What do kids do when their parents are anti-vaccine?
Whether or not they know it, they hide in the herd, at least until they understand what’s going on.
And then they often make a choice to either continue with their parents beliefs and remain unprotected or they get caught up.
Can Minors Consent to Getting Vaccinated?
Since getting vaccinated is a medical procedure, in most cases, you are still going to need the consent of a parent, guardian, or other adult family member if you are still a minor, which leaves out simply going out and getting caught up.
“State law is generally the controlling authority for whether parental consent is required or minors may consent for their own health care, including vaccination.”
Abigail English, JD on the Legal Basis of Consent for Health Care and Vaccination for Adolescents
Are you still a minor?
“In most states, age 18 is the age of majority and thus, before treating a patient under the age of 18, consent must be obtained from the patient’s parent or legal guardian.”
Ann McNary, JD on Consent to Treatment of Minors
When it comes to immunizations and health care, in addition to what state you live in, that likely depends on whether or not you are an emancipated minor (court order), married minor, pregnant minor, or minor parent (situational emancipation). It also can depend on the type of health care you are seeking, like if a minor is seeking birth control or treatment for an STD.
“States Parties shall assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child.”
Convention on the Rights of the Child
Are you a mature minor? In some states, you can also give consent for medical procedures, including getting vaccinated, if you are a mature minor – someone who is old enough to understand and appreciate the consequences of a medical procedure.
In Washington, for example, minors may get immunizations without their parents consent after their health care provider evaluates the minor’s “age, intelligence, maturity, training, experience, economic independence or lack thereof, general conduct as an adult and freedom from the control of parents.”
Yes. The minimum age for the first dose of rotavirus, DTaP, IPV, Hib, Prevnar, is 6 weeks.
Some other vaccines can be given earlier than their recommended age too, including:
the first MMR vaccine, which can be given as early as age 6 months in certain high risk situations, like traveling out of the country or in an outbreak situation, although this dose will have to be repeated once the child is 12 months old
the 4th dose of DTaP, which can be given as early as age 12 to 15 months, as long as at least 4 to 6 months have passed since the third dose
the 2nd dose of Varivax, which may be given as early as 1 to 3 months after the first dose
the Tdap vaccine, which can be given as early as age 7 years, instead of the more typical 11 to 12 years
the HPV vaccine, which can be given as early as age 9 years, instead of the more typical 11 to 12 years
Why would you get a vaccine early?
What if you are going to be traveling just before you infant is going to be 2 months old? Or your 9 year old stepped on a rusty nail, and it had been just over 5 years since his last tetanus (DTaP) shot?
Recommended and Minimum Intervals for Vaccines
In addition to earlier ages, you can sometimes get vaccines more quickly, on an accelerated schedule.
the minimum interval between the 1st and 2nd dose of rotavirus, DTaP, IPV, Hib, Prevnar is 4 weeks, instead of the standard 2 months
the minimum interval between the 2nd and 3rd dose of rotavirus, DTaP, IPV, Hib, Prevnar is 4 weeks, instead of the standard 2 months
the minimum interval between the 1st and 2nd dose of HPV is either 4 weeks (3 dose schedule) or 5 months (2 dose schedule)
the minimum interval between the 2nd and 3rd dose of HPV is 12 weeks
the minimum interval between the 1st and 3rd dose of HPV is 5 months, instead of the standard 6 months
Why give these vaccines more quickly than usual?
The usual reason is that a child is a little behind and is working to get caught up.
Absolute Minimum Ages for Vaccines
It is important to remember that in some cases, there are some hard and fast rules about minimum ages. That means that if you get these vaccines any earlier, they won’t count and you will likely have to repeat them, including getting :
the 3rd dose of hepatitis B before 6 months (24 weeks) or sooner than 8 weeks after 2nd dose and 16 weeks after 1st dose
the first dose of MMR, Varivax or hepatitis A before 12 months
the 4th dose of Hib before 12 months
the 4th dose of Prevnar before 12 months
the 4th dose of DTaP before 12 months
the 5th dose of DTaP before 4 years
the 4th dose of IPV before 4 years
Sticking to the routine schedule helps to avoid vaccine errors, like giving a vaccine too early. In some situations, the 4 day grace period helps if a vaccine is given a little early.
More on Recommended and Minimum Ages and Intervals Between Doses of Vaccines
There is a concern that they were “substandard,” or that they might not work as well as they should.
That’s not good either though.
Getting a substandard vaccine might mean that you could get a disease that you thought you were vaccinated and protected against.
Still, since the scandal seems limited to a few companies (well, really just one company) and a few vaccines (just rabies and DTaP), it is very unlikely that many people in other countries have been affected.
“WHO assessed the national regulatory authorities in 2010 and 2014, and found that they met WHO criteria as a functional regulator for vaccines with a clear commitment to continual improvement. WHO welcomes the fact that China’s NDA continues to work with WHO’s Regulatory Systems Strengthening program, as it has been doing for nearly 20 years. While the current incident is clearly regrettable, the detection of this event by an unannounced inspection shows that the regulatory authority’s system of checks and balances to protect population health is working.”
WHO Statement on Rabies Incident in China
It is also important to realize that:
affected vaccines include 650,000 doses of DTaP vaccine, which were only sent to Chongqing and the provinces, of Shandong and Hebei. And while they initially passed testing for safety and efficacy before being released for distribution, later, routine testing found low titer testing in vaccines from two companies, Changchun Changsheng Life Sciences Ltd. and Wuhan Institute of Biological Products, who’s vaccines were recalled. Batch numbers have been published, so parents should be able to figure out if they got one of these vaccines.
problems with rabies vaccines from Changchun Changsheng Life Sciences Ltd. were discovered on a routine inspection and before the vaccine had been released for distribution. Unfortunately, the problem is that they made up production and inspection records, which is why at least 15 people from the company have been arrested. This is the scandal.
While some folks are concerned of more widespread problems, it is important to keep in mind that vaccines have been working in China. Despite these recent problems, China is polio-free and has “significantly reduced vaccine-preventable diseases such as measles, mumps, rubella, and hepatitis A and B among children.”
If there were a big problem with the effectiveness of their vaccines, they should be seeing more disease. And they aren’t.
And in places that are seeing more disease, like Europe, with their measles outbreaks and deaths, it is clearly unvaccinated folks that are getting sick.
“If you are unsure as to whether or not your child was vaccinated, the doctor can have their blood tested for antibodies to determine their immunity to certain diseases. However, these tests may not always be accurate, so the doctor may not be sure your child is truly protected. In some cases, doctors may prefer to revaccinate your child anyway for best protection. It is safe for your child to be revaccinated, even if your child received that vaccine in their birth country.”
CDC on Adoption and Vaccines
If you are still concerned about vaccines that your child may have gotten in China, either because you were living in China when your child was vaccinated or your child was adopted from China, remember that you can always have those vaccines repeated.
Until and if we get further guidance on this issue from the WHO, CDC, or AAP, neither seems to be necessary for what seems to be an isolated problem right now.
Update on the Vaccine Scandal in China
There have been a few updates since the initial news of the vaccine scandal in China, including that:
at least 10 officials with the State Food and Drug Administration and the State Drug Administration have been fired and 35 non-centrally-administered officials will be held accountable
an additional 247,200 DTaP vaccines from Changchun Changsheng Life Sciences Ltd. have been found to be substandard
And there are reports of some parents going to Hong Kong to get their kids vaccinated.
Vaccine Scandals in China
Tragically, these aren’t the first vaccine scandals in China.
there were reports of kids getting sick in 2016 in Shandong providence after getting vaccines that had not been stored properly
there were reports of kids getting sick in 2015 after getting expired vaccines in Henan province
in 2013, several infant deaths were blamed on hepatitis B vaccines, but they were later determined to be coincidental
And before that, in 2010, at least four children reportedly died in Shanxi province after getting what were said to be improperly stored vaccines.
While improperly stored vaccines could become contaminated, getting kids sick, it is unlikely that they would get sick from expired vaccines, which might just be less effective than newer vaccines.
What to Know About Vaccine Scandals in China
While it is horrible that anyone put profits before safety when it comes to keeping kids safe from vaccine-preventable disease, it would also be terrible to further use the China vaccine scandals to scare parents away from vaccinating and protecting their kids.
That’s one of the reasons that it is important for everyone to be vaccinated, so that herd immunity levels of protection can protect those who can’t get vaccines.
Vaccines After Cancer and Chemotherapy
But what happens after they complete their cancer treatments?
“The interval until immune reconstitution varies with the intensity and type of immunosuppressive therapy, radiation therapy, underlying disease, and other factors. Therefore, often it is not possible to make a definitive recommendation for an interval after cessation of immunosuppressive therapy when inactivated vaccines can be administered effectively or when live-virus vaccines can be administered safely and effectively.”
Red Book on Immunization in Immunocompromised Children
After they complete therapy for cancer, whether it is chemotherapy or a bone marrow transplant, many children need to get extra vaccines.
In the UK, for example, 6 months after completing “standard antileukemia chemotherapy,” children get a booster dose of DTaP, IPV, Hib, MenC, and MMR.
Why just a single booster dose?
Because most kids can continue to get non-live vaccines on schedule while they are getting standard chemotherapy. They get a booster dose when they finish chemotherapy because those vaccine doses they got while receiving treatment might not be as effective as usual and typically don’t count as valid doses.
Of course, if they were missing any doses, then they might need extra doses to catch up too.
“Three months after cancer chemotherapy, patients should be vaccinated with inactivated vaccines and the live vaccines for varicella; measles, mumps, and rubella; and measles, mumps, and rubella-varicella according to the CDC annual schedule that is routinely indicated for immunocompetent persons.”
2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
In contrast to those getting standard chemotherapy, if treatment involved a hematopoietic stem cell transplant (HSCT), then these children are essentially revaccinated:
beginning at 6 months after the HSCT, they should get 3 doses of DTaP if they are less than 7-years-old vs a dose of Tdap and 2 doses of Td if they are already 7-years-old
beginning at 3-6 months after the HSCT, they should get 3 doses of Prevnar
beginning at 6-12 months after the HSCT, they should get 3 doses of Hib
beginning at 6-12 months after the HSCT, they should get 3 doses of hepatitis B, followed by postvaccination anti-HBs titer testing
beginning at 6-12 months after the HSCT, they should get 3 doses of IPV
beginning at 6-12 months after the HSCT, they should get 2 doses of a meningocococcal vaccine (if they are already 11 to 18 years old)
beginning at 6-12 months after the HSCT, they should get 3 doses of HPV vaccine (if they are already 11 to 26 years old)
beginning at 12 months after the HSCT, one dose of the Pneumovax vaccine
beginning at 24 months after the HSCT, two doses of MMR
beginning at 24 months after the HSCT, two doses of the chicken pox vaccine
a yearly flu shot
Why not just check titers instead of repeating all of those vaccines?
“protective” concentrations or titers in this population may not be as valid as in healthy children, leaving open the question regarding what levels to use as the basis for revaccination. Furthermore, there are some vaccines for which no serological correlate of protection exists (e.g., pertussis) or for which, in routine practice, it is too difficult to have levels measured (e.g., polio).
Soonie R. Patel et al. on Revaccination of Children after Completion of Standard Chemotherapy for Acute Leukemia
In Canada, they used to check titers at 1, 3, and 5 years after the end of chemotherapy and just vaccinate when titers dropped, but they switched to giving all kids a booster dose, as it works better.
What will your child’s immunization look like after completing treatment for cancer?
Although the specific recommendations will come from your child’s treatment team, they will likely look something like the guidelines included here.
What to Know About Vaccines After Cancer and Chemotherapy
Kids often have to get revaccinated, or at least get booster doses of their vaccines, after completing treatment for cancer.
That’s why the focus on controlling pertussis outbreaks is usually looking at close contacts – those who were within about 3 feet for at least 10 hours a week or who had direct face-to-face contact with the person when they were contagious.
So when you get a letter about a possible case of pertussis in your child’s school, it may be a a general warning and not that your child is at risk.
How do you get pertussis?
“Persons with pertussis are infectious from the beginning of the catarrhal stage through the third week after the onset of paroxysms or until 5 days after the start of effective antimicrobial treatment.”
Manual for the Surveillance of Vaccine-Preventable Diseases
Spread by respiratory droplets (coughing and sneezing), pertussis symptoms usually start about 5 to 10 days after being exposed to someone else who is in the early stage of their pertussis infection.
While pertussis symptoms can linger for up to 10 weeks, someone who has pertussis is most contagious during the first 2 or 3 weeks of symptoms.
Is Your Child Protected Against Pertussis?
Two pertussis vaccines, DTaP and Tdap, help protect us against pertussis.
In the Unites States, they are routinely given as a primary series (DTaP) at 2, 4, and 6, and 15 to 18 months, with a booster dose at age 4 years. And then a booster of Tdap at age 11 to 12 years. Later, Tdap is given again during each pregnancy, between 27 and 36 weeks gestation. Adults who have never had a dose of Tdap should get caught up, especially if they will be around a baby.
Protection from the pertussis vaccines wanes or wears off, so even fully vaccinated children and adults can still get pertussis. Of course, you are much more likely to get pertussis if you are unvaccinated and you will likely have more severe illness if you are unvaccinated.
Postexposure Antimicrobial Prophylaxis for Pertussis
Fortunately, as with meningitis was caused by Neisseria meningitidis and Haemophilus influenzae type b (Hib), taking antibiotics after being exposed to someone with pertussis can help prevent you from getting sick.
There are only specific situations for which this type of postexposure antimicrobial prophylaxis is recommended though, so for example, you wouldn’t usually give everyone in a school antibiotics because a few kids had pertussis.
Why not give antibiotics to everyone who might have been exposed to someone with pertussis?
“…there are no data to indicate that widespread use of PEP among contacts effectively controls or limits the scope of pertussis outbreaks.”
Postexposure Antimicrobial Prophylaxis
In addition to the fact that it likely wouldn’t stop our pertussis outbreaks, overuse of antibiotics can have consequences.
Situations in which postexposure antibiotics (azithromycin, clarithromycin, and erythromycin, or Bactrim) likely would be a good idea include:
household contacts of a known pertussis case
to help control an outbreak in a limited closed setting, like a daycare
contacts of a pertussis cases who are at high risk for severe pertussis, including pregnant women, infants, especially infants less than 4 months old, and people with chronic medical problems
contacts of a pertussis cases who are also contacts of someone who is at high risk for severe pertussis
What if you were exposed to someone with pertussis and have already gotten sick?
If your child was exposed to pertussis and is now coughing, then in addition to antibiotics, pertussis PCR testing and/or culture will also likely be done to confirm that they have pertussis. And remember that their contacts might need postexposure antibiotics.
Kids who have been exposed to pertussis and who have been coughing for more than 3 weeks won’t need antibiotics or testing, as it is too late for the antibiotics to be helpful and likely too late for testing to be accurate. Fortunately, after 3 weeks, they should no longer be contagious.
What to Do If Your Unvaccinated Child Is Exposed to Pertussis
Unvaccinated kids who are exposed to pertussis should follow the postexposure antimicrobial prophylaxis guidelines.
They should also get caught up on their immunizations, including DTaP if they are between 2 months and 6 years, or Tdap if they are older.
What to Do If Your Vaccinated Child Is Exposed to Pertussis
Since protection from the pertussis vaccines wanes, even kids who are fully vaccinated should follow the postexposure antimicrobial prophylaxis guidelines if they are exposed to pertussis.
Then why get vaccinated?
Again, being vaccinated, your child will be much less likely to get pertussis than someone who is unvaccinated. Even though the pertussis vaccine isn’t perfect, it has been shown that children who had never received any doses of DTaP (unvaccinated children) faced odds of having pertussis at least eight times higher than children who received all five doses.
What to Know About Getting Exposed to Pertussis
Talk to your pediatrician if your child gets exposed to pertussis to make sure he doesn’t need post-exposure prophylaxis to keep him from getting sick, even if you think he is up-to-date on his vaccines.
“Measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also become infected.”
CDC on Transmission of Measles
Unlike measles, which is so contagious that you can get it if you are simply in the same room with someone that is sick, mumps typically requires prolonged, close contact.
“When you have mumps, you should avoid prolonged, close contact with other people until at least five days after your salivary glands begin to swell because you are contagious during this time. You should not go to work or school. You should stay home when you are sick with mumps and limit contact with the people you live with; for example, sleep in a separate room by yourself if you can.”
CDC on Mumps Outbreak-Related Questions and Answers for Patients
How do you get mumps?
Since the virus spreads through saliva and mucus, you can get sick if you are in close contact with someone with mumps and they:
cough or sneeze
use a cup or eating utensil that you then use
touch an object or surface that you then touch (fomites)
And like many other vaccine-preventable diseases, people with mumps are usually contagious just before they begin to show symptoms.
“The mumps virus replicates in the upper respiratory tract and spreads through direct contact with respiratory secretions or saliva or through fomites. The risk of spreading the virus increases the longer and the closer the contact a person has with someone who has mumps.”
CDC on Mumps for Healthcare Providers
The need for prolonged, close contact is likely why most outbreaks these days are on college campuses.
Is Your Child Protected Against the Mumps?
The MMR vaccine protects us against mumps – and measles and rubella.
One dose of MMR is 78% effective at preventing mumps, while a second dose increases that to 88%. Unfortunately, that protection can decrease over time.
Kids get their first dose of MMR when they are 12 to 15 months old. While the second dose of MMR isn’t typically given until just before kids start kindergarten, when they are 4 to 6 years old, it can be given earlier. In fact, it can be given anytime after your child’s first birthday, as long as 28 days have passed since their first dose.
“Evidence of adequate vaccination for school-aged children, college students, and students in other postsecondary educational institutions who are at risk for exposure and infection during measles and mumps outbreaks consists of 2 doses of measles- or mumps-containing vaccine separated by at least 28 days, respectively. If the outbreak affects preschool-aged children or adults with community-wide transmission, a second dose should be considered for children aged 1 through 4 years or adults who have received 1 dose. In addition, during measles outbreaks involving infants aged <12 months with ongoing risk for exposure, infants aged ≥6 months can be vaccinated.”
CDC on Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices
And although it won’t count as their first dose, in special situations, kids can get an early MMR once they are six months old.
What to Do If Your Unvaccinated Child Is Exposed to Mumps
To be considered fully vaccinated and protected against mumps, kids need two doses of MMR – one at 12 to 15 months and another when they are 4 to 6 years.
“Although mumps-containing vaccination has not been shown to be effective in preventing mumps in persons already infected, it will prevent infection in those persons who are not yet exposed or infected. If persons without evidence of immunity can be vaccinated early in the course of an outbreak, they can be protected prior to exposure.”
Unfortunately, neither a post-exposure dose of MMR nor immune globulin work to prevent mumps after you are already exposed. They should still get an MMR though, as it will provide immunity against measles and rubella, and mumps if they don’t get a natural infection.
“Persons who continue to be exempted from or who refuse mumps vaccination should be excluded from the school, child care, or other institutions until 21 days after rash onset in the last case of measles.”
Manual for the Surveillance of Vaccine-Preventable Diseases
Unvaccinated kids who are exposed to mumps will likely need to be quarantined, as you watch for signs and symptoms of measles developing over the next 12 to 25 days.
If your exposed child develops mumps, be sure to call your health care provider before going in for a visit, so that they can be prepared to see you and so you don’t expose other people to mumps. Your child with suspected mumps should be wearing a mask before going out in public and if possible, will be put in a negative pressure room in the emergency room or doctor’s office.
It is very important to understand that simply wearing a mask doesn’t eliminate the risk that your child with mumps could expose others, it just reduces the risk. You still want to avoid other people!
What to Do If Your Vaccinated Child Is Exposed to Mumps
If your fully vaccinated child is exposed to mumps, does that mean you are in the clear?
Again, it depends on what you mean by fully vaccinated.
It also depends on what you mean by exposed. Is it someone in the same school that your child has had no real contact with or a sibling that he is around all of the time?
And is your child fully vaccinated for his age or has he had two doses of MMR?
Since kids get their first dose of MMR at 12 to 15 months and the second when they are 4 to 6 years old, it is easy to see that many infants, toddlers and preschoolers who are following the immunization schedule are not going to be fully vaccinated against mumps, even if they are not skipping or delaying any vaccines.
“In the case of a local outbreak, you also might consider vaccinating children age 12 months and older at the minimum age (12 months, instead of 12 through 15 months) and giving the second dose 4 weeks later (at the minimum interval) instead of waiting until age 4 through 6 years.”
Ask the Experts about MMR
In most cases, documentation of age-appropriate vaccination with at least one dose of MMR is good enough protection. That’s because the focus in controlling an outbreak is often on those folks who don’t have any evidence of immunity – the unvaccinated.
And one dose of MMR is about 78% effective at preventing mumps infections. A second dose does increase the vaccine’s effectiveness against mumps to over 88%.
An early second dose is a good idea though if your child might be exposed to mumps in an ongoing outbreak, has only had one dose of MMR, and is age-eligible for the second dose (over age 12 months and at least 28 days since the first dose). Your child would eventually get this second dose anyway. Unlike the early dose before 12 months, this early dose will count as the second dose of MMR on the immunization schedule.
“Persons previously vaccinated with 2 doses of a mumps virus–containing vaccine who are identified by public health authorities as being part of a group or population at increased risk for acquiring mumps because of an outbreak should receive a third dose of a mumps virus–containing vaccine to improve protection against mumps disease and related complications.”
Recommendation of the Advisory Committee on Immunization Practices for Use of a Third Dose of Mumps Virus–Containing Vaccine in Persons at Increased Risk for Mumps During an Outbreak
This third dose of MMR is not for post-exposure prophylaxis though, which again, doesn’t work for mumps. It is to prevent mumps from ongoing exposures.
You should still watch for signs and symptoms of mumps over the next 12 to 25 days though, as no vaccine is 100% effective. Your vaccinated child won’t need to be quarantined though.
Most importantly, in addition to understanding that vaccines are safe and necessary, know that the ultimate guidance and rules for what happens when a child is exposed to mumps will depend on your local or state health department.
What to Know About Getting Exposed to Mumps
Talk to your pediatrician if your child gets exposed to mumps, even if you think he is up-to-date on his vaccines, as some kids need a third dose of the MMR vaccine during on-going mumps outbreaks.