Vaccines
If the COVID-19 pandemic has taught us anything, it is that we are truly an international society. While amazing experiences are only a plane flight away, so too are illness and disease. What happens in one corner of the world is no longer limited to this region.
While immunization is one of the most successful public health interventions of our time, coverage has plateaued over the last decade. The COVID-19 pandemic and associated disruptions have strained health systems, with over 25 million children missing out on vaccination in 2021.
We are extremely fortunate to live in a developed country where vaccinations are easy to obtain. In other developing nations, families will walk 40 plus miles for the opportunity to get their child a vaccination. The burden of vaccine preventable disease in the United States is admittedly low. But it is low because of the success of vaccination programs.
Having worked in medicine for over 20 years now, I have had the unfortunate experience of treating children with autoimmune and genetic disorders that limit the vaccinations these children are able to receive. I have seen the devastating effects, prolonged hospitalizations and the life long sequelae that vaccine preventable illnesses can bring. Our children are best protected when the community around them receive the recommended vaccinations and when they are vaccinated per the recommended schedule. This is the key component of vaccination programs and the reason for their success.
The greatest risk and burden of disease is in the early months to years of a child’s life. While it feels like there are a lot of vaccinations in the early part of a child’s life, it is because these children are our most vulnerable. When vaccine rates fall below a certain percentage it is often the youngest infants and children that pay the greatest price.
For example, The COVID-19 vaccine I received protects me, absolutely. But it protects my mother in her late 70’s, my patients, the older gentleman I sit next to on the bus, the young mom and her infant in the plane seat next to me. You get the idea. I truly believe that we, as a developed nation, have a responsibility to protect one another and vaccination is a prime example of how to do just that. It is the public health aspect, if you will, of the recommended vaccine schedule.
It is completely understandable to have questions and fears about what is safe for your child. But it has become increasingly difficult to find factual, evidence based information on the internet. Even with a background in science, I have found myself down some rabbit holes on the internet. The rapid spread of misinformation regarding childhood vaccines is highly concerning and it can be difficult to educate yourself. This packet is my attempt to help you understand the illnesses behind the vaccines recommended in the first few years of your child’s life. It will cover disease burden, morbidity and mortality as well as some common misconceptions about vaccines.
Lets begin with the misconceptions most commonly associated with vaccines.
All these vaccines at once are too much for the infant immune system.
An infant is exposed to hundreds of thousands of antigens (An antigen is any particle that causes the body to mount an immune response. These can be bacterial, viral, environmental particles, pet dander, etc) daily. The antigen components of a vaccine are selectively chosen to get the appropriate immune response. Technology has advanced so that only these finite antigens are selected and used in vaccinations. The vaccines presented to infants today have less component parts to them than the vaccines you received as a child. They have less component parts than you are being exposed to right now.
The truth is, the infant immune system is best suited to receive vaccines when they are young. The immune response is so robust at this age, we need far fewer vaccines to gain the immune coverage desired. This is another reason delayed or spread out vaccine plans are not endorsed. For one, we expose you and your family to the greatest risk (getting in a car and driving to the office) multiple more times than necessary. Delayed and spaced out vaccination schedules have not been validated or studied to ensure adequate immune coverage from the alternative vaccine schedule. The risk of an adverse effect from a vaccine is 1:1,000,000 (this is a low estimate, some studies have it at 1 in 10,000,000). In comparison, the risk of getting struck by lightning is 1:700,000.
Vaccines can cause autism.
In 1998, Andrew Wakefield had an article published in a reputable scientific journal that claimed the MMR (measles, mumps, rubella) vaccine caused autism. The paper was a case study of 12 children with autism spectrum disorder. The data published was preliminary (not all data was evaluated prior to publication) and the article was not peer reviewed. Peer review is standard practice for all scholarly articles to validate the study design and findings. The symptoms of autism in some of these children were present prior to their MMR vaccine and several did not develop symptoms until years after the vaccine. The study was funded by a lawyer who had been hired by the families of these 12 children in their lawsuit against the vaccine manufacturer. Andrew Wakefield was also developing his own MMR vaccine and stood to gain greatly if the manufacturer of the current MMR vaccine suffered from the allegations.
After all data were available for analysis, there was no link found between the MMR vaccine and the development of autism. The funding source (the lawyer and the families suing the vaccine manufacturer) was never disclosed in the paper and the authors of the paper (all except Wakefield) withdrew their names from the article when this information was made public. The article has been retracted from the Journal and Wakefiled has lost his license to practice.
But, the damage was done. The seeds of doubt and mistrust were sown. Although hundreds of studies have been conducted since proving no link between the MMR vaccine and autism, vaccine rates for measles, mumps and rubella continue to lag.
Aluminum containing vaccines can cause autism and are dangerous for brain development.
Aluminum is used in vaccines as an adjuvant. An adjuvant is a vaccine component that boosts the immune response to the vaccine. Adjuvants allow for lesser quantities of the vaccine and fewer doses. The levels of aluminum in vaccines is measured in micrograms, while the levels we ingest daily is measured in milligrams. 1 milligram = 1,000 micrograms. The aluminum particles in vaccines are too large to cross the blood brain barrier and therefore cannot affect neurologic development.
There are now several combination vaccines available which dramatically decrease the amount of aluminum needed to get the appropriate immune response. Dropping the total amount of aluminum required by more than half.
If you have more concerns or questions about vaccine components, the Children’s Hospital of Philadelphia (CHOP) has a fantastic vaccine education center. https://www.chop.edu/centers-programs/vaccine-education-center
Vaccines Recommended at the 2, 4 and 6 month well child exams:
Pentacel (DTaP, IPV, Hib) or Vaxelis (DTaP, IPV, Hib, Hep B), Prevnar 13 and Rotateq - Let's break these down into their component parts.
DTaP (Diphtheria, Tetanus, acellular Pertussis)
IPV (inactivated Polio virus)
Hib (Haemophilus influenza type B)
Hep B (Hepatitis type B)
Prevnar 13 (Pneumococcal 13)
Rotateq (oral Rotavirus)
Diphtheria is a disease caused by a bacterial infection that produces a toxin resulting in a thick membrane in the back of the throat and can extend to any part of the respiratory tract making it difficult to breathe. The disease can also affect the kidneys, heart and nervous system.
Tetanus - Tetanus is a nervous system condition caused by a bacterium that grows in the absence of oxygen (anaerobic). This toxin-producing anaerobic spore (C tetani) found in the soil. Since C. tetani spores cannot be eliminated from the environment, immunization and proper treatment of wounds and traumatic injuries are crucial for tetanus prevention. Tetanus causes very painful muscle contractions. It can cause children’s neck and jaw muscles to lock (lockjaw), making it hard for them to open their mouth, swallow (breastfeed) or breathe. In recent years, tetanus has been fatal in approximately 11% of reported cases. When mothers or newborns contract tetanus through wounds during birth, this is called maternal/neonatal tetanus (MNT). It can be prevented by immunizing the mother during her pregnancy. She then passes the immunity on to her newborn for a few days after birth. This is one reason the TDaP vaccine is recommended for expectant mothers.
Pertussis - Pertussis is commonly known as whooping cough or the 90 day cough. It has been known to cause such severe cough that people fracture ribs and burst blood vessels from the force of cough. Pertussis is caused by a bacteria (Bordatella Pertussis) and can live in respiratory secretions outside of the body for several hours. Pertussis infection in infants may be particularly severe, with increased rates of hospitalization for complications including apnea (periods of not breathing), seizures, and pulmonary hypertension. The incidence of pertussis remains highest among young infants. From 2012 through 2017, 66.7%, of all pertussis-related deaths (n = 72) reported to CDC were among infants less than two months of age, who were too young to have received DTaP vaccine. This is why mother’s are vaccinated with the TDaP (adult version of DTaP)during pregnancy. Mortality rate of pertussis in infants is 1%. It is recommended that all caregivers and close family members be vaccinated for Pertussis prior to baby being born
Polio (IPV) is a highly infectious viral disease that can cause irreversible paralysis. Polio mainly affects children under 5 years of age. However, anyone of any age who is unvaccinated can contract the disease.
1 in 200 polio infections leads to irreversible paralysis. Among those cases, 5 to 10 per- cent die when their breathing muscles (diaphragm) are paralyzed. There is no cure for polio once the paralysis sets in – only treatment to alleviate the symptoms.
Since 1988, more than 18 million people can walk today who would otherwise have been paralyzed, and 1.5 million childhood deaths have been averted thanks to the polio vaccine.
In the summer of 2022, polio virus was detected in waste water in several boroughs in New York city. This is a disease that was considered “eradicated” in the Americas in 1994. Low vaccinations rate are contributing to the spread of the disease, where as many as 70% of those infected are mildly symptomatic to completely asymptomatic.
Haemophilus influenza B (HiB) - despite the name, Hib is not an influenza virus, it is a bacterial infection. Haemophilus influenza type B can cause infections of the tissue covering the brain and spinal cord (meningitis), swelling of the epiglottis (the soft tissue flap that protects the windpipe (trachea) and pneumonia. Prior to vaccination, Hib had a 4% mortality rate in children under 5 years of age and approximately 30% of children who survived Hib infection had permanent sequelae like hearing impairment, seizure disorder, cognitive and developmental delay, and paralysis in 15%–30% of survivors.
Pneumococcal (aka Pneumonia) (Prevnar 13 vaccine) The 13 behind the Prevnar indicates how many pneumococcal strains the vaccine covers. The diseases caused by pneumococcal infections include pneumonia, ear infections, sinus infections, blood infections and meningitis (infections of the tissue covering the brain and spinal cord). A recent analysis estimated that pneumococcal disease was responsible for 4 million illness episodes, 445,000 hospitalizations and 22,000 deaths annually in the United States.
Pneumonia is the single largest infectious cause of death in children worldwide. Pneumonia killed 740,180 children under the age of 5 in 2019, the most recent year for which we have data available. This total accounts for 14% of all deaths of children under five years old (0-5 years of age) and 22% of all deaths in children aged 1 to 5.
Rotaviruses (Rotateq) are the most common cause of severe diarrheal disease in young children throughout the world. Prior to vaccine introduction, almost all U.S. children were infected with rotavirus before their 5th birthday. Rotavirus spreads easily, it is in the stool (poop) of infected people, and can be spread by hands, diapers, or objects such as toys, changing tables, or doorknobs that have a small amount of stool on them. Totally gross, but true. On average, each year, among U.S. children younger than 5 years of age, rotavirus led to more than 400,000 doctor visits, more than 200,000 emergency room visits, 55,000 to 70,000 hospitalizations, and between 20 to 60 deaths.
Hepatitis B - Hepatitis B virus is a dangerous liver infection that, when caught as an infant, often shows no symptoms for decades. It can develop into cirrhosis and liver cancer later in life. Babies born of Hep B positive mothers are at greatest risk of contracting the infection, which is why it is recommended to be given at birth. A baby born of a Hep B positive mother can escape contracting the infection with a delivery dose of Hep B vaccine and the administration of immune globulin. In the US, we are fortunate to know the Hep B status of most delivering mothers. The hepatitis B vaccine is one of the few vaccines that can be delayed with little risk to baby and their immediate community.
Influenza- Seasonal flu is a tricky virus that mutates rapidly. The flu vaccine is altered year to year using medical models that try to anticipate mutations and likely strains that will present during the coming flu season. In a great year, these models predict the mutations correctly and the flu shot truly prevents you from getting the flu. In a not so great year, the flu vaccine does not prevent you from contracting the flu, but it continues to protect you from severe disease, secondary infections (like pneumonia), hospitalizations and death. The flu vaccine is made of killed flu virus and is incapable of “causing the flu”. Sure, you may feel a little crummy the day after the vaccine, but I promise, it is not as bad as getting the actual flu. Because of its rapid mutation rate, the flu vaccine is recommended annually.
Measles (MMR) You’ll have to excuse the length of this one, I get REAL excited about this vaccine. Measles is a highly contagious, serious disease caused by a virus that can result in complications such as pneumonia, encephalitis (swelling of the brain), and death. Before the introduction of the measles vaccine in 1963 and widespread vaccination, major epidemics occurred approximately every 2–3 years and measles caused an estimated 2.6 million deaths each year. The virus causes fever and a distinctive rash that starts on the face and spreads downward over the whole body. Infected people can spread measles to others beginning four days before symptoms appear through four days after the rash appears. Measles virus can live for up to two hours in the air and on surfaces after an infected person leaves an area.
The measles virus also weakens the immune system of a child making them more vulnerable to other infections for years after recovering from infection. This phenomenon is known as immune amnesia. It takes 2-3 years post-measles infection for protective immune memory to be restored. This is why mortality and morbidity rates dropped so dramatically after the introduction of the measles vaccine. Many people who survived an initial measles infection were left vulnerable to secondary infections that could often prove fatal. This is both the coolest and most frightening feature of the measles virus.
Measles by the numbers: Even though a safe and cost-effective vaccine is available, in 2018, there were more than 140,000 measles deaths globally, mostly among children under the age of five. For every 1,000 children who get measles, about one case of encephalitis will occur and one or two children will die from it. Encephalitis can cause seizures and leave a child deaf or with intellectual disabilities. As many as one out of every 20 children with measles gets pneumonia, the most common cause of death from measles in young children. Reported worldwide measles cases increased by 79% in the first 2 months of 2022, compared to the same period in 2021. This was largely due to the drop in vaccine rates during the COVID-19 pandemic.
Mumps (MMR) Mumps is a viral illness that is highly infectious and spread by respiratory droplets and close contact. Mumps has a long incubation period (16-18 days). The most specific symptom associated with mumps is swelling of the parotid (salivary) gland located at the side of the face just below the ears. Complications from infection include; meningitis, encephalitis (swelling of the brain), loss of hearing and orchitis (inflammation of one or both testes) and oophoritis (inflammation of one or both ovaries).
Rubella (MMR) also called German measles or 3 day measles, was declared officially eliminated in the Americas in 2015. The goal of the rubella vaccination campaign is to prevent congenitally acquired (infections in mom that are passed on to baby while mom is pregnant) infection. Congenital rubella infection (CRI) may lead to fetal death in utero, preterm delivery, or congenital defects. These congenital defects include eye defects, cardiac defects, hearing impairment, endocrine disorders and intellectual disability.
Hepatitis A This liver infection is caused by the Hepatitis A virus and is usually transmitted by fecal-oral route, either by person to person contact or consumption of contaminated food or water. This vaccine is introduced after one year of life, as children begin to enjoy solid foods. There is not an increased risk of liver cancer with this infection, unlike Hepatitis B infections.
Varicella (chickenpox) - Varicella is highly contagious. The virus can be spread from person to person by direct contact, inhalation of aerosols from fluid of skin lesions and possibly through infected respiratory secretions that also may be aerosolized. The average incubation period for varicella infection is 14 to 16 days, although this interval can range from 10 to 21 days. Complications from varicella zoster infection can include secondary skin and soft tissue infections, encephalitis (swelling of the brain), pneumonia and hepatitis (liver inflammation) pneumonia, cerebellar ataxia, and death. In the early 1990s, prior to widespread vaccination programs, an average of 4 million people got varicella, 10,500 to 13,000 were hospitalized, and 100 to 150 died each year.
Human Papillomavirus (HPV, Gardasil 9) - HPV is the most common viral infection of the reproductive tract and can cause cervical cancer in women (about 10,800 cases annually and 4,000 deaths), penile cancer in men (accounting for about 60% of penile cancers), head and neck cancers (10,700 in men and 2,200 in women annually) anal cancer and genital warts in both men and women. Twenty million Americans are currently infected with HPV and an additional 6 million Americans are infected every year. Half of those newly infected with HPV are between 15 and 24 years of age. Nearly all cervical cancers are attributable to high-risk HPV types. Among the cancer-related outcomes of HPV infection, invasive cervical cancer has been considered the most important worldwide, with about 570,000 new cases and over 300,000 attributable deaths in 2018. This vaccine is offered at age 11 and is a series of 2 vaccines separated by 6 months.
Meningitis- There are two different types of meningitis vaccines, one that covers meningitis B (Bexsero) and one that covers meningitis A, C, Y and W (MenQuadfi). The letters represent the different serogroups of meningococcal infection. Meningitis A,C,Y and W vaccine are given at the 11 year and 16 year visit. Meningitis B vaccine is administered at the 16 yr visit.
Meningococcus usually causes meningitis (inflammation of the lining of the brain) or sepsis (an infection of the bloodstream). These infections spread rapidly and can become life threatening within hours. Every year, about 350 people in the United States are infected with meningococcus and about 50 die. Of those who survive, about 10 to 20 percent will suffer disabilities such as hearing loss, brain damage, kidney damage, loss of limbs, nervous system problems, or severe scars from skin grafts secondary to skin infection.
Partnering with you in the care of your child is not something I take lightly. I believe and practice shared decision making in all the care I provide your family. We will discuss the risk and benefits of vaccination, contracting the illness and delaying vaccines. I will give you the facts, as I have researched and reviewed and we will come to a decision that is best for your family. While I believe that vaccines are safe and extremely effective, I empathize with you in how difficult it can be to make this decision for your child. Ultimately the decision is yours, which is often the hardest part of this process. So give yourself some grace and time to digest the information. Ask your questions, raise your concerns and make a decision knowing you have absolutely done your due diligence.
