several vaccinations recommended in the US schedule for 2 months of age.  This is one of them.

What is this disease?

Rotavirus is a viral infection of the GI tract.  It is the most common cause of severe gastroenteritis worldwide.  The disease involves vomiting and diarrhea, the biggest risk is dehydration.  The virus is stable in the environment (can last weeks to months if not disinfected) and is transmitted by the oral-fecal route.  All children, even those that are vaccinated will likely contract this virus multiple times.  This disease is typically active seasonally in temperate climates, December-June.  All children in the US are likely to contract this by age 5.  Adult symptoms are less severe than those of children.

Rotavirus Stats

With natural infection from the first encounter with rotavirus:  38% of children will be immune, 77% are subsequently protected from diarrhea in future infections, and 87% are protected from severe diarrhea in future infections.  Each subsequent infection provides more protection in the future.

Of note, dehydration is a serious problem when it comes to young children and should never be taken lightly.  78% of children who die due to diarrhea-related dehydration are infants.  Diarrheal deaths of children declined 75% between 1968-1985 and then stabilized at approximately 300 deaths per year.  Early recognition of dehydration and rehydrating a child early is key.  Premature babies are more at risk for complications due to dehydration for up to two years of age.

Prior to vaccination in the US, 4/5 children under 5 years old had rotavirus gastroenteritis.  Out of those children:  1/7 required medical care (highest incidence 3-35 months old), 1/70 were hospitalized, and 1/200,000 died from the disease.  In children under 5, 20-60 annual deaths were attributed to rotavirus.  Winter infant deaths from rotavirus used to peak due to diarrhea and dehydration, but thankfully this pattern has virtually disappeared since 1985.  

Vaccination began in 2006 in the U.S.  Post-vaccination rates of rotavirus have decreased 74-90%.  Seasonal patterns still exist.  

In 2004, WHO estimated that 527,000 children under age 5 died from rotavirus worldwide.  In 2013, this had declined to 215,000. Approximately 2/3 of those deaths in 2013 were in the Indian subcontinent or Africa.   

rotavirus-incidence

How do you treat this disease?

There is no cure.  Treatment is by hydrating the person orally, or in severe cases intravenously.

Extra caution about handwashing and diaper disposal should be used for duration of the illness and for up to 10 days after symptoms first appear.  Be mindful that good sanitation procedures do not always eliminate this virus.

How long is a typical course of this disease?  

Two-three days after infection with the virus, the person will display symptoms which will last approximately 3-7 days.  You are infectious immediately upon infection, for up to 10 days after first symptoms are displayed.

Immunocompromised children tend to have more severe and more complicated cases.  They can also shed the virus for up to 30 days after infection.

Children under 3 months rarely are infected.  This is hypothesized to be due to breastfeeding.  Breastfeeding protects children because the mothers are passing on antibodies to the infant in the milk.  

How effective is this vaccine?

Both current versions tested 74% effective for any rotavirus gastroenteritis, 98% effective for severe rotavirus gastroenteritis for one year.  Various studies worldwide have found vaccination 85-96% effective.  In the US RV5 has been shown to be highly effective for up to 3 years.

Side-effects of vaccine

Your child should not get this vaccine if: they have had a history of intussusception, they have an allergic reaction to the vaccine or any component of it, they have SCID, they currently have gastroenteritis of any type, or are currently are in the NICU.

Use caution and consult with a specialist if your child is immunocompromised.

Possible risks proven in large studies:  intussusception (1-2 cases per 100,000 vaccinated), diarrhea, vomiting, ear, nose, and throat irritations, bronchospasm, cough, runny nose, irritability, and gas.

Vaccine Injury Data 10/3/16

  • Claims filed:  76 injury, 1 death; 45 were compensated

Adverse Reaction and reporting interval for VAERS:

  • Events described in manufacturer’s package insert as contraindications to additional doses of vaccine.  Insert is available on FDA website.

In the recent past there has been an incident of pig viruses in one of the vaccines.

Different versions of this vaccine

An old version of the vaccine, Rotashield, was used for only 1998.  It was pulled from the market because of the risk of intussusception.  This version is no longer used.

RV5 aka Rotateq (Merck):  5 strains, oral vaccine.  Child may shed virus in their stools for up to 5 days post vaccination.  Three doses at 2, 4, and 6 months.  Minimum age:  6 weeks.  Maximum age for first dose:  12 weeks.  Maximum age for any dose:  32 weeks.

RV1 aka Rotarix (GlaxoSmithKline):  1 strain, oral vaccine.  Child may shed virus in their stools for up to 30 days.  Two doses at 2 and 4 months.  Minimum age 6 weeks.  Maximum age for first dose:  14 weeks and 6 days.  Maximum age for any dose:  24 weeks.  Contraindicated for latex allergies.

There has been, to date, no study comparing the effectiveness of the two versions.  

A minimum of 4 weeks should be between doses.  If an infant spits up the vaccine, it is recommended that they not be given any extra, and that you maintain the schedule as if the infant did not regurgitate.  It is a good idea to use the same version for all doses.

Please pay special attention to length of stool shedding listed above.  Use extra care with diaper changes and be sure to wash hands thoroughly.  Although, rotavirus can be pretty stubborn to get rid of even with good sanitation.

Timelines

Recommended standard schedules in the US and all Canadian provinces is at 2 months and again at 4 months.

Some alternative schedules recommend not vaccinating against rotavirus unless you live in an area that you do not have access to healthcare services, others stick to the recommended schedule for rotavirus or follow the vaccination recommendations, e.g. give the recommended 3 doses of Rotateq (RV5).

References:

  • CDC
  • FDA
  • Kilgore PE, Holman RC, Clarke MJ, Glass RI. Trends of diarrheal disease-associated mortality in U.S. children, 1968 through 1991. JAMA 1995;274:1143-8.
  • National Vaccine Injury Compensation Program Data Report-10/3/2016
  • VAERS table of reportable events following vaccination
  • WHO

Informed Consent: Hepatitis B

I am a pro-choice doctor.  Vaccines are a very controversial topic these days.  I, as a chiropractor, do not give out vaccines.  Unfortunately, there is so much pressure from both sides of the debate, pro- and anti- vaccine camps, that it’s hard to find the right answers for your family.  In these posts I am just giving you the facts…using only reliable resources that are free and accessible for anyone with an internet connection.  You can do this research and more, but this is a good place to start.  Here we go with the first vaccine in the US schedule and the first in this series.

Hepatitis B

What is this disease?

This is a liver infection with both acute and chronic forms.  You contract the disease from body fluids, but the virus can survive outside the body for 7 days and during that time can infect anyone that encounters it and is not immune.  

The acute form in most cases is asymptomatic.  If symptoms appear they are:  fever, yellowing of the skin and eyes (jaundice), joint pain, dark urine, extreme fatigue, nausea, loss of appetite, vomiting, clay-colored stools and abdominal pain. A small subset of persons with acute hepatitis can develop acute liver failure which can lead to death. Fatality rates with acute hepatitis are 0.5-1% of cases.

The chronic form is usually asymptomatic.  Patients can develop complications such as cirrhosis or liver cancer (25% of patients).  It is most common for those that contract the virus before age 1 to develop chronic hepatitis B (80-90%).  By age 6 chronic infection rate drops to 30-50%.  Adults are even less (<5%).

The asymptomatic nature of this disease is the most concerning as it leads to spread of the infection.  Only a blood test can tell who has it.  If you are considering not giving this vaccine, it’s a good idea to get the household tested.

Hepatitis B Stats

In the United States, it is estimated that 850,000-2.2 million people have chronic hepatitis.  The population of the US is 319.8 million.  In 2014, there were an estimated 19,200 cases of acute hepatitis B in the US.  Incidence of acute hepatitis B in 2014:  0.9 cases/100,000 people.  Cases were reported in 48/50 states.

Chronic hepatitis B affects 240 million people worldwide.  Hepatitis B prevalence is highest in sub-Saharan Africa and East Asia (5-10% of adults chronically infected).  Other high rates of chronic infection are in the Amazon, southeast and south central Europe.  In the Middle East and India 2-5% are chronically infected.  In Western Europe and North America less than 1% is chronically infected.  Annually, over 686,000 people die due to complications of hepatitis B.

Vaccines for hepatitis B became available in the US in 1982.  At that time, vaccinations were for high-risk people such as healthcare workers or participating in high-risk body fluid exchange situations such as needle sharing or unprotected sex.  Routine vaccination of infants began in 1991.

usincidenceofhbv-chart

How do you treat this disease?

Acute:  No treatment.  Managed with fluids, nutrition, and comfort.  See above for likelihood of becoming chronic.

Chronic:  Life-long oral antiviral drugs can help slow progression and improve long-term survival.  No cure.

How long is a typical course of this disease?

Several weeks to 6 months for acute, life for chronic.

How effective is this vaccine?

95% (77-99%) effective for protective antibodies with 3 injection series.  Protection lasts 20 years.  Since vaccination began, areas where 8-15% of children had chronic Hepatitis B infections, now have 1% chronic infections.

The rate of new hepatitis B infections has declined by approximately 82% since 1991, when a national vaccination program for infants was implemented in the United States.

Side-effects of vaccine

Do not have this vaccine if you have a serious allergic reaction to any prior Hepatitis B vaccine or yeast.  Use with caution if you have a latex allergy, many versions have latex in their delivery devices.

CDC recommends not getting this vaccine if you are not well, it is best to wait until you are recovered from an illness before receiving this vaccine.

Side-effects:  soreness at injection site, low-grade fever, diarrhea, loss of appetite, fatigue, mild fussiness or crying, runny nose, fainting, dizziness, headache, insomnia, tingling, itching at site, sore throat, cough, paresthesias, hypotension, rash, sweating, pain and/or stiffness, swollen lymph nodes

Other side effects may be version specific.  You are encouraged to read the inserts on the FDA site.

Vaccine Injury Data 9/2/2016

Claims filed:  638 injury, 56 death; 260 were compensated (Hepatitis B only data, not combination vaccine)

Adverse Reaction and reporting interval for VAERS:

  1. Anaphylaxis or anaphylactic shock (7 days)
  2. Any acute complications or sequelae (including death) of the above event (interval – not applicable)
  3. Events described in manufacturer’s package insert as contraindications to additional doses of vaccine (interval – see package insert)  Insert is available on FDA website.

There has been some link investigated into multiple sclerosis with some case studies being reported, but no larger studies finding causal relation.

Different versions of this vaccine

Single-antigen hepatitis B vaccines

ENGERIX-B®

RECOMBIVAX HB® has half the antigen of engerix-B or pediarix.

Combination vaccines

PEDIARIX®: Combined hepatitis B, diphtheria, tetanus, acellular pertussis (DTaP), and inactivated poliovirus (IPV) vaccine. Cannot be administered before age 6 weeks or after age 7 years.

TWINRIX®: Combined Hepatitis A and hepatitis B vaccine. Recommended for persons aged ≥18 years who are at increased risk for both Hepatitis A virus and HBV infections.  Not for children.

It is highly recommended that you read the inserts for all of these vaccines before choosing to use one for your child if you have decided to vaccinate.  The most up-to-date versions can be found on the FDA’s website.

There is some concern out of there about aluminum in vaccines, this one does typically contain it.

Timelines

In the US, the recommended schedule of 3 doses begins at birth.

In Canada, the recommendations differ across provinces and have the first dose at any time from infancy to 7th grade.  

Alternative schedules will place this vaccine’s first dose as late as between 12-14 years of age in order to decrease aluminum doses and delay until child is entering a higher-risk period in their life.  Others will place it as a child enters pre-school environment, whenever that may be.

Where did this information come from?

  • CDC
  • Drugs.com
  • FDA
  • Healthycanadians.gc.ca
  • Immunization Action Coalition
  • National Vaccine Injury Compensation Program Data Report-9/2/2016
  • Peto, TJ, et al.  2014.  Efficacy and effectiveness of infant vaccination against chronic hepatitis B in the Gambia hepatitis intervention study (1986-90) and in the nationwide immunisation program.  BMC Infect Dis.  14: 7.
  • WHO
  • Alternative schedule information from various pediatrician websites in US.

3 Simple Ways to Increase Your Aerobic Activity

Want to fight Alzheimer’s, depression, heart disease, and diabetes?  Bump up your aerobic activity that you get each day.  I know it’s a struggle.  Trying to fit in a trip to the gym, you need new shoes, you don’t have the cash for that spin class after all that Christmas spending…the list goes on and on.  Skip all the special place, spending money, and all the other barriers to exercising your heart and try these free and easy tips!

  1. The Physical Commute.  This is the ‘free’ exercise that once in your regular routine, you’ll do it every weekday, no matter what.  Not only will this be a free and easy way to exercise, but it will save you money to boot!  The idea is simple, if you live within 3 miles of work, walk there.  Load up your lunch, work things, and perhaps dress shoes into a backpack and walk to work.  That walk to and from work will boost your mood in the office as well as at home.  If you live within 5 miles of work, it’s time to dust off the old bike.  A five-mile bike ride to work will make you feel like a kid again.  This might require you to pack your work pants in the backpack.
  2. If you commute a longer distance than 5 miles, the physical commute might not work for you.  Counteract all those car/bus/train rides with a regular 3 mile walk in nature.  This requires no fancy equipment or new shoes.  Just wear something comfortable that you already have, dress for the weather and step out your front door.  Most smartphones will download a free app that will help you measure your route.  If you don’t have something like this, just walk at a moderately brisk pace for about an hour, beginning and ending with your front door.  Walk through the woods, a field, a park; try to strive for a natural setting near you.  Picking a spot where you can walk to is key.  The more time you spend driving there, the less time you will have in your day, and the more likely you are to drop this habit.  This will easily be the best hour you spend, even at the end of a long day.
  3. The Buddy System.  The buddy system is a great way to find motivation to commit to a regular walk.  Socializing is something humans crave, so mix it with your exercise.  Get to know a neighbor.  Don’t fall into the oh-so-common buddy system trap though.  You know what I mean.  The time together is great, but it’s raining.  You two decide to have coffee instead of walk.  Pretty soon you have a regular coffee date with your neighbor, or lunch, or drinks….and you never walk anymore.  This is the ugly side of the buddy system.  The solution?  Keep your friend, but perhaps look to that fur ball in the corner for a walking buddy.  Dogs love to walk, it’s great exercise.  If you make a commitment to a pet, this is what they WILL want to do.  Don’t have a dog?  This might be the time to visit the shelter and get one, or offer to walk an elderly neighbor’s dog for them.  It’s a win-win.

I hope that one of these three simple ideas will work for you.  We live in a sedentary society.  After 40+ hours of sitting, get moving to keep your body and your brain healthy!

Stress!

With the advent of modern medicine significantly reducing the rate of death from infection and injury.  Our MAJOR killer is stress.  You’ve heard it before, but what is stress, where does it come from, what does it do to you, and how can you reduce it’s negative effects on you?

Stress comes in three forms:  physical, chemical, and emotional.  Stress from any of these sources creates a physiological cascade of events in your system originating from the fight-or-flight response which evolved to help us stay alive when faced with danger throughout history.  The problem is that many of today’s problems, e.g. sitting at a computer all day, processed foods, and constant cell phone and e-mail alerts, are not solved by shutting down our brains and ramping up muscle abilities.  Further, unlike escaping a predator we can’t run away from modern types of stress.  We are exposed to chronic stress!

You could easily identify the typical feeling of ‘stressed out’, but do you know the effects of stress on your body?  They include:  decreased sex drive, impaired digestion, slowed growth and healing, lowered immunity, increased blood pressure and heart rate, fat storage on your hips and thighs, elevated blood glucose, breakdown of body proteins, decreased HDL (good cholesterol), increased LDL (bad cholesterol), increased cardiac output, decreased learning ability, decreased focus, formation of anxiety memories, decreased logical behavior, increased sensitivity, concentration inhibition, poor short term memory, poor sleep quality.  These symptoms can lead to chronic diseases such as type 2 diabetes, osteoporosis, and heart disease.  Chronic stress also leads to depression, tension headaches, and accelerated aging.

You can’t always avoid stressors, but you CAN reduce their impact and mitigate their effects before the chronic stress slowly kills you.  Key things you can do to protect yourself include:  time in nature (a city park counts!), regular exercise, yoga, meditation, learn to say ‘no’ and pick your commitments mindfully.  Decrease your exposure to chemical stressors by decreasing your sugar and processed food intake and switching to non-toxic cleaning products in your home.  The best way to keep the effects of chronic stress that you can’t avoid under control is regular chiropractic adjustments on a treatment frequency that your doctor feels is appropriate for you.

Start decreasing stress and start optimizing your health!!!