Author: Vincent Iannelli, MD

The Unvaccinated Child

We know that your unvaccinated child is not healthier than vaccinated children.

And we know that among pediatric flu deaths, most are unvaccinated.

What else do we know about unvaccinated children?

Who’s Who Among Unvaccinated Children

Many children with cancer and other medical conditions benefit from herd immunity.
Many children with cancer and other medical conditions have medical exemptions to getting vaccinated and benefit from herd immunity. (CC BY 2.0)

Although it seems like unvaccinated kids all get grouped together, it is important to remember that not all unvaccinated kids are intentionally unvaccinated.

Some are too young to be vaccinated or fully vaccinated, some have medical exemptions, usually to just one or a few vaccines, and sometimes just temporary, and some have skipped or delayed one or more vaccines because of a lack of access to health care.

Whatever the reason, they are all at risk because they are unvaccinated.

The intentionally unvaccinated child poses the bigger risk though, because they tend to cluster together and are more likely to be either completely unvaccinated or to have skipped multiple vaccines. A child with a medical exemption because she is getting chemotherapy, on the other hand, very likely lives with a family who is completely vaccinated and protected. Similarly, a child with an allergy to a vaccine likely isn’t missing multiple vaccines.

Risks to the Unvaccinated Child

Of course, the main risk to the unvaccinated child is that they will get a potentially life-threatening vaccine-preventable disease.

While many vaccine-preventable diseases are no longer endemic in the United States and other developed countries, they have not been eradicated.

People do still get vaccine-preventable diseases in the United States.

And tragically, people do still die of vaccine-preventable diseases in the United States.

Can’t you just hide in the herd, depending on everyone else to be vaccinated and protected to keep these diseases away from your unvaccinated child? While that ends up being what happens most of the time, as there are no real alternatives to getting vaccinated, that strategy doesn’t always work. And it is a gamble that’s not worth taking and won’t keep working if more parents skip or delay getting their kids vaccinated.

Risks of the Unvaccinated Child to Everyone Else

Unvaccinated kids are also a risk to those around them, as they are more likely to get sick with a vaccine-preventable disease, since they have no immunity. No, they are not an instant danger if they don’t actually have a vaccine-preventable disease, but since you can be contagious a few days before you have symptoms, you are not always going to know when your child is sick and a risk to others.

Why does that matter if everyone else is vaccinated and immune?

Well, obviously, everyone else is not vaccinated and immune, including those with medical exemptions and those who are too young to be vaccinated. And since vaccines aren’t perfect, some people who are vaccinated can still get sick.

That’s why it is critical that if your unvaccinated child is sick or was exposed to someone who is sick, you are sure to:

  • notify health professionals about your child’s immunization status before seeking medical attention, as they will likely want to take precautions to keep you from exposing others to very contagious diseases like measles, mumps, and pertussis
  • follow all appropriate quarantine procedures that may have been recommended, which often extends up to 21 days after the last time you were exposed to someone with a vaccine-preventable disease
  • seek medical attention, as these are not mild diseases and they can indeed be life-threatening, even in this age of modern medicine

Hopefully you will think about all of these risks before your unvaccinated child has a chance to sick.

Getting Your Unvaccinated Child Caught Up

Fortunately, many unvaccinated kids do eventually get caught up on their vaccines.

It may be that they had a medical exemption that was just temporary and they are now cleared to get fully vaccinated.

Or they might have had parents who were following a non-standard, parent-selected, delayed protection vaccine schedule, but they have now decided to get caught up to attend daycare or school.

Others get over their fears as they get further educated about vaccines and vaccine myths and decide to get caught up and protected.

Is it ever too late to get vaccinated?

Actually it is.

In addition to the fact that your child might have already gotten sick with a particular vaccine preventable diseases, some vaccines are only given to younger kids.

For example, you have to be less than 15 weeks old to start the rotavirus vaccine. And you should get your final dose before 8 months. That means that if you decide to start catching up your fully unvaccinated infant at 9 months, then you won’t be able to get him vaccinated and protected against rotavirus disease. Similarly, Hib vaccine isn’t usually given to kids who are aged 5 years or older and Prevnar to kids who are aged 6 years or older, unless they are in a  high risk group.

Still, you will be able to get most vaccines. And using combination vaccines, you should be able to decrease the number of individual shots your child needs to get caught up. An accelerated schedule using minimum age intervals is also available if you need to get caught up quickly.

You should especially think about getting quickly caught up if there is an outbreak in your area or if you are thinking about traveling out of the country, as many vaccine-preventable diseases are still endemic in other parts of the world.

What to Know About The Unvaccinated Child

The main things to understand about the unvaccinated child is that they aren’t healthier than other kids, are just at more risk for getting a vaccine preventable disease, and should get caught up on their vaccines as soon as possible.

More on The Unvaccinated Child

Immunization Workshops and Conferences

Can’t make it to an immunization workshop or conference?

You could have learned about the Immunity Community and much more if you had attended the 47th National Immunization Conference.
You could have learned about the Immunity Community and much more if you had attended the 47th National Immunization Conference.

They are a great way to get educated about vaccines.

Immunization Workshops and Conferences

In addition to seeing future immunization workshops and conferences that you might be interested in attending, here are many archived workshop videos, presentations, slides, and posters that you can watch and read online:

Have you been to an immunization conference this year?

What to Know About Immunization Workshops and Conferences

Immunization conferences are a great way to learn about childhood and adolescent immunizations, vaccine preventable diseases, implementing appropriate immunization communication strategies, and addressing vaccine hesitancy.

More on Immunization Workshops and Conferences

We Don’t Know How To Talk About Vaccines

There is a dirty little secret about vaccines that people don’t seem to like to talk about.

No, it’s not about toxins or autism.

“Our systematic review did not reveal any convincing evidence on effective interventions to address parental vaccine hesitancy and refusal. We found a large number of studies that evaluated interventions for increasing immunization coverage rates such as the use of reminder/recall systems, parent, community-wide, and provider-based education and incentives as well as the effect of government and school immunization policies.

However, very few intervention studies measured outcomes linked to vaccine refusal such as vaccination rates in refusing parents, intent to vaccinate, or change in attitudes toward vaccines.

Most of the studies included in the analysis were observational studies that were either under-powered or provided indirect evidence.”

Sadaf et al on A systematic review of interventions for reducing parental vaccine refusal and vaccine hesitancy

It’s that we don’t really know how to talk about vaccines to vaccine hesitant parents, at least not in a way that we know will consistently get them to vaccinate and protect their kids.

Understanding Studies About Vaccine Hesitancy

Sure, a lot of studies have been done about talking to vaccine hesitant parents.

We have all seen the headlines:

  • Study: You Can’t Change an Anti-Vaxxer’s Mind
  • Pro-vaccine messages can boost belief in MMR myths, study shows
  • UWA study shows attacking alternative medicines is not the answer to get parents to vaccinate kids
  • Training Doctors To Talk About Vaccines Fails To Sway Parents

Does that mean that you shouldn’t try to talk to vaccine hesitant parents?

Of course not.

“How providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance.”

Opel et al on The Architecture of Provider-Parent Vaccine Discussions at Health Supervision Visits

Just understand that these headlines are usually about small studies, which if they were about treating a child with asthma or strep throat,  likely wouldn’t change how you do things.

Why do anti-vaccine websites still post misinformation about fake recommendations to stop breastfeeding?
Why do people continue to believe misinformation about fake recommendations to stop breastfeeding?

In one study that concluded that “physician-targeted communication intervention did not reduce maternal vaccine hesitancy or improve physician self-efficacy,” the physicians got a total of 45 minutes of training!

So they shouldn’t have so much influence about how you might talk to parents about vaccines that you throw up your hands at the thought of talking to a vaccine hesitant parent and won’t even think about learning how to use the CASE method, why presumptive language might work, or about vaccination-focused motivational interviewing techniques.

The bottom line is that no matter what the headlines say, we just haven’t found the best way to talk to vaccine-hesitant parents and help them overcome their cognitive biases. And until more studies are done, none of the existing studies about anti-vaccine myth-busting should likely overly influence how you do things.

“Physicians should aim for both parental satisfaction and a positive decision to vaccinate. Researchers must continue to develop conceptually clear, evidence-informed, and practically implementable approaches to parental vaccine hesitancy, and agencies need to commit to supporting the evidence base. Billions of dollars fund the research and development of vaccines to ensure their efficacy and safety. There needs to be a proportional commitment to the “R&D” of vaccine acceptance because vaccines are only effective if people willingly take them up.”

Leask et al on Physician Communication With Vaccine-Hesitant Parents: The Start, Not the End, of the Story

If you spend any time talking to vaccine hesitant parents, especially those who are on the fence, you quickly learn that many are eager to get good information about vaccines and all want to do what is best for their kids.

It’s just hard for many of them to do what is best when their decisions are getting influenced by vaccine scare videos and many of the 100s of myths about vaccines that are out there.

“…while the drivers of vaccine hesitancy are well documented, effective intervention strategies for addressing the issue are sorely lacking. Here, we argue that this may be because existing strategies have been guided more by intuition than by insights from psychology and by the erroneous assumption that humans act rationally.”

Rossen et al on Going with the Grain of Cognition: Applying Insights from Psychology to Build Support for Childhood Vaccination

So while we need more studies on the best ways to talk to vaccine hesitant parents, don’t dismiss all of the ways that might be effective, such as:

It is also important to become familiar with the myths and anti-vaccine talking points that may be scaring your patients away from getting vaccinated on time.

Why is this important?

If a parent is concerned about glyphosate, you might not sound too convincing telling them not to worry if you don’t even know what glyphosate is.

What to Know About Vaccine Hesitancy Studies

While we learn better ways to talk about vaccines, so that vaccine-hesitant parents can more easily understand that vaccines are safe and necessary, don’t dismiss current strategies because of small studies and attention grabbing headlines.

More on Vaccine Hesitancy Studies

 

How Effective Is the Flu Vaccine?

The flu vaccine works.

How well does it work?

It depends…

How Effective Is the Flu Vaccine?

What does it depend on?

“The vaccine effectiveness of seasonal influenza vaccines is a measure of how well the seasonal influenza vaccine prevents influenza virus infection in the general population during a given influenza season.”

WHO on Vaccine effectiveness estimates for seasonal influenza vaccines

Is the flu virus that is going around the same strain that was picked to be in the flu vaccine?

Once upon a time, we didn't have flu vaccines to help keep us healthy.
Once upon a time, we didn’t have flu vaccines to help keep us healthy.

Has the flu virus drifted, even if it is the same strain that is in the flu vaccine, becoming different enough that your protective flu antibodies won’t recognize it?

Is the H3N2 strain of flu virus the predominate strain during the flu season? H3N2 predominant flu seasons are thought to be worse than others.

In general, the flu vaccine is going to be less effective in a season where there is a poor match between the circulating strain of flu virus that is getting people sick and the strain that is in the flu vaccine, especially if it is an H3N2 strain that has drifted.

That’s why, since the 2004-05 season, the average flu vaccine effectiveness has been about 41%.

How Effective Is This Year’s Flu Vaccine?

It’s probably also why, every year, we seem to hear the same questions:

  • Should I get a flu vaccine? – yes, definitely
  • Will we have enough flu vaccines? – while historically there have been some delays and shortages, we have a very good supply of flu vaccine this year, between 151 to 166 million doses
  • How effective is this year’s flu vaccine???

Unfortunately, we really won’t know the answer to that last question until this year’s flu season really gets going.

What about reports that the flu vaccine effectiveness will be as low as 10% this year?

It is important to note that those reports are not based on flu activity in the United States and it has been a long time since we have seen flu vaccine effectiveness that low – the 2004-05 flu season. That was the year that because of a drifted A(H3N2) virus, “only 5% of viruses from study participants were well matched to vaccine strains.”

The 10% number is instead based on reports of Australia’s flu season, in which early estimates found that the A(H3N2) component of the flu vaccine was only 10% effective. Importantly, the overall vaccine effectiveness was much higher. Including other strains, the flu vaccine in Australia was at least 33% effective this past year.

“In the temperate regions of the Southern Hemisphere, influenza activity typically occurs during April – September.”

CDC on Influenza Prevention: Information for Travelers

Couldn’t we see a drifted A(H3N2) virus this year?

Sure, especially since an A(H3N2) virus will likely be the dominant strain, but so far “data indicate that currently circulating viruses have not undergone significant antigenic drift.”

“It is difficult to predict which influenza viruses will predominate in the 2017–18 influenza season; however, in recent past seasons in which A(H3N2) viruses predominated, hospitalizations and deaths were more common, and the effectiveness of the vaccine was lower.”

CDC on Update: Influenza Activity — United States, October 1–November 25, 2017

Again, it is too early to predict how effective the flu vaccine will be, but based on an undrifted H3N2 virus that is matched to the vaccine, you might expect an effectiveness between 30 to 40%.

It might be less if theories about egg-adapted mutations are true and are a factor this year.

“…some currently circulating A(H3N2) viruses are less similar to egg-adapted viruses used for production of the majority of U.S. influenza vaccines.”

CDC on Update: Influenza Activity — United States, October 1–November 25, 2017

It is also important to keep in mind that vaccine effectiveness numbers from Australia and the United States don’t always match up.

For example, in 2009, Australia reported an interim flu vaccine effectiveness of just 9%, but in the United States, the flu vaccine ended up being 56% effective! On the other hand, in 2014, the flu vaccine worked fairly well in Australia, but vaccine effectiveness was found to be just 19% in the United States.

Vaccine Effectiveness by Year
Australia United States
2007 60% 2007-08 37%
2008 NE 2008-09 41%
2009 7% 2009-10 56%
2010 73% 2010-11 60%
2011 48% 2011-12 47%
2012 44% 2012-13 49%
2013 55% 2013-14 52%
2014  50% 2014-15 19%
2015  ?% 2015-16 48%
2016  ?% 2016-17 42%
2017 33% 2017-18 ?%

What does all of this mean?

Not much.

“This season’s flu vaccine includes the same H3N2 vaccine component as last season, and most circulating H3N2 viruses that have been tested in the United States this season are still similar to the H3N2 vaccine virus. Based on this data, CDC believes U.S. VE estimates from last season are likely to be a better predictor of the flu vaccine benefits to expect this season against circulating H3N2 viruses in the United States. This is assuming minimal change to circulating H3N2 viruses. However, because it is early in the season, CDC flu experts cannot predict which flu viruses will predominate. Estimates of the flu vaccine’s effectiveness against circulating flu viruses in the United States will be available later in the season.”

CDC on Frequently Asked Flu Questions 2017-2018 Influenza Season

The reports about what happened in Australia should not have made headlines beyond Australia.

As you should get your family vaccinated if you haven’t yet.

The Flu Vaccine Works

Getting a flu vaccine has many benefits with few risks and can:

  • reduce your chances of getting the flu
  • reduce the chances that your newborn gets the flu if you get your flu shot while pregnant
  • lead to milder symptoms if you do get the flu
  • reduce your risk of being hospitalized
  • reduce your risk of dying from the flu

And while it isn’t perfect, getting a flu vaccine is certainly better than remaining unprotected and simply taking your chances that you won’t get the flu and complications from the flu.

What to Know About Flu Vaccine Effectiveness

Although the effectiveness of the flu vaccine varies from year to year, depending on how well matched the vaccine is to circulating flu virus strains, which strains are dominant, and whether they have drifted, it is always a good idea to get vaccinated and protected.

More on Flu Vaccine Effectiveness

There Is a Vaccine For That

Many diseases were once big killers.

Diphtheria, tetanus, polio, measles, rubella, Haemophilus influenzae type b, pertussis, rotavirus, and smallpox, etc.

Some still are.

There Is a Vaccine For That

Fortunately, many have been brought under control thanks to vaccines, at least in certain parts of the world.

diphtheria-vax-for-that
There is a vaccine for diphtheria and many other diseases that unfortunately continue to be big killers where vaccines are not readily available.

Smallpox, of course has been eradicated.

Polio, will hopefully soon be next.

What other diseases do we have vaccines to protect us against?

You might be surprised that the list is so long, as many of these vaccines aren’t routinely used in developed countries, but “we” have a vaccine for:

  1. adenovirus
  2. anthrax
  3. chicken pox
  4. cholera
  5. dengue
  6. diphtheria
  7. hepatitis A
  8. hepatitis B
  9. hepatitis E
  10. HPV
  11. Haemophilus influenzae type b
  12. influenza
  13. measles
  14. meningococcal disease types A, B, C, W, Y
  15. mumps
  16. pneumococcal disease
  17. pertussis
  18. polio
  19. Q-fever
  20. rabies
  21. rotavirus
  22. rubella
  23. smallpox
  24. shingles
  25. tetanus
  26. tick-borne encephalitis
  27. tuberculosis
  28. typhoid fever
  29. yellow fever

Other diseases, including Rocky mountain spotted fever, plague, and typhus, were once vaccine-preventable, but their vaccines were discontinued and are no longer available.

How many of these available vaccines are on the CDC immunization schedule?

In the United States, children routinely get 13 vaccines that protect them against 16 vaccine-preventable diseases including diphtheria, chicken pox, hepatitis A, hepatitis B, Hib, HPV, influenza, measles, meningococcal disease, mumps, pertussis, pneumococcal disease, polio, rotavirus, rubella, and tetanus.

Some of the other vaccines on the list are also given in special situations, like if your kids have chronic medical problems, or if they travel out of the country.

What to Know About Available Vaccines

We are fortunate that there are vaccines for many diseases that once caused deadly epidemics and outbreaks and unfortunately are still around in many parts of the world.

More on Available Vaccines

Vaccines and the HAZMAT Team Myth

Do unused vaccines need to be disposed of as hazardous waste?

If you drop a vaccine vial and it breaks, do you need to call in a HAZMAT team to clean it up?

If a HAZMAT team shows up a pediatricians office, it is probably because someone got sick from fumes - from burned popcorn...
If a HAZMAT team shows up a pediatricians office, it is probably because someone got sick from fumes – from burned popcorn… Photo by Kathy Nellis Chastney

Have you heard any of these anti-vaccine myths?

Would you be scared to vaccinate your kids if you had?

Vaccines and the HAZMAT Team Myth

While spilling elemental or metallic mercury, like by breaking a mercury filled glass thermometer (about 500mg of mercury), could release dangerous mercury vapors that need to be cleaned up carefully, vaccines never contained this type of elemental mercury that could vaporize like that.

And the amount of thimerosal or ethylmercury that used to be contained in vaccines, before it was removed beginning in 2000, was very small, even in multi-dose vial of vaccines.

Believe it or not, kids used to play with metallic mercury...
Believe it or not, kids used to play with metallic mercury… Photo by Bionerd (CC BY 3.0)

While you should be concerned if you drop a fluorescent light bulb in front of your kids, you don’t have to be if someone drops a vaccine vial.

And that being said, you don’t have to call a HAZMAT team if you break a CFL or other mercury containing light bulb, even though they might contain about 4,000mcg of mercury. As a precaution, you just let the room air out for out 10 minutes and then you carefully clean it up.

You don’t even have to call a HAZMAT team if you break a mercury thermometer, which can contain up to about 500,000mcg of mercury! Just let the area air out and then follow instructions to carefully clean it up.

How much mercury is in a typical multi-dose vaccine vial?

None.

But those that still contain thimerosal can contain up to 250mcg of ethylmercury per 10 dose vial. That’s about 6% of the amount of mercury that is in the light bulb (and 0.05% of the amount in the thermometer) and it is mixed with other ingredients, so you don’t have to worry about it being released as a mercury vapor.

And since you don’t have to call a HAZMAT team for the much larger quantities of metallic mercury in light bulbs and thermometers, why would you ever think you would have to for vaccine vials, which don’t even contain metallic mercury that can become a vapor that you can inhale?!?

Vaccines as Hazardous Waste

But if you don’t need a HAZMAT team, then how do you get rid of unused vaccines?

“In general, most empty vaccine vials are not considered hazardous or pharmaceutical waste and do not require disposal in a biomedical waste container. However, requirements for medical waste disposal are regulated by state environmental agencies so you should contact your immunization program or state environmental agency to ensure that your disposal procedures are in compliance with state and federal regulations.”

CDC on Vaccine Storage and Handling

It depends.

Still, most can be thrown away as medical waste.

Those that contain a preservative, like thimerosal, usually need to be thrown away in a hazardous waste container and disposed of through a hazardous waste disposal company.

Hazardous waste? Wait, doesn’t that mean HAZMAT?

No, but that’s where the myth likely comes from. Remember, you’re not supposed to throw out old CFLs in the trash either.

In the real world, most unused vaccines that are expired are simply returned to the manufacturer.

While having to deal with a hazardous waste disposal company sounds like a big deal, it is important to remember that almost all vaccines are now preservative free. The flu shot may still contain thimerosal, but the great majority,  at least 130 million doses, were preservative free this year.

So, few pediatricians likely have to deal with vaccines with preservatives or hazardous waste disposal companies. And hopefully they don’t have any old mercury thermometers lying around either.

That just leaves these myths about vaccines which never seem to go away…

What to Know About Vaccines and the HAZMAT Team Myth

Having to call a HAZMAT team to clean up after a broken vaccine vial is another myth about vaccines that is simply meant to scare you away from vaccinating and protecting your kids.

More on Vaccines and the HAZMAT Team Myth

Typhus vs Typhoid Fever

Typhus and typhoid have both been in the news recently.

  • Texas officials issue alert about typhus threat
  • Typhoid: Two children die‚ 60 ill after drinking from contaminated stream in South Africa

Should you start panicking?

Of course not.

Even before they knew which bacteria actually caused typhus and typhoid fevers, they knew they were different diseases.
Even before they knew which bacteria actually caused typhus and typhoid fevers, they knew they were different diseases.

While neither is usually a threat to most people in developed countries, instead of panicking, get educated and learn how you can prevent these still common infections.

Typhus Fever

Epidemic typhus fever is spread by human body lice (not head lice!) that are infected with the Rickettsia prowazekii bacteria.

Symptoms of typhus fever can include the sudden onset of:

  • fever
  • muscle aches (myalgias)
  • headache
  • chills
  • not feeling well (malaise)
  • cough

Some patients develop a characteristic rash made up of small red spots (macules) that start on the upper trunk. It then spreads to the rest of the body, but spares the face, palms, and soles. The rash can eventually become petechial.

Untreated, the fever may last up to two weeks, followed by a slow recovery of two to three months for all of the other symptoms. Typhus fever can be fatal.

Fortunately, treatment is available – the antibiotic doxycycline.

How do you prevent epidemic typhus fever? You avoid body lice. And avoid flying squirrels, which can be infected with Rickettsia prowazekii bacteria.

Is typhus fever vaccine-preventable? No, although a typhus vaccine was once available, it was discontinued in 1979.

Keep in mind that in addition to epidemic typhus, which is now very rare, typhus can also be spread by fleas (murine typhus) and chiggers (scrub typhus).

Murine or endemic typhus is common in tropical and subtropical climates, where it is spread by rats and fleas. In the United States, it is mainly found in California, Hawaii, and Texas, where it has also been associated with cat fleas found on cats and opossums.

Scrub typhus is associated with chiggers in rural areas of Southeast Asia, Indonesia, China, Japan, India, and northern Australia.

Typhoid Fever

Although typhus and typhoid some very similar, there are some big differences between these two diseases.

What are they?

Unlike typhus, typhoid fever is:

  • caused by the Salmonella typhi bacteria
  • spread by ingesting contaminated food and water
  • characteristic by symptoms that include a gradual onset of fever, with stomach aches, headache, loss of appetite, and sometimes a rash.
  • still vaccine preventable – in fact, there are two typhoid vaccine, one oral and the other a shot

Fortunately, typhoid fever can be treated with antibiotics, although it is sometimes multi-drug resistant and some people become chronic carriers, even with treatment (Typhoid Mary).

While adventurous and fun, eating street vendor food is probably a good way to get typhoid fever.
While adventurous and fun, eating street vendor food is probably a good way to get typhoid fever. Photo by Sam Sherratt (CC BY-SA 2.0)

That it can still be treated is a good thing, because unlike epidemic typhus, typhoid fever is still very much around.

The CDC estimates that there are about 5,700 cases of typhoid fever in the United States each year, mostly in travelers that leave the country.

Worldwide, there are about 21 million cases of typhoid fever and 222,000 typhoid-related deaths each year!

In addition to getting vaccinated, if traveling to the developing world, to avoid typhoid, you should avoid risky food and be sure to “Boil it, cook it, peel it, or forget it.”

What to Know About Typhus and Typhoid Fever

Typhus and typhoid fevers are two very different diseases that can both be avoided with good hygiene practices.

More on Typhus and Typhoid Fever