Tag: reporting vaccine side effects

Can I Give My Kids Tylenol When They Have Their Vaccines?

Many parents ask about acetaminophen (Tylenol) when kids get their vaccines.

Is it okay to give kids Tylenol when they get their shots?

The Tylenol and Vaccines Controversy

As you can probably guess, there is no real controversy about Tylenol and vaccines.

Instead, what we are talking about are the myths surrounding Tylenol and vaccines that anti-vaccine folks have created, including that:

  • giving Tylenol right before a child gets their shots somehow increases the risk that they will have side effects
  • giving Tylenol right after a child gets their shots somehow masks the symptoms of serious vaccine damage
  • giving Tylenol after the MMR vaccine is associated with developing autism

Fortunately, most parents understand that like other anti-vaccine misinformation, none of these statements are true.

Why do some folks believe it?

Well, there have been studies warning people about giving Tylenol before vaccines. It had nothing to do with side effects though. They suggested that a vaccine might be less effective if the child got Tylenol before his vaccines. It is important to note that they never really found that the vaccines didn’t work as well, as all of the kids in the study still had protective levels of antibodies, they were just a little lower than kids who didn’t get Tylenol.

Other studies have found the same effect if Tylenol was given after a child got his vaccines. Although interestingly, other studies have found that giving Tylenol after vaccines does not affect antibody titers.

“Antibody titres to diphtheria and tetanus toxoids and pertussis bacteria of the placebo (n = 25) and acetaminophen (n = 34) groups did not differ significantly from each other. It is concluded that acetaminophen in a single dose schedule is ineffective in decreasing post-vaccination fever and other symptoms.”

Uhari et al on Effect of prophylactic acetaminophen administration on reaction to DTP vaccination

Giving Tylenol after the MMR vaccine is not associated with autism.
Giving Tylenol after the MMR vaccine is not associated with autism.

The only thing that this had to do with side effects though, is that the kids who got Tylenol had a little less fever.

Could giving Tylenol mask something like encephalitis, which some anti-vaccine folks think can be vaccine induced?

Nope. It typically can’t even keep someone from getting a febrile seizure.

What about the association of MMR, Tylenol and autism? Although one study did suggest that to be true, the study, a parental survey, was found to be “fatally flawed.”

Can I Give My Kids Tylenol When They Have Their Vaccines?

So, can you give your kids Tylenol when they get their vaccines?

The better question is, should you give your kids Tylenol either before or after they get their vaccines?

Have some Tylenol or Motrin on hand after your kids get their vaccinations, just in case they need a dose.
Have some Tylenol or Motrin on hand after your kids get their vaccinations, just in case they need a dose. Photo by Vincent Iannelli, MD

Notwithstanding the very small chance that giving Tylenol might cause decreased immunogenicity (lower antibody production) if you give it before your kids get their vaccines, since there is a good chance that they won’t have any pain or fever and won’t even need any Tylenol, then why give it?

Skip the “just in case” dose and wait and see if they even need it.

What about afterwards?

If your kids have pain or fever and are uncomfortable, then you should likely give them something for pain or fever control, such as an age appropriate dose of either acetaminophen or ibuprofen. Will that cause lower antibody production? Maybe. Will that mean that their vaccines won’t work. That’s doubtful. It certainly won’t lead to increased side effects though, unless they a reaction to the dose of Tylenol itself.

Should you give a pain or fever reducer after a vaccine “just in case?” Again, there is a good chance that your kids might not need it, so it is likely better to wait and see if they do, instead of giving a dose automatically after their shots.

There is even some evidence that giving acetaminophen or ibuprofen before vaccines, or as a routine dose right after, especially with booster shots, doesn’t really prevent side effects that well anyway. They work better if given on an as needed basis instead, and these kinds of doses are less likely to be associated with decreased antibody production.

What to Know About Tylenol and Vaccines

Giving a pain or fever reducer either before or after your child’s vaccinations likely won’t affect how it works, but since it often isn’t necessary, it is likely best to only given one, like Tylenol or Motrin, if it is really needed.

More on Tylenol and Vaccines

Can Vaccines Cause ITP?

ITP is an abbreviation for idiopathic thrombocytopenic purpura.

It is a condition in which our platelets get destroyed, leading to excessive bruising and bleeding, since platelets are needed for normal blood clotting.

What Causes ITP?

To understand what causes ITP, it is important to know it is also often referred to as immune thrombocytopenic purpura, because it is typically the cells of our own immune system that destroys our platelets.

Why?

Well, that’s where the idiopathic part comes in.

We don’t know why people develop ITP, although classically, ITP is thought to follow a viral infection, including Epstein-Barr virus (mono), influenza, measles, mumps, rubella, and varicella (chicken pox). ITP has also been associated with many other viral infections, from Dengue fever to Zika.

“Often, the child may have had a virus or viral infection approximately three weeks before developing ITP. It is believed that the body’s immune system, when making antibodies to fight against a virus, “accidentally” also made an antibody that can stick to the platelet cells. The body recognizes any cells with antibodies as foreign cells and destroys them. Doctors think that in people who have ITP, platelets are being destroyed because they have antibodies.”

Pediatric Idiopathic Thrombocytopenia Purpura (ITP)

These children with ITP, usually under age 5 years, develop symptoms a few days to weeks after their viral infections. Fortunately, their platelet counts usually return to normal, even without treatment, within about 2 weeks to 6 months. Treatments are available if a child’s platelet count gets too low though.

Can Vaccines Cause ITP?

The measles vaccine is the only vaccine that has been clearly associated with ITP.

“The available data clearly indicate that ITP is very rare and the only vaccine for which there is a demonstrated cause-effect relationship is the measles, mumps and rubella (MMR) vaccine that can occur in 1 to 3 children every 100,000 vaccine doses.”

Cecinati on Vaccine administration and the development of immune thrombocytopenic purpura in children

Even then though, the risk of ITP after a measles containing vaccine, like MMR or ProQuad, is much less than after getting a natural measles infection, so worry about ITP is a not a good reason to skip or delay getting vaccinated.

What about other vaccines?

There is no good evidence that other vaccines, including the chicken pox vaccine, DTaP, hepatitis B vaccine, or flu vaccine, etc., cause ITP.

What about Gardasil? ITP is listed in the package insert as an adverse reaction for Gardasil, but only in the postmarketing experience section, so it does not mean that the vaccine actually caused the reaction, just that someone reported it.

Although ITP is listed in the PI for Gardasil, studies have shown that there is no association.
Although ITP is listed in the PI for Gardasil, studies have shown that there is no association.

Several large studies have actually been done that found no increased risk for ITP after getting vaccinated with Gardasil.

What to Know About Vaccines and ITP

Although measles containing vaccines can rarely cause ITP, vaccines prevent many more diseases that can cause ITP.

More on Vaccines and ITP

 

Myths About the Yellow Fever Vaccine

Endemic yellow fever was eliminated in the United States in 1905, way before the first yellow fever vaccine was developed (1935) and licensed (1953).

How did that work?

Yellow fever is a now vaccine preventable disease that is spread by mosquito bites.

In the United States, it was actually eliminated by controlling the Aedes aegypti mosquitoes that spread the yellow fever virus before the vaccine was even developed. These control efforts were also done in Cuba, Panama, and Ecuador, etc., places where yellow fever was common and led to outbreaks in the United States.

Why Haven’t We Eradicated Yellow Fever?

So why is yellow fever still a problem if we can control the the Aedes aegypti mosquitoes that carry the yellow fever virus?

“Mosquitoes breed in tropical rainforests, humid, and semi-humid environments, as well as around bodies of still water in and close to human habitations in urban settings. Increased contact between humans and infected mosquitoes, particularly in urban areas where people have not been vaccinated for yellow fever, can create epidemics.”

Yellow fever: Questions and Answers

It’s because we can control the mosquitoes in urban areas, in and around cities. You can’t really control or eliminate mosquitoes in tropical rain forest regions, which is why it is difficult to eradicate yellow fever, malaria, dengue fever, and other mosquito borne diseases.

But we have a vaccine, don’t we?

“Eradication of yellow fever is not feasible since we are unable to control the virus in the natural animal hosts.”

Yellow fever: Questions and Answers

Unfortunately, we aren’t the only ones who can become infected with yellow fever. Monkeys get infected with the yellow fever virus in rain forests, infect Haemagogus and Sabethes mosquitoes, which bite people in those areas.

“Urban transmission of yellow fever virus occurs when the virus is spread from human to human by the Aedes aegypti mosquitoes.”

Yellow fever – Brazil

That likely means that yellow fever will never be completely eradicated, unlike small pox.

Yellow Fever Vaccines Myths

But just because yellow fever can’t be eradicated doesn’t mean that it can’t be eliminated.

A single dose of the yellow fever vaccine is safe and provides life-long protection for 99% of people.

“Vaccination is the most powerful known measure for yellow fever prevention: a single dose can provide life-long immunity at a cost of approximately US$1.”

WHO on Eliminating Yellow Fever Epidemics (EYE) Strategy: Meeting demand for yellow fever vaccines

And as cases of yellow fever increase in some countries, like Brazil, getting more people vaccinated is the only way to stop this deadly disease.

People line up to get a yellow fever vaccine near Kinshasa.
People line up to get a yellow fever vaccine near Kinshasa. Photo by WHO/E. Soteras Jalil

Tragically, anti-vaccination myths and misinformation may be keeping folks from getting vaccinated and protected. Propaganda and anti-vaccine scare videos have them thinking that the yellow fever vaccine is dangerous, part of a conspiracy to depopulate the world, or that it doesn’t work.

It is also important to know that:

  • When traveling to or from some countries, a yellow fever vaccine isn’t enough – you need an International Certificate of Vaccination proving that you were vaccinated.

    You should not skip getting the yellow fever vaccine if you are traveling to an area where yellow fever is endemic, including many parts of areas of Africa and South America.

  • While you are most at risk during the rainy season, especially during outbreaks, it is also possible to get yellow fever during the dry season.
  • Yellow fever is a serious, life-threatening disease.
  • There is no cure for yellow fever.
  • While serious side effects to the yellow fever vaccine have been reported, including anaphylaxis, yellow fever vaccine-associated neurologic disease (YEL-AND), and yellow fever vaccine-associated viscerotropic disease (YEL-AVD), they are very rare.
  • The yellow fever vaccine is a live virus vaccine, but shedding is not an issue. Unless at a high risk of exposure, getting the yellow fever vaccine is usually not recommended if you are pregnant or breastfeeding though.
  • It is not usually necessary to get a booster dose of the yellow fever vaccine.
  • Some countries require proof of yellow fever vaccination if you have traveled from a country where there is still a risk of getting yellow fever, so that you don’t import yellow fever into their country.

As yellow fever cases are on the rise in Brazil, with an associated increase in travel associated cases, it is important that everyone understand that vaccines are safe and necessary.

What to Know About Yellow Fever Vaccine Myths

Yellow fever cases are increasing and so are anti-vaccine myths about the yellow fever vaccine, which are keeping some folks from getting vaccinated and protected, even as they are threatened by a potential outbreak.

More on Yellow Fever Vaccines Myths

What Causes Non-Stop Crying After DTaP Vaccines?

Most children cry after getting a shot.

Fortunately, they can usually be comforted quickly.

Historically, there has been one situation where kids might cry for longer periods of times.

Non-Stop Crying After DTaP Vaccines

The DTP vaccine was known to cause non-stop crying, for 3 hours or more in up to about 1 child out of 1,000.

“Persistent crying following DTaP (as well as other vaccines) has been observed far less frequently than it was following the use of DTP. When it occurred after DTP, it was considered to be an absolute contraindication to further doses of pertussis-containing vaccine. When it occurs following DTaP, it is considered a “precaution” (or warning). If you believe the benefit of the pertussis vaccine exceeds the risk of more crying (which, although unnerving, is otherwise benign), you can administer DTaP.”

Immunization Action Coalition on Ask the Experts about DTP

Although uncommon, it is certainly scary to have a child cry for 3 hours or more after a vaccine.

I guess that’s one good reason we don’t use the DTP vaccine anymore. On the other hand, although the newer DTaP has fewer side effects, it doesn’t work as well as the older DTP vaccine at protecting kids against pertussis.

What Causes Non-Stop Crying After DTaP Vaccines?

Some people have very wrong ideas about what caused this non-stop crying after the DTP vaccine, which is reflected in the nick-names they gave it, such as the “DTP scream,” “cry-encephalitis,” or the “encephalitic cry.”

If your child has had non-stop crying after their DTP vaccine, or DTaP vaccine for that matter, you can be reassured that they didn’t have encephalitis!

The forums of Mothering.com are notorious for pushing anti-vax misinformation, including the idea of an "encephalitic cry."
The forums of Mothering.com are notorious for pushing anti-vax misinformation, including the idea of an “encephalitic cry” after DTP vaccines.

Again, although it is scary to have your child crying non-stop for 3 hours or more, this crying is benign and has no long term effects.

So what is causing it?

It is thought to be a painful local reaction.

Remember that the next time you see a vaccine scare video about the “DTaP scream” or talk about encephalitis

What to Know About DTaP Crying

Crying non-stop for 3 hours or more after a vaccine can be scary. Fortunately, DTaP crying is not caused by encephalitis or any other terrible thing you might read about. It is a painful local reaction.

More on DTaP Crying

Rash After the MMR – Is This Normal?

It is not uncommon to get a rash after your child gets their MMR vaccine.

In fact, about 1 in 20 people get a rash after their first dose of MMR.

It typically shows up about 6 to 14 days after the dose.

Fortunately, it doesn’t mean that your child has full-blown measles as some people suspect.

Rash After the MMR

So why do some kids get a rash after their MMR?

It depends on which rash they have.

While there is one classic MMR rash that we think about, there are actually a few other rashes that can occur even more rarely, including:

  • hives – an allergic reaction to the vaccine or one of it’s components
  • petechia and/or purpura – caused by temporary thrombocytopenia (low platelet count) in about one out of every 30,000 to 40,000 doses of vaccine given

And then there is the rash that up to 5% or people get about 7 to 10 days after their dose of MMR – a mild vaccine reaction that goes away on its own without treatment.

Most importantly, the presence of this measles-like rash does not mean that your child has actually gotten measles from the vaccine.

How do we know?

For one thing, the MMR vaccine is made with an attenuated or weakened form of the measles virus, so it can’t actually cause full-blown measles, unless maybe a child has a severe immune system problem.

Also, there is no viremia after vaccination.

“There are no reports of isolation of vaccine virus from blood in normal humans.”

Plotkin’s Vaccines

It is also important to note that “person-to-person transmission of vaccine virus has never been documented.”

And kids who get a rash after their MMR vaccine are not considered to be contagious. At most, you would expect them to shed the weakened vaccine virus, but they don’t.

What’s causing this measles-like rash then?

Like the fever, it is thought to be a delayed immune response to the live, attenuated virus in the vaccine.

When the Rash Really is Measles

Are there any situations in which a child gets a rash after their MMR vaccine and it could really be measles?

Sure.

An infant hospitalized during a measles outbreak in the Philippines in which 110 people died.
An infant with wild type measles hospitalized during a measles outbreak in the Philippines in which 110 people died. Photo by Jim Goodson, M.P.H.

Your child could have been exposed to wild type measles right around the time they got vaccinated, and then went on to develop regular measles.

While getting a measles vaccine within 72 hours of exposure (post-exposure prophylaxis) can reduce your chance of getting measles, it isn’t a perfect strategy.

Or your child could have been vaccinated and been one of the few people for whom the vaccine failed to work. So their rash, again, would be from a wild type strain of measles that they were exposed to and not from the shot.

Can you tell the difference if someone has measles from the vaccine or from a wild type strain?

Sure.

“During outbreaks, measles vaccine is administered to help control the outbreak, and in these situations, vaccine reactions may be mistakenly classified as measles cases.”

CDC on Genetic Analysis of Measles Viruses

You just have to test the measles strain to see if it is the wild type virus or a vaccine strain.

Does It Matter If It Is the MMR Vaccine or Measles?

About now, you are probably wondering why it matters knowing if a child’s rash is caused by measles or the MMR vaccine, right?

For one thing, if a parent thinks a vaccine gave their child measles, then they might not want to get vaccinated again. They will especially think twice about getting another MMR.

Also, if a child really does have full-blown, wild type measles and you simply blame their MMR vaccine, then you might miss someone else in the community that exposed the child to measles. And that’s why some outbreaks are hard to stop.

Lastly, if you simply blame the vaccine, you might miss something else that is causing the child to be sick.

Need an example?

During the 2010 measles outbreaks in Canada, a 15-month-old develop a rash, fever, and other symptoms 12 days after getting their MMR vaccine. Did the have measles, a vaccine reaction, or something else?

Turns out that he had scarlet fever.

The child tested positive for Streptococcus pyogenes (group A streptococcus), the bacteria that causes strep throat and scarlet fever. He also tested positive for vaccine strain measles. He did not have the wild strain of measles, and in fact, did not have measles at all.

Again, he had scarlet fever and it was just a coincidence that he had recently received an MMR vaccine.

But isn’t there another case report from Canada that does prove that you can get full-blown measles from the MMR vaccine? While there is such a case report, it is hardly proof of anything.

“It is possible that the case’s symptoms were not measles-vaccine-related but an inter-current illness confounding the presentation.”

Murti et al on Case of vaccine-associated measles five weeks post-immunisation, British Columbia, Canada, October 2013

The problem with the case?

For one thing, the child already had high levels of IgG antibodies at the time he had the rash, which developed 37 days after he got his vaccine.

“The two-fold rise between acute and convalescent measles-specific IgG suggests the vaccine-mediated immune response had been underway prior to the onset of symptoms.”

Murti et al on Case of vaccine-associated measles five weeks post-immunisation, British Columbia, Canada, October 2013

This was neither a typical reaction nor a typical case. And it very well might not have been measles. If it was, it was a very rare exception to the rule that rashes after the MMR vaccine aren’t full-blown measles.

What to Know About Rashes After the MMR Vaccine

The rash that your child can get after their MMR vaccine is not a sign that they have developed full-blown measles, instead, it is a mild vaccine reaction that will quickly go away without any treatment.

More on Rashes After the MMR Vaccine

 

What Are Hypotonic-Hyporesponsive Episodes?

Just about any side effect after a vaccine can be scary for parents.

What if your child suddenly became limp, wasn’t responsive, and was pale?

That would be scary for any parent.

What Are Hypotonic-Hyporesponsive Episodes?

But that’s just what can happen when a child has a hypotonic–hyporesponsive episode (HHE).

“A hypotonic-hyporesponsive episode (HHE) is the sudden onset of hypotonia, hyporesponsiveness, and pallor or cyanosis that occurs within 48 hours after childhood immunizations.”

DuVernoy et al on Hypotonic-hyporesponsive episodes reported to the Vaccine Adverse Event Reporting System (VAERS), 1996-1998

These types of episodes were once thought to happen once for every 1,750 DTP vaccines given.

HHE is much more rare since we switched to a new pertussis vaccine.
HHE is much rarer since we switched to a new pertussis vaccine.

Fortunately, although they certainly do sound scary, the episodes stop on their own and  don’t cause any permanent harm.

Hypotonic-hyporesponsive episodes were even removed as table injuries after DTP back in 1995. It is not that HHE can’t occur after DTP, DTaP, or other vaccines, but rather that HHE doesn’t then cause any permanent neurological damage to the child.

And it is rare for kids to have a second episode, so they can continue to get vaccinated. HHE is not a good reason to skip or delay all of your child’s vaccines. While not a contraindication to getting vaccinated, having an episode of HHE “within 48 hours after receiving a previous dose of DTP/DTaP,” is listed as a precaution to getting another dose of DTaP or Tdap though.

“In general, vaccinations should be deferred when a precaution is present. However, a vaccination might be indicated in the presence of a precaution if the benefit of protection from the vaccine outweighs the risk for an adverse reaction.”

CDC on Vaccine Contraindications and Precautions

Also, HHE has become even more rare since we switched to using DTaP, instead of the older DTP vaccine. So being worried about HHE is definitely not a good reason to skip or delay any vaccines.

What to Know About Hypotonic-Hyporesponsive Episodes

Hypotonic-hyporesponsive episodes were more common after the older DTP vaccines, but still didn’t cause any long term problems and aren’t a good reason to skip or delay your child’s vaccines.

More About Hypotonic-Hyporesponsive Episodes

Vaccines and the Risk of Intussusception

Many people first heard the term intussusception after it became associated with Rotashield, the first rotavirus vaccine, back in 1999.

What is Intussusception?

Intussusception is a type of intestinal blockage that occurs when one part of a child’s intestine in pulled into or slides into another.

This leads to younger children, typically between the ages of 3 months and 3 years, developing colicky abdominal pain (severe pain that comes and goes) and loose stools that are filled with blood and mucous.

Fortunately, if caught early, it can be both diagnosed and treated with an air contrast enema.

Do Rotavirus Vaccines Cause Intussusception?

Intussusception in children is not a new condition. In fact, Samuel Mitchel reported treating children with intussusception as early as 1838!

So what causes intussusception?

Surprisingly, in most cases, we just don’t know why kids get intussusception.

We do know that it occurs in about 1 in 100,000 US infants, with about 2,000 cases being diagnosed and treated each year.

“There is also a small risk of intussusception from rotavirus vaccination, usually within a week after the first or second dose. This additional risk is estimated to range from about 1 in 20,000 to 1 in 100,000 US infants who get rotavirus vaccine.”

CDC on Questions & Answers about Intussusception and Rotavirus Vaccine

And we know that getting a rotavirus vaccine adds a small extra risk for intussusception.

The association was found by looking at reports to VAERS and studies by the FDA’s Post-licensure Rapid Immunization Safety Monitoring System (PRISM).

And it is not just the original Rotashield vaccine, which was withdrawn, but the rotavirus vaccines that we now use that have also been linked to intussusception. The difference is that the risk is much less with the newer rotavirus vaccines.

“Given the magnitude of declines in rotavirus disease compared with this small increase in intussusception, the benefits of rotavirus vaccination outweigh the increase risk of intussusception.”

Tate et al on Intussusception Rates Before and After the Introduction of Rotavirus Vaccine

This small risk must also be viewed against the many benefits of the rotavirus vaccines.

“Rotavirus is the leading cause of severe gastroenteritis among young children worldwide, and was estimated to account for approximately one-third of the estimated 578,000 deaths from childhood gastroenteritis and more than 2 million hospitalizations and 25 million outpatient clinic visits among children <5 years of age each year in the pre-vaccine era.”

Parashar et al on Value of post-licensure data on benefits and risks of vaccination to inform vaccine policy: The example of rotavirus 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.
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. Photo by Vincent Iannelli, MD

It is also still not clear if the rotavirus vaccines actually “trigger” intussusception or if they simply cause it to occur earlier in infants that would have gotten it anyway. That’s because while the latest studies have found excess cases shortly after the first dose of vaccine, studies looking at intussusception trends “have not consistently demonstrated an overall increase in rates post-vaccination.” So there were the same number of total cases, even with the few extra cases right after the kids were vaccinated.

Also, it is thought that wild type rotavirus infections can also trigger intussusception, so the rotavirus vaccines might prevent those cases.

Most importantly though, remember that even if the rotavirus vaccines cause an extra 35 to 100 hospitalizations a year because of intussusception, they are preventing up to 70,000 hospitalizations from severe rotavirus diarrheal disease that occurred in the pre-vaccine era. The vaccines are also preventing about 20-60 deaths from rotavirus disease, while intussusception is rarely life-threatening.

If you are on the fence about vaccines, worry about intussusception is not a good reason to skip or delay your child’s vaccines.

What to Know About Vaccines and Intussusception

Because of a small risk of intussusception, parents should be aware of the symptoms and signs of intussusception and that they may appear six to eight days after an infant’s first dose of rotavirus vaccine.

More on Vaccines and Intussusception