Tag: combination vaccines

Should Parents Be Concerned About Combination Vaccines and Febrile Seizures?

Anti-vaccine folks have parents worried about everything and anything having to do with vaccines these days.

Unlike most of the ideas that anti-vaxxers push, febrile seizures really can occur after vaccines. Fortunately, they aren’t something to be worried about.

Should Parents Be Concerned About Combination Vaccines and Febrile Seizures?

While febrile seizures can be scary, it is important to know that without other risk factors, kids who develop febrile seizures after a vaccine are at the same small risk for developing epilepsy as other kids.

And know that vaccines aren’t the only cause of febrile seizures. Vaccine-preventable diseases can cause both febrile seizures and more serious non-febrile seizures.

What about the extra risk of febrile seizures following combination vaccines?

“Studies have shown a small increased risk for febrile seizures during the 5 to 12 days after a child has received their first vaccination with the measles, mumps, rubella (MMR) vaccine. The risk is slightly higher with the measles, mumps, rubella, varicella (MMRV) combination vaccine, but the risk is still small. Studies have not shown an increased risk for febrile seizures after the separate varicella (chickenpox) vaccine.”

Childhood Vaccines and Febrile Seizures

The small extra risk of febrile seizures for the measles, mumps, rubella, varicella (MMRV) combination vaccine vs the separate MMR and chicken pox vaccines is just for the first dose of these vaccines, so pediatricians and parents might choose to give the separate vaccines instead. And only use this combination vaccine for the second dose.

Are any other combination vaccines a concern for febrile seizures?

Nope, even though some anti-vaccine sites push that idea and that vaccines can cause epilepsy.

Parents will likely be reassured by one of the studies that anti-vaccine folks like to cite, which states that “vaccination with DTaP-IPV-Hib was not associated with an increased risk of epilepsy.”

We do know that there is a small increased risk for febrile seizures when the influenza vaccine is given at the same time as either the Prevnar13 vaccine or the DTaP vaccine, although “the risk of febrile seizure with any combination of these vaccines is small and CDC’s Advisory Committee on Immunization Practices (ACIP) does not recommend getting any of these vaccines on separate days.”

Is the risk really small though?

After all, an article by Sheri A Marino talks about a 6-fold extra risk in some cases.

Isn’t that a lot?

“Does this mean we should stop giving these vaccines together or stop giving them at all? We say, emphatically, no. With the results of this study, we can accurately calculate the risks and benefits of this practice. The risk is 1 febrile seizure per pediatric practice every 5 to 10 years. Febrile seizures, although frightening to parents, rarely have any long-term sequelae. The benefits of giving these vaccines simultaneously include decreased office visits associated with painful vaccines, decreased episodes of vaccine-associated fussiness, and, most important, the assurance that children will be fully immunized and protected from infections that carry real morbidity and mortality. It is well established that the vaccines we miss when we fail to give all the vaccines we can (simultaneously at each health care visit) may never be administered to some children, thus leaving them at risk for the diseases the vaccines prevent. It goes without saying that influenza, diphtheria, tetanus, pertussis, and pneumococcal infections may result in serious illness. These infections also have the potential to cause fevers and febrile seizures. Without vaccines to prevent these illnesses, pediatricians would see many more than 1 case of most of these infections each decade. In fact, they would see children in their practices with both febrile seizures and life-threatening infections. The risk from these diseases far outweighs the risk from the vaccines.”

Sawyer et al on Vaccines and Febrile Seizures: Quantifying the Risk

Because the risk of febrile seizures is so small, it remains small even with any extra risk.

What’s more concerning? The risks of following anti-vaccine propaganda and leaving your kids unvaccinated and unprotected.

Vaccines are safe, with few risks, and necessary.

More on Vaccines and Febrile Seizures

Are the Tdap and DTaP Vaccines the Same Thing?

You have probably already figured out the Tdap and DTaP aren’t the same vaccine, after all, if they were, why would they have different names, right?

Are the Tdap and DTaP Vaccines the Same Thing?

I bet you don’t know the difference between the two vaccines though.

Yes, they both are both combination vaccines that protect against diphtheria, tetanus, and pertussis.

The difference is that one (DTaP) is used as the primary series for infants and younger children (age 6 years and under) and the other (Tdap) is given to older children (age 7 years and above), teens, and adults.

Okay, that’s not the only difference.

The DTaP vaccine actually contains more diphtheria and pertussis antigens than Tdap, which is why it has the capital “D” and “P” in its name. The amount of tetanus toxoid antigens are about the same in both vaccines.

So Tdap contains the same amount of tetanus toxoid, plus a reduced amount of diphtheria and acellular pertussis antigens, as compared to DTaP.

While you would think that older children and adults would get the vaccine with the higher amount of antigens, since they are bigger, that’s not how this works. Vaccines typically start working at the injection site, so body size isn’t a key factor in determining the amount of ingredients.

As a booster dose of vaccine, the lower amount of antigens works just fine and helps reduce the risk of side effects from repeated doses that you might get with higher antigen counts.

More on Tdap vs DTaP

Does Pentacel Contain Mercury?

Thimerosal was taken out of most childhood vaccines in 2001, only remaining in muti-dose vials of flu vaccines, which could easily be avoided, as a good supply of thimersosal-free flu vaccine has been available for many years.

“Thimerosal is a mercury-based preservative that has been used for decades in the United States in multi-dose vials (vials containing more than one dose) of medicines and vaccines. There is no evidence of harm caused by the low doses of thimerosal in vaccines, except for minor reactions like redness and swelling at the injection site. However, in July 1999, the Public Health Service agencies, the American Academy of Pediatrics, and vaccine manufacturers agreed that thimerosal should be reduced or eliminated in vaccines as a precautionary measure.”

CDC on Thimerosal in Vaccines

For some reason, that hasn’t kept some parents from still being concerned about mercury in vaccines.

Does Pentacel Contain Mercury?

Pentacel is vaccine that combines the diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus and Haemophilus b conjugate (tetanus toxoid conjugate) vaccines (DTaP-IPV/Hib) into one shot.

Pentacel is mercury free.
Like most other vaccines on the childhood immunization schedule, Pentacel is mercury free.

It is routinely given to children as a four dose series, when they are 2, 4, 6, and 15 to 18 months old.

Like most other vaccines given to children, Pentacel is thimerosal-free.

It does not contain mercury.

More on Mercury in Vaccines

What Is a Hexavalent Vaccine?

Most folks know that we have combination vaccines that help reduce the number of injections that kids have to get at one visit.

You might not think of it as a combination vaccine, but one of the first, DPT, simply combines protection against diphtheria, pertussis, and tetanus into one shot.

Of course, we have come a long way since the days when DPT and MMR were considered combination vaccines.

Wait, why aren’t they considered combination vaccines anymore?

It’s not part of any conspiracy. It’s simply because you can’t get their individual components separately anymore. There is no measles or rubella shots anymore. Just the MMR. There is no tetanus shot.

Combination Vaccines

Not surprisingly, it is now becoming routine for kids to get combination vaccines instead of separate shots.

That’s because while the great majority of us want our kids vaccinated and protected, few enjoy shots and needles.

“The use of licensed combination vaccines is preferred over separate injection of their equivalent component vaccines.”

AAP on Combination Vaccines for Childhood Immunization

Does this mean more vaccines at one visit?

Nope.

“So, at a doctor’s visit, your child may only get two or three shots to protect him from five diseases, instead of five individual shots. Fewer shots may mean less pain for your child and less stress for you.”

CDC on Combination Vaccines

It just means fewer injections.

Combination vaccines combine the vaccines that you are already getting into one injection.

What Is a Hexavalent Vaccine?

And they might get even fewer with the latest hexavalent vaccines (six-in-one).

This is the next step up from our current pentavelent vaccines (five-in-one), like Pediarix (combines DTaP, Hep B, and IPV) and Pentacel (combines DTaP, IPV, and Hib).

The hexavalent vaccines combine protection against diphtheria, tetanus, acellular pertussis, Haemophilus influenzae type B, poliovirus and hepatitis B (DTaP-Hib-IPV-HepB) into one injection.

Sounds good, right?

Although not approved in the United States, hexavalent vaccines, including Infanrix Hexa have been used in many other countries since 2000! Another, Hexavac was withdrawn from the market because of issues with waning hepatitis B antibody titers (kids had levels that were still protective, but were on the low side).

When will get a hexavalent vaccine in the United States?

Obviously, the early problems with Hexavac kept us from getting a hexavalent vaccine, at least before the next generation of vaccines was developed.

Hexavalent vaccines are widely available in most parents of the world.
Hexavalent vaccines are widely available in most parents of the world.

Two new hexavalent vaccines, Vaxelis and Hexyon, have recently been licensed in Europe, after many studies showed that they worked and were safe when given with all of the other vaccines on the schedule, including Prevnar, rotavirus, Men C, and MMRV.

And one of these might soon be coming to the United States.

Vaxelis

V419 (Vaxelis), which was developed in collaboration between Merck and Sanofi Pasteur, has been under review by the FDA since 2014 has already received a Complete Response Letter that was “deemed complete and acceptable for review.”

And it was approved by the FDA on December 21, 2018.

Remember, that could mean just two shots at infant well check ups, but continued protection against eight vaccine-preventable diseases, as they get a hexavalent vaccine, Prevnar and the rotavirus vaccine!

It may be at least another year before Vaxelis makes it way to your pediatrician’s office though.

More on the Hexavalent Vaccine

Do Kids Really Get 72 Doses of Vaccines?

Most parents vaccinate their kids according to the recommended immunization schedule.

They know that’s the best way to keep them protected.

Do Kids Really Get 72 Doses of Vaccines?

Saying kids get 72 doses of vaccines is a propaganda too to scare parents.
Saying kids get 72 doses of vaccines is a propaganda tool to scare parents.

While kids do get more vaccines than their parents did, that’s only because we have more vaccines available to protect them from more now vaccine-preventable diseases.

Do they get their kids 72 doses of vaccines?

That sounds like a lot…

It sounds like a lot because it is an inflated number that is meant to scare parents.

Kids today do routinely get:

  • 13 vaccines, including 5 doses of DTaP, 4 doses of IPV (polio), 3 or 4 doses of hepatitis B, 3 or 4 doses of Hib (the number of doses depends on the vaccine brand used), 4 doses of Prevnar, 2 or 3 doses of rotavirus (the number of doses depends on the vaccine brand used), 2 doses of MMR, 2 doses of Varivax (chicken pox), 2 doses of hepatitis A, 1 doses of Tdap, 2 or 3 doses of HPV (the number of doses depends on the age you start the vaccine series), 2 doses of MCV4 (meningococcal vaccine), and yearly influenza vaccines
  • protection against 16 vaccine-preventable diseases, including diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, chicken pox, pneumococcal disease, hepatitis A, hepatitis B, meningococcal disease, HPV, rotavirus, Hib, and flu
  • about 28 doses of those vaccines by age two years (with yearly flu shots)
  • about 35 doses of those vaccines by age five years (with yearly flu shots)
  • as few as 23 individual shots by age five years if your child is getting combination vaccines, like Pediarix or Pentacel and Kinrix or Quadracel and Proquad
  • about 54 doses of those vaccines by age 18 years, with a third of that coming from yearly flu vaccines

How do you get a number like 72?

You can boost your count to make it look scarier by counting the DTaP, MMR, and Tdap vaccines as three separate vaccines each, even though they aren’t available as individual vaccines anymore.

To boost the Vaccine Doses for Children a bit more, they add pregnancy doses too.
To boost the Vaccine Doses for Children a bit more, they add pregnancy doses too.

This trick of anti-vaccine math quickly turns these 8 shots into “24 doses.”

It’s not a coincidence.

Anti-vaccine folks want to scare you into thinking that vaccines are full of toxins, that kids get too many vaccines, that we give many more vaccines than other countries, and that this is causing our kids to get sick.

Can an unvaccinated child really get tetanus after a toe nail injury?
Can an unvaccinated child really get tetanus after a toe nail injury? Photo by Petrus Rudolf de Jong (CC BY 3.0)

None of it is true.

At age four years, when your preschooler routinely gets their DTaP, IPV, MMR, and chicken pox shots before starting kindergarten, how many vaccines or doses do you think they got? Two, because they got Kinrix or Quadracel (DTaP/IPV combo) and Proquad (MMR/chickenpox combo)? Four, because they got separate shots? Or Eight, because you think you should count each component of each vaccine separately?

Know that even if you do want to count them separately, it really just means that with those two or four shots, your child got protection against eight different vaccine-preventable diseases – diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, and chicken pox.

Vaccine-preventable diseases that have not disappeared, something that the “72 doses” sites don’t ever warn you about.

What to Know About Anti-Vaccine Math

Many websites use anti-vaccine math to inflate vaccine dose numbers and scare parents away from vaccinating and protecting their kids.

More on Anti-Vaccine Math

Avoiding the Most Common Vaccine Errors

Although it would be great if mistakes never ever happened, the best we can do is to understand that mistakes do sometimes happen and take steps to avoid them.

How can we avoid mistakes and errors about vaccines?

Avoiding Vaccine Errors

It can help to:

  • understand the 7 Rights of vaccine administration, including that you give the Right vaccine to the Right patient at the Right time by the Right route at the Right injection site and then follow it with the Right documentation
  • use a 2d barcoding  system with your EMR to help catch vaccine errors before administration
  • use a screening checklist to help avoid giving vaccines that are contraindicated
  • double check vaccines that look alike or have names that sound like, such as DTaP and Tdap
  • double check expiration dates
  • make sure you aren’t giving live vaccines within 28 days of each other, unless they are given at the same time
  • make sure you aren’t giving the wrong dosage amount for the patient’s age, as some vaccines have different formulations depending on the age of the patient, including flu shots, hepatitis A, and hepatitis B vaccines
  • be careful so that you don’t give a combination vaccine, such as Pediarix, Pentacel, Kinrix, Quadracel, or ProQuad, inappropriately

That we are have a 4-day grace period does help avoid the need to revaccinate some kids when vaccines are given a little too early.

“With the exception of rabies vaccine, ACIP allows a grace period of 4 days (i.e., vaccine doses administered up to 4 days before the recommended minimum interval or age can be counted as valid). However, if a dose was administered 5 or more days earlier than the recommended minimum interval between doses, it is not valid and must be repeated. The repeat dose should be spaced after the invalid dose by the recommended minimum interval.”

Ask the Experts About Scheduling Vaccines

In many cases, as long as vaccine doses were administered less than or equal to 4 days before the minimum interval or age, then they can still be counted and are considered valid.

Common Vaccine Errors

It’s easier than you think to prevent vaccine errors.

Especially if there are more than one child in the room getting vaccines, either the tray itself or the vaccines should be labeled with each child's name so that they don't get the wrong vaccines.
Especially if there is more than one child in the room getting vaccines, either the tray itself or the vaccines should be labeled with each child’s name so that they don’t get the wrong vaccines. Photo by Vincent Iannelli, MD

When are you most likely to make a vaccine error?

When you are doing something that isn’t routine, which most commonly happens when folks delay or skip some vaccines and are now playing catch-up.

In addition to the tips above, remember that:

  • the first dose of the rotavirus vaccines must be given by 15 weeks
  • the rotavirus vaccine series must be completed by 8 months (32 weeks)
  • ProQuad, the MMR and chicken pox combination vaccine, is not licensed for kids who are older than 12 years, although if a teen or adult did get ProQuad, it could be considered an off-label dose and could still count.
  • Kinrix and Quadracel, the DTaP and polio combination vaccines are only licensed for the 5th dose of DTaP and 4th dose of polio in children who are 4 to 6 years old, so wouldn’t be appropriate for an 18-month-old, even if he needs both (DTaP and polio) vaccines. Earlier doses can sometimes count as off-label doses though.
  • the combination vaccines Pediarix and Pentacel are only licensed up through age six years, but don’t necessarily need to be repeated if given to older kids.
  • children and adolescent’s get a pediatric dose (0.5ml) of the hepatitis A vaccine, while older teens, who are at least 19-years-old, get an adult (1.0ml) dose. Since most kids get vaccinated when they are younger, many pediatricians may not have the adult version of the hepatitis A or even realize that there is a different version.
  • children and adolescent’s get a pediatric dose (0.5ml) of the hepatitis B vaccine, while older teens, who are at least 20-years-old, get an adult (1.0ml) dose. Since most kids get vaccinated when they are younger, many pediatricians may not have the adult version of the hepatitis B vaccine or even realize that there is a different version.

Most importantly, even when giving vaccines on schedule, be sure to triple check everything. This is especially important if multiple kids in the same room are getting immunizations.

Also remember that vaccine errors should be reported to the ISMP National Vaccine Errors Reporting Program (VERP) or VAERS, with the correct dose repeated if necessary.

What to Know About Common Vaccine Errors

Although none of these vaccine errors are very common (hundreds of millions of doses of vaccines are given in the United States each year), understanding which ones occur the most often can help to make sure that they don’t happen in your office.

More on Common Vaccine Errors

Updated September 16, 2018

Your Baby’s First Vaccines

Your baby’s first vaccines are very important.

While they don’t provide instant protection, they do start your baby on the path to eventually getting protected from 16 different vaccine-preventable diseases.

Your Baby’s First Vaccines

Rotavirus vaccines are associated with a very small risk of intussusception, but that is not a good reason to miss the benefits of this vaccine.
The rotavirus vaccine will be among your baby’s first vaccines. Photo by Vincent Iannelli, MD

After the birth dose of the hepatitis B vaccine, your baby’s first vaccines when you visit your pediatrician for their two month check up will include:

  • DTaP – diptheria – tetanus – pertussis
  • IPV – polio
  • Hepatitis B
  • Hib – haemophilus influenzae type b
  • Prevnar 13 – pneumococcal disease
  • Rotavirus

Sound like too many? Those vaccines work to protect your baby against eight vaccine-preventable diseases! Before these vaccines were routine, when infants got fewer immunizations, they got more disease.

And it doesn’t mean that your baby has to get six shots.

The rotavirus vaccine is oral – your baby drinks it.

And many of the other vaccines can be given as a combination vaccine, either Pediarix (combines DTaP-IPV-HepB) or Pentacel (combines DTaP-IPV-Hib), to reduce the number of individual shots your baby needs to get even more.

While that still means multiple injections, there are things you can do to minimize the pain during and after the vaccines, from breastfeeding and holding your baby to simply trying to get them distracted.

Your Baby’s Next Vaccines

After their first vaccines at two months, your baby will complete their primary series of vaccines with repeated dosages of the same vaccines at four and six months.

Why do we need to repeat the same vaccines?

Because that’s often what it takes to help us build up an immune response to a vaccine, especially at this age.

These first vaccines prime the immune system, which when followed by a later booster vaccine, provide good protection against each disease.

start your baby on the path to eventually getting protected from 16 different vaccine-preventable diseases.
Ari Brown, MD explains why you shouldn’t delay or skip your child’s vaccines.

And the requirement of multiple dosages of a vaccine is a small price to pay to be able to skip the symptoms and risk of more serious consequences that come from getting a natural infection and natural immunity.

Did your baby have a reaction to their first set of vaccines?

While some fever, pain, and fussiness is not unexpected, be sure to tell your health care provider if your baby had a reaction that you think was more severe, like a high fever or non-stop crying for several hours.

Can you expect a reaction to your baby’s second set of shots if they had a reaction to the first? Probably not. Side effects, even those that are serious, rarely happen again, even when the same vaccines are given.

Your Baby’s Vaccines

While you certainly shouldn’t skip or delay any of these vaccines, you should know that:

  • the routine age for starting these vaccines is at two months, but
  • if necessary, they can be given as early as when a baby is six weeks old.
  • the routine interval between dosages of the primary series of these vaccines is two months, but
  • if necessary (usually as part of a catch-up schedule), these vaccines can be usually be given as soon as four weeks apart, although the third dose in the series of DTaP, IPV, and Hepatitis B vaccines shouldn’t be given any sooner than at age six months.
  • infants who will be traveling out of the United States should get an early MMR vaccine – as early as six months of age

And if your baby is at least six months old during flu season, then they will also need two doses of the flu shot given one month apart. The minimum age to get a flu shot is six months, and kids get two doses during their first year of getting vaccinated against the flu to help the vaccine work better.

Learn more about if you are on the fence. Your baby needs to be vaccinated and protected.

What to Know About Your Baby’s First Vaccines

Your baby’s first vaccines are safe and necessary to start them on a path to eventually getting protected from 16 different vaccine-preventable diseases.

More on Your Baby’s First Vaccines

Updated February 7, 2018