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Daily Dose

Why 'Herd Immunity' Does Not Work

With all of the recent anxiety surrounding Swine Flu and the possibility of epidemics, lets be pro active in protecting all of us from diseases that we can prevent with the current immunizations that are available.There is an article in the June issue of the journal Pediatrics, which looked at whether parental refusal of pertussis vaccination could be associated with increased risk of pertussis infection in those unimmunized children. The study was conducted between the years 1996 - 2007 and looked at case controlled studies which compared a child with documented pertussis (whooping cough) to 4 other randomly selected children who did not develop pertussis. This study is important as many parents believe that if they choose not to vaccinate their child, that their child is protected by herd immunity (in other words, by all of the rest of us that are immunized).

In this case the study showed that 11% of all pertussis cases in this pediatric population were attributed to parental vaccine refusal. This study is important for several reasons. It is one of the first to document that herd immunity does not seem to completely protect unvaccinated children from pertussis. Children of parents who refuse pertussis immunizations are at high risk for pertussis infection relative to vaccinated children. One would assume, but further studies need to be done, that similar results would be found if you looked at diseases like measles, or H. flu meningitis. Herd immunity is important to the general health and well being of all of us, but it is not 100% at any time and risk of disease is still there. As we see increases in whooping cough in many communities across the country the need to educate parents about the importance of vaccines is paramount. Parents need to be protected too and we should all have a TdaP as an adult to provide pertussis protection for ourselves, as well as for those infants around us who are too young to be immunized. With all of the recent anxiety surrounding Swine Flu (H1N1) and the possibility of epidemics, lets be pro active in protecting all of us from diseases that we can prevent with the current immunizations that are available. That's your daily dose, we'll chat again tomorrow.

Daily Dose

Fight The Flu

1:30 to read

It is National Influenza Immunization Week, and I am hopeful that most everyone reading this has already had their flu vaccine….but if not, it is NOT too late! Just like the after Thanksgiving sales being extended…..your opportunity to be vaccinated has not passed!  Lucky for you, there are still vaccines available. If you act quickly there may be some places having a two for one sale, a coupon for shopping after getting vaccinate or even free vaccines…no excuses, everyone in the family ( over 6 months) may be vaccinated.

All kidding aside, this is an important time to remind people that it is not too late to get your flu vaccine and as of the first week of December there has not been a significant amount of flu in the country. But with that being said, influenza typically circulates December thru February but some years flu may even last into April or May.  But one thing is sure, flu is coming!!

No one is immune from the flu and the best protection is to get a flu vaccine!!  I hear people tell me, “they have never had the flu before so why should I get a vaccine?”, or “ I got sick after I had the flu vaccine, so I am not getting it again”.   Both of those are myths and are just a few of the anecdotes that I hear from patients and their families.

It is recommended that everyone over the age of 6 months receive a flu vaccine as it is the best protection against getting sick from the flu, and by vaccinating everyone we are also protecting those infants under 6 months that cannot yet get a flu vaccine.  Infants have a higher incidence of complications from the flu ( as do children with asthma and other underlying health issues ), and those precious babies born during the late summer and into the winter depend on the community to help keep them healthy. This is especially important for infants and children in day care, as influenza is a respiratory virus that is spread when someone in close proximity has coughed or sneezed. So, check to make sure that everyone in your daycare center is vaccinated, including the parents.

Statistics show that flu vaccination activity drops off after the end of November, but it is never too late to get the vaccine.  Remember,  it does take about two weeks to develop immunity after being vaccinated.  People also tell me, “I think I have already had the flu this year”, but even if you have, you have not had all of the strains of influenza that are in the vaccine and yes…you could get sick again. This years flu vaccine is available as a trivalent vaccine (which contains 2 type A, flu and 1flu B) and a quadrivalent vaccine ( with 2 type A and 2 B strains), and either vaccine is fine….get whatever your doctor, health department, pharmacy, grocery store, or employer has.  Most children over the age of 2 years may also take the live attenuated intranasal flu vaccine ( because how many kids want a shot -right?) and it is a quadrivalent vaccine.

So now is the time to run…not walk to get your flu vaccine!!  Don’t delay, put it on the top of the holiday “to do list”.

Daily Dose

Measles Outbreak

1.15 to read

With all of the news about the measles (rubeola) in California (51 cases) and New York (25 cases), (we) pediatricians are also on the alert for any measles cases in our areas.  I have written many times about the importance of vaccines, but this latest outbreak of measles is just a reminder of the importance of vaccines and the concept of herd immunity.  

By maintaining high vaccine rates for all children (adults too),  even those who may not have been vaccinated are protected because the “herd”, in otherwords the largest group of children, has received the vaccine.  It typically takes a 90-95% vaccination rate to maintain this herd immunity. Once the vaccination rate drops below this there is more likelihood to see a re-occurrence of a disease. In some areas of the country, where parents may choose to “opt out” of vaccines, the vaccination rates are below 90%. This is a critical situation.

Although measles was pronounced eliminated in the United States in 2000, measles is still widespread worldwide.  With international travel an everyday occurrence it only takes one person to “import” measles into the United States. Measles is a very contagious disease and is spread by respiratory droplets. The virus can remain in a room for up to 2 hours after an infected person has been there!!! Viruses are smart and hardy.  You would never know if you walked into a room or airplane after someone had just left who had measles. Remember, an infected person is contagious even before the measles rash appears.  Measles symptoms may occur up to 3 weeks after exposure. The illness begins like many others with fever, runny nose, cough and red eyes. It takes several days and then the measles rash develops.  By this time many others have likely been exposed. 

There are certain children who cannot receive vaccines due to medical reasons. Those children are protected by all of the others who are vaccinated. Making sure that your own children are vaccinated is paramount.  Measles vaccine, given as the MMR is typically given at the 12-15 month old visit and again between the ages of 4-6 years.  

There has also been a great deal of confusion on social media sites about measles (rubeola) and exanthem subitum (roseola). These are different illnesses and measles IS a vaccine preventable disease, while roseola is not. More to come on roseola....

 

Daily Dose

Deciding to Vaccinate Your Child

1.15 to read

I was recently doing a 4 year old well-child check up. This little girl was the youngest in a family of 4 girls with the oldest daughter being 18.

Through the many years of taking care of this family of girls, I have come upon new issues and changes that have occurred in pediatrics.  There have also been and will continue to be, different parental concerns. 

When this child was born, there was still a lot of discussion about immunization safety and parental concerns surrounding vaccines and autism. Although all of her older siblings had been immunized on schedule, without any issues at all, when the “baby” was born her mother and I had many discussions about giving this little girl her vaccines. 

The mother told me that she was now “hanging out with younger parents and they had made her concerned about vaccines, specifically as they related to autism.”  

Well, after much discussion and hand wringing on the mother’s part, the little girl was vaccinated on schedule just as her siblings had been. In fact, the father brought the daughter for her 1 year old vaccines (which include the MMR) just because the mother was anxious.  The dad and I had a bit of a chuckle about this, but nevertheless the child received her MMR without problems. 

So, fast forward to the 4 year old check up. This little girl is quite precocious and worldly as well, being the youngest in the family. She has always been exceptionally verbal, and doesn’t mind telling you exactly what she has on her mind. (sometimes with words she may have picked up from her older siblings!). Birth order, a daily dose for a later date! 

At the end of the check up, as it became time to discuss vaccines, I turned to the mother and said, “ Sally, is going to get her immunizations today including her MMR”.  Are you still concerned about giving her vaccines as surely you don’t think that Sally is autistic?” 

As the mother was getting ready to speak, little Sally quickly interrupted in her usual loud voice and said, “ Dr. Sue I am to artistic, I drew those pictures for you!” 

Enough said, ice broken, subject over and vaccines all given on time and without a problem. 

Daily Dose

Protecting Your New Bundle of Joy

When I see newborns in my office this fall I am already thinking into the winter season ahead.

As I see new parents in my office this fall, bringing in that most precious newborn for their first pediatric visit, I am already thinking into the winter season ahead. Infants born during fall and winter are exposed to more upper respiratory viruses and flu in their first six months of life. Infants under six months of age are at more risk of complications from viruses like RSV and flu. Unfortunately, infants under six months cannot receive flu vaccine.

But a recent study showed that mothers who received a flu vaccine during pregnancy reduced influenza illness in their newborns. That study is important in reminding pregnant mothers of the importance of receiving flu vaccine during their pregnancy. Unfortunately, in my practice, I do not see this information being given to pregnant mothers while they are in for their OB visits. It is also important that new parents are vaccinated against whooping cough with a newer vaccine which is given to adults called a TDaP. If you are pregnant or thinking about becoming pregnant this winter discuss these vaccines with your obstetrician. If they do not have the vaccines in their office, your local health department has them. The best way to protect that new bundle of joy is by immunizing those around them. This would also apply to grandparents, aunts, uncles and cousins. Spread the word about flu vaccine and TDaP and not the germs. That's your daily dose, we'll chat tomorrow!

Daily Dose

Pregnant? Get Your Flu Shot

1.45 to read

If you are pregnant, know someone that is pregnant, or are even thinking about becoming pregnant, you need a flu vaccine!!  (That is not to say that we all need to be thinking about flu vaccine’s right now!)

A study out of Duke University showed that of 1,600 women who delivered during the 2009-2010 flu season, those that had received a dose of flu vaccine delivered more term babies and also delivered babies who had higher birth weights. Women who received at least one flu vaccine during the season were also less likely to require a doctor’s visit for flu prior to delivery and they had lower hospitalization rates.

Another study out of Wake Forest University which was recently published in the Journal of Obstetrics and Gynecology looked at women who had received flu vaccine during their pregnancy.  This study showed that infants born to mothers who received flu vaccine while pregnant were 50% less likely to be hospitalized with flu than infants born to mothers who had not received flu vaccine. This was a study conducted over the years 2002-2009 (before H1N1) Impressive!

Flu vaccine is recommended for everyone 6 months of age and older. Infants 6 months of age and younger have the highest rate of hospitalization for flu related illness among all children.  The only reason that flu vaccine it is not given to younger infants is that the vaccine is not effective. How do we protect those babies, by protecting the mothers who are carrying the child? 

So…bottom line, pregnant women who get their flu vaccines not only protect themselves, they are protecting their newborn infants as well. A mother’s job of protecting her children is life long, but it begins even with a baby in utero. Go get that vaccine, as flu season is upon us!  

That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

HPV Is An Equal Opportunity Virus

Human Papilloma Virus (HPV) is the most common sexually transmitted infection in the United States and most genital warts (condyloma accuminata) are caused by HPV.

In 2006 a vaccine (Gardasil) was approved for girls and women aged nine to 26 to prevent cervical, vulvar and vaginal cancers caused by HPV 16 and 18, as well as genital warts caused by HPV types 6 and 11. This vaccine has been shown to be quite efficacious in preventing these conditions, especially when given before adolescents and young adults become sexually active. When looking at national statistics among teens regarding their sexual activity and first intercourse, over 60 percent of teenage girls had intercourse before graduating from high school and the percentage just continues to rise during college. Among those girls, in one study up to 50 percent may be exposed to HPV by their partner after their sexual debut. Not all of those exposed to HPV will go on to develop warts or cancer, as many people can clear this viral infection on their own. The difficulty is, we don’t know who can clear the virus and who will go on to become infected. Obviously, girls and boys pass this virus to one another, and it is not through intercourse alone. Genital to genital contact as well as oral and anal sex may cause transmission of this virus. In my practice, I have many adolescent girls who test positive for HPV on pap smears, as well as both girls and boys who have genital warts. Prevention is the key. Ideally that is through education and abstinence, but as any parent knows, kids make mistakes, and some are more serious than others. Most of the patients in my practice begin taking their HPV (Gardasil) vaccine series between 11 and 13 years of age and upon completion of their three dose series are well protected. I personally have not seen any complications from the vaccine, besides complaints of pain with the injection and sore arms (most of my patients complain with ALL shots anyway). When the vaccine was released there were many questions as to why it was not offered to boys too. It would seem like that would be appropriate? It was in fact given in other parts of the world to boys and young men. I even vaccinated my three sons (completely off label from FDA recommendations) as I felt it would protect them and their partners one day. Of course they complained, and said they “were guinea pigs”. Well, validation came this week when the FDA approved the use of Gardasil to prevent genital warts due to HPV types 6 and 11. The vaccine was approved for use in boys ages 9 – 26, in the same 3 dose series as girls. Each year, about 2 out of every 1,000 men in the U.S. are newly diagnosed with genital warts. I recently saw a 24-year-old male with a wart on his penis, and he could not believe that it was a genital wart. Something about penis and wart just did not connect for him, how could that be a genital wart, I must be confused? Again, education and prevention is the key. The studies in men showed that Gardasil was nearly 90 percent effective in preventing genital warts caused by HPV types 6 and 11. So talk to you doctor at your next checkup with your sons and ask about HPV prevention in boys. HPV is an equal opportunity virus and now we can equally protect both girls and boys. That’s your daily dose, we’ll chat again tomorrow. Send your question or comment to Dr. Sue!

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Daily Dose

Booster Shots

1:00 to read

Under the heading “kids say the smartest things” comes one of the latest entries!! I was seeing a 4 year old for their check up...this is a great age as most kids are very conversational and engaged and most are over their fear of the doctor.  I think “Doc McStuffins” has helped this out as well. Thank you Doc!

So, if you didn’t know it, 4-5 year olds get immunized before they start kindergarten.  I give 4 year olds their DTaP, IPV, MMR and Varicella vaccine, all in preparation for school.After a wonderful chatty and interactive visit, I always find it hard to now tell this precious child that at the end of the visit they are going to get some “vaccinations”.  Many times, in fact most, the idea of shots does not go over well.

Last week I saw this 4 year old, had a great visit, talked all about school and his soccer team and his new bike and bike helmet, only to end with “you are going to get several shots to keep you healthy”.  Then you wait for the reaction, right?

So, this little boy looked me right in the eye and said, “I get shots to protect and help my immune system!”.  What a smart kid! I think he is going to be an immunologist one day and save the world. I couldn’t be happier that he already understands re-boosting immunity.  

Daily Dose

Can a Little Cough Ease the Pain of a Shot?

1.30 to read

A study that was published in an issue of Pediatrics caught my eye online. The title “Cough Trick May Reduce Pain of Routine Immunizations” seemed relevant to my practice so I decided to preview the study a little early. 

The study was performed at The University of Nebraska and involved 68 children (small sample size) and they were all receiving vaccines at either the pre-kindergarten visit (age four to five years) or at the 11 to12-year-old visit when routine immunizations are again given. 

In this study the children were all instructed to COUGH while getting their vaccines and then the children as well as their parents and nurses were surveyed to see how painful the procedure seemed. For the kids they used visual scales (pictures of painful faces) to demonstrate degree of pain. 

There have been numerous studies done in previous years looking at methods to reduce pain during simple office visits for immunizations. Strategies from the use of topical anesthetics (EMLA cream), to sucking on sucrose dipped nipples for babies, to blowing bubbles to distract patients have all been used. 

In many of these cases the cost or time involved in these strategies was prohibitive for routine use in a busy office or clinic setting But, in this study, the time and cost was NONE as the children were taught to give one BIG cough prior to the injection and then coughed again at the time of injection. What a wonderful discovery! Easy, efficient and no training necessary for staff. In this study it wasn’t clear that it helped all children, and interestingly it seemed to be more effective in certain racial groups than others? 

In the meantime, while the academic and research docs are at work, I am going to try this approach in my own office I hate the four to five-year-old shots almost as much as the children and parents and have watched my own children scream and yell while getting all of those vaccines. Not fun for anyone. 

If that screaming, yelling and anxiety can be even slightly diminished by a cough or two, why not? It seems so easy. (I still think a lollipop at the end is helpful too). I guess we could all do a study on the “combo technique” of a cough followed by sugar and see what results we all get. Maybe get it published in next year? 

So, if you are headed to the doctor in the near future, and you know that it is time for immunizations, why not try “coaching” your child on the “cough trick” and see what you think. If your doctor isn’t aware of this study let them know it will be published in the next few weeks, but you can read it on line now. 

That’s your daily dose, we’ll chat again tomorrow.

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