Dr. Maller’s Blog

Vaccination represents one of the great triumphs of modern medicine. There are several new developments you need to know about, which I have included below along with the more familiar facts we have learned about this vital subject.
DTaP:
This vaccine is given at 2, 4, 6, 15-18 months and 4-6 years. This newer version known as “acellular” gives greater immunity than the previous DPT with fewer side effects. The three diseases protected against are:
Diphtheria, which infects the throat or a wound in the skin and produces a toxin which attacks the heart and other muscles and is about 10% fatal
Tetanus (lockjaw), which also results from toxin production within a wound with inadequate oxygen, and which is also often fatal
Pertussis (whooping cough) which is a bronchial infection caused by a bacterium which produces a toxin that causes weeks of paroxysmal cough and is often fatal in infants.
Pertussis vaccine is now available beyond age 6, and this new combination DPT (”Tdap”) called Adacel needs to be given at age 11 and continued routinely throughout life, every ten years for adults and within 72 hours of a serious wound in anyone not immunized within the past five years.
Pertussis vaccine is 70-90% effective. In areas where vaccination rates have dropped because of adverse publicity, epidemics are occurring. Much of that effort to interfere with vaccination is politically inspired by groups such as the “church” of scientology, and has contributed greatly to the cost and the mediocre success rates in reaching the children who need vaccination. Some children receiving DTaP vaccine have moderate fever and discomfort for a day or so. It has been established that the formerly used pertussis vaccine did not cause brain damage or death, as was previously suspected.

Polio:
This vaccine is given at 2, 4, 18 months and 4-6 years. Polio (infantile paralysis) caused tens of thousands of cases of permanent paralysis and hundreds of deaths yearly until the 1950’s. The Salk (injectable) vaccine slowed the disease, and the Sabin vaccine has virtually eliminated it. There are no side effects to either vaccine. The injectable polio vaccine has been reintroduced and is now replacing the oral form. Polio has now been eliminated from most of the world including the Western Hemisphere. There is hope that polio vaccination may soon become unnecessary.

MMR:
This vaccine is given at 12-15 months (a second dose should be given in adolescence or at school entry, as is now required by state law) and protects against three diseases:
Measles (rubeola), a severe viral infection with a high incidence of complications, typically in a pre-vaccine year producing 4,000,000 cases, 4000 children institutionalized with brain damage, and 400 deaths.
Mumps, a viral infection of the salivary glands, rarely serious but often involving the nervous system, pancreas, and reproductive glands, formerly a leading cause of deafness
Rubella (German measles, 3-day measles), a mild viral disease but one which is devastating to the fetus of most mothers who acquire it in the early months of pregnancy.
Before the vaccine was available, tens of thousands of severely damaged babies were delivered annually with congenital rubella, which has now disappeared! Fewer than 5% of children getting MMR will develop a fever 5-10 days later followed by a rash which is not contagious. This is a remarkably effective, safe vaccine.

Hepatitis B
This viral liver disease is usually transmitted via blood and body fluid contact, including sexual, but it can also be spread from a mother who is a carrier to her newborn baby. All pregnant women are now tested for HBV. The highest priority for vaccination is adolescents, but newborns are also vaccinated because some cases are suspected to occur in day care. The vaccine is now required for school entry and prior to entering seventh grade, and is given in three doses over 6-18 months. It does not cause significant side effects.

HIb (Hemophilus Influenzae type B):
This bacterial organism causes two very serious types of infections in children, spinal meningitis and epiglottis (similar to croup). Since this vaccination was introduced in 1985, both diseases have virtually disappeared, saving thousands of lives yearly. The vaccine is usually given in combination with Hepatitis B vaccine during infancy. Side effects are insignificant.

Varicella (Chickenpox)
This vaccine was introduced in the U.S. in 1995 after being used in Japan and elsewhere for over 20 years. It is a safe and effective live vaccine and can be given to children over one year; adolescents need two doses a month apart. Chickenpox is rarely serious, but can be, especially in young adults. This vaccine becomes mandatory for school attendance in 2001. A second dose is now recommended after school entry because outbreaks have occurred, albeit mild, among children who were previously vaccinated. I prefer giving the first dose at 18-24 months because it is more effective then.

Hepatitis A:
This form of viral liver infection is transmitted by contaminated food and water or by person-to-person contact. It is rarely serious, especially in children, but tends to occur in epidemics, Older patients often become jaundiced. The vaccine can be given in a two-dose schedule 6-18 months apart and is very safe. The first dose protects at least 90% of recipients within two weeks so it is highly recommended for foreign travel. Southern California is considered a high-risk area and the schools may soon require this vaccine. It can be started as early as one year if necessary but I prefer two.

Influenza:
This viral disease differs from what people commonly call “flu” in its classic severity and epidemic characteristics. The respiratory tract is attacked suddenly with high fever, dry cough, and muscle aches. The vaccine is unique in having to be reformulated yearly because the strains change. Healthy children are now vaccinated from 6 months to 5 years but immunity from the vaccine is brief and partial, but older patients and children with chronic disease (e.g. diabetes, heart defects, severe asthma) should be vaccinated yearly.

Pneumococcal Conjugate Vaccine (Prevnar):
This vaccine protects against invasive, life-threatening infections caused by this common group of bacteria. Although this family of bacteria causes more ear infections than any other, the vaccine is not aimed at those. Some drop in incidence of otitis media has occurred since Prevnar came into use. It is a very expensive vaccine but a useful one, and safe.

Rotavirus:
Infants between eight and thirty-two weeks can now receive RotaTeq, an oral 3-dose vaccine that prevents most cases of severe vomiting and diarrhea caused by this agent. Rotavirus is the leading cause of infant hospitalizations and kills at least half a million infants yearly around the world. An earlier version of this vaccine released in 1998 had safety problems, and I never used it. I have total confidence in the new version, but if all infants were breast-fed throughout infancy the vaccine would be unnecessary!

Menactra:
With the improved version of this vaccine, we can now prevent the three major types of spinal meningitis. Meningococcal meningitis is the stuff of legends; it was the dog sled race with serum to protect the children of Nome that inspired the Iditarod race in Alaska. In the pre-antibiotic era some patients did recover, but many were left with lost limbs and other horrible sequelae. Menactra in a single dose protects against the commonest strains and is given in early adolescence, offering ten years of protection or longer. Young people living in dorms and military barracks are at highest risk, although the actual risk is low (about 3 per 100,000) and avoiding smoking and other high-risk activities improves one’s odds.

Gardasil:
Our newest vaccine arrived in 2006 and caused immediate controversy. It protects against the human papilloma virus and is given in a three-dose regimen over six months. Once young women become sexually active almost all become infected, but the vaccine is approved up to 26 and since it contains 4 strains, there can still be benefit. It has been promoted as a “cancer vaccine” and that is true. Of the millions of women infected with HPV, most will be unaffected, but some will get genital warts, a most vexing and embarrassing condition, and about 3700 women in America will die each year of cancer of the cervix because of this infection. Another major benefit is that Pap smears are more reliable in vaccinated women.
The controversy is over when to vaccinate. Girls as young as nine may receive the vaccine, and there have been efforts to mandate it by sixth grade. In my practice, very few teenagers indulge in high-risk behavior and most parents and I prefer to wait until 14-16, but it does create an opportunity to discuss sexually transmitted diseases at earlier ages. HPV can be transmitted by skin contact or oral sex. Of course the vaccine confers no immunity to herpes, chlamydia, HIV, syphilis or gonorrhea. Boys may eventually be targeted for HPV vaccine as well. The vaccine is very expensive and insurance coverage is problematic.