Category Archives: Vaccine

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The Underused HPV Vaccine, from the New York Times

Category : Advice , Vaccine

The Underused HPV Vaccine

You’d think that when parents are told of a vaccine that could prevent future cancers in their children, they’d leap at the chance to protect them. Alas, that is hardly the case for a vaccine that prevents infections with cancer-causing human papillomavirus, or HPV. The vaccine, best given at age 11 to 12, is currently the most underutilized immunization available for children.

HPV is by far the most common sexually transmitted infection in the United States, and nearly every sexually active person becomes infected at some time in life. The virus in one or another of its variants causes more than 90 percent of cervical cancers, as well as most cancers of the vulva, vagina, anus, penis and oropharynx, which includes the back of the throat, base of the tongue and tonsils. It also causes genital warts.

Every year, the Centers for Disease Control and Prevention reports, about 14 million Americans become infected with HPV, most of them teenagers or young adults, and a cancer caused by HPV is diagnosed in an estimated 17,600 women and 9,300 men.

Yet, when one of my sons was urged to get the HPV vaccine for his boys, ages 11 and 14, he replied, “Why? They’re not yet sexually active.” I reminded him that not all sex is consensual, and exposure to the virus does not require sexual penetration. However, his response reflects a common misunderstanding among millions of parents, and often their children’s doctors, of the value of the vaccine and the fact that it is most effective if given to preteenagers when the immune response is strongest and before they are exposed to an offending form of the virus.

But as of 2014, only 40 percent of girls and 21 percent of boys ages 13 to 17 had received all three doses of the HPV vaccine, whereas 88 percent of boys and girls had been vaccinated against tetanus-diphtheria-pertussis and 79 percent had gotten the meningococcal vaccine.

There are several explanations for the low rate of HPV immunization among young teens. One is that the vaccine is relatively new — it was first approved in 2006 — and expensive. At about $300 a dose, the three-dose series can approach $1,000 a child, although now, as with other government-recommended vaccines, it is covered by insurance with no co-pay, and the federal Vaccines for Children program provides free vaccination for children who are uninsured or underinsured, according to the American Cancer Society.

The society last month updated its immunization guideline for the HPV vaccine, bringing it in line with the advice issued two years ago by the federal Advisory Committee on Immunization Practices. While the committee considered evidence primarily from company-sponsored studies, the cancer society looked at additional studies conducted by independent researchers.

The society also more carefully defined the effect of age at the time of immunization, finding decreased effectiveness with age that underscores the importance of early vaccination.

“If the vaccine is to be given to people 22 to 26, doctors should inform patients that it is less effective,” said Debbie Saslow, the director of cancer control intervention for the cancer society. Still, it is not too late to immunize college students who did not get the vaccine when they were younger, she said.

A second obstacle to wider HPV immunization is the erroneous belief that it would promote teenage promiscuity, an argument more commonly used to counter birth control advice for teenagers. There is no direct connection between the vaccine and sexual activity and no reason to suggest one, said Dr. Saslow, the lead author of the cancer society’s updated guidelines. If asked, a parent or doctor could simply say the vaccine prevents infection by a very common virus that can cause cancer.

Although some early publicity for the vaccine focused on preventing sexually transmitted disease, Dr. Saslow said, “first and foremost, this is a cancer-prevention vaccine. Multiple studies have shown no negative impact on any measure of sexual activity among girls given the HPV vaccine. You don’t tell teenagers learning to drive not to wear a seatbelt because it may encourage them to run red lights.”

Parental support for having 11 and 12 year old children vaccinated against HPV has been very weak, with only one in five thinking it should be required for school entry. Several states have proposed mandatory vaccination for school entry, and a national sampling of 1,501 parents of children ages 11 to 17 showed that including an “opt out” provision would almost triple parental support for such a requirement, according to researchers at the University of North Carolina Gillings School of Global Public Health.

The most pernicious argument against HPV immunization involves postings on the web of undocumented horror stories that some parents attribute to the vaccine, not unlike the misattribution of autism to the vaccine for measles-mumps-rubella. None of the accounts of severe adverse effects parents have linked to the HPV vaccine have been borne out by sound research.

Three HPV vaccines have been developed, although only one, which protects against nine variants of the virus, now remains on the market. The C.D.C. has stated unequivocally that clinical trials have shown them all to be “very safe.”

Before being licensed in 2009, the vaccine called Cervarix, which protects against the two variants of HPV linked to cervical cancer, was studied in more than 30,000 females. The four-variant vaccine called Gardasil, licensed in 2006 for females and in 2009 for males, was studied in more than 29,000 recipients, and the newest nine-variant vaccine, called Gardasil 9, licensed in December 2014 and the only one now sold, was studied in more than 15,000 males and females.

“Each HPV vaccine was found to be safe and effective,” the agency has declared.

The most common side effects are local pain, redness or swelling at the site of the intramuscular injection. As with other vaccines given to teenagers, fainting sometimes occurs, and patients should be advised to sit or lie down for 15 minutes after getting the vaccine.

The three-dose vaccines should be given to boys and girls as follows: The first dose should ideally be given at age 11 or 12, but can be given to children as young as 9 or to young adults through age 26. The second dose is administered one or two months after the first. And the third dose is given six months after the first. Protection is not complete until all three doses are received. However, there is no maximum interval; if any dose is delayed, it should be given at the next opportunity. There is no need to restart the series.

The vaccine can be safely administered at the same time as other vaccines are given, like the Tdap, meningococcal or influenza vaccine. Although HPV vaccine should not be given during pregnancy, no fetal harm has yet been shown when pregnancy was discovered after one or more doses of the vaccine were administered.

Thus far, there is also no indication that vaccine protection diminishes with time. Individuals followed for up to 10 years post-immunization have shown no sign of decreased protection, and booster doses are not required.

About HPV and the Vaccine to protect against it (From the CDC)

HPV vaccine for males (from the CDC)

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Why Meningococcal Vaccine (From Children’s Hospital of Philadelphia)

Category : Advice , Vaccine

About 1 in 20 children with meningitis caused by meningococcus and about 1 in 3 children with bloodstream infections (i.e., sepsis) caused by meningococcus will die from the infection. Death from sepsis can occur within 12 hours of the beginning of the illness. Meningococcus is one of the most rapid and overwhelming infectious diseases known to man.

The disease

What is meningococcus?

The bacterium, Neisseria meningitidis, primarily targets children younger than 1 year of age. Because meningococcus is contagious, outbreaks can occur in childcare centers and schools. Cases also occur in high schools and on college campuses.

Meningococcus usually causes meningitis (inflammation of the lining of the brain) or sepsis (an infection of the bloodstream). Symptoms of meningitis include stiff neck, headache, fever and drowsiness. Symptoms of sepsis caused by meningococcus include fever, shock and coma. The disease is so rapid that a child can be perfectly well and, in a matter of only a few hours, be in a coma. For these reasons, meningococcal infections that occur in childcare centers, elementary schools or high schools often cause panic in the community. Every year about 800 to 1,500 people in the United States are infected with meningococcus and about 120 die. Meningococcus can also cause pneumonia and arthritis.

Consequences of meningococcal infection occur in about 12 of every 100 survivors and include limb amputation, skin grafting, hearing loss, seizures, kidney disease and mental retardation. About 10 of every 100 people infected with meningococcus will die from the disease. Immunization is the most effective way to reduce the incidence of death and permanent sequelae caused by meningococcus.

How do you catch meningococcal infection?

Usually meningococcal infection is acquired after intimate contact with an infected person. Intimate contact includes kissing, sharing food or beverages, or staying in the same house or room (including a classroom) for more than four hours a day.

Because smoking disrupts the lining of the throat, people who smoke are at increased risk of some infections, including pneumococcus and meningococcus. Both of these vaccine-preventable diseases can cause meningitis.

The vaccine

How are the meningococcal vaccines made?

Two types of meningococcal vaccines are available. One has been available for several years and protects against four of the five types of meningococcus (A, C, Y, and W-135). The other version is newer and protects against the fifth type of meningococcus, type B.

Meningococcus A, C, Y and W-135 vaccine

This meningococcal vaccine is similar to those for pneumococcus and Haemophilus influenzae type b (Hib) in that protection against disease occurs when one develops antibodies to the sugar (or polysaccharide) that coats the bacterium. A meningococcal vaccine, made using only the polysaccharide coating of meningococcus, has been available for several years. Unfortunately, children less than 2 years of age are not very good at making immune responses to the polysaccharide alone.

In order for young children to make an immune response, the polysaccharide must first be attached to a harmless protein. (see How Are Vaccines Made?). The polysaccharide attached to the protein is known as a conjugate vaccine. There are two conjugated meningococcal vaccines:

  • One, available since 2005, can be given to people between 9 months and 55 years of age
  • The second, available since February 2010, can be used in people between 2 and 55 years of age

In both vaccines, the polysaccharides have been stripped from the surface of four of the five different types of meningococcal bacteria that cause disease and each is linked to a harmless protein. The four conjugated polysaccharides are combined into a single shot.

Meningococcal B vaccine

Hib and pneumococcal vaccines have been easier to make than the meningococcal vaccine. The Hib vaccine was easier to make because there is only one type of Haemophilus influenzae that commonly causes severe disease in children (type b). The pneumococcal vaccine was easier to make than the meningococcal vaccine because, although there are about 90 different types of pneumococcus, most of the disease in children is caused by 13 types. Therefore, the pneumococcal vaccine contains these 13 different types of polysaccharides — each linked to a protein.

Although there are only five different types of meningococcus that commonly cause disease (types A, B, C, Y and W-135), it has been very difficult to make a vaccine that includes type B, and meningococcus type B accounts for two-thirds of meningococcal infections in infants and one-third of meningococcal infections in adolescents and adults. Two vaccines to prevent meningococcus type B were licensed for use in adolescents in 2015 — Bexsero® and Trumenba®.  Both of these vaccines were made using proteins, not polysaccharides, that reside on the surface of the bacteria. Trumenba contains two proteins, and Bexsero contains four.

Who should get the meningococcal vaccine?

The A, C, Y, W-135 meningococcal vaccine is recommended for:

  • Adolescents and teens 11 to 18 years old
  • Children and adults without a spleen (see additional information about MenHibRix® below)
  • Children and adults who lack a particular group of serum proteins, called complement proteins, that help the body fight infection (see additional information about MenHibRix® below)
  • College freshmen living in dormitories
  • People exposed to someone infected with meningococcus during an outbreak if the type of meningococcus is one contained in the vaccine (types A, C, Y or W-135)
  • Children and adults who will be traveling to sub-Saharan Africa between December and June
  • Military recruits
  • Lab workers who work with the bacteria

The meningococcal B vaccine is recommended for:

  • All 16- to 18-year olds
  • People aged 10 years and older who have complement deficiencies, no spleen or a spleen that does not function
  • Lab workers who work with the bacteria
  • People exposed to someone infected with meningococcus type B during an outbreak, such as on a college campus

Does the meningococcal vaccine have side effects?

The meningococcal vaccines may cause pain or tenderness where the shot is given, but do not cause any serious side effects. Although a possible association with Guillian-Barre Syndrome (GBS) was investigated, no causal association was found.

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Why Varivax (from Children’s Hospital of Philadelphia)

The disease

What is chickenpox?

Chickenpox is an infection caused by the varicella virus, and it is highly contagious. It can spread in one of three ways: by coughing or sneezing, physical contact with broken blisters, or by virus particles from the blisters that are sprayed in the air. The rash of chickenpox begins as red bumps that turn into blisters that cover the entire body. As many as 300-500 blisters can occur during a single infection.

Chickenpox is usually a relatively benign infection. However, chickenpox infections can have severe complications. About 1 of every 1,000 children infected with varicella will develop severe pneumonia (infection of the lungs) or encephalitis (infection of the brain). In addition, about 1of every 50 women infected with varicella during their pregnancy will deliver children with birth defects. These birth defects include mental retardation and shortened or atrophied limbs. Finally, a bacterium called Group A streptococcus, commonly known as “flesh-eating” bacteria, can enter through the skin during a varicella infection and cause severe, and sometimes fatal, disease.

How contagious is chickenpox?

Chickenpox is very contagious. If 100 people are sitting in a room together for several hours talking and one of them has chickenpox and the other 99 have never been infected with chickenpox or vaccinated with the chickenpox vaccine, about 85 of the remaining 99 will get chickenpox.

Who should get the chickenpox vaccine?

The varicella vaccine is given to children between 12 and 15 months and again between 4 and 6 years of age. Children, adolescents and young adults who have received only one dose should get a second dose. For previously unimmunized adolescents (13 to 18 years old) or adults, the vaccine is given as a series of two shots, separated by four to eight weeks.

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Why flu vaccine (from Children’s Hospital of Philadelphia)

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Category : Advice , Vaccine

iconmonstr-facebook-5-48iconmonstr-email-11-48Every year in the United States, influenza kills thousands to tens of thousands of people. Probably the best example of how devastating influenza can be was the influenza pandemic in 1918 — this worldwide outbreak killed between 50 and 100 million people in a single influenza season.

The disease

What is influenza?

Commonly known as the flu, influenza is a virus that infects the trachea (windpipe) or bronchi (breathing tubes). Symptoms come on suddenly and include high fever, chills, severe muscle aches and headache. The onset of shaking chills is often so dramatic that many people will remember the exact hour that it started. The virus also causes runny nose and a cough that can last for weeks.

Complications of influenza include severe, and occasionally fatal, pneumonia.

Animals can be infected with influenza

Some diseases are only found in humans; however, influenza can infect many types of animals, such as:

  • Birds and poultry, such as chickens and turkeys
  • Aquatic birds, such as ducks
  • Pigs
  • Horses
  • Dogs
  • Cats
  • Sea mammals, such as seals and whales

When animals are infected with different strains of influenza at the same time, a new type can emerge. If the new type can infect humans, be easily passed from one person to another and causes illness, a pandemic, or worldwide epidemic can occur.

What is the difference between an epidemic and a pandemic?

Influenza epidemics occur every year. An epidemic does not affect all people because many people have at least some immunity. On the other hand, when new strains emerge, people do not have immunity, and, therefore, almost everyone is susceptible.

Flu pandemics occur about three times every century. The most recent pandemics have occurred in 1889, 1900, 1918, 1957, 1968, and 2009. The pandemics in 1957 and 1968 each claimed four to six million lives, but the pandemic in 1918 was the most devastating. Between 50 and 100 million people died from the strain of influenza known as “Spanish flu” during that pandemic.

Who should get the influenza vaccine?

The Centers for Disease Control and Prevention (CDC) recommends that everyone 6 months of age and older receive the influenza vaccine each year.

Children 6 months to 8 years of age require two doses of influenza vaccine separated by four weeks if they:

  • Have never received an influenza vaccine
  • Have not received at least 1 dose of influenza vaccine last year (2015-16 influenza season) or have not received two doses of influenza vaccine since July 2010
  • Have an uncertain influenza vaccination history

How is the influenza vaccine made?

All of the vaccines listed below contain either three or four of the influenza strains circulating in the community during a particular year.

One influenza vaccine is made by growing influenza viruses in hen’s eggs, purifying it, and completely killing it with a chemical (formaldehyde). Historically, this influenza shot has been administered into the muscle. However, a newer version of the vaccine, available for adults between 18 and 64 years old, is administered into the skin. Since the newer version uses a much smaller needle, it may be preferred for adults who are apprehensive about getting needles.

Two other influenza vaccines are also given as shots. One is made using recombinant DNA technology, and contains two proteins that reside on the surface of influenza virus. The other is made by growing influenza viruses in mammalian cells (not eggs), and killing it with formaldehyde. Both of these vaccines are advantageous for people who have egg allergies.

The influenza vaccine is unusual in that most years a different vaccine is made. Because strains of influenza virus that circulate in the community can differ from one season to the next, the vaccine must change to best protect against those different strains. Every year in the United States, the Centers for Disease Control and Prevention (CDC) determines what strains of influenza are circulating, and makes sure that all the influenza vaccines that are made that season contain viruses that would protect against the circulating strains. For this reason, the influenza vaccine is probably the hardest vaccine to make.

Do the benefits of the influenza vaccine outweigh the risks?

The influenza vaccine can cause mild side effects. On the other hand, influenza hospitalizes and kills more people in this country than any other vaccine-preventable disease — about 200,000 hospitalizations and thousands to tens of thousands of deaths occur every year. Therefore, the benefits of the influenza vaccine clearly outweigh its risks.

Disease risks

  • High fever and chills
  • Severe muscle aches
  • Headaches
  • Pneumonia
  • Runny nose and coughing for weeks
  • Disease can be fatal

Vaccine risks

  • Pain, redness and swelling at the injection site
  • Fever or muscle aches

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Why MMR Vaccine (From CHOP)

Category : Advice , Vaccine

Measles, mumps and rubella are all viral infections that caused widespread illness. Vaccines are now available for each and have been combined to form the MMR vaccine.

The diseases


The face of measles

In 1991 the city of Philadelphia was in the grip of a measles epidemic. At the center of the epidemic were two religious groups that refused immunizations for themselves and their children. Children with measles developed high fever; a red, raised rash that started on the face and spread to the rest of the body; and “pink eye.” For some, the disease got much worse. Six children in these church groups and three children in the surrounding community died from measles.

By 2000, due to effective use of vaccine, measles was essentially eliminated from the United States. However, in 2014, more than 600 cases were reported, the largest outbreak in about 20 years. The reason: some parents were choosing not to vaccinate their children.

What is measles?

Measles is a disease that is caused by a virus. People with measles may have some or all of the following:

  • A fever that gradually goes up to 103°-105°F
  • Cough, runny nose, pink eye
  • Raised, bluish-white spots inside the mouth
  • A rash consisting of red spots, raised in the middle. The rash begins at the hairline and moves to the face and neck before descending downward and outward over the rest of the body
  • Diarrhea
  • Lack of appetite

How does measles spread?

When an infected person coughs or sneezes, measles viruses are spread in the small respiratory droplets. If a susceptible person breathes in these droplets or touches an infected surface and then puts his hand in his mouth or nose, he is likely to get measles.

How contagious is measles?

Measles is one of the most contagious diseases. In fact, if 100 susceptible people are in a room with someone who is infected, 90 of them are likely to become ill with measles. Further, if someone who has not had measles enters an elevator or other small space up to two hours after an infected person has left, he or she can still “catch” measles.

Are there complications from measles infections?

Yes. About 3 of every 10 people who get measles will develop complications such as:

  • Ear infection
  • Pneumonia
  • Swelling of the brain
  • Subacute sclerosing panencephalitis (a disease characterized by progressive neurological deterioration and early death)
  • Hemorrhagic measles – includes seizures, delirium, difficulty breathing and bleeding under the skin
  • Clotting disorder
  • Death

Pregnant women who are infected with measles can miscarry, deliver early, or have a low-birth-weight baby. People who are immune compromised are at risk of having prolonged and severe illness.

What if I suspect measles?

Call your healthcare provider and mention your concern. Because measles is so contagious, providers typically do not want infected patients sharing a waiting room with other patients. This is particularly important for infants who are too young to receive the vaccine.


What is mumps?

Mumps is a virus that usually causes swelling in the salivary or parotid glands, just below the ear, lasting for about seven to 10 days. The chipmunk-like appearance of people infected with mumps is how mumps got its name.

But not all mumps infections were mild. Before the mumps vaccine, mumps was the most common cause of meningitis (inflammation of the lining of the brain and spinal cord). Virtually all children recovered from meningitis, but some were left with permanent deafness. Before the mumps vaccine, mumps was the most common cause of acquired deafness in the United States.

Mumps can also infect testicles and cause a disease known as orchitis. Some men with orchitis were found to be sterile after the infection resolved. Additionally, mumps infection during pregnancy occasionally resulted in the death of the unborn child.


The face of rubella

Before the rubella vaccine, children infected with rubella would develop a light, mild rash on the face. Some children would also develop swelling of the lymph glands behind the ear. Rubella was a mild infection of childhood. But in 1941, an Australian ophthalmologist made a curious observation. He found that many children were born with congenital cataracts and blindness following an outbreak of rubella. This was evidence that rubella could permanently damage the developing fetus.

What is rubella?

Rubella is a viral infection also known as German measles. Rubella infection of children causes a mild rash on the face, swelling of glands behind the ear, occasionally a short-lived swelling of small joints (like the joints of the hand), and low-grade fever. Children virtually always recover from rubella infection without consequence.

But rubella is not always a mild infection. Before the rubella vaccine as many as 20,000 babies were born every year with birth defects because of the capacity of rubella virus to infect the unborn child. In fact, 85 of 100 women infected with rubella in the first trimester of pregnancy had babies that were permanently harmed. Rubella virus can cause blindness, deafness, heart defects or mental deficits in infants whose mothers were infected early in pregnancy.

Rubella parties

While rubella was not typically a severe childhood illness, it could be fatal when pregnant women were infected. Before the vaccine, each year about 20,000 babies were harmed when their mothers were infected during pregnancy. For this reason rubella parties were recommended by pediatricians to ensure that young girls were exposed before they were old enough to become pregnant. Today, with the availability of a vaccine, doctors and parents can be assured that children are becoming immune to these diseases in the safest way possible.

MMR vaccine

The MMR vaccine contains vaccines that protect against three viral infections: measles, mumps and rubella.  It is given as a series of two doses at 12 to 15 months of age and at 4 to 6 years of age.


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