Tag: travel vaccines

Understanding the Vaccine Injury Table

The Vaccine Injury Table was created by the National Childhood Vaccine Injury Act of 1986.

“The Table makes it easier for some people to get compensation. The Table lists and explains injuries/conditions that are presumed to be caused by vaccines. It also lists time periods in which the first symptom of these injuries/conditions must occur after receiving the vaccine. If the first symptom of these injuries/conditions occurs within the listed time periods, it is presumed that the vaccine was the cause of the injury or condition unless another cause is found.”

What You Need to Know about the National Vaccine Injury Compensation Program

A table injury is an illness, disability, injury or condition covered by the National Vaccine Injury Compensation Program.

“For example, if you received the tetanus vaccine and had a severe allergic reaction (anaphylaxis) within 4 hours after receiving the vaccine, then it is presumed that the tetanus vaccine caused the injury if no other cause is found.”

What You Need to Know about the National Vaccine Injury Compensation Program

To quality as a table injury, the illness, disability, injury or condition has to occur within a specific “time period for first symptom or manifestation of onset or of significant aggravation after vaccine administration.”

Understanding the Vaccine Injury Table

So if there is a Vaccine Injury Table, then that proves that vaccine injuries are real, right?

The Vaccine Injury Table is easier to understand if you actually look at the table.
The Vaccine Injury Table is easier to understand if you actually look at the table.

Wait, does anyone dispute that vaccine injuries are real?

No one says that vaccines are 100% safe, so yes, of course, it is known that they have risks and cause adverse effects. While most of these adverse effects are usually mild, they can rarely be severe or even life threatening.

The idea the vaccine injuries are common is what is misunderstood and misrepresented by anti-vaccine folks.

It's no joke, studies have shown fewer side effects after the second dose of MMR!
It’s no joke, studies have shown fewer side effects after the second dose of MMR!

Consider the above post by Bob Sears

Yes chronic arthritis after a rubella containing vaccine is a table injury, but it is very rare. Arthritis after the rubella vaccine is typically mild and temporary, lasting just a few days.

While rubella containing vaccines can cause arthritis, they do not cause lifelong rheumatoid arthritis. So even if you were to be one of the very rare people who developed chronic arthritis after a rubella containing vaccine, a table injury, it would still not be the same thing as rheumatoid arthritis.

“The association between rubella vaccination and chronic arthritis is less clear. Most recently published research, has shown no increased risk of chronic arthropathies among women receiving RA27/3 rubella vaccine and do not support the conclusion of the IOM (Slater et al., 1995; Frenkel et al., 1996; Ray et al., 1997). These studies have included a large retrospective cohort analysis which showed no evidence of any increased risk of new onset chronic arthropathies and a double-blind historical cohort study. One randomised placebo-controlled, double-blind study of rubella vaccination in sero-negative women demonstrated that the frequency of chronic (recurrent) arthralgia or arthritis was marginally increased (1.58 [1.01-2.45], p = 0.042) (Tingle et al., 1997). In 2011, the United States Institute of Medicine (IOM) reviewed available research and concluded that the evidence is inadequate to accept or reject a causal relationship between MMR vaccine and chronic arthralgia in women.”

Information Sheet Observed Rate of Vaccine Reactions Measles, Mumps and Rubella Vaccines

And it wouldn’t even be clear if your chronic arthritis was caused by the vaccine!

“The Table lists and explains injuries and/or conditions that are presumed to be caused by vaccines unless another cause is proven.”

What You Need to Know about the National Vaccine Injury Compensation Program

To be added to the Vaccine Injury Table, there only has to be scientific evidence that a condition could be caused by a vaccine.

“Where there is credible scientific and medical evidence both to support and to reject a proposed change (addition or deletion) to the Table, the change should, whenever possible, be made to the benefit of petitioners.”

Guiding Principles for Recommending Changes to the Vaccine Injury Table

That makes sense, as the NVICP is a “is a no-fault alternative to the traditional legal system for resolving vaccine injury petitions” for VICP-covered vaccines.

Vaccines Covered by the Vaccine Injury Table

Most routinely used vaccines are covered by the Vaccine Injury Table, including vaccines that protect against:

  • diphtheria, tetanus, and pertussis – DTaP, Tdap, Td
  • measles, mumps, and rubella – MMR, ProQuad
  • chickenpox – Varivax, ProQuad
  • polio – IPV, OPV
  • hepatitis B
  • hepatitis A
  • Hib
  • rotavirus
  • pneumococcal disease – Prevnar
  • influenza – seasonal flu vaccines
  • meningococcal disease – MCV4, MenB
  • human papillomavirus – HPV4, HPV9

In fact, “any new vaccine recommended by the Centers for Disease Control and Prevention for routine administration to children, after publication by the Secretary of a notice of coverage” is automatically included, at least for Shoulder Injury Related to Vaccine Administration and vasovagal syncope.

New vaccines are also covered if they are already “under a category of vaccines covered by the VICP.”

Immunizations given to pregnant women are also covered.

A few others, including vaccines that protect against pandemic flu, smallpox, and anthrax are covered by the Countermeasures Injury Compensation Program (CICP).

Vaccines Not Covered by the Vaccine Injury Table

What about vaccines that aren’t routine?

Other vaccines that are used in special situations, including vaccines that protect against rabies, yellow fever, Japanese encephalitis, cholera, and typhoid aren’t listed in the Vaccine Injury Table and aren’t covered by the National Vaccine Injury Compensation Program.

Have you seen any TV ads for lawsuits against the shingles vaccine, which isn't in the vaccine injury table.
Have you seen any TV ads for lawsuits against the first shingles vaccine?

Shingles vaccines and the older pneumococcal vaccine, Pneumovax, aren’t covered either.

And since they are not covered by the National Vaccine Injury Compensation Program, there are no restrictions on lawsuits against the manufacturers of these vaccines or the health providers who administer them.

So much for the idea that you can’t sue a vaccine manufacturer or that vaccine manufacturers have no liability for vaccines…

Why weren’t these vaccines covered?

Remember, the NVICP and Vaccine Injury Table were created by the National Childhood Vaccine Injury Act of 1986. The vaccines that aren’t covered are not on the routine childhood immunization schedule.

“There are no age restrictions on who may receive compensation in the VICP. Petitions may be filed on behalf of infants, children and adolescents, or by adults receiving VICP-covered vaccines.”

National Vaccine Injury Compensation Program Frequently Asked Questions

Still, since many of the covered vaccines can be given to adults, they are included, even if some of the vaccines adults routinely get aren’t covered.

Will they ever be covered?

“They found a low liability burden for these vaccines, that serious adverse events were rare, and that no consensus existed among stakeholders. After considering the staff report, NVAC chose, in 1996, not to advise the Department of Health and Human Services to include adult vaccines in VICP.”

Loyd-Puryear et al on Should the vaccine injury compensation program be expanded to cover adults?

Adding more adult vaccines to the Vaccine Injury Compensation Program (VICP) is something that has been looked at in the past, but it wasn’t thought to be necessary.

What to Know About the Vaccine Injury Table

The Vaccine Injury Table is a list of conditions set up to make it easier for people to get compensated from the National Vaccine Injury Compensation Program.

More on Understanding the Vaccine Injury Table

When is Measles Season?

For a while, especially once we eliminated the endemic spread of measles, we weren’t thinking about measles seasons anymore.

In addition to the recent rise in measles cases, this slide shows the patterns of measles seasons in different parts of the world.
In addition to the recent rise in measles cases, this slide shows the patterns of measles seasons in different parts of the world.

Unfortunately, with ongoing outbreaks and rising cases, many people are asking again – just when is measles season?

When is Measles Season?

Traditionally, the time when measles case counts are the highest occurs:

  • during the late winter and early spring (temperate climates, like the United States)
  • after the rainy season (tropical climates)
  • when kids are in school

So just like flu season, it’s always measles season somewhere…

And in areas of the world where measles is still highly endemic, you can expect cycles of larger measles epidemics every 1 to 4 years.

Can you guess why?

“As higher uniform population immunity is achieved the scale of epidemics, both their duration and absolute number of cases, progressively decreases. Epidemic frequency simultaneously decreases with increasing time intervals between epidemics. Another uniform feature as elimination is approached is the loss of epidemic seasonality.”

Durrheim et al on Measles – The epidemiology of elimination

I’ll give you a hint – there is nothing different about the measles virus during those years.

Eventually though, as the number of people susceptible to measles builds up, there is the opportunity for bigger outbreaks. Of course, that doesn’t happen if most people are vaccinated and protected.

When is Measles Season in the United States?

What about in the United States in the post-vaccine era?

Visiting a place with a lot of measles, especially if you aren't vaccinated and protected, increases the risk that you will bring measles home with you and start an outbreak.
Visiting a place with a lot of measles, especially if you aren’t vaccinated and protected, increases the risk that you will bring measles home with you and start an outbreak.

We don’t really have a measles season, as all of our cases are now imported from other parts of the world.

  1. Where and when are folks traveling?
  2. Where is measles on the rise?

That’s when we will see more measles cases here.

“Source countries included Philippines (14 cases), Ukraine (8), Israel (5), Thailand (3), Vietnam (2), Germany (2), and one importation each from Algeria, France, India, Lithuania, Russia, and the United Kingdom.”

Increase in Measles Cases — United States, January 1–April 26, 2019

In the early part of 2019, we saw a lot of cases because unvaccinated travelers were returning from Philippines, Ukraine, and Israel, countries in peak measles season.

Are Europe's measles outbreaks slowing down yet?
Are Europe’s measles outbreaks slowing down yet?

As cases in those countries hopefully slow down over the summer, unfortunately, we might see a rise in other parts of the world.

Of course, there is an easy way to end our measles seasons once and for all.

Two doses of MMR is your best protection against measles.

Get vaccinated and protected, especially before traveling out of the country.

More on Measles Season?

How Do You Know If You Have Measles Immunity?

With all of the measles cases, you might be wondering if you have immunity to measles?

Are you worried that you might get measles?

Should you get a booster dose of MMR?

Or a titer test?

How Do You Know If You Have Measles Immunity?

Fortunately, most of us can feel confident that we do have measles immunity and that we won’t get caught up in any of the ongoing outbreaks.

Why?

If you have had two doses of MMR, then you can be confident that you have measles immunity.
If you have had two doses of MMR, then you can be confident that you have measles immunity.

Because we are vaccinated and protected!

If you haven’t had two doses of MMR (or any measles containing vaccine since 1967), then understand that two doses is your best protection against measles.

Is There a Blood Test for Measles Immunity?

What about titer tests?

While there is a blood or titer test for measles immunity, it isn’t routinely used.

The one situation in which a measles titer test might be useful though, is for those born before 1957 to confirm that they really had measles.

For others considering a titer test in place of vaccination, it is typically better to just get another dose of MMR, but only if you haven’t already had two doses.

Why Was My Measles Titer Negative?

A positive measles titer does mean that you are immune, but what about a negative measles titer?

“For HCP who have 2 documented doses of MMR vaccine or other acceptable evidence of immunity to measles, serologic testing for immunity is not recommended. In the event that a HCP who has 2 documented doses of MMR vaccine is tested serologically and determined to have negative or equivocal measles titer results, it is not recommended that the person receive an additional dose of MMR vaccine. Such persons should be considered to have presumptive evidence of measles immunity. Documented age-appropriate vaccination supersedes the results of subsequent serologic testing.”

Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP)

If you have had two doses of MMR and have a negative measles titer, you don’t need another dose of MMR. You are likely immune, even with that negative titer.

“Most vaccinated persons who appear to lose antibody show an anamnestic immune response upon revaccination, indicating that they are probably still immune.”

Epidemiology and Prevention of Vaccine-Preventable Diseases

And since you would need a second dose if you had a negative titer after having just one shot, you might as well just get the second dose instead of checking your titer.

Do You Need a Measles Booster?

Have you had two doses of MMR?

If so, then you don’t need another dose.

The second dose isn’t technically a booster anyway. It is just for those who might not have responded to their first dose.

And two doses of MMR are about 97% effective at preventing measles.

That’s why most of the people in measles outbreaks are unvaccianted.

Neither primary nor secondary (waning immunity) vaccine failure are common with the measles vaccine.

What’s the biggest issue with the MMR? Folks who are still too scared to get their kids vaccinated and protected!

More on Measles Immunity

What Is Your Protocol to Stop Measles Before Kids in Your Office Get Exposed?

Measles outbreaks have reached record levels this year. Unless you’re prepared, with a strict protocol to stop measles, that could mean that someone could get exposed in your office.

“Many of today’s physicians may never have seen a patient with measles— a disease that can cause serious complications in infants, young children, and adults. CDC is urging all physicians to “think measles” when evaluating patients who have fever and rash, and to know what to do to prevent, control, and report measles cases.”

CDC Asking Physicians to “Think Measles” and Help Stop the Spread

Have you ever seen a child with measles?

What Is Your Protocol to Stop Measles Before Kids in Your Office Get Exposed?

To help everyone understand how important it is to think about measles and prevent unnecessary exposures, it can help to understand what happens when a child with measles does go to their pediatrician, an urgent care center, or the ER.

Part of your protocol to stop measles will be making sure th unvaccinated children exposed to measles are quarantined for at least 21 days.
Unvaccinated children exposed to measles are quarantined for at least 21 days.

Since measles is so contagious and can remain infectious for up to two hours after a person has left a room, with each measles case, you will have to:

  • isolate the person with measles (or suspected measles) in a negative pressure isolation room. If that’s not possible, at least have the person wear a mask in their own private room and/or schedule them at the end of the day, bypassing the waiting room. You might even go out to their car for a quick interview and exam before they come into the office.
  • not use that exam room for at least two hours after the person with measles leaves.
  • report the case to your local health department ASAP, as they will likely have more extra resources to help you manage your patient.
  • locate everyone who could have been exposed, including anyone who was in the same area as the suspected case or entered the area over the next two hours. If they aren’t already immune, these folks might need immune globulin (younger than six months or immunocompromised) or a dose of MMR. They will probably also be quarantined to make sure they don’t develop measles and expose others.
  • only allow those who are immune to measles (two doses of MMR or natural immunity) to take care of the suspected case. Everyone should still wear an N95 respirator or at the very least, a general facemask, just in case.
  • limit anyone else’s exposure as you work to confirm that they have measles (PCR testing of throat swab and urine), provide supportive care as necessary, or quarantine them at home.

Unfortunately, it usually ends up being more than a single exam room that has to be closed when a child shows up with measles. After all, before they got to that exam room, they were probably in the waiting room and other general areas of the office.

And that’s why you will want to have a protocol in place to avoid or minimize these exposures.

Don’t Spread Measles

Of course, that starts with trying to get everyone vaccinated and protected, including an early dose of MMR when appropriate, so that your patients don’t get measles in the first place!

“Failure to promptly identify and appropriately isolate measles cases has led to the investigation of hundreds of healthcare contacts this year. Measles transmission has occurred in emergency departments and other healthcare settings, including transmission to one healthcare worker.”

Recommendations for Measles Case Identification, Measles Infection Control, and Measles Case and Contact Investigations

Next, make sure everyone understands how to recognize the signs and symptoms of measles. Otherwise, some of these kids might unexpectedly end up in your office when they are sick.

The classic measles rash, which begins on the face, typically doesn't begin until these kids have had fever for two or three days.
The classic measles rash, which begins on the face, typically doesn’t begin until these kids have had fever for two or three days. Photo by Jim Goodson, M.P.H.

Think that’s easy? You just watch out for kids with a fever and a rash, right?

Wrong.

If you wait until they have the classic measles rash, you will likely miss the diagnosis the first time they come to your office. Remember, the rash typically doesn’t show up until they have already had a fever for three or four days.

Unfortunately, these kids are contagious well before they have a rash. They are even contagious before they have a fever and know they are sick.

As part of your protocol to stop measles, post a warning sign before parents come into your office.
As part of your protocol to stop measles, post a warning sign before parents come into your office.

So you should suspect measles in kids:

  • with a high fever and cough, coryza, and conjunctivits, even if they don’t yet have a rash
  • with classic measles symptoms who have had a possible exposure. This includes kids who recently traveled out of the country (get a travel history), had contact with international travelers, or just because there are a lot of cases in your area.
  • who are unvaccinated or not completely vaccinated, with two doses of MMR. Keep in mind that even fully vaccinated kids can sometimes get measles though.

And then, if you suspect that a child has measles, work to limit their exposure to others. Patients should know to call ahead. Staff at your office, lab, or the ER should be alerted and ready to see anyone with suspected measles. That way the family knows to wear a mask before going inside.

Ideally, if you have a strong suspicion that the child has measles, this visit will occur in a facility with a negative pressure airborne infection isolation room.

What’s the problem with this kind of protocol?

Lots of kids have fever and rashes! And since you can’t send everyone that calls with adenovirus, roseola, or hand, foot and mouth disease to the ER, part of your protocol should likely be that a health care professional carefully assesses the child’s signs, symptoms, and risks for measles before deciding what to do.

Mostly, be suspicious if a child has returned from a trip oversees, especially if they are unvaccinated, and they have a febrile illness.

More on Your Protocol to Stop Measles Before Kids in Your Office Get Exposed