Kids are heading back to school – that means it’s vaccine time!
J. Gary Wheeler, MD
Back-to-school physicals are a great opportunity for physicians to update patients on their immunizations. But this task becomes more daunting each year. The vaccine schedule continues to become more crowded, and more groups of patients become candidates for vaccination.
The Centers for Disease Control and Prevention (CDC) lists its current vaccine recommendations at www.cdc.gov/vaccines/recs/schedules/default.htm. Here are a few highlights about vaccines that every physician should know.
Arkansas needs to improve vaccination rates
Combination vaccines are available for children
Adolescents need catch-up vaccines
Safety concerns for vaccines
Vaccine benefits outweigh the risks
Arkansas needs to improve vaccination rates
First and foremost, Arkansas physicians should be aware that the state’s vaccination rate is one of the lowest in the nation – and this puts our youth at great risk. In 2005, the latest year with published national data, Arkansas was ranked next to last, with a 67.8% vaccination rate, of all the states with children aged 19-35 months who were fully vaccinated against the five recommended childhood vaccines. Complete 2005 data is available at: www.commonwealthfund.org/snapshotscharts/snapshotscharts_show.htm?doc_id=364633
The 2005 rate was a significant drop from 2004, when Arkansas had a rate of 82.4% for the same group, and earlier, when we had the best varicella vaccination rate in the country. The state’s rate improved in 2006, at 75%. However, we should strive to match Massachusetts’ 2005 rate of 93.4%.
The vaccine registry is up and running. It provides physicians with a simple, convenient way to track a patient’s vaccine status at every visit. For more information about the vaccine registry, contact the registry help desk at 1-800-574-4040.
Combination vaccines are available for children
Of interest to both providers and parents is the ongoing release of combination vaccines. Two of these, Pentacel (DTaP-IPV-HiB) and Kinrix (DTaP-IPV) are licensed and waiting to move into the VFC line.
By now, most providers and state health departments have incorporated the Hepatitis A vaccine into their well child schedules. A third combination vaccine, Twinrix, (for Hepatitis A and B) is available for youth 18 and older under the VFC program.
Another combination vaccine now licensed for children two years and older is the cold adapted, live attenuated influenza vaccine. This LAIV product (Flumist) is not a regular part of the VFC program, but it is available if a patient should not take the regular influenza vaccine.
Rotavirus, however, is on the VFC schedule, and is now seeing widespread use.
Adolescents need catch-up vaccines
The Institute of Medicine (IOM) recommends that all adolescents receive a well child visit to catch up on missed vaccines, and to receive new, adolescent-specific vaccines.
Many adolescents, depending on the year they were born, did not receive two VZ vaccines and two MMR vaccines. They should receive these vaccines to assure adequate protection against the diseases.
New vaccines for this age group, provided through the VFC program, include:
- Conjugate meningococcal vaccine: A one-time single shot for strains A,C, W-135, Y.
- TdaP: Reconfigured to be less painful for adolescents and adults. One shot every 10 years, and at least two years beyond a dT.
- HPV vaccine: Three shots over six months.
Safety concerns for vaccines
Gardisil
Physicians should be aware that Gardisil has been associated with fainting spells in the adolescent girls to whom it is given, typically shortly after administration. Patients should be held in the office for 15 minutes after receipt. The Gardisil vaccine offers protection against human papilloma virus (HPV) and cervical cancer. Click here for more information: www.fda.gov/cber/label/gardasilppi.pdf
MMR-V
There is a mild increase in the rate of febrile seizures days after MMR-V use (0.2/1000 when individual vaccines are given simultaneously, compared to 0.5 /1000). The package information has been changed to reflect this new data. Since the availability of MMR-V has been reduced due to manufacturing priorities, this will not be an immediate problem. However, it should be noted when the supply is restored in the future. Click here for more information: www.fda.gov/cber/label/proquadLBinfo.htm
Autism
The public continues to worry about whether autism and other disorders are linked to vaccines. To date, there are no studies that show any causative role for vaccines in the development of autism. The most recent review published this year in the Journal of Clinical Investigation confirms earlier observations of “no effect” and that most changes in the brains of children with autism are suspected to have occurred early in utero, long before vaccination. The only data that supported a link between vaccines and autism was retracted by The Lancet after the author was shown to have manipulated data. His co-authors supported the retraction when they became aware of the situation. Click the following link for a full report: www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18451989
Thimerosal
Another recurrent concern involves the presence of Thimerosal (50% mercury) in vaccines. There is no proven evidence that mercury in vaccines leads to disease in children. However, Thimerosal has now been removed from all vaccines intended for use in children under six years of age in the United States. It is important to specify the Thimerosal-free product when ordering influenza vaccinations. Notably, although the use of Thimerosal has dropped, autism rates have actually risen. Visit the FDA Web site for specifics on Thimerosal concentrations in vaccines: www.fda.gov/cber/vaccine/thimerosal.htm#t3
Vaccine benefits outweigh the risks
Parents may argue against the need for vaccinating children because of the risk of vaccine-associated disorders. But the fact is, elimination of disease via vaccines continues to be listed among the top ten achievements of medicine, according to the Morbidity and Mortality Weekly Report (MMWR). For a complete list, click here:
www.cdc.gov/mmwr/preview/mmwrhtml/mm4850bx.htm
While we may never eliminate diarrhea, the recent drop in rotavirus since the introduction of the rotavirus vaccine gives hope that more widespread use of the vaccine may reduce this infant plague to even lower levels. As reported in the MMWR, 2008 rotavirus rates have reached an all-time low of 6%, compared to 51% in 2006 and 54% in 2007. Causation is not yet proven, but the decline is a strong incentive to follow through on this new vaccine. For more information, click here: www.cdc.gov/mmwr/preview/mmwrhtml/mm5725a6.htm
The news on hepatitis A vaccine is more mature and shows that the rates of hepatitis A dropped three-fold after introducing that vaccine into the well child series in states with a high incidence of Hepatitis A (J Infect Dis 2008:197:1282-87).
On the other hand, the “flattening” of the globe puts everyone at risk, regardless of the background rate of disease in a specific locale. Outbreaks of mumps, pertussis and whooping cough continue to occur periodically. And just this spring (2008), a measles outbreak occurred in Arizona when a Swiss tourist visited the Tucson area. The outbreak involved 13 proven cases and four probable ones. Click here for the local story: www.tucsoncitizen.com/ss/byauthor/91569
The bottom line is that as more children are vaccinated, the number of background cases of any disease drops to a very low level. However, we must always be aware that the threat of an outbreak exists, whether it originates across international borders or within specific populations of unvaccinated children. Therefore, we must continue to keep our immunization rates as high as possible.