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Archive-name: misc-kids/vaccinations/part1
Posting-Frequency: monthly Last-Modified: October 23, 1999 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D Collection maintained by: Lynn Gazis-Sax )=20 To contribute to this collection, please send e-mail to the address given a= bove, and ask me to add your comments to the FAQ file on vaccination. Please try to be as concise as possible, as these FAQ = files tend to be quite long as it is. And, unless otherwise requested, your name and e-mail address will remain in the file, = so that interested readers may follow-up directly for more information/discussion.=20 Copyright 1994-1999, Lynn Gazis-Sax. All rights reserved. Use and copying o= f this information are permitted as long as (1) no fees or compensation are charged for use, copies or access to this infor= mation, and (2) this copyright notice is included intact.=20 For a list of other FAQ topics, ftp to the pub/usenet/misc.kids directory o= f rtfm.mit.edu, look for the FAQ File Index posted to misc.kids weekly, or tune in to misc.kids.info. =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D [NOTE: this is information collected from many sources and while I have str= ived to be accurate and complete, I cannot guarantee that I have succeeded. This is not medical advice. For that, see = your doctor or other health care provider.]=20 [This version is updated to reflect the approval of the chicken pox and hep= atitis A vaccines by the FDA, the approval of an acellular pertussis vaccine for all shots, the approval of IPV for all poli= o shots, the rise and fall of the new rotavirus vaccine, new information about adverse events, and new information about vaccine res= earch. ] =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Contents=20 Section 1. Introduction and General Information Q1.1 What is vaccination? Q1.2 What are active and passive vaccination? Q1.3 What is herd immunity? Q1.4 How effective is vaccination at producing immunity? Q1.5 What are some of the risks of vaccination? Q1.6 What are some contraindications to vaccinations? Q1.7 How common are the diseases vaccinated against? Q1.8 What percentage of children are vaccinated? Q1.9 What are some sources of further information about vaccinations? Section 2. The recommended vaccination schedule and official organizations Q2.1 What is the recommended vaccination schedule in the US for infants? Q2.2 What is the recommended vaccination schedule in the US for older child= ren who were not vaccinated in infancy? Q2.3 What is the recommended vaccination schedule in the US for adults? Q2.4 Who determines this schedule? Q2.5 What other US government organizations are concerned with vaccinations= ? Q2.5.1 What is the National Vaccine Injury Compensation Program (VICP)? Q2.5.2 What vaccines are covered? Q2.5.3 Who may file a claim? Q2.5.4 Who can I contact to get more information about the Program? Q2.5.5 = What is VAERS? Q2.5.6 Who can report to VAERS? Q2.5.7 What events should be reported to VAERS? Q2.5.8 Are all events reported to VAERS caused by vaccinations? Q2.5.9 How can I get rapid information on VAERS, such as how to file a repo= rt? Q2.5.10 Have there been any comprehensive scientific studies on adverse eve= nts following immunization? Q2.5.11 Are VAERS data available to the public? Q2.6 What vaccination schedules are used in other countries? Q2.7 What international bodies are concerned with vaccinations? Section 3. Specific vaccines Section 3a. DTP (diptheria, tetanus, and pertussis) and DT Q3a.1 What is diptheria, and what are the risks of the disease? Q3a.2 How common was diptheria before routine vaccination, and how common i= s it now? Q3a.3 How effective is the diptheria vaccine? Q3a.4 How long does the diptheria vaccine last? Q3a.5 What is pertussis, and what are the risks of the disease? Q3a.6 How common was pertussis before routine vaccination, and how common i= s it now? Q3a.7 How effective is the whole cell pertussis vaccine? Q3a.8 How long does the pertussis vaccine last? Q3a.9 What is tetanus, and what are the risks of the disease? Q3a.10 How common was tetanus before routine vaccination, and how common is= it now? Q3a.11 How effective is the tetanus vaccine? Q3a.12 How long does the tetanus vaccine last? Q3a.13 What are some of the risks of the DTP vaccine? Q3a.14 Did SIDS disappear in Japan after the Japanese changed their pertuss= is vaccination policy in 1975? Q3a.15 When is the DTP vaccine contraindicated? Q3a.16 What are the advantages and disadvantages of the new acellular pertu= ssis vaccine? Q3a.17 What are some of the risks of the DT (diptheria and tetanus) vaccine= ? Q3a.18 When is the DT vaccine contraindicated? Q3a.19 Under what circumstances is tetanus toxoid given to pregnant women?= =20 Section 3b. Polio Q3b.1 What is polio, and what are the risks of the disease? Q3b.2 How common was polio before routine vaccination, and how common is it= now? Q3b.3 How effective is the polio vaccine? Q3b.4 How long does the polio vaccine last? Q3b.5 What is the difference between oral polio vaccine (OPV) and inactivat= ed polio vaccine (IPV)? Q3b.6 I've heard that it is possible to contract polio from handling the di= apers of recently immunized infants. How long after receiving the vaccine does the child's excrement continue to contain the vi= rus? Q3b.7 What are some other risks of the polio vaccine? Q3b.8 When is the polio vaccine contraindicated? Q3b.9 Isn't it true that wild polio has been eliminated in the US? Q3b.10 Why are we still vaccinating for polio, then? Section 3c. MMR (measles, mumps, and rubella) Q3c.1 What is measles, and what are the risks of the disease? Q3c.2 How common was measles before routine vaccination, and how common is = it now? Q3c.3 How effective is the measles vaccine? Q3c.4 How long does the measles vaccine last? Q3c.5 What are some of the risks of the measles vaccine? Q3c.6 What is mumps, and what are the risks of the disease? Q3c.7 How common was mumps before routine vaccination, and how common is it= now? Q3c.8 How effective is the mumps vaccine? Q3c.9 How long does the mumps vaccine last? Q3c.10 What are some of the risks of the mumps vaccine? Q3c.11 What is rubella, and what are the risks of the disease? Q3c.12 How common was rubella before routine vaccination, and how common is= it now? Q3c.13 How effective is the rubella vaccine? Q3c.14 How long does the rubella vaccine last? Q3c.15 What are the pros and cons of vaccinating all infants for rubella ve= rsus vaccinating females only at puberty? Q3c.16 What are some of the risks of the rubella vaccine? Q3c.17 When is the MMR vaccine contraindicated? Section 3d. HiB (Hemophilus influenze B) Q3d.1 What is hemophilus influenze B, and what are the risks of the disease= ?=20 Q3d.2 How common was HiB before routine vaccination, and how common is it n= ow? Q3d.3 How effective is the HiB vaccine? Q3d.4 How long does the HiB vaccine last? Q3d.5 What are some of the risks of the HiB vaccine? Q3d.6 When is the HiB vaccine contraindicated? Q3d.7 What about rifampin prophylaxis? Section 3e. Hepatitis B gamma globulin and hepatitis B vaccine Q3e.1 What is hepatitis B, and what are the risks of the disease? Q3e.2 How common is hepatitis B? Q3e.3 What is hepatitis B gamma globulin, and when is it given? Q3e.4 How long does the immunity provided by hepatitis B gamma globulin las= t? Q3e.5 What are the risks and contraindications of hepatitis B gamma globuli= n?=20 Q3e.6 How effective is the hepatitis B vaccine? Q3e.7 How long does the hepatitis B vaccine last? Q3e.8 What are some of the risks of the hepatitis B vaccine? Q3e.9 When is the hepatitis B vaccine contraindicated? Q3e.10 Why did the ACIP and AAP change their recommendation about the hepat= itis B vaccine? Q3e.11 Does vaccination for hepatitis B affect one's ability to donate bloo= d? Q3e.12 Do people who have showed up positive on the blood banks' tests for = hepatitis B exposure still need to be vaccinated? Q3e.13 I will be travelling to an area where hepatitis B shots are recommen= ded, but I have less than six months before I leave. Is there an accelerated schedule for hepatitis B vaccination? Section 3f. Influenza Q3f.1 What is influenza, and what are the risks of the disease? Q3f.2 How common is influenza? Q3f.3 How effective is the influenza vaccine? Q3f.4 How long does the influenza vaccine last? Q3f.5 What are some of the risks of the influenza vaccine? Q3f.6 When is the influenza vaccine recommended? Q3f.7 When is the influenza vaccine contraindicated? Q3f.8 Is it OK to be vaccinated for influenza during pregnancy? Section 3g. Pneumococcal vaccine Q3g.1 What is pneumococcal disease, and what are the risks of the disease?= =20 Q3g.2 How common is pneumococcal disease? Q3g.3 How effective is the pneumococcal vaccine? Q3g.4 How long does the pneumococcal vaccine last? Q3g.5 What are some of the risks of the pneumococcal vaccine? Q3g.6 When is the pneumococcal vaccine recommended? Q3g.7 When is the pneumococcal vaccine contraindicated? Section 3h. Meningococcal vaccine Q3h.1 What is meningococcal disease, and what are the risks of the disease?= =20 Q3h.2 How common is meningococcal disease? Q3h.3 How effective is the meningococcal vaccine? Q3h.4 How long does the meningococcal vaccine last? Q3h.5 What are some of the risks of the meningococcal vaccine? Q3h.6 When is the meningococcal vaccine recommended? Q3h.7 When is the meningococcal vaccine contraindicated? Section 3i. Varicella (chicken pox) vaccine Q3i.1 What is chicken pox, and what are the risks of the disease? Q3i.2 How common is chicken pox? Q3i.3 What is Herpes Zoster? Q3i.4 What is the current recommendation for the chicken pox vaccine be par= t for children? Q3i.5 What is the current recommendation for adults? Q3i.6 How effective is the chicken pox vaccine? Q3i.7 How long does the chicken pox vaccine last? Q3i.8 What reactions have been reported following the chickenpox vaccine? Q3i.9 Will a second dose be necessary in younger children? Q3i.10 For which groups is the chicken pox vaccine especially recommended? Q3i.11 When is the chicken pox vaccine contraindicated? Q3i.12 Is there a gamma globulin for chicken pox? Section 3j. BCG (tuberculosis) vaccine Q3j.1 What is tuberculosis, and what are the risks of the disease? Q3j.2 How common is tuberculosis? Q3j.3 How effective is the BCG vaccine? Q3j.4 How long does the BCG vaccine last? Q3j.5 What are some of the risks of the BCG vaccine? Q3j.6 When is the BCG vaccine recommended? Q3j.7 When is the BCG vaccine contraindicated? Q3j.8 What are some other methods of controlling tuberculosis? Section 3k. Hepatitis A vaccine Q3k.1 What is hepatitis A and what are the risks of the disease? Q3k.2 How common is hepatitis A? Q3k.3 Who is at risk for acquiring hepatitis A? Q3k.4 Is there a vaccine to protect against hepatitis A? Q3k.5 How is it to be administered? Q3k.6 How effective is the vaccine? Q3k.7 How long does immunity last? Q3k.8 What are some of the risks of the vaccine? Q3k.9 When is hepatitis A vaccine contraindicated? Q3k.10 What groups at risk may be included in a recommendation to receive h= epatitis A vaccination? Q3k.11 Is it possible that hepatitis A vaccine (like hepatitis B vaccine) m= ight eventually be recommended for routine administration to children and adults? Section 3l. Rotavirus vaccine Q3l.1 What is rotavirus, and what are the risks of the disease? Q3l.2 How common is rotavirus? Q3l.3 What is the current status of the rotavirus vaccine? Q3l.4 How effective is the rotavirus vaccine? Q3l.5 Is the rotavirus vaccine effective for breastfeeding infants? Q3l.6 How long does the rotavirus vaccine last? Q3l.7 What is intussusception? Q3l.8 What is the relationship between the rotavirus vaccine and intussusce= ption? Q3l.9 Why was a connection between the rotavirus vaccine and intussusceptio= n not observed prior to FDA approval of the vaccine? Q3l.10 What other reactions have been reported following the rotavirus vacc= ine? Q3l.11 Can the rotavirus vaccine be effectively used in developing countrie= s? Q3l.12 When is the rotavirus vaccine contraindicated?=20 Section 3m. Other vaccines which are available Q3m.1 What other vaccines are available and when are they given? Section 3n. Vaccines under development Q3n.1 What vaccines are currently under development? Q3n.2 What other research is being done to improve vaccines? Section 4. References Section 5. Stories of Parents =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 1. Introduction and General Information [This section last updated on September 25, 1999.]=20 Q1.1 What is vaccination?=20 The basic principle of vaccination is that a disease-causing agent is given= to a person in a killed or weakened form (or in the form of proteins genetically engineered to look like a disease-causing agen= t), in order to stimulate the production of antibodies to fight off the disease.=20 Q1.2 What are active and passive vaccination?=20 Active immunization involves trying to stimulate antibodies by giving a per= son a killed or weakened form of a disease-causing agent. Passive immunization involves giving a person antibodies from someon= e who was infected with the disease (these are called gamma globulins). Passive immunization doesn't last very long, but c= an be useful for someone who expects to be exposed to a disease (e.g. someone travelling to another country who takes = hepatitis A gamma globulin right before leaving), or to someone who has just been exposed to a disease. Most of the vaccinations= discussed in this FAQ fall under the active vaccination category.=20 Q1.3 What is herd immunity?=20 If a large enough percentage of a population is immune to a disease, their = immunity protects the rest of the "herd."=20 Some discussion of this concept from misc.kids follows:=20 ************************************************** *********************** From: (Paula Burch) | Paula Burch ) wrote: | : If one child remains unvaccinated, but all other children are | : vaccinated, the one child who does not get vaccinated is pretty safe | : from getting the disease. If many children remain unvaccinated, | : epidemics occur, and children die needlessly. | (Mark Dolson) writes:=20 | This is exactly what occured with measles in the 80's, BTW. Fewer | vaccinated, and the incidence skyrocketed, with resulting complications | of eye problems, etc, and even some deaths. I agree that people who | let their children remain unvaccinated are riding on the backs of=20 | everyone that does vaccinate, and I resent it. (Cerebus) writes: | To be fair, most of the major outbreaks (as well as most of the | serious complications) were and are on college campuses, and occurred *n= ot* | because of failure to vaccinate, but because the vaccine that was given | to kids between '69-'76 turned out not to give total immunity. Many kid= s | who were vaccinated were victims of measles, before people became consci= ous | that it was necessary for many teens and young adults to be re-vaccinate= d. | | I had measles my first year in college, after vaccination at the appropr= iate | age. After that outbreak my college began requiring re-vaccination. Bu= t it | is not technically correct to blame the measles outbreak on the failure = of | parents to vaccinate. It's true that that's what happended in that case, but it's not true for other cases, in which failure to vaccinate has been a major factor: "The nation [U.S.] has experienced a marked increase in measles cases=20 during 1989 and 1990. Almost one half of all cases have occurred in *unvaccinated* preschool children." (JAMA. 1991 Sep 18. 266(11). =20 P 1547-52.) "Beginning in October, 1990, a large measles outbreak involving predominantly *unvaccinated* preschool age children occurred in Philadelphia. By June, 1991, 938 measles cases had been reported to the Philadelphia Health Department. In addition to these cases, 486 cases and 6 measles-associated *deaths* occurred between November 4, 1990, and March 24, 1991, among members of 2 Philadelphia church groups that do not accept vaccination." (Pediatr-Infect-Dis-J. 1993 Apr= ..=20 12(4). P 288-92.) "In 1989 and 1990 the United States experienced a measles epidemic with= =20 more than 18,000 and 27,000 reported cases. Nearly half of all persons with measles were *unvaccinated* preschool children under 5 years of age= .."=20 (Am-J-Public-Health. 1993 Jun. 83(6). P 862-7.) Measles is bad, but I'm more concerned myself about pertussis (whooping cou= gh): "From 1980 through 1989, 27,826 cases of pertussis were reported to the Centers for Disease Control....Infants less than 2 months of age=20 had the highest reported rates of pertussis-associated hospitalization= =20 (82%), pneumonia (25%), seizures (4%), encephalopathy (1%), and *death*= =20 (1%)." (Clin-Infect-Dis. 1992 Mar. 14(3). P 708-19.) [Many of these= =20 infants would not have caught the disease if enough older children were= =20 appropriately vaccinated.] "Two large *epidemics* of pertussis occurred in Britain during 1977-79 and 1981-83." (Commun-Dis-Rep-CDR-Rev. 1992 Dec 4. 2(13). P R155-6.) This explains the herd immunity concept rather well: "The epidemiology of whooping cough [pertussis] in Denmark is described = =20 on the basis of the notified cases of the disease. The frequency of whooping cough has decreased to approximately one sixteenth of the previous level in children following the introduction of vaccination for whooping cough in 1961....deaths from whooping cough still occurred in the eighties, all of these among *unvaccinated* infants. The risk of whooping cough in an *unvaccinated* child is approximately one sixth of the risk prior to introduction of vaccination. In a vaccinated child, the risk, as judged from the notified cases, is one twentieth of the risk during the time prior to introduction of vaccination. In all age groups "herd immunity" is considered to have contributed considerably to the reduced incidence. The incidence in Denmark is, however, high compared with the incidence in some other industrialized countries. A vaccination programme with more numerous whooping cough vaccinations...may be recommended on the basis of the=20 strategy aimed at keeping the incidence of whooping cough, and thus the= =20 risk of exposure, as low as possible." (Ugeskr-Laeger. 1990 Feb 26. =20 152(9). P 597-604.) Paula Burch not speaking for Baylor College of Medicine ************************************************** *********************** Q1.4 How effective is vaccination at producing immunity?=20 Vaccination does not always work. For one thing, vaccines can lose effectiv= eness when they aren't stored properly. And even if they are stored effectively, they will fail to stimulate immunity a cert= ain percentage of the time. The effectiveness of vaccines varies, depending on the vaccine. Effectiveness can also vary depending on = the age, sex, and health of the recipient. Sometimes different strains of a vaccine can have different effectiveness.=20 Vaccine effectiveness is measured in two ways. First, antibody levels are m= easured after a vaccine is given. Second, people are vaccinated and then followed to see whether they get the disease when they = are exposed to it. Estimates of effectiveness can vary in some cases depending on the level of antibodies which is considered= as passing, and the criteria for measuring whether someone has the disease (for instance, pertussis vaccine is more effective = at preventing full-blown pertussis than at preventing a mild cough). Also, some sources give estimates of field effectiveness which= take into account difficulties in storing vaccines in some areas; these estimates tend to be lower than estimates based on studie= s of vaccination in the US or other developed countries.=20 Estimates of effectiveness of individual vaccines are given in the section = for each vaccine (and, where I have found variations in estimates of effectiveness, I have noted that as well).=20 ************************************************** *********************** From=20J Thompson ):=20 In addition to all of the factors you mentioned which determine the variabi= lity of response to a vaccine, another very important factor is the genetic inheritance of every individual. To give an example I= feel sure of, I'll use the Hepatitis B vaccine. A certain small percentage of the population has no response at all to the recombinan= t Hep B vaccine. This occurs because these people lack the particular forms of major histocompatibility complex (MHC) protein= s which are necessary to "present" the _single_ protein in the vaccine to the immune system. These people can make a good r= esponse to the whole virus, but they have a problem with the protein in the vaccine.=20 This also highlights the need for "herd immunity," since people who cannot = make an immune response to a vaccine component will _never_ have a good response to the vaccine, regardless of how often i= t is given. ************************************************** *********************** Q1.5 What are some of the risks of vaccination?=20 Again, these risks vary with the vaccine. However, there are some risks whi= ch are common to several vaccines. People may be allergic to a component of the vaccine, such as eggs or neomycin. Occasiona= lly, these allergies can lead to anaphylactic shock (doctors keep epinephrine on hand when giving vaccinations to guard against= this risk). Vaccines can produce the same symptoms as the disease (in a milder form, and with less frequent incidence= of the risks associated with the disease). Live vaccines in particular can be risky for people with weakened immune systems= , who have less ability to resist even the weakened form of the disease. Common minor adverse reactions include sorene= ss or swelling at the injection site and fever. Because of the latter, vaccinations are often postponed if the recipient al= ready has a fever.=20 Another risk is the risk that the vaccination will wear off, and the recipi= ent will get the disease later. Depending on the illness, the disease could be either less or more harmful to adults. While this risk= can be dealt with by giving boosters, it is worth bearing in mind in setting vaccination policies and making vaccination dsci= sions, because in some case getting the vaccine and then *not* getting the booster might lead to increased risk.=20 Further information related to vaccination risks follows:=20 From=20Cyndy Brunken: I posted this for Kathleen over on sci.med then I realized that=20 misc.kidders might also benefit from the info contained herein. ************************************************** *************** DISCLAIMER: THIS MESSAGE IS BEING POSTED FOR KATHLEEN STRATTON BY SOMEONE NOT AFFILIATED WITH THE MESSAGE. I have read-only access to USENET and have followed the immunization discussions in the last few weeks. I think some of the participants will have an interest in the following information. An Institute of Medicine (IOM) committee has concluded in a new report that a causal relation exists between certain common childhood vaccines and specific, but rare, health problems. The committee also determined that there appears to be no causal relation between some of those same vaccines and other specific health problems. The vaccines studied include those used against tetanus, diphtheria, measles, mumps, polio, hepatitis B, and Haemophilus influenzae type b (Hib). =20 The IOM is a private, non-profit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences. The IOM committee was NOT asked to assess risk- benefit or cost-benefit relations. Rather, the task was to evaluate all medical and scientific evidence bearing on the causal relation between childhood vaccines and specific, serious health outcomes. The report is entitled "Adverse Events Associated with Childhood Vaccines: Evidence Bearing on Causality". A previous IOM committee submitted a report in 1991 entitled "Adverse Effects of Pertussis and Rubella Vaccines". Both reports were mandated by the U.S. Congress in the 1986 National Childhood Vaccine Injury Act (P.L. 99-660). This law addressed many aspects of childhood immunization. Notably, it established a federal compensation program for those who have been injured by mandated childhood vaccines. The IOM committee reported that the evidence established a causal relation between diphtheria, tetanus, measles-mumps-and-rubella, and hepatitis B vaccines and anaphylaxis. The evidence established a causal relation between measles-mumps-and rubella vaccine and thrombocytopenia; between measles vaccine and death from measles infection (primarily in immunocompromised individuals); between oral polio vaccine and death from poliovirus infection (primarily in immunocompromised individuals); and between the oral polio vaccine and poliomyelitis disease. On the other hand, the committee found that the evidence favored rejection of a causal relation between diphtheria and tetanus vaccines and encephalopathy, infantile spasms, and SIDS. The committee found similarly regarding certain Hib vaccines and increased susceptibility to Hib disease. The committee investigated other serious health problems and classified their relation to vaccines in three other categories: no evidence, inadequate evidence to accept or reject a causal relation, and evidence favors acceptance of a causal relation. The specific relations are too numerous to list here. =20 The committee noted that in most cases it was impossible to calculate an incidence rate or relative risk for these reactions, but that they were, on the whole, extremely rare. The final report will be available in late October or early November from National Academy Press, 1-800-624-6242. It will cost approximately $60.00. (The report on pertussis and rubella is still available) A few prepublication copies of the Executive Summary of the new, 1993 report are available from the project director at no cost on a first come-first served basis. Anyone wishing specific information about this report can email me, Kathleen Stratton, directly. I am the study director for this project. My internet address is ************************************************** *********************** More information on the findings of the expert committee of the Institute o= f Medicine, along with a table showing in which categories they have placed various adverse events, and modified ACIP recom= mendations based on these findings, can be found in (MMWR 1996;45[No. RR-12]), or http://www.medscape.com/govmt/CDC/MM= WR/1996/sep/rr4512/rr4512.html. Between the publication of the 1993 report, and the publication of the 1996= update, two other IOM committees had met, and published findings concerning "concerning both the diphtheria and tetanus t= oxoids and pertussis vaccine (DTP) and chronic nervous system dysfunction ... and research strategies for vaccine-associat= ed adverse events" (MMWR 1996;45[No. RR-12]).=20 From=20Mike Dedek: ************************************************** *********************** New England Journal of Medicine 1987; 316: 1283-1288, May 14, 1987,=20 "Compensating Children with Vaccine-Related Injuries", Iglehart, John K. The federal immunization program, by virtually all economic, medical, an= d political measures, is a stunning success story because of its record of protecting millions of children against the common infectious diseases of t= he young. But in recent years the program has come under a legal cloud that is threatening its stability, slowing the development of new vaccines, and sending vaccine prices sharply upward. To address these problems, Congress = has created a new federal program to compensate children who suffer vaccine-rel= ated injuries, but how it will be funded and whether it will achieve its goals r= emain open questions. The legal cloud has formed because, even when the best vaccine products = are properly administered and used, vaccines pose minute risks to those who rec= eive them, and an increasing number of lawsuits are seeking damages on behalf of injured persons. Dr. Louis Z. Cooper, representing the American Academy of Pediatrics, testified before Congress on March 5 about the nature of these risks. Cooper stated: One case of polio-like disease will result from each 2.6 million doses = of oral polio vaccine OPV , and a serious, permanent neurological injury will result from every 310,000 doses of DTP diphtheria, tetanus, and pertussis vaccine . In extremely rare cases, an encephalitis or nerve deafness will develop from MMR measles, mumps, and rubella vaccine . Approximately 75 vaccine-related injuries per year are the price we pay to protect the more = than 3.8 million children born each year in this country. For five years, Congress has struggled to fashion legislation that addre= sses he complex issues related to the compensation of children injured by vaccin= es; in the process, it has explored virtually every conceivable policy option. ************************************************** *********************** Q1.6 What are some contraindications to vaccinations?=20 Contraindications vary with the vaccine, so contraindications for each spec= ific vaccine are given in the appropriate sections. Some common ones a allergy to some substance contained in the vaccine (s= uch as eggs or thimerosal, a preservative used in some vaccines), a weakened immune system (which may make attenuated live va= ccines more risky), and pregnancy.=20 The allergies to worry about, in particular, are those with an anaphylactic= or anaphylactoid reaction, e.g. hives, swelling of mouth and throat, difficulty breathing, hypotension, or shock.=20 Breastfeeding is not a contraindication to vaccination. From Harrison's Int= ernal Medicine, "Breastfed infants can be immunized on a normal schedule. Breast feeding does not adversely affect the immunce = response and is not a contraindication for any vaccine. Breast-feeding mothers also may be vaccinated without any problem.= " (British Medical Journal 1994; 309:1073-5 contains an article which confirms that breastfeeding will not interfere wi= th vaccination, and provides references to a couple of relevant studies.)=20 Q1.7 How common are the diseases vaccinated against?=20 I have extracted from table number 190, in _Statistical Abstracts of the Un= ited States_, the following table, showing the frequency, in the US, of some diseases for which vaccinations are either av= ailable and diseases for which I knew a vaccine was being developed or researched (obviously with more success in some cases th= an in others). Table information extracted from:=20 No. 190. Specific Reportable Diseases - Cases Reported: 1970 to 1990 Disease 1970 1980 1983 1984 1985 AIDS (N/A) (N/A) 2,117 4,445 8,249 Chickenpox (1000) (N/A) 190.9 177.5 222.0 178.2 Diptheria 435 3 5 1 3 Hepatitis B (serum) (1000) 8.3 19.0 24.3 26.1 26.6 A (infectious) (1000) 56.8 29.1 21.5 22.0 23.2 Measles (1000) 47.4 13.5 1.5 2.6 2.8 Meningococcal infections 2,505 2,840 2,736 2,746 2,479 =20 Mumps (1000) 105.0 8.6 3.4 3.0 3.0 Pertussis (1000) 4.2 1.7 2.5 2.3 3.6 Plague 13 18 40 31 17 Poliomyelitis, acute 33 9 15 8 7 Rabies, animal 3,224 6,421 5,878 5,567 5,565 Rabies, human 3 _ 2 3 1 Rubella (1000) 56.6 3.9 1.0 1.0 0.6 Tetanus 148 95 91 74 83 Tuberculosis (1000) 37.1 27.7 23.8 22.3 22.2 Typhoid fever 346 510 507 390 402 Disease 1986 1987 1988 1989 1990 AIDS 13,166 21,070 31,001 33,722 41,595 Chickenpox (1000) 183.2 213.2 192.9 185.4 173.1 Diptheria _ 3 2 3 4 Hepatitis B (serum) (1000) 26.1 25.9 23.2 23.4 21.1 A (infectious) (1000) 23.4 25.3 28.5 35.8 31.4 Measles (1000) 6.3 3.7 3.4 18.2 27.8 Meningococcal infections 2,594 2,930 2,964 2,727 2,451 Mumps (1000) 7.8 12.8 4.9 5.7 5.3 Pertussis (1000) 4.2 2.8 3.5 4.2 4.6 Plague 10 12 15 4 2 Poliomyelitis, acute 8 6 9 5 7 Rabies, animal 5,504 4,658 4,651 4,724 4,826 Rabies, human _ 1 _ 1 1 Rubella (1000) 0.6 0.3 0.2 0.4 1.1 Tetanus 64 48 53 53 64 Tuberculosis (1000) 22.8 22.5 22.4 23.5 25.7 Typhoid fever 362 400 436 460 552 Measles: 45 million cases and around 1 million deaths estimated in developi= ng countries in 1990. (Clements, Strassburg, Cutts, and Torel)=20 Polio: 16,435 cases reported by 46 countries to the Expanded Programme on I= mmunization in 1990, a 39% decrease from 1989 when 26,916 cases were reported. (Hull and Ward)=20 "Neonatal tetanus claimed the lives of over 433,000 infants in 1991. It is = endemic in over 90 countries throughout the world." (Whitman, Belgharbi, Gasse, Torel, Mattei, and Zoffman)=20 Pertussis (whooping cough): 659,973 cases reported in 1987. (Galazka)=20 The incidence of some of these diseases has changed significantly since the= tables in this section. More up to date information on worldwide incidence of vaccine preventable diseases can be found at http= ://www.who.org.=20 Q1.8 What percentage of children are vaccinated?=20 Some estimates of vaccination rates, from articles in World Health Statisti= cs Quarterly, 45, 1992:=20 Measles: About 80% of the world's children aged less than 1 were reported t= o have received measles vaccine (a dramatic increase from 1983, when the figure was less than 20%). (Clements, Strassbu= rg, Cutts, and Torel)=20 Polio: Estimated vaccination rate of 85% worldwide in 1990. This rate isn't= equally distributed, though. The Western Pacific Region had a coverage rate of 95%, and the South-East Asia Region 91%, but = the Africa Region had a coverage rate of only 56%. (Hull and Ward)=20 DTP: Varies widely from country to country. The US, Canada, France, Norway,= Poland, Australia, China were among the countries with coverage rates over 80% in 1987-1989. (The article gives Yug= oslavia as also being in this category, but in view of the breakup of the country and the civil war there, I would suspect that= level hasn't been maintained.) England, Spain, Mexico, Turkey, and most of the countries in South America, as well as the = Soviet Union (now defunct) were in the 50-80% category. Sweden and many African countries had coverage rates of under 50%= .. Coverage rates in the WHO regions were as follows: Africa 57%, Americas 75%, Eastern Mediterranean 80%, South-East As= ia 89%, Western Pacific 94%. (Galazka)=20 From=20_Statistical Abstracts of the United States, tables no. 189, Percent= of Children Immunized Against Specific Diseases, by Age Group: 1980 to 1985 (I am including the totals only, but the table also= includes a breakdown by race)=20 Disease All Respondents =20 1 to 4 years old =20 1980 1984 1985=20 Diptheria-tetanus-pertussis 66.3 65.7 64.9 Polio 58.8 54.8 55.3 Measles 63.5 62.8 60.8 Rubella 63.5 60.9 58.9 Mumps 56.6 58.7 58.9 Disease All Respondents =20 5 to 14 years old 1980 1984 1985=20 Diptheria-tetanus-pertussis 74.0 73.8 73.7 Polio 70.0 70.2 69.7 Measles 71.0 73.5 71.5 Rubella 74.0 72.4 70.2 Mumps 63.2 70.9 71.6 Respondents consulting records, 1985 (29 percent of white and 15 percent of= black or other respondents who consulted records for some or all vaccination questions)=20 Disease 1 to 4 years 5 to 14 years Diptheria-tetanus-pertussis 87.0 93.0 Polio 75.7 88.4 Measles 76.9 87.4 Rubella 73.8 85.3 Mumps 75.5 87.1 According to the California Morbidity for May 21, 1993, about one third of = infants were found not to be vaccinated, and more than half of all toddlers were behind schedule at their second birthday. Va= ccination rates were lower among black and Hispanic children. Only at school entry age did vaccination levels really rise, the = result of school requirements. By 1990, more than 90% of school age children were vaccinated. Immigration was cited as one factor= keeping vaccination rates low.=20 The May 1, 1994 HICNet Medical News, citing MMWR, reports on vaccination co= verage of 2 year old children in the US from 1992-1993,=20 "Vaccination coverage increased for three vaccines from 1992 to 1993: for t= hree or more doses of Hib, from 28.0% to 49.9% (p less than 0.05); for three or more doses of poliomyelitis vaccine, from = 72.4% to 78.4% (p less than 0.05); and for three or more doses of DTP/ diphtheria and tetanus toxoids (DT), from 83.0% to 87.2%= (p greater than 0.05). Coverage with measles-containing vaccine decreased from 82.5% to 80.8% (p greater than 0.= 05). Among 19-35-month-olds, 12.7% had received three or more doses of Hep B.=20 From=201992 to 1993, the proportion of children who had received a combined= series of four or more doses of DTP/DT, three or more doses of polio vaccine, and one dose of MMR increased from 55.3% to= 64.8% (p less than 0.05), primarily because of increased coverage with the fourth DTP/DT dose (from 59.0% to 71.1% [p l= ess than 0.05])."=20 More details on these statistics in that issue of HICNet Medical News. For = those who are interested, MMWR gives quarterly updates of vaccination coverage in the US, evaluating progress toward the n= ational goal of 90% coverage. These updates are included in HICNet Medical News when they come out, and MMWR itself can als= o be retrieved over the net. See the reference section in section 3 of this FAQ for information on retrieving MM= WR over the net. HiB and hepatitis B vaccination coverage has been increasing (as is to be expected, since those are the mos= t recently instituted vaccines). The March 5, 1995 HICNet includes an MMWR report which shows HiB coverage rising to a record = high of 70.6% and Hep B coverage rising to 25.5% during the first quarter of 1994. However, a report in JAMA, cited in= a summary in Journal Watch for Jan 15, 1995 (paper) or Feb 7, 1995 (electronic), "found that only 46 percent of white c= hildren and only 34 percent of black children had received adequate immunization by eight months of age (JAMA Oct 12, pp. 110= 5 and 1111)."=20 Q1.9 What are some sources of further information about vaccinations?=20 I don't have any addresses for information outside the US (except for the W= HO book on travel vaccinations); if people contribute them I'll add them.=20 Information on vaccinations is available from: The Academy of Pediatrics, C= ommittee on Infectious Diseases, Evanston, Illinois 60204; Centers for Disease Control, Atlanta, Georgia 30333; Council on Envi= ronmental Health, American Medical Association, Chicago, Illinois 60610. The CDC also has a Voice/Fax Informat= ion Service. To access the CDC Voice Information System, telephone (404) 332-4555; to access the CDC Fax Informa= tion System, telephone (404) 332-4565. Their Web site is http://www.aap.org.=20 Not specific to vaccinations, but useful in general for the effects of drug= s, illnesses, etc., during pregnancy is the UCSD Teratogen Registry (1-800-532-3749). Another general source of information = on illnesses is the National Foundation for Infectious Diseases, 4733 Bethesda Ave., Suite 750, Bethesda, Maryland 2081= 4 (USA).=20 Critics of routine vaccination have set up their own information center; it= is called the National Center for Information on Vaccination and is based in Virginia. Their telephone number is 1-800-909-S= HOT (for orders only) or 703-938-DPT3 and their address is 512 W. Maple Ave. #206, Vienna VA 22180. Their web site ca= n be found at http://www.909shot.com/default.htm.=20 Information on travel vaccinations is available from _Health Information fo= r International Travel_, published annually by the Centers for Disease Control, and available from: Superintendent of Document= s, US Government Printing Office, Washington, DC 20402. This publication also has a lot of other information on health-re= lated travel issues, and some information on the regular childhood vaccinations as well (it also includes a table, for all v= accinations, of which are contraindicated during pregnancy). It is also available in some public libraries. The CDC informs = all state and many city and county health departments twice monthly about changing risks and requirements. Another source is _INT= ERNATIONAL TRAVEL AND HEALTH: Vaccination Requirements and Health Advice_, copies of which may be ordered= from WHO Distribution and Sales, CH-1211, Geneva 27, telephone (41 22) 791 2476; fax (41 22) 788 0401. (More= sources of information about travel vaccinations can be found in the section of this FAQ which covers them.)=20 The reference section of this FAQ lists the sources I used in putting toget= her the FAQ. Some of the ones I used most heavily include Harrison's Principles of Internal Medicine, The Merck Manual, _Taki= ng Care of Your Child: A Parents' Guide to Medical Care_, by Pantell, Fries, and Vickery, The Physician's Desk Referen= ce, The American Hospital Formulary Service Drug Information, and _The Wellness Encyclopedia_ From the editors of the U= C Berkeley Wellness Letter, and, more recently, http://www.medscape.com. Here is a list of other people's suggest= ions (to which people are welcome to add):=20 Suggested by Heather Madrone:=20 Robert Mendelsohn _How to Raise a Healthy Child_ George Wootan _Take Charge= of Your Child's Health_=20 Suggested by Roger Barr:=20 recommend books by Harris Coulter among others: Shot in the Dark (about DPT= vaccinations) and another about violence in society due to neurological damage caused by vaccinations (autoimmune respo= nses leading to meningitis)=20 Suggested by John:=20 http://www.whale.to/vaccines.html=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 2. The recommended vaccination schedule [This section last updated on October 23, 1999.]=20 Q2.1 What is the recommended vaccination schedule in the US for infants?=20 The following schedule is based on the schedule published on January 15, 19= 99, published in MMWR 48(01);8-16 and the schedule on the AAP website as of August 1999.=20 Vaccine Recommended Age (or Range) Hepatitis B Birth to 2 mos, 2-4 mos, 6-18 mos=20 DTaP 2 mos, 4 mos, 6 mos, 15-18 mos, 4-6 yrs DT 11-12 yrs or 14-16 yrs, every ten years thereafter HiB 2 mos, 4 mos, 6 mos, 12-15 mos Polio (IPV) 2 mos, 4 mos, 6-18 mos, 4-6 yrs MMR 12-15 mos, 4-6 yrs Varicella 12-18 mos Notes: (1) At 11-12 years, hepatitis B, MMR, and Varicella vaccines to be a= ssessed and administered if necessary. (2) Hepatitis B vaccine schedule in infants depends on the mother's hepatitis B= surface antigen status; where this status is positive or unknown, hepatitis B vaccination is recommended within 12 hours of birth= , but where this status is negative, the vaccine may be given at any time between birth and 2 months. (3) Three different Hib co= njugate vaccines are licensed. Depending on which is used, the dose at 6 months may or may not be required. (4) As of July, 1= 999, the AAP recommended a temporary delay (until thimerosal-free Hepatitis B vaccine is available), for children of H= epatitis B surface antigen negative mothers, in the first shot, to six months. The CDC continues to recommend that the shot be given = at from 2-6 months. As of September, 1999, a hepatitis B vaccine without thimerosal has become available, so, as supplie= s of this vaccine are distributed, the temporary delay should come to an end. (5) In 1999, ACIP recommended hepatitis A vaccine fo= r all children aged 2 years and older in the 11 Western states where incidence is especially high (at least 20 cases per 10= 0,000 people, twice the national average). These states a Arizona, Alaska, California, Idaho, Nevada, New Mexico, Oklahom= a, Oregon, South Dakota, Utah and Washington.=20 There has been a difference of opinion about when the second dose of MMR sh= ould be given. ACIP recommended 4-6 years, but the AAP recommended at entry to middle or junior high school. Health au= thorities in different states in the US have adopted one or the other of these requirements. The advantage of giving the= second dose at 4-6 years is that compliance may be higher if it is made a requirement of entrance to public schools. The ad= vantage of giving the second dose later is that it will be closer in time to the age at which measles outbreaks have been occuring,= and may increase immunity at that time. The AAP and ACIP have since coordinated their recommendations and agreed on 4-6 yea= rs.=20 This schedule is subject to change, and so, if you look at different medica= l and childcare books, you may see slightly different schedules. Recent changes include the addition of a new vaccine for haemoph= ilus influenzae B, the addition of the hepatitis B vaccine to the schedule, and the addition of a second dose of MMR at entry = to primary or middle school, in response to an increased incidence in measles among teenagers, and the addition of the chi= cken pox vaccine to the schedule. The FDA approved a couple of new vaccines in 1993: a combination of Haemophilus inf= luenzae B vaccine and DTP vaccine, and a new dosage for the hepatitis B vaccine. In 1992, a new acellular pertussis vacc= ine was approved. In 1995, the varicella zoster (chicken pox) vaccine was approved. On July 12, 1996, ACIP recommended that= this vaccine be added to the schedule. The newly approved hepatitis A vaccine was *not* added to the schedule; this va= ccine was recommended only for people at particular risk, such as travellers to countries where hepatitis A is more = prevalent (more recently, it has been recommended in states where hepatitis A is particularly prevalent). In 1996, an acellular = pertussis vaccine was approved for the earlier shots in the pertussis series (previously it had only been approved for the fourth a= nd fifth shots), so that it is now the preferred vaccine for all shots. As a result of progress in the global eradication of polio, = in 1997, ACIP recommended that the first doses of polio vaccine use the inactivated polio vaccine (IPV) rather than the oral polio = vaccine (OPV). In January, 1999, the AAP recommended that all doses use IPV, and on June 17, 1999, the ACIP followed= suit (this new ACIP recommendation will become effective on January 1, 2000).=20 Rotavirus vaccine was added to the schedule at 2, 4, and 6 months, after it= s approval on August 31, 1998, but on July 7, 1999, this recommendation was suspended, pending collection of further data= , based on early surveillance reports of intussusception (a type of bowel obstruction), and on October 15, 1999, the= vaccine was withdrawn from the market.=20 Q2.2 What is the recommended vaccination schedule in the US for older child= ren who were not vaccinated in infancy?=20 Schedules for people not vaccinated in infancy can be found, among other pl= aces, in the Merck Manual and in AMA Drug Evaluations Annual. There are two schedules, one for children under 7, and = one for people (children or adults) over 7. The reason is that pertussis vaccine should not be given to anyone over 7. Pert= ussis is a mild disease over the age of 7, but a serious one for the very young. For that reason, the risks of the vaccine outweigh = the risks of the disease after the age of 7. It is possible that, with the availability of a less reactogenic acellular vaccin= e, this recommendation may change, and pertussis vaccine be give to older people as well, but such a change will not occur w= ithout further study.=20 Q2.3 What is the recommended vaccination schedule in the US for adults?=20 If they haven't been vaccinated at all, see the answer to question 2.22.2. = If they have been vaccinated, then a tetanus and diptheria booster is recommended every ten years (or five years in case of = a very dirty wound). People in certain high risk groups are advised to get flu shots annually (see the section on the flu va= ccine).=20 Q2.4 Who determines this schedule?=20 Two bodies set these schedules. They are the Immunization Practices Advisor= y Committee (ACIP) of the Public Health Service, and the American Academy of Pediatrics Committee on Infectious Dis= eases. During 1994, these organizations were part of a working group which included representatives from the American Ac= ademy of Family Physicians which developed one schedule to incorporate ACIP and AAP recommendations. A new schedule wa= s been endorsed by these groups and became effective January 1995. In modifications of the schedule since then,= sometimes one group has differed slightly from the other, but in time they reconcile their schedules.=20 Q2.5 What other US government organizations are concerned with vaccinations= ?=20 Q2.5.1 What is the National Vaccine Injury Compensation Program (VICP)?=20 [Note: Answers to this and the following several questions are extracted fr= om a longer list of questions and answers put out by the National Vaccine Injury Compensation Program (1-800-338-2382).]=20 The National Childhood Vaccine Injury Act of 1986 (the Act) established the= VICP. This Program went into effect in October 1988 and is a Federal "no-fault" system designed to compensate those indivi= duals, or families of individuals, who have been injured by childhood vaccines, whether administered in the private or publi= c sector. The Program is administered jointly by the Court, the Department of Health and Human Services (HHS), and the Departmen= t of Justice (DOJ).=20 Q2.5.2 What vaccines are covered?=20 Diphtheria, tetanus, pertussis (DTP, DT, TT, or Td), measles, mumps, rubell= a (MMR or any components), and polio (OPV or IPV).=20 Q2.5.3 Who may file a claim?=20 A claim may be made for any injury or death thought to be a result of a cov= ered vaccine. These injuries may include, but are not limited to: anaphylaxis, paralytic polio, seizure disorders, and enceph= alopathy. The injured individual may file; or a parent, legal guardian, or trustee may file on behalf of a child or an incapacitate= d person.=20 Claims need to be filed within 36 months after the first symptoms appeared = and show that effects have continued for at least 6 months (in the case of vaccine related injuried) or be filed within 24 mont= hs of the death and within 48 months after the onset of the vaccine-related injury from which the death occurred. The time for fili= ng claims for injuries resulting from vaccines administered prior to October 1, 1988, has expired.=20 The petitioner must either prove that the vaccine caused the injury or sign= ificantly aggravated a preexisting condition, or the petitioner must show that an injury on the Vaccine Injury Table occurred (m= ost claims involve "Table Injuries" because it is easier to demonstrate a Table Injury than to prove that the vaccine caused = the condition). A modified Vaccine Injury Table is effective for claims filed on or after March 10, 1995.=20 Q2.5.4 Who can I contact to get more information about the Program?=20 1. The toll-free number for the National Vaccine Injury Compensation Progra= m is 1-800-338-2382 to obtain an information packet detailing how to file a claim, criteria for eligibility, and the doc= umentation required. For further information write to: National Vaccine Injury Compensation Program, Parklawn Building, Room 8A-35= , 5600 Fishers Lane, Rockville, Maryland 20857.=20 2. For information on the rules of the U.S. Court of Federal Claims, includ= ing requirements for filing a petition, call 1-202-219-9657 or write to: U.S. Court of Federal Claims, 717 Madison Place= , N.W., Washington, DC 20005.=20 Q2.5.5 What is VAERS?=20 [LG: Information about VAERS excerpted and summarized from material from VA= ERS. This section last updated in 1994.]=20 The National Childhood Vaccine Injury Act (NCVIA) of 1986 mandated the repo= rting of certain adverse events following vaccination. This Act led to the establishment of the Vaccine Adverse Event= Reporting System (VAERS) in November 1990 by the Department of Health and Human Services. VAERS provides a database m= anagement system for the collection and analysis of data from reports of adverse events following vaccination. VAER= S is operated jointly by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Bo= th the CDC and the FDA review data reported to VAERS.=20 Between January 1, 1991 and December 31, 1994, VAERS has received approxima= tely 45,000 reports. VAERS currently receives approximately 800-1000 reports each month.=20 Q2.5.6 Who can report to VAERS?=20 Any one can report to VAERS. VAERS reports are usually submitted by health = care providers, vaccine manufacturers, and vaccine recipients (or their parents/guardians). Patients, parents, and gua= rdians are encouraged to seek the help of a health-care professional in reporting to VAERS.=20 Q2.5.7 What events should be reported to VAERS?=20 The NCVIA requires the reporting of any events in the Reportable Events Tab= le which occur within the time period specified and any event listed in the manufacturer's package insert as a contraindica= tion to subsequent doses of the vaccine. A copy of the Table can be obtained by calling 1-800-822-7967. Although NCVIA only re= quires reporting of the events mentioned in the Table, VAERS encourages all reporting of any clinically significant adv= erse event occurring after the administration of any vaccine licensed in the United States.=20 On average, about 17% of the reports reflect adverse events resulting in li= fe-threatening illness, hospitalization, permanent disability, extended hospital stay or death. The remaining 83% of the repor= ts primarily describe events such as fever, local reactions transient crying or mild irritability, and other less serious exp= eriences.=20 Q2.5.8 Are all events reported to VAERS caused by vaccinations?=20 Again, VAERS accepts all reports of adverse events following vaccination, s= o not all events reported to VAERS are caused by vaccines. In fact, limitations such as differential reporting rates, sim= ultaneous administration of different vaccine antigens, temporal reporting bias and lack of background vaccination rate data genera= lly prevent the determination of vaccine-event causal associations using VAERS data.=20 Q2.5.9 How can I get rapid information on VAERS, such as how to file a repo= rt?=20 There is a toll-free VAERS information line that is currently receiving ove= r 650 calls per month.=20 A VAERS report form has been designed to facilitate and standardize the pro= cess of reporting adverse events following vaccination to VAERS. For a sample copy of the VAERS report form, see the l= ast page of the 1995 Physician=FFs Desk Reference (PDR) or page 34 of the 1994 Redbook.=20 Report forms can be obtained by calling VAERS at 1-800-822-7967. Xerox copi= es of the PDR or Redbook forms may also be used.=20 Q2.5.10 Have there been any comprehensive scientific studies on adverse eve= nts following immunization?=20 Yes. In 1986, the US Congress mandated the Institute of Medicine to conduct= a scientific review of the possible adverse events following commonly used childhood vaccines. The Institute convened a= n expert panel to implement this mandate and has published two reports on its findings. Both reports concluded that adverse = events caused by vaccines are rare.=20 1. Howson, et al., Adverse Effects of Pertussis and Rubella Vaccines. Washington, DC: National Academy Press, 1991. 2. Stratton, et al., Adverse Events Associated with Childhood Vaccines, Evidence Bearing on Causality. Washington, DC: National Academy Press, 1993. Q2.5.11 Are VAERS data available to the public?=20 Yes. Once any identifying information is removed, VAERS data are made avail= able to the public, for a fee, through the National Technical Information Service (NTIS) at:=20 National Technical Information Service 5285 Port Royal Road Springfield, VA 22161 (703-487-4650). Q2.6 What vaccination schedules are used in other countries?=20 Routine vaccination is practiced in many countries, but specific schedules = vary from country to country. The vaccine for tuberculosis is given in some countries where tuberculosis is common, but i= s not given in the US. Tetanus toxoid is given to pregnant women in countries where neonatal tetanus is common. Some countrie= s, like the US, vaccinate all infants against rubella, while others choose instead to vaccinate adolescent girls (as of 1= 992 - I am not sure whether this is still true, as I know that the UK, at least, has switched to infant vaccination since then). (Gal= azka). When this FAQ was first written, there were significant differences between countries in requirements and coverage for = the pertussis vaccine, but, with the introduction of the new acellular pertussis vaccine, countries which had increased the age = of pertussis vaccination or made it optional have returned it to their schedules.=20 There is also some variation in the schedules at which vaccines are given. = For example, schedules for DTP vaccine include 2, 3, and 4 months, or 3, 4, and 5 months, or 3, 5-6, and 7-15 months, and boo= ster doses are given in some countries at 12-14 months, and in some countries at 3-6 years (Galazka - two charts in this ar= ticle give DTP schedules for various countries in Europe and percentages of countries following different schedules in differ= ent regions of the world).=20 People outside the US are advised to consult their doctors about the specif= ics of vaccination schedules in their countries (keeping vaccination schedules for all the countries represented in misc.ki= ds current is probably too big a job for one FAQ maintainer). http://www.who.org is also a good source for vaccination sched= ules in various countries.=20 Q2.7 What international bodies are concerned with vaccinations?=20 The World Health Service Expanded Programme on Immunization works to increa= se the percentage of the world's children vaccinated against certain target diseases: poliomyelitis, measles, tubercu= losis, diptheria, and tetanus. The WHO/UNDP (United Nations Development Programme) Programme for Vaccine Development pr= omoted research into new and improved vaccines. The Children's Vaccine Initiative, founded in 1990 by UNICEF, UND= P, the Rockefeller Institute, the World Bank, and WHO, promoted new and better vaccines for the world's children, coopera= ting with the Programme for Vaccine Development and the EPI. (Hartveldt) WHO also has three centers which coope= rate with organizations in 79 countries to formulate the annual flu vaccine. (Ghendon) |
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Archive-name: misc-kids/vaccinations/part3
Posting-Frequency: monthly Last-Modified: October 23, 1999 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3f. Influenza [This section last updated on October 23, 1999.]=20 Q3f.1 What is influenza, and what are the risks of the disease?=20 Influenza has a fairly high mortality rate among the elderly and the chroni= cally ill. Complications include pneumonia, neurological complications, myocardia, heart block, and peripheral vasoconstriction.=20 Q3f.2 How common is influenza?=20 Outbreaks of flu occur almost every year, generally in the winter, and can = cause thousands to be hospitalized.=20 Q3f.3 How effective is the influenza vaccine?=20 About 70-80% in young, healthy adults. About 50% effective in adults over 6= 0. (For studies on older adults, see JAMA 1994 Dec 7, N Engl J Med 1994.) For a summary of recent studies showing benefits= in elderly adults, young children in day care, and healthy adults, see Journal Watch for January 1, 1996, Volume 16, Numbe= r 1, "Top Medical Stories of 1995." Of particular interest to parents is a study published in Arch Pediatr Adolesc= Medicine, Oct 1995, 149:1113, in which children at high risk for otitis media (ear infections) showed 32% fewer cases during t= he flu season when they received the flu vaccine.=20 Note that influenza vaccine protects against influenza only, and not agains= t other respiratory infections.=20 An intranasal flu vaccine has shown efficacy in trials and may be available= within a year.=20 Q3f.4 How long does the influenza vaccine last?=20 It has to be repeated every year, as the strains of influenza vary from yea= r to year.=20 Q3f.5 What are some of the risks of the influenza vaccine?=20 Public confidence in flu shots was reduced by the swine flu controversy of = 1976-1977. Of the nearly 48 million people who were vaccinated that year, about 500 came down with a rare paralytic condit= ion called Guillaine-Barre syndrome. This was many more than could normally be expected to come down with this disease (t= hough still a small percentage of all the vaccinated people). After this year, there were changes to the vaccine, and= medical sources (Berkeley, PDR) report that the vaccine has not been clearly associated with Guillaine-Barr syndrome since = that time.=20 Adverse reactions include local tenderness, and, infrequently, fever, "most= often [affecting] people who have had no exposure to the influenza virus antigens in the vaccine (e.g. small children)." (PDR= ) Allergic reactions also occur.=20 Q3f.6 When is the influenza vaccine recommended?=20 It is recommended for people who are over 65 and for people with various ch= ronic illnesses, particularly those affecting the lungs (including asthma) or the heart. Candidates among children include si= milar groups to those for pneumococcal vaccine: sickle cell, chronic renal and metabolic disease, diabetes, chronic pulmona= ry disease, long-term aspirin therapy, and significant cardiac disease (Catalana).=20 In the US, the rate of vaccination for influenza in the groups for whom the= vaccine is recommended is only 20%. Among children, the rate is 1-7% (Catalana).=20 The antiviral drugs amantadine and rimantadine are also effective against i= nfluenza A, but not influenza B.=20 Q3f.7 When is the influenza vaccine contraindicated?=20 Egg allergy, hypersensitivity to thimerosal. Delay in case of an active neu= rological disease or fever. (PDR) The AHFS gives the same contraindications, but adds a history of Guillaine-Barre syndrome and = bleeding disorders which would contraindicate intramuscular injection.=20 Vaccine components capable of causing adverse reactions: chick embryo compo= nents, formaldehyde, thimerosal (Travel Medicine Advisor).=20 Q3f.8 Is it OK to be vaccinated for influenza during pregnancy?=20 It depends. When this topic has come up on misc.kids, people have reported = different recommendations from their doctors. And, when I consulted the PDR, I found the same result: the PDR says that t= he risks of the vaccine (especially during the first trimester) have to be weighed against the risks of a particular patient get= ting the flu, and that "The clinical judgment of the attending physician should prevail at all times in determining whether to a= dminister the vaccine to a pregnant woman."=20 The CDC, in the October 8, 1999 issue of MMWR, recommended that "Pregnant w= omen with high-risk medical conditions should be vaccinated before the start of the influenza season regardless of= their stage of pregnancy. Pregnant women without high-risk medical conditions, but who will be in their second or third trim= ester during the influenza season, are at elevated risk of complications and should be vaccinated. Some experts prefer to vaccinate= these women during the second trimester to avoid a coincidental association with spontaneous abortion, which is common= in the first trimester, and because exposures to vaccines traditionally have been avoided during the first trimester. "=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3g. Pneumococcal vaccine [This section last updated September 18, 1999.]=20 Q3g.1 What is pneumococcal disease, and what are the risks of the disease?= =20 It causes ear infections and sinusitis in children, and sometimes meningiti= s and pneumonia.=20 Q3g.2 How common is pneumococcal disease?=20 From=20Nelson Textbook of Pediatrics, Behrman and Vaughn, eds.,14th edition= , 1992: ------------------------------------------------------------------------ Pneumococcus (_Streptococcus pneumoniae_) is a normal inhabitant of the upper respiratory tract (as many as 91% of children between 6 mo and 4 1/2 yr of age carry this bacterium at some time). Pneumococcus is the most common cause of bacteremia (bacteria in the blood), bacterial pneumonia, and bacterial otitis media (middle ear infections). Pneumococcus causes 25-30% of acute middle ear infections. It is also high on the list for bacterial causes of meningitis. =20 ------------------------------------------------------------------------ There has been recent evidence of antibiotic-resistant pneumococci (see JAM= A 1994; 271:1831; and MMWR 1994; 43:23; articles summarized in Journal Watch, January 15, 1995 in the paper edition= and February 7, 1995 in the electronic edition).=20 Q3g.3 How effective is the pneumococcal vaccine?=20 It protects against 23 strains of pneumococcus, 85% of those which cause ea= r infections and almost all of those which cause pneumonia and meningitis. Harrison's Internal Medicine estimates its effect= iveness at 60-80%.=20 Some recent articles discussing (and debating about) the effectiveness of p= neumococcal vaccine can be found in Arch Intern Med 1994 Dec; 154:373, 154:2666 and 154:2531; these articles and others are= summarized in "Featu Does Pneumococcal Vaccine Live Up to Its Reputation?" in the February 28, 1995 Journal Watch = (electronic form) or Mar 1, 1995 Journal Watch (print form). Other relevant articles are in the Annals of Internal Medicin= e 1988;108:616-625 and the New England Journal of Medicine for 11/21/91.=20 Q3g.4 How long does the pneumococcal vaccine last?=20 According to a chart I got from Kaiser, one dose is good for life, except f= or immune suppressed or immunodeficient patients, who should get a booster two years later. _Travel Medicine Advisor_ also sa= ys that no booster is required. _AHFS Drug Information_, however, says that antibodies are elevated at least five year= s in healthy adults, but decline to prevaccination levels after ten years in some.=20 The reason for the apparent conflict in recommendations is that allergic re= actions are more common after the booster shots, but, at the same time, the booster shots are useful for maintaining immunit= y. For this reason, there has been some debate about the booster shots; the most recent recommendation is "revaccination with pn= eumococcal vaccine after six years in people with high-risk chronic conditions" (Journal Watch for Oct 18, 1994). (An example= is a person without a functioning spleen.) The 23-valent vaccine was introduced in 1993; prior to that the vaccine was onl= y 14-valent.=20 Journal Watch for Oct 18, 1994 summarizes an article in the Archives of Int= ernal Medicine (1994 Oct 10; 154:2209-14) on pneumococcal boosters. "Antibody levels wane significantly within six years= after vaccination, necessitating revaccination of high-risk patients. This interesting study evaluated immunogenicity associa= ted with revaccination." Shots of pneumococcal vaccine were found to increase antibody levels "at least 1.4-fold in about = 55 percent" of both previously unvaccinated adults and those who had been vaccinated 5.5 to 9 years previously.=20 Q3g.5 What are some of the risks of the pneumococcal vaccine?=20 Discomfort at injection in 30-40% of recipients, and fever in 5-20% of reci= pients. (Catalana)=20 Q3g.6 When is the pneumococcal vaccine recommended?=20 It is recommended for children 2 or older who are at increased risk of pneu= mococcal infection. Conditions which increase risk of pneumoccoal infection include HIV positive status, functional or anatomi= c asplenia, and sickle cell or other hemoglobinopathies. It is also recommended for adults 65 or older and adult= s with significant cardiovascular or pulmonary disorders, splenic dysfunction, asplenia, Hodgkin's Disease, multiple myelo= ma, cirrhosis, alcoholism, renal failure, CSF leaks, or immunosuppressive conditions.=20 Work is underway now to develop and test a pneumococcal conjugate vaccine (= analogous to the HiB conjugate vaccine) to allow immunization of those younger than 24 months (which is the age group = most affected by S. pneumoniae). This might open up a new indication for pneumococcal vaccine: prevention of middle ear infe= ctions. As of 1997, four different conjugate pneumococcal vaccines for infants were in Phase II/III trials (Williams, 19= 97)=20 Q3g.7 When is the pneumococcal vaccine contraindicated?=20 It should not be given to children under 2. It also shouldn't be given to p= eople who have already been vaccinated (except for booster shots for those in the highest risk categories).=20 Vaccine components capable of causing adverse reactions: phenol, polysaccha= rides, thimerosal (Travel Medicine Advisor).=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3h. Meningococcal vaccine [This section last updated on September 1= 8, 1999.] Q3h.1 What is meningococcal disease, and what are the risks of the disease?= =20 Meningococcal disease is a rare disease which causes meningitis as well as = widespread blood infection, leading to shock and death.=20 Q3h.2 How common is meningococcal disease?=20 About 2,500 cases a year in the US, but tens of thousands annually in sub-S= aharan Africa.=20 Q3h.3 How effective is the meningococcal vaccine?=20 The current vaccine not highly immunogenic in children under 2, or very lon= g lasting, and it is children under 2 who have the highest rate of the disease. Research is being done on conjugate vaccines w= hich would produce a greater immune response. Global cooperation would be needed to make these affordable in developing c= ountries. (Williams, 1997)=20 Q3h.4 How long does the meningococcal vaccine last?=20 I don't have this information.=20 Q3h.5 What are some of the risks of the meningococcal vaccine?=20 Adverse reactions are infrequent and mild, mostly redness at the injection = site for 1-2 days. Up to 2% of children vaccinated will experience transient fever (Health Information for the International T= raveller, 1992).=20 Q3h.6 When is the meningococcal vaccine recommended?=20 For children with certain types of immune disorders and during epidemic out= breaks. It is also given to children travelling to certain areas, and is required for pilgrims to Mecca for the annual Haj (as= of 1992, according to the CDC).=20 Q3h.7 When is the meningococcal vaccine contraindicated?=20 I haven't found any, except pregnancy (when it should be given only in case= of an outbreak).=20 Vaccine components capable of causing adverse reactions: phenol, polysaccha= rides, thimerosal (Travel Medicine Advisor).=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3i. Varicella (chicken pox) vaccine=20 [Note: The varicella section has been modified slightly and updated. Inform= ation is from FDA press releases on 1/28/94 and 3/17/95 and and an article in Infectious Diseases in Children newsletter {v= ol 8(2) February l995}. It has been further updated based on the July 12, 1996 recommendation by ACIP. This section last update= d on September 25, 1999. I have some additional information on zoster which I will be merging into this section = in my next update.]=20 Q3i.1 What is chicken pox, and what are the risks of the disease?=20 Varicella or chickenpox is a highly contagious disease caused by varicella = zoster virus. Complications are rare in normal children, but more common in children with immune deficiencies. The disease= is somewhat more severe in adults, and can be serious for newborns and pregnant women. Possible (infrequent) complication= s include hemorrhagic varicella, encephalitis, pneumonia, and bacterial skin infection. Possible complications in pregnanc= y include premature birth and congenital varicella, and mortality (of the infant, not the mother) is high. "It is estimated tha= t there are about 9,600 chicken-pox related hospitalizations annually, with 50 to 100 deaths." (FDA announcement, Janua= ry 28, 1994) Another risk, unfortunately on the increase, is invasive group A streptococcal infections, to which children i= ll with varicella may be susceptible.=20 A study of the effects of congenital varicella and herpes zoster (Enders G;= et al. Consequences of varicella and herpes zoster in pregnancy: prospective study of 1739 cases. Lancet 1994 Jun 18; 343:1548-51= .., summarized in Journal Watch Summaries for July 1, 1994.) followed 1373 women with varicella and 366 women with herpes= zoster acquired during the first 36 weeks of pregnancy. Nine of the infants had congenital varicella syndrome, with defe= cts ranging from "multisystem involvement to limb hypoplasia and skin scars." There were no cases of congenital varicella syn= drome among infants whose mothers had varicella after 20 weeks or among those whose mothers received anti-varicella-zoster = immunoglobulin after they were exposed.=20 Q3i.2 How common is chicken pox?=20 An estimated 3.7 million Americans are affected by chickenpox each year, wi= th more than 90% of the cases occurring in persons under 15 years of age. 33% of cases are estimated to occur in child= ren ages 1 to 4, and 44% in children ages 5 to 9 (estimates from January 28, 1994 FDA announcement).=20 In tropical regions, chicken pox is less common, and many people may reach = adulthood without immunity (adult immigrants from tropical to temperate regions may therefore be at risk).=20 I do not have data on how varicella incidence has been affected by the avai= lability of the vaccine, but vaccine coverage is still (as of 1999) fairly low for this particular vaccine.=20 Q3i.3 What is Herpes Zoster?=20 Following chickenpox infection, the varicella zoster virus persists in a la= tent form in sensory nerve ganglia without any signs of illness. The virus can be reactivated causing herpes zoster or shingles, wh= ich is a painful small blister-like rash in the distribution of one or more sensory nerve roots. It is estimated that 15% of the populat= ion will experience zoster during their lifetimes. Zoster develops most frequently among the elderly and among individuals who= are immunocompromised. Most people only have one episode of herpes zoster; fewer than 4% will have repeated episode= s. Postherpetic neuralgia is a common complication; this complication is more common among the elderly (25-50% of= those over 50 who have shingles, but only 10% of all people who have shingles.=20 (Information on the effect of the vaccine on herpes zoster will be added to= this FAQ later.)=20 Q3i.4 What is the current recommendation for the chicken pox vaccine be par= t for children?=20 The chickenpox (varicella) vaccine was first licensed for use among high-ri= sk children in several European countries in 1984, in Japan in 1986, and in Korea in 1988. It has been used for healthy children = in Japan and Korea since 1989. This vaccine was licensed by FDA on March 17, l995. It is manufactured by Merck and Co. Inc.= under the trade name "Varivax." On July 12, 1996, ACIP came out with its recommendations for the new vaccine. ACIP reco= mmends that all children be routinely vaccinated at 12-18 months of age. The American Academy of Pediatrics recom= mends that it be given to everyone over the age of one who is not already immune to chicken pox. Currently it is approv= ed by the FDA for a single injection in children ages 12 months to 12 years, and two injections 4-8 weeks apart for adolesce= nts and adults--ages 13 and older-- who have not contracted chickenpox. Since the vaccine has been shown to be safe and = effective when given at the same time as measles, mumps and rubella vaccines, it is likely many physicians will give it eithe= r at the 12 or 15 month checkup. Research is underway for development of a combination measles, mumps, rubella and varicella vacc= ine to avoid the need for a second injection. It is unknown when this product may become licensed.=20 Q3i.5 What is the current recommendation for adults?=20 ************************************************** *********************** [Contributed shortly before the vaccine was licensed.] From=20J Thompson ): I think it is almost guaranteed that adults will be able to get the varicella vaccine. The only area where there is _no_ scientific controversy over the wisdom of using this vaccine is in adults who are not immune. Varicella in adults is a dangerous disease, sometimes leading to hospitalization, and usually lasting two to three weeks. ************************************************** *********************** ACIP recommends that people 13 years and older be assessed for varicella im= mune status, and that those who are not immune be vaccinated. Priority should be given to vaccinating those at highest ris= k for exposure and for transmitting the disease. There is an antibody titre which can be done on adults who are not sure whether t= hey are immune to chicken pox.=20 Q3i.6 How effective is the chicken pox vaccine?=20 Clinical trials, which span a decade and involved more than 11,000 persons = in the United States, indicate that it is 70-90 percent effective in preventing chickenpox. Studies also show that almost a= ll of the vaccinated patients who got chickenpox had a milder form of the disease.=20 Q3i.7 How long does the chicken pox vaccine last?=20 We don't know yet. It is estimated to last at least six years. (Lancet, Apr= il 16, 1994) "Children immunized as long as six years earlier continued to be well protected. . . . So far, the US data show pers= istence of antibodies for three to four years after immunization; data from Japan show persistence of antibodies for seven to 1= 0 years in healthy children." (Gershon)=20 Q3i.8 What reactions have been reported following the chickenpox vaccine?= =20 Adverse reactions reported were mild and included redness, hardness and swe= lling at the injection site, fatigue, malaise and nausea. The vaccine has been used in Japan routinely for more than 10 years= with no complications.=20 Q3i.9 Will a second dose be necessary in younger children?=20 The question of a "booster" dose remains uncertain at this point. The manuf= acturer has agreed to perform postmarketing studies to determine the long-term effects of the vaccine and whether there is a ne= ed for a booster immunization.=20 Q3i.10 For which groups is the chicken pox vaccine especially recommended?= =20 People with HIV, nephrosis, severe asthma, and similar chronic diseases, bu= t especially leukemia. Conditions for vaccination of leukemic children a remission for at least a year, off maintenance thera= py for a week before and a week after getting the vaccine, and cellular immunity intact. (Catalana)=20 Q3i.11 When is the chicken pox vaccine contraindicated?=20 ************************************************** *********************** From=20the April 1995 issue of Medical Sciences Bulletin, published by=20 Pharmaceutical Information Associates ) and=20 available by Email subscription as MSB-L. Use of Varivax is contraindicated for patients who are hypersensitive to an= y component of the vaccine; those with a history of anaphylactoid reaction to neomycin; those with active febrile infections, pregnancy, blood dyscrasias= or other malignancies, or primary or acquired immunodeficiency; and those undergoing immunosuppressive therapy. ************************************************** *********************** The July 12, 1996 ACIP recommendation lists, for the most part, the same gr= oups, but adds people who have experienced an anaphylactoid reaction to gelatin, and people who have a family history of = congenital or hereditary immune deficiency in parents or siblings (unless their own immune competence has been clinically substan= tiated or confirmed by a laboratory). Pregnant women should not be vaccinated, as the effect on the fetus is unknown.=20 Although no adverse reactions from taking aspirin after the vaccine have be= en reported, it is recommended that people receiving the varicella vaccine refrain from taking aspirin for 6 weeks aft= erwards, because of the association between aspirin and Reyes syndrome following varicella.=20 Q3i.12 Is there a gamma globulin for chicken pox?=20 Yes, but it is only available to people at especially high risk from chicke= n pox. It needs to be given within 72 hours of exposure. More common on misc.kids is the concern of adults who haven't had chicken p= ox, but aren't otherwise at high risk from exposure. The varicella immune globulin isn't likely to be available to the= se people, but something else is available: acyclovir. This antiviral drug will lessen the severity of chicken pox if it is given = promptly, as soon as the rash first begins to appear.=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3j. BCG (tuberculosis) vaccine [This section last updated on September 25, 1999, based on the ACIP recomme= ndation which was published in MMWR on April 26, 1996, and which can be found at ftp://ftp.cdc.gov/pub/Publication= s/mmwr/rr/rr4504.pdf]=20 Q3j.1 What is tuberculosis, and what are the risks of the disease?=20 Tuberculosis is a chronic bacterial infection that is spread by inhaling dr= oplets sprayed into the air by someone infected with TB (it can also be spread through unpasteurized milk). It isn't as contagious = as a cold (you need to inhale a higher concentration of the droplets to catch it). The disease most commonly affects the lungs, the= bones of the spine or large joints, and the kidneys, but can reach almost any organ of the body.=20 Q3j.2 How common is tuberculosis?=20 In 1930, mortality was 101.5 per 100,000 population in the US. It declined = steadily, and in 1970 was 18.3 per 100,1000 population (Historical Statistics). 37.1 thousand cases were reported in 19= 70, and the number was down to 25.7 thousand in 1990 (Statistical Abstracts). Unfortunately, while that number represents a= decrease from 1970, it represents an *increase* from 1985. In 1985, after decades of decline, TB cases began to rise again = in the US, and have continued to rise ever since. A similar increase has occurred in several other industrialized countries (TB= was never really brought under control in the Third World). Moreover, new, multi-drug-resistant strains of TB have emerged. The= AIDS epidemic has worsened the TB situation. (Ryan) The percentage of cases of drug-resistant TB varies in different are= as. A Morbidity and Mortality Weekly Report article summarized in the June 15, 1994 HICN726 Medical News gives the inci= dence overall in New Jersey as 5% of the state's TB patients, the incidence in Jersey City as 13%, and the incidence= in New York City as 19%.=20 A joint statement by ACIP and the Advisory Council for the Elimination of T= uberculosis, published in MMWR, Volume 45, No. RR-4, April 26, 1996 states that the incidence of TB declined through 1= 984, increased from 1985 through 1992, and declined slightly in 1993 and 1994. 57% of the total number of TB cases wer= e reported in five states: California, New York, Florida, Illinois, and Texas. Overall incidence rates are twice as high for= men as for women.=20 Q3j.3 How effective is the BCG vaccine?=20 The AHFS Drug Information, 1992 says that its effectiveness is unknown, "Di= agnostic and clinical evidence has generally demonstrated a reduction` in the incidence of tuberculosis." Tuberculin sen= sitivity is highly variable, depending on the strain, and the relationship between tuberculin sensitivity and immunity has not been a= dequately studied.=20 _The Forgotten Plague_ says that results of research varied in different co= untries. In Great Britain, a Medical Research Council survey of 50,000 children showed an 80% reduction in the infection rate aft= er vaccination, leading Great Britain to introduce BCG vaccination of school children in the 1950s. In the US, the results wer= e the opposite, so the US has not used the vaccine. A New York Times article ("Tuberculosis Vaccine Found Surprisingly Effectiv= e in Studies", New York Times, 03/02/94, P. C14), recently reported that "A new statistical study by the Centers for Di= sease Control and Prevention reports that the vaccine, known as BCG, reduced the risk of full-fledged tuberculosis of the= lung by 50 percent and death by 71 percent." A study reported in J Infect Dis in August 1994 concluded that BCG vaccine is= effective, but local reactions are common.=20 The joint ACIP and ACET report in the April 26, 1996 MMWR says that there a= re different strains of BCG vaccine in use worldwide, and they differ in their ability to induce an immune response to= tuberculin. Reported rates of efficacy may also have been affected by methods of vaccine administration and the characteristics = and environment of the populations to which the vaccine was given. Protective efficacy rates for different studies of diffe= rent BCG strains have ranged from 0% to 80%. Two recent meta-analyses of the published literature have attempted to calculat= e summary estimates of efficacy. The first analyzed data from 10 randomized clinical trials and 8 case-control studies since 19= 50. It estimated protective efficacy against meningeal and miliary TB in children in clinical trials as 88%, and the efficacy in c= ase-control studies as 75%. There was too much variability in data on efficacy against pulmonary TB for them to come up wi= th a summary efficacy rate. The second meta-analysis reviewed 14 clinical trials and 12 case-control studies. They= estimated the overall efficacy of the vaccine in clinical trials to be 51%, with higher efficacy for children than for adult= s.=20 Q3j.4 How long does the BCG vaccine last?=20 It is of limited duration (Ryan). _AHFS Drug Information_ says that several= studies showed tuberculin sensitivity lasting 7-10 years.=20 Q3j.5 What are some of the risks of the BCG vaccine?=20 It rarely has serious side effects. (See _AHFS Drug Information_ for a list= ..) The most common reactions are local. More severe local reactions include ulceration at the vaccination site, regional= lymphadenitis with draining sinuses, and purulent drainage at the puncture site. The most serious reaction is disseminated BC= G infection; BCG osteitis of the epiphyses of the long bones, particularly epiphyses of the legs, can occur from 4 months to = 2 years after vaccination. The rate varies from 0.01 cases per million vaccinees, in Japan, to 32.5 and 43.4 cases per million v= accinees, in Sweden and Finland, respectively. Reactions may be more frequent among people with symptomatic HIV infection.= =20 ************************************************** *********************** From=20J Thompson ): The main strategy of TB control in the US is monitoring those at risk o= f exposure to the disease for signs of TB infection. The main method used is something called a "PPD" (which stands for purified protein derivative, i.e= .. proteins purified from TB). A PPD is "placed" (injected subcutaneously) and then the site of injection is monitored (usually at 48 hrs. after the injection). Anyone who has mounted an immune response to a TB infection wil= l exhibit redness and swelling at the site of the PPD injection (the criterio= n for calling a "true positive" PPD is that the inflammation must be at least 10 mm. wide). Also, this reaction must take place at a 1-2 day delay to be diagnostic for TB infection (anything sooner is allergy, not a sign of infection). OK, what does all this have to do with BCG? Well, BCG, since it is very similar to TB, can cause a positive PPD. Thus, widespread immunization with BCG makes it more difficult to screen for TB, since the screening will pull up many people who are not infected. The reaction due to BCG drops over time, but it is still a problem, so that (combined with the low effectiveness) has ruled out BCG in the US. Of course, now that drug-resistant strains are becoming more common, opinions might change... ************************************************** *********************** Q3j.6 When is the BCG vaccine recommended?=20 BCG vaccine is given in developing countries because it is easy to administ= er, inexpensive, and rarely has serious side effects. Some industrialized countries (e.g. Great Britain, France, Scandinavia) hav= e also used it, for vaccination of children in general and of household contacts of people with TB. Others (e.g. the US, the Nethe= rlands) have not.=20 Because of the low rate of new infections, the availability of low-cost iso= niazid prophylaxis for people who are exposed, and the availability of effective treatment which quickly make patients non-con= tagious and cures them, the BCG vaccine hasn't been considered necessary in the US. There might be some changes in these recomm= endations with the increase in multiple-drug-resistant strains (one misc.kids poster reports that her city= college system is now requiring TB shots). In the meantime, the FDA has approved a new combination tuberculosis drug, Rifater= , which combines isoniazid, rifampin, and pyrazinamide, in hopes of making it easier for patients to take their medic= ation and thus increasing patient compliance (antibiotic treatment which is discontinued too early increases the development of drug= resistant TB strains).=20 In the US, the AAP, ACIP, and the American Thoracic Society recommend BCG f= or infants and children intimately exposed to TB that is "persistently untreated, ineffectively treated, or resistant = to isoniazid and rifampin and who cannot be removed from the source of exposure or placed on long-term preventive therapy." The= AAP and ACIP also recommend it for children in groups with a rate of new TB infections greater than 1% annually "and fo= r whom the usual surveillance and treatment programs have failed or are not feasible." (_AHFS Drug Information_) ACIP a= lso recommends vaccination for children who are continually exposed to a patient who is infected with a strain of TB wh= ich is resistant to isoniazid and rifampin (MMWR, April 26, 1996). It is recommended for travel only for people who will be i= n a high risk environment for a long time without access to TB skin testing. It is currently not recommended for health care = workers (skin testing and isoniazid is considered to be enough), but this recommendation is periodically reevaluated because of = the incidence of TB in AIDS patients.=20 BCG also has some use against certain tumors (in particular, bladder cancer= ).=20 ************************************************** *********************** From=20J Thompson ): The TB "shots" a poster on misc.kids referred to ("one misc.kids poster reports that her city college system is now requiring TB shots") are most likely PPD, not BCG. I believe that all schools receiving federal funding (and I know that all schools I have attended) require either a PPD or the (less accurate but easier to administer) "tine test" as part of the pre-matriculation physical. ************************************************** *********************** Q3j.7 When is the BCG vaccine contraindicated?=20 Hypersensitivity to the vaccine, positive TB skin test, recent smallpox vac= cination, burn patients, various immune deficiencies or immunosuppressive therapy (see _AHFS Drug Information_ for a list). In case= of eczema or other skin disease, give it in a different area of the skin. Although no harmful effects to the fetus are as= sociated wtih BCG vaccination, its use is not recommended during pregnancy.=20 Vaccine components capable of causing adverse reactions: Triton WR 1339 (Tr= avel Medicine Advisor).=20 Q3j.8 What are some other methods of controlling tuberculosis?=20 Tuberculin skin screening and use of drugs such as isoniazid. Pasteurizatio= n of milk and testing of cows for tuberculosis are also useful.=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3k. Hepatitis A=20 [Hepatitis A: The following was taken from an article in JAMA (March 22/29,= l995--Vol 273 (12) 906-907) and information from the *draft* hepatitis A vaccine recommendation which was, as of April = l995, under consideration by the ACIP It has since been updated based on the ACIP and AAP recommendations as of December= 1996, the CDC Vaccine Information Statement on hepatitis A as of 8/25/98, and articles at Medscape. This sect= ion last updated September 19, 1999.]=20 Q3k.1 What is hepatitis A and what are the risks of the disease?=20 There are several forms of hepatitis (infection of the liver) which cause j= aundice, nausea and weakness. Hepatitis A is caused by infection with hepatitis A virus (HAV) which is acquired primarily throu= gh a fecal-oral route, most often from person to person. It can also occur via ingestion of contaminated food or water. The = illness consists of mild flu-like symptoms or severe nausea lasting for weeks. Hepatitis A does not become chronic and is rarely= fatal. In children under 6, most cases (70%) of hepatitis A are asymptomatic, and if illness occurs, it is usually not acco= mpanied by jaundice. Among older children and adults, the illness is usually symptomatic, and jaundice occurs in 70% of cases. S= ymptoms usually last for 2 months, but 10-15% of people infected have illness or relapses for up to 6 months. 11-22% of peop= le who have hepatitis A are hospitalized, and hepatitis A is responsible for an estimated 100 deaths a year (these number= s from the ACIP recommendation on hepatitis A - the AAP recommendation gives similar, but not identical, numbers).=20 Hepatitis A should not be confused with hepatitis B, which is less contagio= us but more serious. Hepatitis B becomes chronic in 5-10% of those infected. Complications include hepatic necrosis, cirrhosis = of the liver, chronic active hepatitis, and hepatocellular carcinoma.=20 Some sources of general information on hepatitis can be found in the hepati= tis B section of this FAQ.=20 Q3k.2 How common is hepatitis A?=20 During the past several decades, the incidence of hepatitis A in the U.S. h= as been cyclic, with nationwide epidemics occurring every 10-15 years; the last occurred in l989. Between epidemics, hepatitis = A continues to occur at relatively high levels. Nationally, CDC estimates that around 75,000 cases occur annually. Children= play an important role in HAV transmission, with highest rates among those aged 5-14 years. Rates are substantially hig= her, in the Western US states than in other US regions. The highest rates of hepatitis A are among children 5-14 years of = age. In the US, 33% of the population has evidence of prior hepatitis A infection, as determined by a survey conducted from 19= 88-1991 (reported in the ACIP recommendation for hepatitis A). Prevalence is generally higher among Native Americans and= Mexican Americans. Hepatitis A is the most common vaccine preventable illness among travelers. It can be avoided by av= oiding contaminated food and drink, but many travelers succumb to temptation, assume food at hotels is safe, buy from st= reet vendors, etc. Incidence is 1.6 per 1000 person-months of travel among travelers to developing countries (including = those who stay in luxury hotels), and 20 per 1000 among backpackers and others who eat and drink in poor hygienic conditions.= Incidence is 0.05 to 0.10 per 1000 person-months of travel in Southern Europe. (JAMA Sept 21, 1994 p. 885)=20 Q3k.3 Who is at risk for acquiring hepatitis A?=20 International travelers and individuals residing in hepatitis A endemic are= as are at risk for acquiring disease. Other risk groups include homosexual men, injecting drug users, hemophilic patients, veterina= ry workers and certain research occupations working with infected animals (particularly people working with non-human p= rimates). Workers at day care centers, institutions for the developmentally disabled, food service establishments and healthcar= e settings are also at some increased risk.=20 Q3k.4 Is there a vaccine to protect against hepatitis A?=20 Yes, the FDA licensed the hepatitis A vaccine for use in persons 2 years of= age and older on February 22, l995. An ACIP recommendation was published in the MMWR for December 27, 1996. The America= n Academy of Pediatrics also published a policy statement in December 1996. The vaccine has been in use in Europe = since 1992.=20 Q3k.5 How is it to be administered?=20 According to the labeling, the vaccine is given in a two-dose schedule to a= dults 18 years of age and older, the second dose being given 6-12 months after the first. Children and adolescents 2-18 year= s of age are given 3 doses. The second dose is given 1 month after the first and the third dose 6-12 months later. It is a= dministered by intramuscular injection in the deltoid (upper arm), and can be given with other vaccines without loss of immunogen= icity.=20 Q3k.6 How effective is the vaccine?=20 A single dose of the vaccine induced antibodies in 88% to 96% of subjects b= y two weeks and in 97% to 100% by one month. Completion of the full vaccine schedule is recommended to ensure high antib= ody levels and long-term protection. Efficacy trials in children and adolescents show it is 94% (or more) effective against ende= mic hepatitis A virus.=20 According to the AAP recommendation for hepatitis A, on December, 1996: "Cl= inical studies suggested a possible herd-immunity effect if more than 80% of the estimated susceptible individu= als were vaccinated. A single dose of Havrix in Alaskan native villages with endemic HAV disease resulted in a dramatic dec= rease in cases within 8 weeks of vaccination. A similar abrupt decrease in HAV cases was observed after two doses of vaccin= e in two Slovak Republic villages experiencing a large community outbreak. In the Vaqta trial in New York State, no cases of= clinical and confirmed hepatitis A occurred in vaccine groups more than 21 days after the first dose, and the calculated p= rotective efficacy was 100%. "=20 Q3k.7 How long does immunity last?=20 Firm data on long-term protection are limited because the vaccine was under= investigation for only 4 years before being approved in 1995. Estimates of antibody persistence derived from kinetic mo= dels of antibody decline suggest that the protective levels of anti-HAV could persist for at least 20 years.=20 Q3k.8 What are some of the risks of the vaccine?=20 Information on adverse events comes from prelicensure clinical studies worl= dwide and reports following vaccine licensure in Europe, the US, and Asia. No serious adverse events have been attributed to= the vaccine. Side effects include soreness and redness at the injection site, headache and fatigue. In very rare cases, th= ere is a severe allergic reaction within a few minutes to a few hours of the shot.=20 Q3k.9 When is hepatitis A vaccine contraindicated?=20 The vaccine should not be administered to persons with a history of hyperse= nsitivity reactions to any of the vaccine components, including alum or the preservative (2-phenoxyethanol). Because = it is inactivated, no special precautions need be taken when vaccinating immunocompromised individuals. The inactivation also= means that they theoretical risk to a fetus is low, but there are no data to determine the safety of the vaccine during pregnan= cy. People mildly ill at the time of vaccination may get the vaccine, but people moderately to severely ill should wait until th= ey recover.=20 Q3k.10 What groups at risk are be included in a recommendation to receive h= epatitis A vaccination?=20 ACIP recommends the vaccine for:=20 1. Persons 2 years of age or older traveling or working in countries with h= igh or intermediate endemicity of infection. The vaccine series should be started at least one month before travelling.=20 2. Persons living in communities with high rates of HAV infection; for exam= ple, American Indian, Alaska Native, Pacific Islander, and some religious communities.=20 3. Men who have sex with men.=20 4. People who use street drugs (injected or non-injected).=20 5. People who work with hepatitis A infected primates or with hepatitis A i= n a research setting should be vaccinated. No other groups have been shown to be at increased risk for hepatitis A due to occup= ational exposure.=20 6. Persons with chronic liver disease.=20 7. Persons who use clotting factor concentrates.=20 8. Since people who work as food handlers can contract hepatitis A and pass= the disease to others, they may be vaccinated in areas where state and local health authorities determine such vaccination t= o be cost effective.=20 The AAP recommends the vaccine for the first six of the groups listed above= , and suggests consideration of potential use for child care center staff and attendees, custodial care institutions, hospita= l personnel, food handlers, and people with hemophilia.=20 In 1999, ACIP recommended hepatitis A vaccine for all children aged 2 years= and older in the 11 Western states where incidence is especially high (at least 20 cases per 100,000 people, twice t= he national average). These states a Arizona, Alaska, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dako= ta, Utah and Washington.=20 Any healthy individual 2 years of older may receive hepatitis A vaccine at = the discretion of the physician and patient or parent.=20 Q3k.11 Is it possible that hepatitis A vaccine (like hepatitis B vaccine) m= ight eventually be recommended for routine administration to children and adults?=20 Those in public health say that control of hepatitis A infection will be fa= cilitated by the development of vaccines that combine hepatitis A with other routine childhood immunizations. The CDC's draft sta= tement notes the important role of children in hepatitis A transmission, and that "it is likely that routine childhood vac= cination will be the only way to significantly decrease hepatitis A rates in the U.S."=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3l Rotavirus vaccine [This section last updated on October 23, 1999.]=20 Q3l.1 What is rotavirus, and what are the risks of the disease?=20 Rotavirus is one of the major causes of gastroenteritis among infants and s= mall children in most countries. Symptoms are fever, vomiting, diarrhea, and dehydration, with vomiting and dehydration more com= mon than with other diarrheas. The illness normally lasts 3-9 days, and becomes chronic only in immunodeficient childr= en.=20 Group A rotavirus is a major cause of infant mortality in many parts of the= world. 873,000 infants and children under 5 die per year of rotavirus in developing countries. Non-group A rotavirus is less fr= equent, and is epidemic only in China. In tropical climates, rotavirus infection occurs year round, while in temperate climate= s it is seasonal. Rotavirus can survive for hours on human hands and for days on inanimate surfaces, and resists common disinfec= tants.=20 Rehydration therapy makes death infrequent in developed countries. On the o= ther hand, it is one of the most common causes of hospitalization among infants during the winter months. Cecil Textbook of M= edicine estimates that it is responsible for 35-52% of the cases acute diarrheal illness needing hospitalization in infants and= young children, in US.=20 Q3l.2 How common is rotavirus?=20 The AAP Committee on Infections Diseases estimates that rotavirus is respon= sible for 3 million cases of diarrhea, 50,000 hospitalizations, and 20 to 40 deaths each year in the United States.=20 Q3l.3 What is the current status of the rotavirus vaccine?=20 On October 15, 1999, Wyeth Lederle Vaccines announced that it has withdrawn= its RotaShield vaccine from the market and has requested the immediate return of all doses of the vaccine. The company= 's press release can be accessed at the web address below. http://www.ahp.com/releases/wa_101599.htm=20 A brief history of the release and withdrawal of this vaccine follows.=20 After years of research (animal studies beginning in 1983, and human trials= in 1987) into an effective rotavirus vaccine (with a couple of candidates being rejected), a live, oral, tetravalent rotavirus v= accine was approved by the FDA on August, 1998. This vaccine is composes of one rhesus monkey virus, and three genetically = engineered combinations of rhesus monkey and human rotavirus. In the December, 1998 issue of Pediatrics, the AAP Committ= ee on Infections Diseases recommended that the vaccine be added to the standard vaccination schedule, with shots being= given at 2, 4, and 6 months, with the understanding that it might take time to incorporate the new vaccine into the schedule.= =20 On July 18, 1999, US health officials recommended postponement of rotavirus= vaccine. Shipments have temporarily been suspended. The company which makes the vaccine is working with the CDC to i= nvestigate reports of bowel obstruction among infants who received the vaccine. An additional reason for postponement was= the fact that the rotavirus season, in the US, occurs during the winter, allowing several months for investigation of thes= e adverse reactions, before a decision needed to be made about whether the vaccine should be used prior to this year's rotaviru= s season. Results of a case-control study were expected to be available by October, 1999. Additional studies could continu= e into next year. Further information from the CDC about rotavirus vaccine and intussusception can be found at http://www.= cdc.gov/nip/Q&A/genqa/Rotavirus.htm and at http://www.cdc.gov/nip/news/rotavirus.htm.=20 Q3l.4 How effective is the rotavirus vaccine?=20 Although the rotavirus vaccine has been withdrawn as of October, 1999, I am= retaining the answer to this question, in case it should be later reintroduced in some form.=20 The rotavirus vaccine doesn't confer full immunity, but protects against se= vere illness (this is also the case with natural immunity from prior rotavirus infections). Trials by the manufacturer, used for FDA = approval, showed the following results:=20 Trial 1: None of the infants receiving the vaccine got dehydrated, compared= to 3% in the placebo group. 11% fewer in vaccine group needed a visit to the doctor. 88% showed elevated IgA titers.=20 Trial 2: 9% of infants in placebo group saw a doctor for diarrhea and vomit= ing, compared with 2% in vaccine group. None in the vaccine group needed hospitalization.=20 Both trials were by the manufacturer, and not published in the medical lite= rature at the time of approval.=20 A third trial, in Finland, showed similar results.=20 Q3l.5 Is the rotavirus vaccine effective for breastfeeding infants?=20 Although the rotavirus vaccine has been withdrawn as of October, 1999, I am= retaining the answer to this question, in case it should be later reintroduced in some form.=20 For infants receiving the full three doses, breastfeeding infants show the = same level of immunity as formula-fed infants. For infants receiving only one dose, immunity may be less among breastfed infan= ts.=20 Q3l.6 How long does the rotavirus vaccine last?=20 Although the rotavirus vaccine has been withdrawn as of October, 1999, I am= retaining the answer to this question, in case it should be later reintroduced in some form.=20 Efficacy persisted for two years in US and Finnish trials. Since followup h= as only been done for two years, it is not known whether efficacy persists beyond that time.=20 Q3l.7 What is intussusception?=20 Intussusception is a bowel obstruction in which one segment of the bowel be= comes enfolded within another segment.=20 Q3l.8 What is the relationship between the rotavirus vaccine and intussusce= ption?=20 15 cases of intussusception, possibly associated with administration of the= rotavirus vaccine, have been reported to VAERS. These cases were analyzed in "Intussusception Among Recipients of Rotavirus= Vaccine -- United States, 1998-1999," MMWR 48(27);577-581, 1999, Centers for Disease Control.=20 VAERS reports of intussusception were reviewed, and parents or guardians or= health-care providers contacted by phone for clinical and demographic data. Data on vaccine distribution was also obtain= ed from the manufacturer.=20 13 of the 15 developed intussusception after the first dose, and 12 of the = 15 developed symptoms within a week of receiving any dose. Intussusception confirmed radiologically in all. 8 needed surgica= l reduction. All recovered. 14 were spontaneous reports, and one was obtained through active postlicensure surveillance. Ac= cording to the report, "The manufacturer had distributed approximately 1.8 million doses of RRV-TV as of June 1, 1999, a= nd estimated that 1.5 million doses (83%) had been administered. Given this information, 14-16 intussusception cases amon= g infants would be expected by chance alone during the week following receipt of any dose of RRV-TV.=20 As part of a preliminary analysis of postlicensure adverse events, cases of= intussusception during December 1, 1998-June 10, 1999 were identified in Northern California and Minnesota, and the rate in = vaccinated and unvaccinated children was compared. Vaccinated children showed a statistically higher incidence of in= tussusception.=20 A further announcement by the FDA, made on September 14, 1999, reported tha= t the number of cases of intussusception that may be related to the rotavirus vaccine (15 as of July 7), is now up to 99,= including two deaths. The FDA's Dr. Kathryn Carbone, one of the initial reviewers of the rotavirus data, reported to a = gathering of the FDA's Vaccines and Related Biological Products Advisory Committee that all these cases are still under= investigation, and it is not clear yet whether the two deaths or the other cases were caused by the vaccine.=20 Further study is being done.=20 Q3l.9 Why was a connection between the rotavirus vaccine and intussusceptio= n not observed prior to FDA approval of the vaccine?=20 Approval by the FDA only requires trials on about 5,000-10,000 subjects. Ra= re reactions to a new drug or vaccine will therefore be unknown at the time of FDA approval.=20 Q3l.10 What other reactions have been reported following the rotavirus vacc= ine?=20 Although the rotavirus vaccine has been withdrawn as of October, 1999, I am= retaining the answer to this question, in case it should be later reintroduced in some form.=20 Mild, fever, for usually less than 24 hours. Fever after the first dose is = more common in older children, for which reason it is recommended that the vaccination series be begun by the time a baby is six = months old. All doses should be given by 12 months, because data regarding the safety and efficacy of vaccine administr= ation to older children are not available.=20 Irritability, decreased appetite, and decreased activity, were reported mor= e often than with the placebo for five days. Diarrhea was not reported more often than with the placebo.=20 Q3l.11 Can the rotavirus vaccine be effectively used in developing countrie= s?=20 Price may be the major barrier, as it is one of the more expensive vaccines= (and not likely to get cheaper if any modified version is reintroduced later).=20 Q3l.12 When is the rotavirus vaccine contraindicated?=20 Although the rotavirus vaccine has been withdrawn as of October, 1999, I am= retaining the answer to this question, in case it should be later reintroduced in some form.=20 The rotavirus vaccine should not be given in case of: Infants with hypersen= sitivity to aminoglycoside antibiotics, amphotericin B, or monosodium glutamate that are components of the vaccine, or an anaphylac= tic reaction to a previous dose of the rotavirus vaccine.=20 Until further data are available, this live-attenuated vaccine should not b= e given to children who are immunosuppressed or immunodeficient. Babies of women who are HIV-infected should not get the va= ccine unless these babies have tested as HIV-negative at the age of two months or older.=20 The rotavirus vaccine should be postponed in case of: Acute vomiting and di= arrhea (efficacy is uncertain in this case). Moderate or severe fever.=20 The rotavirus vaccine may be given in case of: Breastfeeding, premature bir= th, and low grade fever. The vaccine can be given at same time as DTaP or DTP, HiB, hepatitis B, or IPV/OPV, and there is no = need to adjust the timing for antibody-containing blood products. Infants living with people known or suspected to be immunoc= ompromised may be immunized.=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3m. Other vaccines which are available [This section last updated September 17, 1999.]=20 Q3m.1 What other vaccines are available and when are they given?=20 Other vaccines available include vaccines for cholera, Japanese encephaliti= s, typhoid, yellow fever, rabies, plague, Lyme disease, and anthrax. _Travel Medicine Advisor_ also mentions a vaccine for= typhus, but, according to the 1996-1997 edition of the CDC Yellow Book (CDC Health Information for International Travel), "= production of this vaccine has been discontinued in the US and there are no plans for commercial production of = a new vaccine." Since other countries may offer typhus vaccination (though, to the best of my knowledge, it is not required= for travel to any country), I am drawing information for this vaccine from a German web site. Immune globulins are also availabl= e for a variety of diseases.=20 For more information on these other vaccines, check the _American Hospital = Formulary Service Drug Information_ (a better source than the PDR in this case) and _Health Information for Travelers_, w= hich is put out by the CDC every year (vaccination and booster schedules for all of these vaccines can be found there, as can = information on where these diseases are common and what vaccination requirements various countries have for entrance). The= latter can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402, and = most local health departments have a copy which can be consulted, sometimes by telephone. It can also be found in som= e public libraries. The CDC also has a Worldwide Web site which can be accessed for travel information: http://www= ..cdc.gov/. The International Association for Medical Assistance to Travellers (IAMAT), which has affiliated institutions= in over 115 countries, puts out a _World Immunization Chart_. The address of the U.S. affiliate is IAMAT, 736 Center= Street, Lewiston, N.Y. 14092. The World Health Organization produces a publication on international travel; it is c= alled _INTERNATIONAL TRAVEL AND HEALTH: Vaccination Requirements and Health Advice_, and copies may be orde= red from WHO Distribution and Sales, CH-1211, Geneva 27, telephone (41 22) 791 2476; fax (41 22) 788 0401. The p= rice is 15 Swiss Francs; in developing countries: 10.50 Swiss Francs. Further information about rabies can be foun= d in books on mountaineering and spelunking (the one I consulted is _Medicine for Mountaineering_, by James A. Wilkerson, M.= D.). Hepatitis B, hepatitis A, and meningococcus vaccines are given for travel, so people interested in travel= vaccinations may want to check the sections of this FAQ dealing with those vaccines.=20 Anthrax vaccine, in the US, is mainly used by the military as a protection = against biological warfare; small quantities are also made available to people with an occupational exposure, such as veterinaria= ns and lab workers. Since vaccines given by the military to soldiers are outside the scope of a FAQ primarily concerned wit= h vaccines which might be given to children, I will not be discussing the anthrax vaccine further.=20 Cholera is an intestinal infection spread by contaminated food and water. C= holera vaccination is about 25-50% effective in reducing clinical illness for 3-6 months after vaccination (with the greate= st protection during the first two months). (_Health Information for Travellers_ gives the effectiveness as 50%, and AHFS Drug I= nformation gives it as 25-50%.) Boosters are every six months for travelers who will be staying for a long time in chole= ra-endemic areas. Serious reactions are rare. Since the effectiveness is so low, neither the CDC nor the WHO actually recommend= s the vaccine, but some countries require it. According to AHFS Drug Information, "_Cholera vaccine does not prevent tran= smission of infection_, and should not be used to manage contacts of imported cholera cases or to control the spread of in= fection."=20 Vaccine components capable of causing adverse reactions: bacterial componen= ts (Travel Medicine Advisor). The vaccine should not be given to children under 6 months.=20 Japanese encephalitis B vaccine, licensed in 1993, is given to travelers "w= ho expect to go beyond the usual tourist routes or to spend extended time in rural areas in disease endemic regions" (Harrison's)= Its efficacy is estimated at 80-90%. Anaphylactic and severe delayed allergic reactions are common, so people who receive thi= s vaccine should be observed for ten days.=20 Lyme disease vaccine, licensed on December 21, 1998, is licensed (as of Sep= tember, 1999) only for people 15 years or older, though that age limit may soon be eliminated. It is recommended for adults = and older teens who spend lots of time outdoors in Lyme-endemic areas. You should still protect yourself against ticks if usin= g the vaccine, both because the vaccine isn't 100 per cent effective and because ticks also carry other diseases. In a randomized= , double-blind, multicenter trial involving 10,936 people living in the northeastern and upper north central United States, th= e vaccine efficacy at preventing Lyme disease was 50% (MMWR, January 22, 1999 / 48(02);35-36,43). The duration of immunity is= unknown. Side effects included local reactions, transient myalgia or arthralgia, influenza-like illness, fever, = and chills.=20 It is unlikely that your child will ever need a plague vaccination. The dis= ease is found among rural rodents in some areas, including the Western third of the US, but urban outbreaks are now rare. Va= ccination is only recommended for people at increased risk due to research or field activities in epizootic areas. An a= lternative for people at increased risk is tetracycline prophylaxis. _AHFS Drug Information_ gives the vaccine's effectiveness as 9= 0% for 6-12 months. Other measures for avoiding plague in epizootic areas are getting rid of wild rodent food and = shelter, defleaing dogs and cats weekly, avoiding sick or dead rodents, and routine bacteriologic precautions in labs.=20 Vaccine components capable of causing adverse reactions: phenol, beef prote= in, soya, casein (Travel Medicine Advisor).=20 Rabies, an almost universally fatal disease transmitted by saliva and brain= tissue of infected animals, is rare in the US but more common in some countries where pet vaccination is not common. Dogs are the = main reservoir in developing countries, but all animal bites should be evaluated. The most common animal vectors in the US = are carnivorous small animals (such as skunks, racoons, foxes, coyotes, and bobcats) and bats. There has been a recent inc= rease in racoon rabies in the mid-Atlantic and northeastern states of the US (MMWR 29 Apr 1994), and programs to institute= oral rabies vaccination of racoons, foxes and coyotes have been initiated in some state (similar programs have been used = to control fox rabies in Canada and Europe). More than 50% of rabies cases in the US come from exposure to rabid dogs outside= the US. The disease is most commonly spread by animal bites, but can also be caught through non-bute exposure, includin= g contact between infected saliva or brain tissue and pre-existing cuts, scratches, open wounds, or mucuous membranes. There are = also cases of aerosolized transmission in medical laboratories and caves inhabited by rabid bats, and transmission through co= rnea transplants from people who had died of undiagnosed (before the transplant) cases of rabies. The chance of infectio= n is more likely in case of bite or non-bite exposure to the head, neck, face, shoulders, or hands, than with similar exposure to= the trunk or legs.=20 In case of exposure to rabies, the wound should be immediately and thorough= ly cleaned with soap and water. "Although not included in the ACIP recommendations, some clinicians also rinse the wound = thoroughly with water or 0.9% sodium chloride solution and then cleanse with a topical antiseptic (e.g. povidone-iodine).= " (AHFS Drug Information 1992) It is also important to promptly vaccinate anyone exposed to rabies (and give rabies immune glob= ulin if the person has not been previously vaccinated), as the disease is, for all practical purposes, always fatal on= ce rabies symptoms begin to show up. (A few people have recently survived after symptoms appeared, but they all had serious br= ain damage.) Pre-exposure vaccination is given to people who live in or visit rabies endemic areas and to people whose profes= sions or activities put them at extra risk, such as lab workers, veterinarians, and spelunkers. The highest travel risk is where do= g rabies is still endemic.=20 There is some drug interference between chloroquine (an anti-malarial drug)= and rabies vaccine, but intramuscular injection can take care of the problem. Need for boosters depends on risk category, and r= anges from regular tests of antibody levels every six months, with vaccination when they drop, for rabies lab workers, to no = pre-exposure vaccination for most people. Post-exposure, unvaccinated people get rabies immune globulin and rabies va= ccine, while previously vaccinated people get rabies vaccine alone, in a smaller amount. Adverse effects include local re= actions (30-74% of vaccinees) and mild systemic reactions (e.g. headache, nausea, 5-40% of vaccinees). About 6% of vaccinee= s have a reaction characterized by urticaria, pruritis, and malaise. Rarely, anaphylactic shock may occur. Because rabies= is so deadly, pregnancy is *not* a contraindication to postexposure vaccination.=20 Vaccine components capable of causing adverse reactions: neomycin, phenol r= ed, thimerosal (Travel Medicine Advisor).=20 The following posting from sci.med, by Achim Lohse, provides further inform= ation about rabies vaccine (the side effect under discussion is anaphylactic shock):=20 ----------------------------Original message---------------------------- .... In Canada (at least as of two years ago) there is only one rabies vaccine availble, and the manufacturer supplies it only in one-millitre vials, with strict instructions to use the entire vial for one injection only. At $60 + per vial, the series of three costs over $180. I was fortunate to have a physician who had worked among fur trappers up north, and had some familiarity with the vaccine. He informed me that if injected _intra_dermally, a dose of only 0.1 millilitre is enough. I confirmed this with the local public health nurse, who showed me that it had been standard public health procedure in British Columbia for five years to use the 10% dose intradermally (10 trappers would arrange to share the contents of a standard vial). Later investigation via Medline showed that this particular vaccine human diploid cell (HDCV) is not only the most expensive to produce, but may also have a significantly higher rate of side-effects when compared to the much less expensive purified chick embryo vaccine. I had a taste of physician non-acceptance when my physician was away after administering the first in the series of three shots. He assumed any of the other five doctors in the rural practice could and would complet= e the series. NOT! I was turned down flat by the two experienced doctors on duty, and had to get my shot from the public health nurse. Rabies antibodies (assuming the initial titres are adequate) are considered to be reliably adequate for only three years, after which a booster is required (and with the HDVC adverse reactions have most often been experienced with the booster). The alternative is to get a Rabies titre test, but I understand (anyone have figures?) that this is quite expensive, and in Canada's health system, may simply not be available on demand in some provinces (unless you can persuade a sympathetic public health officia= l of the need). However, since it's unusual for people to get rabies and the vaccine does work fine after exposure, it will probably not be part of the usual childhood vaccines. Mike K As someone noted in a previous post, the urgency of treatment depends on the proximity of the infection site to the brain. A report from a researcher from pre-war Yugoslavia (Zagreb) indicated that there wolf attacks resulting in bites to the face and neck have resulted in death, due to inability to get the antibody titres high enough in time. One possib= le strategy to improve this situation (suggested to me by Richard Passwater's book "Selenium as Food and Medicine") is to take a large dose of selenium concurrent with or within a few hours of vaccination. He reports that this has greatly increased antibody titres with other vaccines. Finally, aside from the risk of not being able to get to treatment in time after clear exposure, there is the very real danger of unnoticed infection, expecially in children, by having a cut finger or lip, etc. come in contac= t with saliva from the tongue or coat of an infected animal. There is even one reported instance of a spelunker dying after supposedly no other exposu= re than inhaling saliva droplets from rabid bats. Since unvaccinated victims can't be treated successfully once symptoms appear, pre-vaccination is the only available protection for this last type of exposure. Achim ------------------------------------------------------------------------ From: Achim Lohse=20 Subject: rabies vaccine - update Hi Lynn. I did a little more reasearch on rabies vaccine in the past two days, and learned that the Canadian manufacturer - Connaught Labs, also markets the vaccine in the U.S.. In fact, it markets two versions in the U.S., both are human deploid cell vaccines (HDCV), but one, called "Merieux" is marketed in a 0.1 ml format for intradermal injection. In Canada, ironically, this form is not available, and only the 1 ml intramuscular form is marketed (suggested retail about CDN$75 per vial). I wasn't able to get any us prices, but was given a U.S. information number= : 1-800-VACCINE , which of course, doesn't work from my (Canadian) calling ar= ea. I wasn't able to learn whether HDCV is the still the _only_ type of rabies vaccine available in the U.S. (it is the only typpe in Canada). Finally, I learned that there are two methods of testing rabies antibody ti= tre (to find out if you need a booster). The preferred one is the neutralization assay type, in which diluted serum is mixed with infected cell culture and checked for reaction. The titre is reported as the highes= t dilution ratio that provokes a reaction, with 1:32 being the minimal acceptable titre. If titre is at 1:32, then retesting or boosting is adviseable in a year to maintain adequate protection. I couldn't get any details about the other method, called complement fixation, except that the local expert considered it less reliable. BTW - for Alberta and Saskatchewan (and possibly other Canadian provinces) all rabies titre testi= ng is done by the _Ontario_ Provincial Laboratory, so it's a slow and costly undertaking. regards, Achim ------------------------------------------------------------------------ Smallpox vaccine is no longer given, because smallpox has been eliminated b= y vaccination. The virus is currently kept in labs in the US and Russia, just in case it is needed at some point (there has been = talk of destroying the last samples, but the virus recently got a reprieve). Since the elimination of smallpox is one of the m= ajor triumphs of vaccination, which is mentioned in many medical texts which I consulted as an argument in favor of vaccination= , I'll also mention at this point that smallpox mortality was 25-30%, that it infected 90% of the population at risk, and t= hat there were 10-15 million cases worldwide as recently as 1967. The last natural case was reported in 1977, and the last = cases were reported in 1978, as a result of an escape of the virus from a lab (the lab director committed suicide while un= der quarantine). (Kiple) The only people who still need to be vaccinated for smallpox are the people who work in the labs wher= e the virus is kept.=20 Vaccine components capable of causing adverse reactions: polymyxin B, strep= tomycin, chlortetracycline, neomycin, phenol, brilliant green dye, glycerin (Travel Medicine Advisor).=20 Typhoid is spread by contaminated food and water. The vaccine protects 70-9= 0% of recipients. There are two forms of the vaccine: oral (live), and parenteral (killed). The oral vaccine shouldn't b= e given to immune-compromised people. Otherwise, there are few adverse reactions, mostly local discomfort and sometimes feve= r and malaise. Boosters are every three years for parenteral and five years for oral vaccine.=20 Vaccine components capable of causing adverse reactions: phenol, bacterial = components (Travel Medicine Advisor).=20 The following posting from sci.med gives further information on typhoid vac= cine:=20 ------------------------------------------------------------------------ From: "Mark A. Shelly"=20 Subject: Oral form of typhoid vaccine A typhoid vaccination is recommended for a trip to Costa Rica. My family doctor said that the last time she gave someone a prescription for the vaccine they came back with an oral vaccine. Since then she hasn't been able to find any information comparing the oral to the injectable form: - efficacy - scheduling (the injectable form requires 2 doses, the first a month before the trip) - side effects (she says that the injectable form tends to make you feel sick, the oral form may be an improvement). Oral typhoid vaccine is a live but weakened (attenuated) strain (Ty21a) of the Salmonella germ that causes typhoid fever. The oral vaccine is probably equal to the injected vaccine in efficacy, at about 80%. It is given orally on an empty stomach every other day for 4 doses (total elapsed time 6 days). It must be kept refrigerated but not frozen, a signif= icant limitation to use in other countries. You can't be taking antibiotics at th= e same time. It is very well tolerated. (The injected form has 80+% side effects). If yo= u have weakened immunity, or if you are too young to take pills, you shouldn'= t use this vaccine. I almost never recommend the injected form of typhoid vaccine. Typhoid vaccine is recommended for travel to areas with poor water supplies when the trip is over 3 weeks and when your eating will be "high risk". Hope this helps Mark Shelly ------------------------------------------------------------------------ Typhus vaccine (not available in the US) is described by Andreas Kaunzner's= travel medicine Web site (http://members.aol.com/reisemed/impfung/typhus.htm). According to this sit= e, there are two different typhus vaccines on the market in Germany. One is a live oral vaccine, which is given in three dose= s, and gives protection for about three years, if one stays in a region where typhus is endemic; otherwise its immunity lasts for= about a year. The most common side effect, seen in fewer than 1% of those receiving the vaccine, is stomach trouble. General s= ymptoms such as fever and chills can appear, and very seldom a rash. The other is a killed vaccine, which may be given to ad= ults and children two years or older, and which provides immunity for at least three years. Its side effects are described = as "typical side effects of vaccinations" (local reactions, fever, and allergic reactions) appearing only seldom. Kabel 1 Online has a = chart of German travel vaccine recommendations (http://www.kabel1.de/reise/1998/06/26/11/) which says that typhus vaccine = is given for trips of more than three months. The CDC, on the other hand, recommends hygiene and, in areas where tick typhus = is endemic, tick removal and tick repellant; typhus vaccine production has been discontinued in the US.=20 Yellow fever is a viral infection which is spread by mosquitos. Yellow feve= r vaccine is a live vaccine which can be given only at certain vaccination centers. Many countries require this vaccination for en= try. A booster is needed every ten years. Contraindications include egg allergy and immune deficiency. Reactions are = mostly mild.=20 Vaccine components capable of causing adverse reactions: chick embryo compo= nents (Travel Medicine Advisor).=20 Travelers may also want to take anti-malarial drugs, bring insect repellant= containing N,N diethylmethylbenzamide, and avoid unboiled water, raw vegetables, fruit they haven't peeled themselves, under= cooked fish and shellfish, and food kept at room temperature. Other sources of travel health information are _Fielding's Tra= velers' Medical Companion_ and the US State Department Citizen's Emergency Center, which provides information on a vari= ety of foreign travel risks 24 hours a day at 202-647-5225. CDC Travelers' Health Section, 404-332-4559, and Immunization= Alert, 203-487-0611, have up-to-date information on vaccinations for international travel.=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3n. Vaccines under development=20 [This section most recently updated on September 18, 1999. References inclu= de the Report of the Technical Review Group Meeting, 7-8 June 1998 WHO Global Program for Vaccines and Immunization Vac= cine Research and Development (http://www.who.org/gpv-documents/DocsPDF/www9845.pdf), a New England Journ= al of Medicine editorial on malaria vaccine development at http://www.nejm.org/content/1997/0336/0002/0128.asp,= reports on AIDS vaccine research at http://www.iapac.org/ and http://www.nih.gov/news/pr/may98/od-15a.htm, an I= ntellihealth report on vaccine news for 1999 (http://www.intelihealth.com/IH/ihtIH?t=3D18784&p=3D~br,IHW|~st,408|~r,WSIH= W000|~b,*|), Lon Morgan's Web site on vaccine developments: http://fp1.cyberhighway.net/~lmorgan/developments/vac= cine_development.htm, and National Institute of Health information on clinical trials at http://www.niaid.nih.gov/.]=20 Q3n.1 What vaccines are currently under development?=20 New vaccines under development include vaccines for HIV (vaccines are being= tested both to improve the immune response in those already infected and to resist infection), respiratory syncytial viru= s (Rathone), malaria, leprosy, gum disease, herpes, shigella, dengue, cervical cancer, type I diabetes, and other illnesses, as= well as an intranasal flu vaccine, new versions of the pneumococcal, meningococcal, and TB vaccines. Harrison's Internal Medicine = has a list of vaccines in human trial, and a list of those toward which priority efforts are being targetted.=20 As of May, 1998, the National Institutes of Health had evaluated 23 vaccine= candidates and 10 adjuvants (substances that might enhance the effect of a vaccine) in 49 Phase I and Phase II clinical = trials to determine the safety of the vaccine candidates and their effect on the human immune system. These studies have been conduc= ted with 2,900 volunteers. Despite all these vaccine candidates, the variation of retroviruses and the virus transmissio= n directly from cell to cell by fusion pose significant obstacles. It's anyone's guess when (and if) an AIDS vaccine will be ready.= Two articles which discuss AIDS vaccine development are "Vaccine Against AIDS?" in the British medical journal Lanc= et ((02/26/94) Vol. 343, No. 8896, P. 493) and "AIDS Vaccine: Shooting Blanks or Loaded for Bear?" in Men's Fitness ((03/9= 4) Vol. 10, No. 3, P. 118). Information about efforts to produce an AIDS vaccine is sometimes posted in sci.med.aids, and= references, updates, and current information is available by gophering to odie.niaid.nih.gov. If you have gopher, gopher od= ie.niaid.nih.gov will get you there. The AIDS FAQ (available from the pub/usenet/sci.med.aids directory of rtfm.mit.edu) desc= ribes some other Internet resources with information about AIDS.=20 When I wrote this section in 1994, I had, "The malaria vaccine has shown po= sitive results in Phase I/II trials, which were reported on February 18, 1994 issue in the British medical journal _Vaccine= _ (volume 12 no. 4, pp 328-336; 1994). (A report on an earlier trial can be found in the medical journal Lancet, volu= me 341, pp 705-710; l993). More details can also be found in a WHO press release kept on gopher.who.ch. The first results of Ph= ase III trials are expected to be available in October 1994." Unfortunately, the years since then have not seen as much pr= ogress toward a malaria vaccine as was hoped. It is known to be possible to induce immunity to malaria, as letting volunteer= s be bit by irradiated mosquitos has done so. But translating that into an effective vaccine has proved tricky. An editorial = in The New England Journal of Medicine -- January 9, 1997 -- Vol. 336, No. 2 reported that, though one vaccine has shown efficac= y, recent trials in malaria endemic areas couldn't confirm that efficacy. An improved subunit vaccine reported in the same iss= ue of NEJM, but needs to be tested in malaria endemic areas. WHO has malaria vaccine as a high priority, and aims to have= an effective and affordable vaccine within the next decade.=20 Respiratory syncytial virus (RSV) is a major respiratory pathogen among inf= ants and young children which results in an "estimated 90,000 hospitalizations among infants in the US every winter" (W= illiams, 1997). Trials have indicated that the vaccine is safe and immunogenic (produces antibodies), but there are mixed = results so far on efficacy.=20 Shigella is one of the leading causes of diarrhoeal illnesses. A shigella v= accine is moving toward clinical trials soon.=20 The vaccine for periodontitis (gum disease) has shown some positive results= in macaque monkeys (less bacterially induced bone loss in the vaccinated monkeys), indicating that a human periodontitis= vaccine is feasiable. Full-fledged clinical trials, however, may be a decade away.=20 Q3n.2 What other research is being done to improve vaccines?=20 Research is being done to improve existing vaccines (such as the research w= hich resulted in the new acellular pertussis vaccine). This includes efforts to decrease the number of visits, the numbe= r of doses, and the number of injections, to move immunization as early in life as possible (including research into the valu= e of giving vaccines to pregnant women to provide protection to infants very early in life), to decrease adverse effects, to = increase protection, and to increase thermal stability. One area being explored is whether it is possible to combine more vaccines in a= single shot. Micro-encapsulation is an attempt to encase vaccines in microcapsules which will be released over time, mimickin= g repeated injections. Trans-disease vaccinology is an attempt, by genetic engineering, to create vaccines which protect agains= t more than one disease. Efforts are also under way to produce a heat-resistant polio vaccine. (Hartveldt) (There is also a Uni= ted Press International article from 3/25/94, included in the CDC AIDS Daily Summary for March 28, 1994, which discusses the effor= t to make a vaccine which will be effective against a variety of different viruses.)=20 A major vaccine safety problem is the widespread reuse of syringes in devel= oping countries, due to scarcity, resale value, and cultural resistance to waste. In response to this problem, monodose, dispos= able vaccines, and solid, non-injected vaccines are being looked at. Solid vaccines would also eliminate the cost of keeping va= ccines cold (a major factor in vaccine delivery costs, and reduce the cost of wasted vaccines. Other research on different vaccine= delivery methods includes work on an intranasal flu vaccine and on an aerosol measles vaccine.=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 4. References=20 AAP recommendations (found at http://www.aap.org).=20 ACIP recommendations (found at http://www.cdc.gov/nip)=20 AMA Drug Evaluations Annual, 1993.=20 The American Medical Association Family Medical Guide. Random House, New Yo= rk. 1987.=20 The American Hospital Formulary Service Drug Information, 1992. Published b= y the American Society of Hospital Pharmacists.=20 Boughton, Clement R. "Varicella-zoster vaccine." The Medical Journal of Aus= tralia. Vol. 159. 4 October 1993.=20 California Morbidity, a Biweekly Report from the Division of Communicable D= isease Control, part of the State of California Health and Welfare Agency. Issues from October 31, 1987, May 21, 1993, and = November 19, 1993.=20 Catalana, Paul, MD. "The 'Other' Childhood Immunizations." Emergency Medici= ne, October 15, 1992. Center for Disease Control. _Health Information for International Travel_, 1992.=20 Center for Disease Control Vaccine Information Statements (found at http://= www.cdc.gov/nip).=20 Clements, C. John, Strassburg, Marc, Cutts, Felicity T. and Torel, Carol. "= The epidemiology of measles." In _World Health Statistics Quarterly, Vol 45, No 2/3, 1992.=20 FDA. "Advisory Committee Discusses Chickenpox Vaccine." January 28, 1994. (= Pulled off of fdabbs.fda.gov. Connect with login bbs to find this and other FDA information.)=20 Fettner, Ann Giuici. _The Science of Viruses._ Quill. William Morrow, New Y= ork, 1990.=20 Galazka, Artur. "Control of Pertussis in the World." In _World Health Stati= stics Quarterly_, Vol 45, No 2/3, 1992.=20 Gershon, Anna A. "Varicella - Immunization Practices in Children." Hospital= Practice. Sept. 15, 1990.=20 Ghendon, Y. "Influenza - its impact and control." In _World Health Statisti= cs Quarterly, Vol 45, No 2/3, 1992.=20 Harrison's Principles of Internal Medicine, Eleventh Edition. McGraw Hill B= ook Company, 1987.=20 Hartveldt, Frank. "The Children's Vaccine Initiative." World Health 46th ye= ar, No. 2, March-April 1993.=20 Historical Statistics of the United States, Colonial Times to 1970. Bicente= nnial Edition. US Department of Commerce, Bureau of the Census.=20 Hull, Harry F. and Ward, Nicholas A. "Progress towards the global eradicati= on of poliomyelitis." In _World Health Statistics Quarterly, Vol 45, No 2/3, 1992.=20 Journal Watch, 9-1-93. "Infant HBV Vaccination: Doubts Remain."=20 Kiple, Kenneth E., Editor. _The Cambridge World History of Human Disease_.= =20 The Lippincott Manual of Nursing Practice, Fourth Edition. 1986.=20 Mandell/Douglas/Bennett. Principles and Practice of Infectious Diseases, Th= ird Edition, 1990.=20 The Medical Letter on Drugs and Therapeutics, Vol. 34 (Issue 875), July 24,= 1992.=20 The Merck Manual, Sixteenth Edition. Merck Research Laboratories, 1992.=20 Nossal, Sir Gustav. "Prospects for new vaccines." World Health 46th year, N= o. 2, March-April 1993.=20 Onorato, Ida M., MD, Wassilak, Steven G. Md, Meade, Bruce, PhD. "Efficacy o= f Whole-Cell Pertussis vaccine in Preschool Children in the United States." JAMA, May 27, 1992, Vol. 267, No. 20.=20 Pantell, Robert H., MD, Fries, James F., MD, and Vickery, Donald M., MD. _T= aking Care of Your Child: A Parents' Guide to Medical Care._ Third Edition.=20 The Physician's Desk Reference, 1993.=20 Rathone, Mobeen H., MD. "Childhood Immunizations: An Update." Infections in= Medicine, June 1992.=20 Ryan, Frank, M.D. _The Forgotten Plague: How the Battle Against Tuberculosi= s Was Won - And Lost_. Little, Brown, and Company, 1993.=20 Shapiro, Eugene D., MD "Editorial: Pertussis Vaccines: Seeking a Better Mou= setrap." JAMA, May 27, 1992, Vol. 267, No. 20.=20 Smith, Alice Lorraine. Principles of Microbiology. The C. V. Mosby company.= St. Louis, Toronto, and London, 1992.=20 Statistical Abstracts of the United States, 1992.=20 Travel Medicine Advisor. May 1993.=20 Trollfors, B. and others. "A Placebo-Controlled Trial of a Pertussis-Toxoid= Vaccine." NEJM, Vol 333, Number 16, October 19, 1995.=20 University of California, Berkeley. _The Wellness Encyclopedia._ From the e= ditors of the UC Berkeley Wellness Letter. Houghton Mifflin Company, Boston, 1991.=20 Viral Hepatitis Prevention Board. Safety of hepatitis B vaccination program= mes. http://esoc-www.uia.ac.be/esoc/VHPB/statement.html=20 Whitman, Cynthia, Belgharbi, Lahevari, Gasse, Francois, Torel, Carol, Matte= i, Vittoria, and Zoffman, Henrik. "Progress towards the global elimination of poliomyelitis." In _World Health Statisti= cs Quarterly, Vol 45, No 2/3, 1992.=20 WHO. The Work of WHO 1990-1991. Biennial Report of the Director General.=20 Wilkerson, James A., M.D. Medicine for Mountaineering, Third Edition. The M= ountaineers, Seattle, Washington, 1985.=20 Williams, Amelia L., Ph.D. News and Perspectives: New Vaccines for Childhoo= d Immunization. Drug Benefit Trends 9(3):10-11,15-22, 1997. (Found on Medscape.)=20 Wyngaarden/Smith/Bennett. Cecil Textbook of Medicine, 19th edition, 1992.= =20 Electronic resources consulted:=20 American Association of Pediatrics Web site. http://www.aap.org=20 CDC AIDS DAILY SUMMARY (regularly posted on sci.med.aids)=20 CDC National Immunization Program Web site. http://www.cdc.gov/nip/=20 Degos, Francoise. Immunisation contre le virus de l'h=E9patite B : bilan de= quinze ann=E9es de vaccination. http://www.john-libbey-eurotext.fr/a...7/index.htm=20 fdabbs.fda.gov (login using name "bbs") (more recently, http://www.fda.gov)= =20 gopher.who.ch (gopher gopher.who.ch, also:=20 telnet gopher.who.ch login:gopher) (more recently, http://www.who.org)=20 HICNet Medical News Digest (available from ET; regular= ly posted to sci.med)=20 Immunization Action Coalition Web site. http://www.immunize.org=20 Journal Watch Summaries (regularly posted to sci.med by = m)=20 Le point sur la vaccination contre l'h=E9patite B http://www.sante.gouv.fr/= htm/pointsur/vaccins/effets_sec_hep_b.htm=20 Levy-Bruhl, Daniel et al. Comparaison entre les Risques de Premieres Attein= tes Demyelinisantes Centrales Aigues et les Benefices de la Vaccination Contre L'Hepathite B. http://www.rnsp-sante.fr/= beh/1999/9909/index.html=20 Medscape http://www.medscape.com=20 Also available on the net is the Morbidity and Mortality Weekly Report (MMW= R). It is available by Worldwide Web at:=20 http:/www.cdc.gov/; Go to publications and scientific data, then Morbidity = and Mortality Weekly Report, OR=20 by gopher at Duke University.=20 Morgan, Lon. Immunization, Vaccines, Vaccination in the Modern World http:/= /fp1.cyberhighway.net/~lmorgan/=20 Swiss Medical Weekly. http://www.smw.ch=20 A list of Internet and Bitnet Health Sciences resources, compiled by Lee Ha= ncock, can be ftped from the pub/nic directory of ftp.sura.net.=20 |
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Archive-name: misc-kids/vaccinations/part2
Posting-Frequency: monthly Last-Modified: October 23, 1999 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3. Specific vaccines ---------------------------------------------------------------------------= ---- Section 3a. DTP (diptheria, pertussis, and tetanus) and DT [Last updated October 2. 1999.]=20 Q3a.1 What is diptheria, and what are the risks of the disease?=20 Diptheria is a contagious disease affecting the nose, throat, and skin. Com= plications include paralysis (about 20% of patients) and heart damage (about 50%) (Pantell, Fries, and Vickery). The Merck manua= l has a very long list of complications, mostly involving the heart, and says that complications are likely if antitoxin is= n't administered properly. The death rate was 35% before antitoxin was available, and is now 10% (Harrison).=20 Q3a.2 How common was diptheria before routine vaccination, and how common i= s it now?=20 In 1900, there were 40.3 deaths per 100,000 population from diptheria in th= e US. There was a sharp decline in the number of deaths per 100,000 both before and after routine vaccination was instituted= in the 1940s, and in 1990 there were 4 cases of diptheria reported in the US. (_Historical Statistics of the United States,= Colonial Times to 1970_ and _Statistical Abstracts of the United States_.=20 In Europe, there were large diptheria epidemics during and after World War = II, with an estimated one million cases and 50 000 deaths in 1943 (source: WHO web page on diptheria, written March 1998, http://www.who.org/gpv-dvacc/disease...theria_dis.htm). More recently, t= here have been large epidemics in Russia and the Newly Independent States.=20 Q3a.3 How effective is the diptheria vaccine?=20 "The fatality rate in immunized populations is one-tenth that in the unimmu= nized population. Paralysis is 5 times and 'malignant' disease 15 times less common in immune than in nonimmune individuals." (Har= rison)=20 Q3a.4 How long does the diptheria vaccine last?=20 Ten years.=20 Q3a.5 What is pertussis, and what are the risks of the disease?=20 Pertussis, or whooping cough, is a very contagious disease of the respirato= ry tract. Its attack rate in unvaccinated household contacts is over 90% (PDR) or up to 90 and in some cases 100% (Harrison).= =20 Pertussis is very serious in children under 2, with a mortality rate on abo= ut 1 to 2%. (Merck) "Prior to the availability of a vaccine, pertussis caused as many deaths as all other contagious disease _c= ombined_." (Harrison, p. 607) Complications include various lung complications (The Merck Manual has a long list of the= se), cerebral complications, hemorrage into the brain, eyes, skin, and mucuous membranes. In addition to killing, it can le= ave surviving infants with lasting lung damage and neurological diseases.=20 The mortality rate is higher in developing countries, partly because childr= en in these countries contract pertussis at a younger age (and mortality is higher at younger ages), and partly due to an associa= tion with protein-energy malnutrition (Galazka). This same article estimated that in the industrialized world, 0.04% of infected = children die from pertussis and complications, usually pneumonia "Among vaccine-preventable diseases, pertussis rivals measles and= neonatal tentanus in importance and severity in young children in developing countries and is third only to measles and neo= natal tetanus as a cause of death. It is estimated that pertussis is still causing some 340,000 deaths of children in the world eac= h year." (Galazka)=20 Q3a.6 How common was pertussis before routine vaccination, and how common i= s it now?=20 [Note: This section may be outdated, since the introduction of the new acel= lular vaccine has caused changed in vaccination schedules and vaccination coverage. More recent information on internationa= l vaccine schedules and disease incidence may be found at http://www.who.org.)=20 "Since immunization against pertussis (whooping cough) became widespread, t= he number of reported cases and associated mortality declined from about 120,000 cases and 1,100 deaths in 1950, to an= annual rate of about 3,500 cases and 10 fatalities in recent years." (PDR) For unknown reasons, there has been an i= ncrease in the US recently. "Over 6000 cases of pertussis were reported in the U.S. in 1993, the highest number in 25 years= .." (N Engl J Med 1994 Jul 7; 331:16-21, summarized in Journal Watch for July 22, 1994.) There is also a recent repo= rt (MMWR Nov 11, p. 807) of a strain of pertussis resistant to erythromycin.=20 In some other countries, pertussis is more common (most of the following in= formation is taken from Galazka). "Before the introduction of widespread immunization of young children with pertussis va= ccine, the incidence rates in Europe and the United States were very high. The reported rates per 100,000 population ranged fro= m 200-300 in England and Wales and Sweden, to more than 1,000 in Denmark and Norway." (Galazka) Annual incidence in th= e US and Canada before the introduction of pertussis vaccine in the 1940s ranged from 98 to 210 per 100,000 population= .. After the introduction and widespread use of DTP vaccine, incidence declined dramatically in most countries, and this tr= end continued for about 20 years. For example, in England and Wales, more than 150,000 cases of pertussis were reported a yea= r in the 1950s; by 1973, when vaccine acceptance was over 80%, only about 2,400 cases were reported.=20 However, in the late 1970s and the 1980s, different trends began to appear = in different European countries. In one group of countries, reported incidence is between 10 and 100 per 100,000. This grou= p includes Sweden and Italy, which don't routinely give pertussis vaccine to infants. It also includes Germany, the = former USSR, Ireland, Spain, and the United Kingdom, where infants are routinely vaccinated, but coverage is less than = 80%. In Denmark, incidence is high despite high coverage, but Denmark uses a different vaccination schedule from the other = countries. Countries with a moderate reported incidence (between 1 and 10 per 100,000) include Austria, Finland, Greece, = Israel, Norway, the Netherlands, Portugal, Romania, and Yugoslavia. Countries with a low incidence (less than 1 per 10= 0,000) include Hungary, Switzerland, Bulgaria, Czechoslovakia, Poland, and Turkey.=20 Q3a.7 How effective is the whole cell pertussis vaccine?=20 It's one of the less effective childhood vaccinations. The PDR estimates it= s effectiveness at 70-80%. It's effectiveness rating depends on the severity of the cases of pertussis being observed. One study= of 1797 households found the vaccine to be 64% effective against a mild cough, 81% effective against a paroxysmal cough, a= nd 95% effective against severe clinical illness. "Requiring laboratory confirmation improved efficacy to 95 to 98% for cultu= re-positive children and to 77% to 95% for culture- or serology-confirmed cases, depending on disease severity. Vaccin= e efficacy for typical paroxysmal cough increased from 44% for one diptheria, tetanus, and pertussis vaccine to 80% for four = or more doses." (Onorato, Wassilak, and Meade) The variation in estimates of efficacy may be because the more severe cases= were more likely to actually be pertussis, or it may be that the vaccine protects better against severe pertussis than against a= mild form of the disease. Note: these effectiveness ratings are for the older, whole cell pertussis vaccine. For information on= the effectiveness of the newer, acellular vaccines, which is generally comparable to that of the older whole cell vaccines, see= below.=20 Q3a.8 How long does the pertussis vaccine last?=20 It doesn't. According to _Harrison's Internal Medicine_, "the protection ..= .. is transient, with minimal resistance being evident a decade later." However, the critical years for pertussis immunity are when = a child is young; the disease is not dangerous for adults. With introduction of the new, less reactogenic acellular vaccine, i= t is possible that boosters may eventually be given to adults. (This estimate is for the older, whole cell vaccine, but the newer = acellular vaccine is apparently at least as durable as the whole cell one was.)=20 Q3a.9 What is tetanus, and what are the risks of the disease?=20 Tetanus is very dangerous. Even with antibiotics, mortality can be 40% or h= igher (Pantell, Fries, and Vickery, Harrison). Tetanus bacteria and its spores are everywhere. Because tetanus is so ubiqu= itous, the only way to counter it is widespread vaccination.=20 ************************************************** *********************** From=20J Thompson ): The tetanus vaccine is actually against the tetanus toxin (a protein called tetanospasmin), rather than the bacterium alone. The bacterium doesn't really do much of significance, but the toxin it secretes can cause muscular spasms. Thus, antibiotic therapy is rather pointless in preventing the spasms, but it is given anyway. The administration of antitoxin (passiv= e immunity) is helpful. (see Harrison's, 13th ed., p. 635) The vaccine consists of what is called "tetanus toxoid," which is simpl= y a purified version of the toxin, which has been treated to render it ineffective as a toxin (but still immunogenic). ************************************************** *********************** Q3a.10 How common was tetanus before routine vaccination, and how common is= it now?=20 300,000 to 500,000 cases are reported worldwide, with a mortality of about = 45%. In the US, there are about 100 cases a year, with a mortality of 40-60% (Harrison).=20 Q3a.11 How effective is the tetanus vaccine?=20 According to Taking Care of Your Child, "Tetanus is one of our best immuniz= ations.... Of all the vaccines available, tetanus comes closest to 100 percent effectiveness after the initial series of shot= s."=20 Q3a.12 How long does the tetanus vaccine last?=20 Generally ten years. In the case of a really dirty wound, a booster is reco= mmended if the person hasn't been vaccinated for tetanus within the last five years.=20 Q3a.13 What are some of the risks of the DTP vaccine?=20 DTP, particularly in its earlier form (with the whole cell pertussis compon= ent) is probably the most controversial of the childhood vaccines, because of risks associated with its pertussis componen= t. Anecdotal evidence has linked the vaccine with a variety of problems, including convulsions, physical collapse, brain damage= and SIDS. Supporters of the vaccine have argued that these problems are common in any case at the age at which children are= vaccinated for pertussis, and therefore are not necessarily effects of the vaccine.=20 The association between DTP and SIDS has not been confirmed by further stud= y (see Q1.5 for a study which found the evidence to be against such an association). The story on brain damage is s= omewhat different. Criticism of the pertussis vaccine received some confirmation in 1976, when a large British study of all child= ren 2 to 36 months old in Britain found that 1 in 310,000 doses resulted in permanent brain damage.=20 Critics argue that the rate of complications from the pertussis vaccine is = too high, and the effectiveness too low. Some argue that the decline in pertussis cases in this century has been an effect more= of improved sanitation than of the pertussis vaccine. The side effects of this vaccine have inspired groups critical of vaccinati= on in several countries, including the US, where the group Dissatisfied Parents Together (DPT) has lobbied Congress for changes = to laws about vaccination and set up its own vaccine information center.=20 Supporters of the pertussis vaccine differ in their response to the British= study which linked pertussis to brain damage. Some say that further analysis indicates that a link between the vaccine and bra= in damage is not so clear. "Meticulous reexamination of the data from this study led to the conclusion that the preliminary resu= lts were due to a systematic bias that favored finding an association between the vaccine and serious neurological sequelae. In fact,= there was no valid evidence from the study that the vaccine was associated with permanent neurological damage." (Shapiro)=20 Some smaller studies done since the British study didn't find a connection = between DTP vaccine and neurological damage, and a new study was just published in the Journal of the American Medical Assoc= iation which finds no increased risk of serious neurological illness. I haven't seen the article yet, so my information com= es from the January 11, 1994 San Jose Mercury (from the New York Times news service), which reports that the study is in the cu= rrent (as of 1/11/94) issue of JAMA. According to the article, "The federally financed study, the largest of its kind in the = United States, involved 218,000 children up to 24 months old in Oregon and Washington who were studied for a one-year period, beginn= ing Aug. 1, 1987." However, the study is also described as "not intended to give a definitive answer to the question of w= hether whooping cough vaccine causes neurological illness."=20 Others do not dispute the 1976 British study, but argue that a 1 in 310,000= risk of brain damage is still much smaller than the risk of actually getting pertussis. Supporters agree that it is important t= o maintain high vaccination levels against pertussis, lest we see a resurgence in the disease. In Great Britain, Japan, and Sweden, th= ere were sharp increases in the number of cases of pertussis when vaccination levels fell. Routine use was discontinued in Swe= den as a result of reports of side effects, while acceptance in Great Britain declined to 30% (Harrison), and vaccination dec= lined in Japan as well. "Within two years, one hundred thousand cases (with twenty-eight deaths) appeared in Great Britain= and thirteen thousand cases (with forty-one deaths) in Japan. Even in the US, the disease has by no means been wiped ou= t; there are still about fifteen hundred to two thousand cases (with four to ten deaths) each year. That is why virtually a= ll health care authorities recommend that we keep using this vaccine." (UC Berkeley)=20 ACIP considered the available data on brain damage in 1991, and concluded t= hat "Subsequent studies have failed to provide evidence to support a causal relation between DTP vaccination and either se= rious acute neurologic illness or permanent neurologic injury." It further noted that "The risk estimate from the NCES = study of 1:330,000 for brain damage should no longer be considered valid on the basis of continuing analysis of the NCES = and other studies." (Staff, Diptheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures, i= n Recommendations of the Advisory Committee on Immunization Practices (ACIP). Aug 8, 1991, CDC: Atlanta. p. 1-21.)=20 Known and non-controversial (i.e. everyone agrees that they occur) side eff= ects of DTP vaccine include redness and tenderness at the injection site, fever, drowsiness, fretfulness, vomiting,= and convulsions. (A vaccine information pamphlet from Kaiser gave the frequency as being 1 in 100 to 1 in 1000 for crying without= stopping for three hours or longer, a temperature of 105 F or greater, or an unusual, high-pitched cry, and 1 in 1,750 for co= nvulsions, generally from high fever, or shock collapse. I didn't see any frequencies in the PDR, other than describing th= ese side effects as rare.) It is a good idea to give acetaminophen to children being vaccinated for pertussis, to reduce the cha= nce of fever and febrile convulsions.=20 From=20Mike Dedek: ************************************************** *********************** American Journal of Diseases of Children 1992; 146: 173-176, February 1992,= =20 "Pertussis outbreaks in Groups Claiming Religious Exemptions to Vaccination= s",=20 Etkind, Lett, et. al.: 2% non-vaccinated students are monitored : Key measures in preventing pertussis are immunization and judicious use of prophylactic antibiotics. Pertussis can be prevented in children by immunization. Unfortunately, controversy over the safety of the pertussis vaccine has reduced acceptance. Highly publicized accounts of reactions t= o the vaccine and a dramatic increase in the number of malpractice lawsuits have= made physicians and parents wary of using the diphtheria-tetanus toxoid and per= tussis vaccine. {n4-n6} This publicity may have caused overinterpretation of the guidelines for medical contraindications. {n7} However, this overinterpret= ation creates its own risk for malpractice if a child given an inappropriate med= ical contraindication suffers damage due to disease. ************************************************** *********************** Q3a.14 Did SIDS disappear in Japan after the Japanese changed their pertuss= is vaccination policy in 1975?=20 This claim is examined at length by Lon Morgan, DC,DABCO in his Web site "A= summary of JAPAN, SIDS, and PERTUSSIS IMMUNIZATION" at http://fp1.cyberhighway.net/~lmorgan/fearmongers= /japan_sids.htm. It turns out that what went away, in 1975, when Japan increased the age at which it administered t= he first dose of the vaccine from three months to two years, was *claims of vaccine injuries* for SIDS. Japan had a compensat= ion system for vaccine injuries, in which claims were to be paid unless other causes were clearly provable. Under this syste= m, 11 claims were paid for what was termed Sudden Death, between 1970-1975 (this out of 25-30 million doses of pertuss= is vaccine). After the vaccination age was raised, no further claims were paid for Sudden Death related to vaccination= .. Since SIDS occurs before 12 months of age, any cases of SIDS can not be attributed to a vaccine which is given starting at= 24 months.=20 Japan has, however, kept statistics for SIDS, and these statistics showed t= he numbers of SIDS cases *increasing*, rather than decreasing, at the time that the age of the first pertussis vaccination was= raised. Though the delay in age for the first pertussis vaccination did not reduce the incidence of SIDS, it did result in a huge i= ncrease in pertussis cases, peaking at 13,105 cases and 41 deaths by 1979. For more details, and references, see Lon Morgan's s= ite.=20 As a side note, recent vaccination rates for Japan, as listed in http://www= ..who.int/gpv-surv/country/japan.html, were, in 1996, 98% for polio, 100% for diptheria, pertussis, and tetanus, and 94% for meas= les; the coverage for BCG in 1993 was 91%.=20 Q3a.15 When is the DTP vaccine contraindicated?=20 Hypersensitivity to a vaccine component, including thimerosal, a mercury de= rivative. Defer vaccination in case of fever or acute infection (but not nececcarily for a mild cold without a fever). A history = of convulsions is generally a contraindication to pertussis vaccination, but "The ACIP and AAP recognize certain circumstance= s in which children with stable central nervous system disorders, including well-controlled seizures or satisfactorily expl= ained single seizures, may receive pertussis vaccine. The ACIP and AAP do not consider a family history of seizures to be a contr= aindication to pertussis vaccine." (PDR)=20 The following reactions to a previous dose are contraindications: An immedi= ate anapylactic reaction. Encephalopathy occuring within 7 days following DTP vaccination. Precautions include a fever of = =3D 40.5 C (105 F) within 48 hours, collapse of shocklike state within 48 hours, persistent inconsolable crying for more th= an 3 hours within 48 hours, convulsions with or without fever within 3 days. (These latter are precautions rather than cont= raindications, because there might be circumstances, such as a pertussis epidemic, where you would still want to give the vaccin= e.)=20 Pertussis vaccine should not be given to anyone over seven years old (this = may change, in time, with the new acellular vaccine, but further study is needed first).=20 Vaccine components capable of causing adverse reactions: for diptheria, thi= merosal and toxoid; for tetanus, thimerosal and toxoid; for pertussis, bacterial components (Travel Medicine Advisor).=20 (Note: There is currently, as of 1999, a move toward replacing thimerosal i= n vaccines, so the reference to thimerosal here may shortly be out of date.)=20 Q3a.16 What are the advantages and disadvantages of the new acellular pertu= ssis vaccine?=20 The big advantage is that the acellular vaccine has fewer side effects. The= FDA initially held off on approving it for the earlier shots (while approving it for the fourth and fifth shots), mainly due to re= maining uncertainty as to whether it is as effective as the whole cell vaccine. Reports from Japan indicated that it is, but a Swedish = clinical trial indicated efficacy of 59% for one, and 64% for the other acellular vaccine. However, even this trial did show 90%= efficacy against severe pertussis. (Shapiro) More recent results in Sweden and Italy indicate it is both safe and effective. = On July 31, 1996, the FDA licensed one acellular pertussis vaccine for the inital three shots, and more followed. The Americ= an Association of Pediatrics has issued guidelines for the use of the new vaccine, which can be found at their web page, http://ww= w.aap.org.=20 As of 7/14/95, results were available from two large European studies, invo= lving 9,829 infants in Sweden and 15,601 infants in Italy. The National Institute of Allergy and Infectious Disease (in the US)= reported that "three similar experimental vaccines effectively immunized 84% to 85% of the children in the trials, while resul= ting in fewer side effects than current, widely used versions." (Wall Street Journal, 7/14/95, p. A7A) A surprising result of th= e studies was that whole cell pertussis vaccine efficacy rates were lower than usual: "conventional vaccines provided prote= ction for just 36% of children in Italy and 48% in Sweden. In the US the conventional vaccine proves effective in 70% to 95% o= f the children who are vaccinated." Officials suggested that infants in these studies might have had a higher intensity o= f exposure to the bacteria due to the lack of widespread vaccination in those countries, and that might explain the lower= efficacy. A fourth acellular vaccine provided protection in 58% of the cases. The high efficacy and low side effects show= n for the acellular pertussis vaccine in these studies will likely lead to requests that the FDA also approve the acellular vaccin= e for the earlier pertusis shots. More information on recent study results can be found in NEJM, Vol. 333, Number 16, Oct. 19, 19= 95 (B. Trollfors and others).=20 From=20Mike Dedek: This next one indicates there's a better vaccine that may soon become available [Note: this vaccine is now available, and recommended for all doses in the US and some industrialized countries]: ************************************************** *********************** In Pediatrics 1992; 89; 882-887, May 1992, "Acellular Pertussis Vaccination of 2-Month Old Infants in the United States", Pichichero, Francis, et. at.: ABSTRACT: This is the first study in children from the United States that evaluates the immunogenicity of and adverse reactions to the Connaught/Bike= n two-component acellular pertussis vaccine compared with whole-cell pertu= ssis vaccine when given as a primary immunization series at 2, 4, and 6 months o= f age. Three hundred eighty infants were studied; 285 received acellular diphtheria-tetanus toxoids- pertussis (DTP (ADTP)) and 95 received whole-c= ell DTP (WDTP). Following the third dose, ADTP vaccination produced higher ant= ibody responses than WDTP to lymphocytosis-promoting factor (enzyme-linked immunosorbent assay IgG geometric mean titer (GMT) =3D 131 vs 9 and Chinese hamster ovary cell assay GMT =3D 273 vs 16) and to filamentous hemagglutini= n (IgG GMT =3D 73 vs 10) (all P .0001). Agglutinin responses were higher in WDT= P compared with ADTP recipients (GMT =3D 50 vs 37; P =3D .02). Local reactio= ns were fewer for all three doses following ADTP vaccination. Fever, irritability, drowsiness, anorexia, vomiting, and unusual crying all occurred less freque= ntly in ADTP compared with WDTP recipients for one or more of the three doses. = We conclude that this two-component ADTP vaccine when given as a primary serie= s produces greater immunogenicity and fewer adverse effects than the currentl= y licensed WDTP vaccine. ....A large case-control study in Britain (National Childhood Encephalopathy Study) estimated that permane= nt neurologic deficits may occur after its administration in 1 in 310000 doses of WDTP. However, a reanalysis of this and similar studies recently has le= d=20 to the widely held conclusion that a causal association between WDTP vaccin= ation and permanent brain damage has not been demonstrated.... ************************************************** *********************** Public Health Rep 1992; 107: 365-366, May 1992/June 1992, "FDA Approves New Whooping Cough Vaccine" The Food and Drug Administration (FDA) has licensed a new whooping co= ugh vaccine that may cause fewer side effects in children. The new vaccine is being approved at this time only for the fourth an= d fifth shots. The current vaccine will continue to be used for the first t= hree shots. Additional research has been undertaken to ascertain whether it wi= ll be effective for preventing pertussis when used for primary inmunization --= the first three shots -- in infants. The new vaccine is acellular, meaning that it is made from only part o= f the pertussis organism, as opposed to the whole organism from which the curre= nt vaccine is derived. Whooping cough ( pertussis) is a highly contagious disease. As many as= 90 percent of nonimmune household contacts acquire the infection. Since rout= ine immunization against pertussis became common in the United States, the n= umber of reported cases of disease and deaths from it has declined from about 12= 0,000 cases with 1,100 deaths in 1950 to an annual average in recent years of ab= out 3,500 cases with 10 fatalities. The new vaccine appears to be as effective in older children as the cu= rrent vaccine and to cause fewer adverse reactions. It has been widely used in = Japan -- where it was developed -- with apparent success in children older than = 2 years. It will be combined with diphtheria and tetanus toxoids (DTP) and = sold under the brand name Acel-Imune. Gerald Quinnan, MD, acting director of FDA's Center for Biologics, where= the vaccine was evaluated and licensed, said that the availability of an acell= ular vaccine is a significant step forward in infectious disease control. The most common adverse reactions seen in clinical trials of the acellula= r pertussis vaccine included tenderness, redness, and swelling at the injec= tion site, fever, drowsiness, fretfulness, and vomiting. The new pertussis vaccine component is produced by Takeda Chemical Industries Ltd. of Osaka, Japan, and is combined with diphtheria and tetan= us toxoids manufactured by Lederle Laboratories of Wayne, NJ. Lederle will a= lso distribute the product in the United States. The vaccine is administered = by injection. The approval of the new vaccine comes at a time when the Federal Govern= ment is emphasizing early childhood immunizations in the wake of the largest rep= orted measles outbreak in the nation in 20 years -- with more than 27,600 cases a= nd 89 deaths reported in 1990. The aim is to reach a goal of full immunization for 90 percent of childre= n by the time they are 2 years old. ************************************************** *********************** As of September 1999, results are available from still more studies. Since = 1991, seven studies in Europe and Africa evaluated the efficacy of eight DTaP vaccines given to infants. The vaccines were by = different manufacturers, with varying number and quantity of antigens. Number of doses varied (three in some, four in others= ), as did other aspects of the study design, such as the case definition for pertussis and the laboratory method used to confirm= the diagnosis. For this reason, the studies can't be compared directly, but within the individual studies, the efficacy of whole= cell vaccine can be compared with the efficacy of acellular. Acellular was within the range expected for whole cell. Estimate= s of efficacy ranged from 59% to 89%. More serious adverse effects (fever over 105 F, persistent crying for more than three ho= urs, hypotonic hyporesponsive episodes, and seizures) happened less often with acellular. Really rare adverse events (e= ncephalopathy and anaphylactic shock) were too rare to show up in these studies. Acellular pertussis vaccines have also been us= ed routinely since 1981 in Japan.=20 Despite the acellular vaccine's comparable efficacy and few adverse reactio= ns, the whole cell pertussis vaccine retains one advantage which ensures some continued use. It is cheaper, and more organiz= ations know how to make it In developing countries, where pertussis is a major killer, and money for vaccines in sho= rt supply, it is not clear that the advantages of the acellular vaccine justify the additional cost.=20 Q3a.17 What are some of the risks of the DT (diptheria and tetanus) vaccine= ?=20 Most of the risk in the DTP vaccine comes from its pertussis component; the= diptheria and tetanus vaccines are quite safe. Reactions to the diptheria vaccine are quite rare. Most reactions are local= , limited to swelling at the injection site. The same is true of the tetanus shot. "Severe local reactions can occur if too many sho= ts are received; this phenomenon was frequently seen in military recruits who received unneeded immunizations." (Pantell, Fries,= and Vickery)=20 Q3a.18 When is the DT vaccine contraindicated?=20 Should be avoided during the first trimester of pregnancy. People who have = had a reaction (which is very rare) should avoid it.=20 Vaccine components capable of causing adverse reactions: for diptheria, thi= merosal and toxoid; for tetanus, thimerosal and toxoid (Travel Medicine Advisor).=20 (Note: There is currently, as of 1999, a move toward replacing thimerosal i= n vaccines, so the reference to thimerosal here may shortly be out of date.)=20 Q3a.19 Under what circumstances is tetanus toxoid given to pregnant women?= =20 Tetanus toxoid is given to pregnant women in countries where there is a hig= h risk of neonatal tetanus (due to factors which enhance the risk of cord contamination in these countries).=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3b. Polio [This section last updated September 19, 1999.] Q3b.1 What is polio, and what are the risks of the disease?=20 Polio is a contagious viral disease which crippled tens of thousands in the= 1950s, and killed more than a thousand a year. Because it is a mild gastrointestinal illness in young children and a serio= us paralytic illness in older people, it had an unusual epidemiology, with more cases of paralytic polio turning up in wealthy area= s and as sanitation improved. 80-90% of cases of polio are the minor illness; the rest are paralytic poliomyelitis. In paral= ytic poliomyelitis, 25% suffer permanent severe disability, about 25% have mild disabilities, and 50% recover with no res= idual paralysis. Mortality is 1 to 4%. "Recently, a post poliomyelitis syndrome has been described, characterized by muscle fat= igue and decreased endurance... The syndrome occurs many years after an attack of paralytic poliomyelitis..." (Merck).= =20 Q3b.2 How effective is the polio vaccine?=20 The Merck Manual and the Physician's Desk Reference give its effectiveness = as 95%. An article in a WHO publication (Hull and Ward) estimates effectiveness at 80%. (As with other WHO estimates, the= lower effectiveness rating reflects an estimate of effectiveness in the field in a variety of countries, including countrie= s in the Third World. Polio vaccine effectiveness can deteriorate if it is exposed to too much heat, which can happen in vaccinat= ion programs in some countries.)=20 Q3b.3 How long does the polio vaccine last?=20 It provides lifelong immunity.=20 Q3b.4 What is the difference between oral polio vaccine (OPV) and inactivat= ed polio vaccine (IPV)?=20 Oral polio vaccine provides better immunity, and was until recently usually= the recommended form, "because induces intestinal immunity, is simple to administer, is well accepted by patients, results in= immunization of some contacts of vaccinated persons, and has a record of having essentially eliminated disease associated with w= ild poliovirus in this country." (PDR) However, it carries a small risk of paralysis (see the answer to the next question for = details).=20 Recently, with increased progress in worldwide eradication of polio, both A= CIP and AAP have changed their recommendation to IPV for all shots. OPV remains the vaccine of choice for countries where= polio is still endemic, and for people who will be shortly travelling to such countries.=20 Q3b.5 I've heard that it is possible to contract polio from handling the di= apers of recently immunized infants. How long after receiving the vaccine does the child's excrement continue to contain the vi= rus?=20 ************************************************** *********************** From=20Caren Feldman: Speaking of this, I know there has been mention in the past of contractin= g polio from handling diapers of recently immunized infants. Does anyone know how long after receiving the vaccine the child's excrement continues= to contain the virus? The reason I ask is because sean got his polio booste= r and Rachel has only received the first vaccine in the series. The doctor= 's office said she wain no danger of contracting poliofrom him since they do= n't come in contact with each other *that* closely. However, I have to be ex= tra careful after helping Sean clean up (he needs help sometimes) or handling= his underwear to make sure I wash my hands thoroughly. So, how long until I can stop being paranoid about remembering to wash my hands after handling the laundry? (I forgot to ask) =20 The short answer is 6 weeks. But since you brought up the subject...here's = what I fond out about polio immunizations: When I had read one poster's response that the live polio virus from feces was actually weakened virus that would in fact help immunize unimmunized ki= ds they'd come in contact with it, naturally I didn't believe it. Well, not at first. But I had enough doubts of my disbelief to start asking around, and = came up with some (at least to me) little known facts about polio and polio immunizations. I am presenting it to misc.kids for everyone's edification. Indeed, live virus from a recently immunized child's feces is weakened viru= s that health officials actually hope unimmunized kids come in contact with = to provide them with individual immunity and the general population with "herd= " immunity. Now here's the tricky part. One of the attenuated strains used to make the vaccine has a very low but existing back mutation rate, back to the "wild type", i.e. back to "regular" polio. If the weakened virus the child has be= en given mutates back to wild-type polio, any adult with no immunity to it (or an immunized adult for whom the immunization series did not "take") is potentially at risk for full blown polio. Of course, people with weak immun= e systems may be at risk even from weakened virus. Steroid use may also caus= e the immune system to weaken (besides the usual anti-rejection drugs, HIV, leukemia) and thus increase susceptibility for contracting the virus. Polio in young children manifests itself as a mild gastrointestinal ailment= .. Polio in older children and adults starts as a mild gastroenteritis but wit= h complications that may lead to paralysis. Before the advent of improved pub= lic sanitation, most young children were exposed to and probably contracted the polio virus, so by adulthood, chances were everyone had immunity to it. It was only when public sanitation improved to where exposure to the virus was delayed until later childhood that polio epidemics became prevelant. Polio outbreaks in the US were less frequent among poor children than among more= =20 affluent families. The CDC estimates the chances of getting polio from a first immunization (I presume this means gastroenteritis symptoms in babies, not paralytic polio) is one in half million. The chances of getting polio from subsequent immunizations is 1 in 12 million. I assume the chances of secondarily contracting polio from feces are even rarer. These rare cases probably account for the supermarket tabloid (not to menti= on "60 Minutes") stories of adults catching polio from recently immunized kids who'd been given oral vaccine. For those in the US, you will be glad to hear that a federal compensation program exists, called the National Vaccin= e Injury Compensation Program, to help those stricken with paralytic polio as= a result of coming into contact with a recipient of the oral polio vaccine. Thanks go to two posters on sci.med for answering my questions regarding th= is subject. ************************************************** *********************** The 1993 Physician's Desk Reference confirms Caren Feldman's account, with = two small modifications. First, it gives the time when the virus is shed as 6-8 weeks, rather than six. Second, the CDC estim= ates which she gives are the estimates for cases of paralysis in *both* vaccine recipients and contacts of vaccine recipients c= ombined, not for recipients alone.=20 Q3b.6 What are some other risks of the polio vaccine?=20 A small risk of anaphylactic shock.=20 Q3b.7 When is the polio vaccine contraindicated?=20 Because of the small risk of paralytic polio in recipients and contact of r= ecipients of OPV, it should not be given to anyone who is immune-compromised or who has immune-compromised family members. (The PD= R has a really long list of immune deficiencies involved, which you can check if you think anyone in your fami= ly falls in this category.) In these cases, IPV should be given instead. IPV is also recommended for adults who are at risk for po= lio (such as unvaccinated adults travelling to an area where polio is endemic). Both vaccines are contraindicated for people = with an anaphylactic allergy to neomycin or streptomycin.=20 Vaccine components capable of causing adverse reactions: for both OPV and I= PV, streptomycin, neomycin, and phenol red; for IPV, animal protein, formaldehyde, and polymyxin B (Travel Medicine Adv= isor).=20 Q3b.8 Isn't it true that wild polio has been eliminated in the US?=20 From=20Mike Dedek: ************************************************** *********************** From The Reuter Library Report, 2/26/93, "U.N. Warns on need for Polio=20 Immunisation" copyright 1993 Reuters: The last outbreak of polio took place in the Netherlands 15 years ago. T= he virus was carried to Canada and the United States by infected people visit= ing their relatives, the WHO said. This caused the United States' last polio outbreak which hit the Amish community in the state of Pennsylvania in 1= 979. ************************************************** *********************** From The [London] Independent, 2/9/93, pg. 12, "Why child vaccines may be = a shot in the dark", by Tessa Thomas: After numerous cases in which the ''live'' oral polio vaccination was found to have caused the disease, the American government is considering reintroducing the inactivated injectable version. In the UK, the Departmen= t of Health advocates the live version on the basis that it deactivates any wil= d polio virus that reaches the gut, preventing it being excreted into the community, thus conferring community protection. The injectable vaccine ac= ts only on the bloodstream, protecting the individual but not breaking the ch= ain of infection. Lobbying by the Association of Parents of Vaccine Damaged Child= ren has prompted an acknowledgement by Virginia Bottomley, the Secretary of St= ate for Health, that the live vaccine is responsible for 50 per cent of recent= new cases of polio. Between 1978 and 1991 there were 42 cases of polio, 18 = of which followed vaccination and nine of which followed infection through co= ntact with the vaccinated child. ************************************************** *********************** The Atlanta Journal and Constitution, 12/19/92, "Cases in Netherlands put Americas at risk for polio", by Steve Sternberg, Section E; pg. 1 The last polio case in the Americas emerged on Aug. 23, 1991 in the remot= e Peruvian highlands village of Pichinaki... ************************************************** *********************** UPI 12/10/92: Except for a few rare vaccine-associated cases, there have been no cas= es of polio in the United States since 1986 when there was one imported ca= se. The current vaccine, Sutter said, is close to 100 percent effective in preventing the disease. ************************************************** *********************** MMWR's Summary of Notifiable Diseases, United States, 1997 (MMWR, November = 20, 1998 / 46(54);1-87) reports that "Since 1980, a total of 147 cases have been reported, of which 139 were ass= ociated with the use of OPV. The last imported case was reported in 1993."=20 Q3b.9 Why are we still vaccinating for polio, then?=20 The AAP and ACIP continue to recommend vaccination for polio for several re= asons. First, the risk of the disease is much higher than the risk of the vaccine. Second, though there is no wild polio = in the US *now*, with high levels of vaccination, there is still polio elsewhere in the world. 148,000 cases were reported to WHO i= n 1990. China reported 5,065 cases. The USSR reported 337 cases. India reported 7,340. (Hull and Ward) There have been s= everal outbreaks of polio in countries 2 or more years after the last reported case of polio. Importation from polio endemic= countries has led to outbreaks in Oman (1988-89 and 1993), Jordan (1991-92), Malaysia (1992), and the Netherlands (1992-93)= (MMWR, reported in HICNet Medical News on 15 August 1994). Wild poliovirus type 3 was isolated during January= -February 1993 among members of a religious community objecting to vaccination in Canada (although no actual cases of p= arlytic polio occurred in Canada at this time). There is a concern that if levels of vaccination were reduced in the US, po= lio could be reintroduced, and we could see polio epidemics here again.=20 Encouraged by the worldwide elimination of smallpox, WHO, in 1988, set a go= al of eradicating polio from the world by 2000. Since then, the number of cases in the world has declined dramatically (29,= 916 in 1989 and 16,435 in 1990), and the number of countries reporting 0 cases has increased (74 countries in 1985 and 116 = countries in 1990). As of 1993, the number of cases worldwide has falled to 9714, and nearly 70 percent of all countries = reported no cases. (Progress toward global eradication of poliomyelitis, 1988-1993. MMWR 1994 Jul 15; 43:499-503. Summ= arized in Journal Watch Summaries for July 22, 1994.) As of 1999, WHO reports still further progress, "In 1988, virus = circulated widely on all continents except Australia. By 1998, the Americas were polio-free (certification of eradication in 1994= ), transmission has been interrupted in the Western Pacific Region of WHO, including China, and in the European Region, except = for a small focus in south-east Turkey. As shown below, only three major foci of transmission remain: South Asia (Afghanista= n, Pakistan, India), West Africa (mainly Nigeria) and Central Africa (mainly Democratic Republic of Congo)." So another facto= r in the decision to continue vaccinating for polio is the hope that it can be eliminated for good.=20 After much debate, the US has switched to IPV instead of OPV (IPV being les= s effective, but lower in side effects). The decision at first was to continue with OPV because it has been so successfu= l, the rate of side effects is still considered very low, and because of various advantages in producing immunity (see above). Accord= ing to the 1993 PDR, "The choice of OPV as the preferred poliovirus vaccine for primary administration to children in = the United States has been made by the ACIP, the Committee on Infectious Diseases of the American Academy of Pediatrics, and= a special expert committee of the Institute of Medicine, National Academy of Sciences." In 1995, though, that decision was= changed, and the injected vaccine became recommended for the first two polio shots. As progress toward worldwide pol= io eradication continued, and as the change in the vaccination schedule (from an oral to an injected form) did not result = in any decline in vaccination coverage, ACIP and AAP are now recommending IPV for all shots.=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3c. MMR (measles, mumps, and rubella) [This section last updated on October 23, 1999.]=20 Q3c.1 What is measles, and what are the risks of the disease?=20 Measles is one of the most contagious infectious diseases. "A child can cat= ch measles by breathing the air in a doctor's waiting room two hours after an infected child has left." (Fettner) 90% of suscepti= ble household contacts get the disease (Harrison). Measles spreads very rapidly in unexposed populations. In 1951, it was intr= oduced to Greenland by a recently arriaved visitor who went to a dance as he was coming down with it, and in three months it s= pread to more than 4000 cases and 72 deaths. The attack rate was 999 cases per 1000 people. In 1875, measles was introdu= ced to Fiji and killed 30 percent of the population (Smith).=20 In areas where it was endemic, before the measles vaccine, measles epidemic= s used to occur at regular intervals of two to three years, usually in the spring, with small local outbreaks in intervening yea= rs. Mortality is low in healthy, well-nourished children unless complications ensue (Merck), but nevertheless there were 400 deaths = a year before an improved measles vaccine was introduced in 1966 (Pantell, Fries, and Vickery). Complications include bra= in infection, pneumonia, convulsions, blindness, various bacterial infections, encephalitis, and SSPE (a fatal complication = which can occur years after a person has had measles). Pregnant women who get measles have a 20% chance of miscarriage.= =20 Worldwide, measles is one of the leading causes of childhood mortality. "Me= asles has been called the greatest killer of children in history." (Clements, Strassburg, Cutts, and Torel) In 1990, "45 million = cases and around 1 million deaths were estimated to occur in developing countries. Thus measles is still responsible for more d= eaths than any other EPI target diseases. The true number dying as a result of measles may be twice the estimated 1 million if= the recently documented delayed effect of the disease is taken into account." (Ibid.) Mortality is higher in developing c= ountries due to a difference in the age at which most people catch it (measles is a more dangerous disease in the very young), po= orer nutrition, less availability of treatment for bacterial chest infections, and other environmental factors. However, "Even= in countries with adequate health care and healthy child populations, the complication rate can reach 10%." (Ibid.)=20 More information on the incidence of measles complications is found in the = answer to Q3c.2.=20 Q3c.2 How common was measles before routine vaccination, and how common is = it now?=20 ************************************************** *********************** From=20Anthony C.: I havent finished reading this thread so pardon if someone else has already posted this information Rates of complications of measles and measles immunization Measles per 10^5 Vaccine per 10^5 Encephalomylelitis 50-400 .1 sspe .5-2.0 .05-.1 Pneumonia 3800-1000 =20 Seizures 500-1000 .02-19 Deaths 10-10000 .01 These statistics are worldwide, hence the variablility in numbers. The higher rates of pneumonia and death represent figures collected from India, Nambia, Nigeria, bangladesh and other countries with developing health care industries. As far as the number of people afflicted with measles in the US Cases Deaths 1963 385,566 364 Inactivated measles type vaccine available 1964 458,093 421 1966 204,136 261 public health administration of vaccine 1967 62,705 81 1968 22,231 24 .. ..hovers around 20-70,000 .. 1977 57,345 15 1978 26,871 11 1979 13,597 6 1980 13,506 11 1981 3,032 2 1982 1,697 2 1983 1,497 4 1984 2,587 1 1985 2,822 4 1986 6,273 2 1987 3,588 2 1988 2,933 not available 1989 16,236 41 1990 26,520 97 iMajor foci of retransmission barring the complete elimination of measles: 1) unimmunized indigent, inner city youngsters. 2) illegal aliens. I hope this is useful. My source is Zinsser microbiology, 20th edition pages 1013-1015, joklik et al. ************************************************** *********************** As the above table shows, there was a marked increase in measles incidence = in the US from 1989 to 1991. This resulted in more than 50,000 cases including 125 deaths (http://www.immunize.org/nslt.d= /n21/paradx21.htm). Measles has been on the decline again in the US since 1990 (MMWR Feb 4, 1994, p. 57). Colleges enfo= rcing the requirement for a second measles vaccine report fewer measles outbreaks than schools with no requirement (JA= MA, Oct 12, 1994, p. 1127). (Both of these citations from Journal Watch for Jan 15, 1995 - paper edition, or Feb 7, 19= 95 - electronic edition.) During 1998, a provisional total of 100 measles cases was reported to the CDC, making for a record low= , 28% lower than the 138 cases reported in 1997 (MMWR 48(34);749-753, 1999. Centers for Disease Control).=20 Q3c.3 How effective is the measles vaccine?=20 The Merck Manual and the Physician's Desk Reference estimate its effectiven= ess at 95%. This estimate is based on studies of the immunity induced by a series of vaccinations beginning at 15 months. An= other article, estimating the immunity induced in field conditions (including some Third World countries, which may have less= reliable vaccine storage) by a series of injections beginning at 9 months (the injections are started earlier in areas where me= asles is widespread), estimated effectiveness as 85% (Clements, Strassburg, Cutts, and Torel).=20 A recent article in Pediatric News (Imperio. Vaccine-Exempt At Higher Risk = For Measles. Pediatric News 33(9):9, 1999.) reported that "Individuals aged 5-19 years who were not vaccinated due to r= eligious or philosophical exemptions were, on average, 35 times more likely than vaccinated individuals to contract measl= es, according to a population-based, retrospective cohort study."=20 Q3c.4 How long does the measles vaccine last?=20 The Merck Manual describes it as "durable." The PDR says that all of the an= tibody levels induced by MMR have been shown to last up to 11 years without substantial decline, and "continued surveill= ance will be necessary to determine further duration of antibody persistance."=20 Q3c.5 What are some of the risks of the measles vaccine?=20 There is a small chance of complications similar to the complications of me= asles (pneumonia, encephalitis, SSPE). Information on the frequency of these complications is included in the answer to Q3c.2.= There is some risk of anaphylaxis. This risk is low; from the time that VAERS was instituted in 1990 till the publication of Upd= ate: Vaccine Side Effects, Adverse Reactions, Contraindications, and Precautions by ACIP in 1996, 70 million doses of MM= R vaccine had been distributed in the US, and only 33 cases of anaphylactic reactions had been reported to VAERS. It has = been traditionally believed that this risk is mainly for people allergic to eggs or neomycin. However, recent studies indicate t= hat anaphylactic reactions are not associated with egg allergies, but with some other component of the vaccine. There have bee= n some case reports, in the US and Japan, of anaphylactic reactions to the MMR vaccine in people with an anaphylactic se= nsitivity to gelatin.=20 In rare instances, MMR vaccine can cause clinically apparent thrombocytopen= ia within 2 months after vaccination. Passive surveillance systems report an incidence of 1 case per 100,000 doses in Can= ada and France, and 1 per million in the US. Prospective studies have reported a range from 1 in 30,000 in Finland and G= reat Britain to 1 in 40,000 in the US, with a clustering of cases about 2-3 weeks after vaccination.=20 An article in the Feb 28, 1998 Lancet (based on 12 cases) about a possible = association between inflammatory bowel disease, autism, and MMR vaccine (Wakefield et al) raised concerns that the vaccine = might increase the risk of autism. Wakefield and his colleagues did not claim to have actually shown that the vaccine caused= autism, but rather called for further investigation of the question. An accompanying editorial in the same issue of Lancet express= ed concerns about the validity of the study.=20 The article, and the public concern it raised, led to several further inves= tigations of whether such an association existed. A research letter in the May 2, 1998 issue of Lancet reported on a 14-year pr= ospective study, in Finland, of children who had experienced gastrointestinal symptoms after receiving the MMR vaccine. 31 c= hildren (out of 3 million vaccine doses) reported gastrointestinal symptoms; all recovered, and none developed autism. A Work= ing Party on MMR Vaccine of the United Kingdom=92s Committee on Safety of Medicines (1999) examined hundreds of re= ports, collected by lawyers, of autism or Crohn's disease (a gastrointestinal disease) and similar problems, after th= e MMR vaccine, and concluded that there was no causal relationship. A Swedish study (Gillberg and Heijbel 1998) found no d= ifference in the prevalence of autism in children born before the introduction of MMR vaccine in Sweden, and children born af= ter. Wakefield and colleagues did laboratory assays in patients with inflammatory bowel disease (the mechanism which the= y had proposed for autism following the MMR vaccine), and found them negative for measles virus (Chadwick 1998, Duclos = 1998, cited by the CDC at http://www.cdc.gov/nip/vacsafe/vacci...cts/autism.htm).=20 Finally, a study in the June 12, 1999 issue of Lancet examined children bor= n with autism since 1979 in eight North Thames health districts, to look for changes in incidence or age at diagnosis sinc= e the introduction of MMR vaccination in the UK in 1988. The study found a steady increase in cases of autism, with no sudden = change in the trend after the introduction of the MMR vaccine. Parents most frequently reported first noticing symptoms of au= tism at around the age of 18 months, after the MMR vaccine would have been received, but there was no difference in age at= diagnosis between those vaccinated before and after 18 months and those never vaccinated. Developmental regression (which= occurred in about a third of the cases of autism) was not clustered in the months after vaccination.=20 Q3c.6 What is mumps, and what are the risks of the disease?=20 Mumps is a viral disease which is less contagious than measles or chicken p= ox. It causes swollen salivary glands. The most common complication is swelling of the testes (in about 20 percent of males= post puberty) and, less commonly, ovaries. Rarely, it can lead to sterility. Other complications are meningitis (less common t= han in measles) and acute pancreatitits. (A much longer list of complications can be found in the Merck Manual.)=20 Q3c.7 How common was mumps before routine vaccination, and how common is it= now?=20 105,00 cases were reported in 1970; by 1990 the rate of reported cases was = down to 5,300.=20 Q3c.8 How effective is the mumps vaccine?=20 The Merck Manual estimates its effectiveness at 95%. The Physician's Desk R= eference gives its effectiveness as 96%. Switzerland has gotten lower efficacy rates, for mumps, out of its strain o= f the MMR vaccine, and Swiss scientists have been comparing the efficacy of different strains to improve this situation (Swis= s Medical Weekly, http://www.smw.ch/archive/1997/127-26-360-96.html and http://www.smw.ch/arc= hive/1998/128-17-351-98.html).=20 Q3c.9 How long does the mumps vaccine last?=20 The Merck Manual describes it as "durable." "Mumps immunization provides pr= otection through the blood serum antibodies for at least 12 years, and possibly much longer." (Pantell, Fries, and Vickery)= (See also Q3c.4 for the PDR's description of the duration of all the MMR-induced antibodies.)=20 Q3c.10 What are some of the risks of the mumps vaccine?=20 "Rarely, side effects of mumps vaccination have been reported, including en= cephalitis, seizures, nerve deafness, parotits, purpura, rash, and prurittis." (Merck. Encephalitis and convulsions were al= so on Merck's list of complications for mumps itself.) According to ACIP's 1996 report on vaccine adverse reactions, "Aseptic meni= ngitis has been epidemiologically associated with receipt of the vaccine containing the Urabe strain of mumps virus, but= not with the vaccine containing the Jeryl Lynn strain, the latter of which is used in vaccine distributed in the United States." [= MMWR 45(No. RR-12), 1996]=20 Q3c.11 What is rubella, and what are the risks of the disease?=20 Rubella is a mild illness, consisting of a mild fever and rash. Rare compli= cations include ear infections and encephalitis, but the real danger is to pregnant women. During the last rubella epidemic, in 1964= , 20,000 children were born with birth defects caused by rubella. Birth defects include deafness, cataracts, microcephaly,= and mental retardation. Children born with congenital rubella are als susceptible to rubella panencephalitis in their = early teens.=20 Q3c.12 How common was rubella before routine vaccination, and how common is= it now?=20 Before the development of the rubella vaccine, epidemics used to occur at i= rregular intervals in the spring, with major epidemics at 6 to 9 year intervals. (This means that one was just about due when the = vaccine came out in 1969.) There have been no major epidemics since 1969, but the number of cases of rubella and congenit= al rubella syndrome increased starting in 1989 (Merck, also California Morbidity for November 19, 1993). (It was still a s= mall fraction of the pre-vaccine number, though, see table of disease frequencies in section 1.) "Serological surveys conduc= ted in the late 1970s and the 1980s indicated that 10 to 25 percent of United States women of child-bearing age were shown to be = susceptible to rubella." (California Morbidity, November 19, 1993) It now appears to be declining again: "Following a resur= gence of rubella and congenital rubella syndrome (CRS) during 1989-1991, the reported number of rubella cases during 1992 an= d 1993 was the lowest ever recorded." (MMWR, cited in June 9, 1994 HICNet Medical News Digest.)=20 Q3c.13 How effective is the rubella vaccine?=20 The Merck Manual estimates its effectiveness at 95%. The Physician's Desk R= eference gives its effectiveness as 99%.=20 Q3c.14 How long does the rubella vaccine last?=20 The Merck Manual describes it as "sustained." (See also Q3c.4 for the PDR's= description of the duration of all the MMR-induced antibodies.)=20 Another reference, from Heather Madrone: ************************************************** *********************** D. M. Horstmann "Controlling Rubella: Problems and Perspectives" _Annals of Internal Medicine_, vol. 83, no. 3, pg. 412 Horstmann found reduced antibody formation 3-5 years after administering the vaccine and 25% of those tested showed no immunity to rubella at all. ************************************************** *********************** Q3c.15 What are the pros and cons of vaccinating all infants for rubella ve= rsus vaccinating females only at puberty?=20 There is still some uncertainty about the most desirable rubella vaccinatio= n policy. In 1969, when the vaccine came out, it was decided to avert the expected epidemic by vaccinating all children over one= year, so that they would not spread rubella to their possible pregnant mothers - the first time one group of people was vaccinat= ed to avoid having them spread a disease to a different group of people. Supporters of this policy point out that the exp= ected epidemic didn't occur. The possible disadvantage is that we aren't sure how long the immunity lasts. Now that g= eneration of children is old enough to have children, and some of them may no longer be immune. In the past, 80% of the populatio= n was immune due to having had rubella in childhood.=20 Some countries follow a policy of vaccinating girls at puberty if they don'= t have rubella antibodies (Pantell, Fries, and Vickery). The disadvantage is that vaccine side effects are more common at this age. = The most common is joint pain, which occurs in 10% of women who are vaccinated in adolescence or later. In some cases, it = has lasted as long as 24 months. (Pantell, Fries, and Vickery) The PDR describes this same side effect in somewhat milder ter= ms, saying that it generally does not last very long and "Even in older women (35-45 years), these reactions are generally well = tolerated and rarely interfere with normal activities." It does agree with Pantell, Fries, and Vickery that the incide= nce of this side effect increases with age: 0-3% of children and 12-20% of women have joint pain, and the pain is more marked a= nd of longer duration in the adult women. A few women (between 1 in 500 and 1 in 10,000) experience peripheral neuropathy (= tingling hands). Another risk of vaccinating later is the risk that a woman may be pregnant. So far, no connection with birth = defects has been demonstrated, but women are advised to avoid pregnancy for three months after getting the vaccination.= =20 Current US policy is to vaccinate all children at 15 months, and give a boo= ster during school years. Adult women are advised to get an antibody test before becoming pregnant, and, if it comes up negat= ive, get vaccinated and wait three months before getting pregnant.=20 There has not been a rubella epidemic since 1964, either in countries which= vaccinate all children at 15 months, or in countries which vaccinate girls only at puberty.=20 Q3c.16 What are some of the risks of the rubella vaccine?=20 The PDR has a long list of possible adverse reactions (besides arthritis an= d arthralgia, usually short-lived, see above). Most of them are either mild or rare.=20 Q3c.17 When is the MMR vaccine contraindicated?=20 People with an anaphylactic or anaphylactoid allergy to eggs or neomycin sh= ould not get the vaccine. Other allergies or chicken or feather allergies are not a contraindication. Vaccination should be defe= rred in case of fever. The PDR give active untreated tuberculosis as a contraindication, but the AHFS says that there is no evid= ence of a need to worry about TB. Both give immune deficiency as a contraindication (see PDR for a long list of immune deficie= ncies involved). Immune globulin preparation or blood/blood product received in the preceding 3 months. The same contraindi= cations apply individually to measles and mumps vaccines, but the rubella vaccine can be given by itself to people with an = anaphylactic egg allergy. The other contraindications still apply to the rubella vaccine alone. (California Morbidity, October 31= , 1987)=20 Vaccine components capable of causing adverse reactions: for mumps and meas= les, chick fibroblast components; for mump, measles, and rubella, neomycin (Travel Medicine Advisor).=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3d. HiB (Hemophilus influenze B) [This section last updated September 19, 1999.]=20 Q3d.1 What is hemophilus influenze B, and what are the risks of the disease= ?=20 HiB is a bacteria which is one of the leading causes of meningitis in young= children. About 60% of cases are meningitis. The remaining 40% are cellulitis, epiglottis, pericarditis, pneumonia, sepsis, = and septic arthritis. Mortality rate can be about 5%, and there are neurologic sequelae in up to 38% of survivors.=20 Q3d.2 How common was HiB before routine vaccination, and how common is it n= ow?=20 Before routine vaccination, about 12,000 cases a year in the US, with a cum= ulative risk of 1 in 200 that a child would get the disease by age 5. A vaccine was introduced in 1985. Since the introduction = of the Hib conjugate vaccine in 1988, the race-adjusted incidence of Hib among children less than 5, has declined fro= m 41 cases per 100,000 in 1987 to two cases per 100,000 in 1993. (The incidence for people five or older remained stable. H= ib is most serious in children under 5.) (A decline of 95%, despite the fact that the National Health Interview Survey showed o= nly 67% of children 12-23 months had received at least one dose, and 36% three or more doses. This decline is attributed to = the elimination of carriage, which reduces Hib exposure even in unvaccinated children.) The CDC set a goal of eliminating = Hib in the US by 1996. (HICN708 Medical News, "[MMWR] Progress Elimination Haemophilus influenzae type b") As of Se= ptember 1999, this goal wasn't met, but there has been a significant decline; MMWR's "TABLE III. Provisional cases = of selected notifiable diseases preventable by vaccination, United States week ending September 11, 1999" records a cumula= tive total for 1998 of 788 cases, and for 1999 of 820 cases, in the US.=20 Q3d.3 How effective is the HiB vaccine?=20 Estimates from different labs vary a lot. AHFS Drug Information, after noti= ng this variability, and the uncertainty as to what antibody level is adequate for protection, says that in one study, 75% of c= hildren 18-23 months and 85% of children 24-29 months had serum anticapsular antibody levels of one microgram per millilit= er or greater. The PDR lists numerous studies, with results ranging from 100% efficacy to one study in which vaccinated childre= n had more cases of HiB than the unvaccinated group. With the exception of the latter study, all of the studies showed si= gnificant positive results, often with efficacy estimates over 90%.=20 According to a NY Times article of 12/18/90, HiB vaccine produces lower ant= ibody response among Native Americans, but the new conjugated vaccine seems to produce higher antibody response in Nat= ive American children and may protect all children at a younger age.=20 Q3d.4 How long does the HiB vaccine last?=20 The duration of immunity is unknown. However, the disease is only dangerous= to very small children.=20 Q3d.5 What are some of the risks of the HiB vaccine?=20 In a study of 401 infants, fever occurred in 2%, and redness, warmth, or sw= elling in 3.3%. All adverse reactions were infrequent and transient. (PDR) The Institute of Medicine reported in 1994 = that evidence favored rejection of a causal relationship between early onset HiB disease and conjugate vaccines, but fa= vored acceptance of a causal relationship between early onset disease in children 18 months old or more whose first vaccinati= on was with unconjugated PRP vaccine. [MMWR 45(No. RR-12), 1996]=20 Q3d.6 When is the HiB vaccine contraindicated?=20 Hypersensitivity to any component of the vaccine, including diptheria toxoi= d and thimerosal in the multi-dose presentation.=20 Vaccine components capable of causing adverse reactions: phenol, bacterial = polysaccharides, thimerosal (Travel Medicine Advisor).=20 (Note: There is currently, as of 1999, a move toward replacing thimerosal i= n vaccines, so the reference to thimerosal here may shortly be out of date.)=20 Q3d.7 What about rifampin prophylaxis?=20 An alternative to HiB vaccination is rifampin prophylaxis, but it could be = unwieldy to administer. AHFS Drug Information says that it is "effective for eradicating nasopharyngeal carriage of HiB, but t= he efficacy of the drug for prevention of secondary disease has not been firmly established."=20 =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D Section 3e. Hepatitis B gamma globulin and hepatitis B vaccine [This section last updated on September 15, 1999.]=20 Q3e.1 What is hepatitis B, and what are the risks of the disease?=20 There are several forms of hepatitis, infections of the liver which cause j= aundice, nausea, and weakness. Hepatitis B is spread mainly by contact with infected blood and by intimate contact with bodily f= luids, such as in sexual intercourse and childbirth. However, the hepatitis B virus is far more resilient than, for example, the= AIDS virus, and the disease is not strictly a venereal disease, and can be caught even by people who are not sexually active. Hepa= titis B becomes chronic in 5-10% of those infected. Complications include hepatic necrosis, cirrhosis of the liver, c= hronic active hepatitis, and hepatocellular carcinoma. Hepatitis B is endemic throughout the world, and a serious problem in group= s at increased risk. Information about hepatitis B is available by calling 1-800-HEP-B-873. Another source of information about h= epatitis B and many other forms of liver disease is:=20 American Liver Foundation 1425 Pompton Avenue Cedar Grove, NJ 07009 A source on hepatitis B in particular is:=20 Hepatitis B Coalition 1537 Selby Ave #229 St Paul, MN 55104 (612) 647-9009 There is also a hepatitis mailing list, HEPV-L on = U. A Web page on Diseases of the Liver can be found at=20 http://cpmcnet.columbia.edu/dept/gi/disliv.html=20 A US government source of information on hepatitis is:=20 Hepatitis Branch Mailstop G37 CDC Atlanta, GA 30333 or call the CDC Automated Voice Information System at (404) 332-255= 3. Hepatitis B should not be confused with hepatitis A, which is more contagio= us but less serious. Hepatitis A is spread through contaminated food and water. Symptoms can be mild flulike symptoms or sever= e nausea lasting for weeks. Hepatitis A does not become chronic and is rarely fatal. Other forms of hepatitis include he= patitis C, hepatitis D, and hepatitis E, and hepatitis (being a general term for inflammation of the liver) can also be caused by = certain medications. Information on other kinds of hepatitis can be obtained from the American Liver Foundation.=20 Q3e.2 How common is hepatitis B?=20 "The estimated lifetime risk of HBV infection in the United States varies f= rom almost 100% for the highest risk groups to approximately 5% for the population as a whole." (PDR) The CDC estimates ab= out 0.75 - 1 million chronic carriers in the US, and more than 170 million are estimated worldwide.=20 Q3e.3 What is hepatitis B gamma globulin, and when is it given?=20 It is given to people who have already been exposed to hepatitis B, to boos= t their immunity. In particular, it is given to children born to mothers with hepatitis B. It should be given as soon as possible af= ter birth for the best results.=20 Q3e.4 How long does the immunity provided by hepatitis B gamma globulin las= t?=20 Two months, maybe longer.=20 Q3e.5 What are the risks and contraindications of hepatitis B gamma globuli= n?=20 No known contraindications. A couple of diseases (see PDR for more informat= ion) are listed under precautions (a weaker form of warning than contraindication - in the case of precautions gamma gl= obulin may be given, but the extra risks of giving the gamma globulin have to be weighed against the benefits). These diseases, th= ough, aren't ones a newborn is likely to have, so they would probably not apply in the case of giving it to the newborn of a = mother infected with hepatitis B.=20 Q3e.6 How effective is the hepatitis B vaccine?=20 It varies depending on the age, sex, and general health of the recipient. A= bout 96-100% in infants and children 19 and under, 94-99% in adults 20-39, 88-91% in adults 40 or older. May be lower in men t= han women. Lower (only 64% in one study) in hemodialysis patients. (AHFS Drug Information 1992) The PDR estimated 95-96= % for infants, and agrees with AHFS about the conditions which reduce effectiveness.=20 Q3e.7 How long does the hepatitis B vaccine last?=20 There is evidence that immunity lasts up to ten years, but beyond that, the= duration is uncertain, and the need for booster doses not defined. (My source for the duration is Journal Watch, 9/1/93.)=20 Q3e.8 What are some of the risks of the hepatitis B vaccine?=20 Hepatitis B has traditionally been considered one of the safest and least r= eactogenic vaccines:=20 "During clinical studies involving over 10,000 individuals distributed over= all age groups, no serious adverse reactions attributable to vaccine administration were reported." (PDR, 1993) The most= common adverse reactions were injection site soreness (22%) and fatigue (14%). A longer list of adverse reactions can be= found in the PDR. "Update: Vaccine Side Effects, Adverse Reactions, Contraindications, and Precautions," published by ACIP i= n 1996, reported that VAERS data showed a low rate of anaphylaxis (approximately one event per 600,000 doses given).= =20 More recently, controversy has been aroused by news reports, particularly i= n France, of new or reactivated cases of multiple sclerosis, and other demyelinating disorders, within two to three months fo= llowing administration of hepatitis B vaccine. Critics argue that the risk is too high for a vaccine routinely given to children n= ot directly at much risk for hepatitis B. Supporters of vaccination argue that, given the demonstrated risk of liver cancer and cir= rhosis of the liver from hepatitis B, effective vaccination programs should not be abandoned for a hypothetical risk that t= he vaccine might in rare cases lead to multiple sclerosis and other demyelinating diseases.=20 As is the case in other controversies about vaccination risks, part of the = difficulty is assessing just what effect the hepatitis B vaccine may have on demyelinating diseases. Multiple sclerosis is, in some = countries, the most common neurological disease of young adulthood. Though most commonly reported between 20 and 40, it can be= reported at younger and older ages, and, given near universal vaccination of pre-adolescents, some cases of MS are t= o be expected, simply by chance, in proximity to vaccination. Since the incidence of cases of multiple sclerosis attributed = to the vaccine, in France and elsewhere, is less than the number already expected for the age range in question, statistical analysis= is required, to determine whether the risk of MS and other demyelinating diseases is in fact higher in populations vaccinated fo= r hepatitis B, and, if so, what the risk might be.=20 Several studies have been carried out, to date, to assess this risk, and mo= re are ongoing.=20 ACIP reported, in 1996, that evidence was inadequate to establish or reject= a causal relationship between hepatitis B vaccine and demyelinating diseases of the central nervous system.=20 The French National Drug Surveillance Committee studied people who received= more than 60 million doses of hepatitis B vaccine between 1989 and 1997, and found that the prevalence of neurologica= l disease, including MS, was actually lower in this group than in the general population.=20 Three French studies, prompted by reports of MS, showed a slightly increase= d relative risk in the vaccinated population, but not one which was statistically significant. In response to this, the Frenc= h government required a risk-benefit analysis. The risk-benefit analysis did not attempt to determine whether the hepatitis B = vaccine in fact causes MS or other demyelinating diseases, but rather to use the largest possible risks which could be deriv= ed from the studies which had been done, and weigh these against the expected benefits of hepatitis B vaccine (with both being= assessed in a statistical, quantititive fashion). This study concluded that, though it isn't possible to determine yet whether the= re is an association between the hepatitis B vaccine and MS, the benefits of the vaccine for a given vaccinated pre-adolescent c= ohort would clearly outweigh the risks.=20 In Canada, the Alberta Ministry of Health reported that a preliminary exami= nation of hospital admission data between 1975 and 1995 suggests that the introduction of the hepatitis B vaccine in the m= id-1980s has not been marked by an increase in the incidence of multiple sclerosis.=20 The World Health Organization Viral Hepatitis Prevention Board (VHPB) assem= bled experts, on September 28-30, 1998, to review the epidemiology and current understanding of MS. This group examine= d data on the epidemiology of hepatitis B, the epidemiology of multiple sclerosis, from national reporting systems in the = US, Italy, and Canada, from one active pediatric surveillance system in Canada, from industry post-marketing surveillance an= d clinical data, from published studies of hepatitis B safety, and from preliminary reports of a small number of unpublished epide= miological studies in the US, France, and the UK. They tried to decide between three hypotheses for explaining the relationsh= ip between the hepatitis B vaccine and MS: 1) coincidence, 2) "triggering," in which an illness which would have occurred= anyway was unmasked by the vaccine, or 3) a true causal relationship.=20 Evidence for the hypothesis of coincidence included the lack of any statist= ically significant association with MS to date, and the fact that age and sex distributions of reported adverse events resemble age= and sex distributions seen before the vaccine. Evidence in support of an increased risk as precipitating factor was the fa= ct that some studies showed slightly increased risk of MS, though not to a statistically significant degree. Evidence against was = that another study showed no increased risk. The group concluded that the evidence for an association between the hepatitis = B vaccine and MS was weak, and did not meet the criterion for causality.=20 Response to this data has shown a rare divergence in public health policies= .. The French National Network of Public Health, while still recommending the vaccine as useful to pre-adolescents, conclude= d that, because of differences in individual risk for hepatitis B and for side effects of the vaccine and "the need for a medical= consultation including the personal and family history," the vaccination program for pre-teens in the schools would be suspended. Th= is suspension was announced on October 1, 1998. Public health departments in several other countries, along with the = World Health Organization, criticized the French government for making a decision based more on politics than on the actual = risks, and reaffirmed existing vaccination policies. The US Congress held hearings on the subject, while the CDC affirmed that "= The scientific evidence to date does not support hepatitis B vaccination causing MS or other demyelinating diseases." (http:= //www.cdc.gov/nip/vacsafe/fs/qhepb.htm#7) Several organizations concerned with hepatitis B and multiple sclerosis, in the US = and Canada, came out with statements supporting continued hepatitis B vaccination.=20 As I write this section of the FAQ, the CDC reports that at least six resea= rch projects are underway, in the US, France, and the UK, to examine what relationship, if any, exists between the hepatitis = B vaccine and multiple sclerosis. In the meantime, most countries are continuing to recommend universal hepatitis B vaccinatio= n for infants and for pre-teens who have not already been vaccinated.=20 Q3e.9 When is the hepatitis B vaccine contraindicated?=20 Sensitivity to yeast or any other component of the vaccine. Pregnancy is no= t a contraindication to hepatitis B vaccination. A previous anaphylactic response to the vaccine is a contraindication to furt= her doses.=20 Vaccine components capable of causing adverse reactions: aluminum phosphate= , thimerosal, and formaldehyde (Travel Medicine Advisor). (Note, though, that as of September 1999, a thimerosal f= ree hepatitis B vaccine is available.)=20 Q3e.10 Why did the ACIP and AAP change their recommendation about the hepat= itis B vaccine?=20 Up until 1992, the recommendation was that hepatitis B vaccine be given onl= y to people in high risk groups for hepatitis B: people whose professions exposed them to blood, people at extra risk due to= their sexual practices or intravenous drug use, and certain populations (such as Southeast Asian immigrants) with a high in= cidence of the disease. The chief reason was cost; it was felt to be not cost-effective to vaccinate low-risk groups.=20 Unfortunately, this policy was not successful in checking the spread of hep= atitis B. It proved difficult to identify high-risk people, and high-risk people did not volunteer in large numbers to be vacci= nated. For this reason, in 1992, the ACIP recommendation was switched to vaccination of teens and adults in high-risk= groups and universal vaccination of infants. The AAP made a similar recommendation but would also like to extend hepatitis B= vaccination to all adolescents, if possible.=20 The American Liver Foundation also supports hepatitis B vaccination of infa= nts, and their pamphlet on the subject suggests a variety of ways in which even young children could come in contact with the= virus (through contact with blood, etc.). Though young children are at low risk of catching hepatitis B, their risk of devel= oping the chronic form of the disease if they do catch it is higher than for adults.=20 The new policy was well-received internationally, and 30 countries now have= universal infant HBV vaccination programs. Many physicians remain skeptical, however, and a survey in North Carolina s= howed one third of pediatricians and 20% of family physicians supporting the new guidelines (Journal Watch, 9-1-93). (U= pdate: Journal Watch for Jan 15, 1995/Feb 7, 1995 reports that this vaccine is gaining physician acceptance, citing Arch= Pediatr Adolesc Med Sep 1994, p. 936)=20 Why the resistance? One reason is a reluctance to give low-risk infants yet= another vaccination. Another is doubt about the duration of HBV vaccine. There is evidence that it lasts up to 10 years, bu= t we do not know yet whether it wears off beyond that point. There is concern that infants vaccinated for HBV may lose immun= ity during adolescence, when the risk of catching the disease is greatest. An alternative would be to vaccinate all children = at age 10 and give a booster at age 20. But compliance would likely be lower at age 10 than in infancy. Hepatitis B vaccine is adm= inistered in three shots over the course of six months, and it would be difficult to get preteens to all come in for the full serie= s. Also, 8% of hepatitis B infections occur before age 10, and the deadly form is three times greater in children (NY Times, 3/3/93:B8= ). Boosters could be given later to infants vaccinated for HBV if immunity proves to lapse.=20 Hepatitis B vaccine is also often recommended for travel purposes.=20 Q3e.11 Does vaccination for hepatitis B affect one's ability to donate bloo= d?=20 ************************************************** *********************** From=20Gregory Froehlich, MD (from a posting to sci.med): First, hepatitis B *antigen* is used to make Hep B vaccine. The antigen is grown in yeast culture; formerly, it was purified from the blood of people who were chronic hepatitis carriers. Antibodies are used in the gamma globulin shots used for hepatitis A or for passive immunization against hepatitis B if you're exposed. The local blood bank does not specifically test for exposure to hepatitis A (the kind you'd get from contaminated water). If a person has an active hep A infection, it will be picked up by elevated liver enzymes; if the person had such an infection in the past, it's over and done with--hep A doesn't give you a chronic, subclinical infection. Antibodies to hepatitis A should not preclude blood donation. They check for chronic hep B carriers by testing for hep B surface antigen. They test for recent hep B infection by testing for hep B core antibody. This antibody does not carry disease, but rather indicates that the person was recently infected and might or might not still be infectious. They do not test for surface *antibody*, which would indicate either (a) former hep B infection which was cleared, or (b) immunization against hep B--in either case, not infectious. I've got hep B surface antibody, because I was immunized; I can still donate blood. Blood banks also test for hepatitis C antibody; people with this antibody can still be infectious. ************************************************** *********************** Q3e.12 Do people who have showed up positive on the blood banks' tests for = hepatitis B exposure still need to be vaccinated?=20 It is still useful to be vaccinated, because some of the people who show up= positive on the blood bank tests are false positive.=20 Q3e.13 I will be travelling to an area where hepatitis B shots are recommen= ded, but I have less than six months before I leave. Is there an accelerated schedule for hepatitis B vaccination?=20 _Travel Medicine Advisor_ lists an accelerated schedule, with 3 doses at 0,= 30, and 60 days. With this schedule, a fourth dose is recommended at 12 months if there is still a risk for hepatitis B exposu= re.=20 |
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misc.kids FAQ on Childhood Vaccinations, Part 1/4 | [email protected] | Info and FAQ's | 3 | March 18th 04 09:11 AM |
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misc.kids FAQ on Childhood Vaccinations, Part 1/4 | [email protected] | Info and FAQ's | 1 | December 15th 03 09:41 AM |