Vaccines 101

Some things I have heard and read lately make me think we have been so busy debunking spurious claims about vaccine side effects that we have not been doing a very good job of educating people about basic vaccine facts, how they work, and why we give them.

Vaccines incorporate microorganisms (bacteria and viruses) or pieces of microorganisms which are given orally or through a shot. If a whole virus is used, it is “attenuated” (weakened) so it does not produce illness. The recipient’s immune system mounts a response to the weakened germ or pieces of germs in the vaccine so that when it encounters the real thing, it has a response in place to fight it off before it can produce illness.

In 1921, there were over 200,000 cases of diphtheria in the United States and over 15,000 deaths from it. I do not know any doctors who have ever seen a case of diphtheria, though it is still present in some parts of the world. What was previously a feared and deadly illness was eradicated from the United States in the 20^th century.

When I was a child, I remember asking my father once about why a man was limping and had a leg that did not seem to be formed quite right. My father’s reply was that the man had had polio as a child. I have never seen a case of polio and probably (hopefully) never will. Vaccine campaigns have eliminated it from everywhere in the world except a couple of pockets in Africa and the middle east and the hope is that total eradication is not far off.

Smallpox is another disease I have never seen and we do not even immunize against it anymore because it has been eradicated from the entire globe through immunization. The last known case was in 1977.

A now-retired colleague of mine used to talk about how common Haemophilus meningitis used to be and how it was something that kept pediatricians awake at night worrying that they could have missed a case in a child who appeared to have a more benign illness. I have only ever seen one case of Haemophilus meningitis and that was with a strain not included in the vaccine which was introduced in the mid 1980s. This same germ can also cause a condition called epiglottitis. The memories of children being strangled by their own swollen airways led the older pediatricians who trained me to spend a significant amount of time teaching about this. Fortunately, having graduated from medical school in 1993, I have never seen a case of epiglottitis.

The measles vaccine was also introduced prior to my medical training and I have never seen a case of measles. However, recent outbreaks in under-vaccinated parts of the United States are a warning to us not to become complacent about immunizing.

I have also seen the effects of the introduction of new vaccines during my career. When I was a resident physician, it was not unusual for us to care for children hospitalized with complications of chicken pox. Most people do not realize that prior to the introduction of the vaccine, about 100 children in the United States died each year from complications of the disease. Now I can’t even remember the last time I saw a child with chicken pox.

Similarly, the Rotavirus vaccine was introduced since I have been in practice. We used to see a lot of this illness in the winter time and often had children admitted to the hospital for dehydration resulting from it. But it has basically disappeared since the introduction of the vaccine.

So it is important to remember that we do not give vaccines just for something to do. They are given to prevent real diseases, with real consequences, in real people.

 

Hand, Foot, and Mouth Disease

Over the past month or so, we have seen a lot of cases of hand, foot, and mouth disease. This disease is generally benign but seems to cause a lot of concern, especially if affected children are in daycare or a school situation.

Typically we see children with some sores in and around the mouth and small blisters on the palms and soles. There are variations in presentation and sometimes children will have rash on other parts of their body as well. The buttocks are another common place for the rash. Fever is sometimes present and sometimes not.

If there is pain from the mouth lesions or fever, acetaminophen or ibuprofen can be used to make children more comfortable. There are no medications available which shorten the duration of the illness and most affected children have minimal discomfort.

The viruses which cause hand, foot, and mouth disease can also infect children without causing any symptoms at all. When symptoms do develop, children are contagious from before the rash starts and continuing for several weeks thereafter.

Because the contagious period lasts so long and there are likely to be other infected children in the class who have no symptoms, exclusion from daycare or school is generally not recommended because it is unlikely to have any effect on the spread of the disease.

So if your child has hand, foot, and mouth disease, there is no cause for alarm and he should get back to normal fairly soon without causing any undue risk to his classmates.

Yes, Your Epipen is Expensive but...

Many of you have probably heard about the increase in EpiPen prices recently. An EpiPen is a device that can be used to deliver a dose of epinephrine (adrenaline) to a person having a serious allergic reaction to keep things in check until emergency medical attention can be accessed. Many people with food allergies, allergies to bee stings, etc. carry these with them and they can potentially be life-saving.

As I understand the situation, the price has risen as one company has developed a virtual monopoly on the product. Essentially, this is the free market at work. There is a lot of demand and one company has the supply with little competition so the price has gone up. In addition, more people now have insurance plans with high deductibles and co-pays so patients are seeing more of that cost themselves than they used to. This has led to a lot of publicity about the high cost of this commonly-prescribed medication. One could argue about whose fault that is and how it should be fixed.

This got me to thinking about people in similar situations with less commonly used treatments. There are patients who pay thousands of dollars a year out-of-pocket for treatment for disorders which most people have never heard of. They would be delighted to have the $600-a-year problem of EpiPen users. But since their disorders are uncommon and not many people use the medications they use, there is not a large group of patients to catch the ear of politicians and the media. And the treatments are often not covered by insurance at all.

So they end up paying large sums for treatments that are almost certainly not that expensive to make and are just as important to treat their disorders as an EpiPen is for a person with a serious allergy. I don’t know the answer to the problem, but I think it is important for people to know it exists.

Some Thoughts on Youth Sports

While watching our youngest son, Jacob, play soccer last spring, one of the other fathers asked me “Do you think sports teach life lessons or do you think we overdo it?” I replied “Yes.”

I have loved sports for as long as I can remember. As a child I could spend hours by myself playing make-believe sporting events or sorting my baseball cards. And I played hours of driveway basketball with friends or baseball in the pasture across the road from my best friend’s house. We would use major league line-ups and bat the way the actual players batted. That’s why as a natural left-handed hitter, I usually chose Mike Easler over Bill Robinson to play left field in my version of the late 1970s Pirates. It got me another left-handed bat in the line-up.

As I got older, I discovered soccer and ended up being pretty good at it and played both soccer and baseball in college. My wife, Cindy, played college volleyball. So when we had children, I naturally started playing all kinds of ball with them. We ended up involved in youth and high school sports from the recreational to “elite” levels and everything in between. This has included swimming, baseball, football, basketball, volleyball, and soccer.

And we have had some great times with all of these activities and I have enjoyed the times traveling with our kids to games and the opportunity to help coach some of their teams. But sometimes things seem a bit over the top. I hate that seasons have gotten longer and now overlap. What is a kid supposed to do when two different coaches, from two different sports, want them two different places at the same time?

And I have witnessed ten year olds standing on the pitcher’s mound crying. Baseball is fun! I don’t think we ever cried while playing baseball unless we got stung by a bee we stepped on while rounding third base barefooted through a patch of clover or collided with a backyard swing set while attempting a Willie Mays over-the-shoulder catch.

And I know I have my own youth sports weirdness. I like making trading cards of my kids which is clearly mainly for my enjoyment, not the kids’ (if anyone needs a 2013 Rachel Sauder basketball card, I have extras). And we have had some great experiences with youth sports and it is not unusual for us to have conversations that start with “Remember that game when…” And I do think there are a lot of life lessons to be learned. How do you deal with being the best player on the team? How do you deal with not getting to play very much? What do you do when the coach puts you at a position you don’t like? How do you react to getting cut from a team? How do you react when the season is only half over and you don’t want to play anymore?

I recently finished reading Overplayed, which was co-written by Dave King who is the athletic director at Eastern Mennonite University where Zach, our oldest child, attends and plays soccer. It has some great practical insights for parents who may be figuring out how to proceed with youth sports (or not) in their family. It is written from a Christian perspective which may not resonate with everyone but I think everyone would find the insights from the perspective of a college athletic director helpful.

My Reality and the News

This is a bit of an unusual topic for me on this blog as it is not really an issue specific to pediatrics. But I have been thinking about the difference between the news coverage of racial, ethnic, ideological, and religious hatred and what I experience every day.

I probably interact with at least a hundred different people every day. I interact with folks from different racial and ethnic backgrounds, different countries of origin, different religions, different socioeconomic circumstances, different political parties, and different sexual orientations. I interact with police officers as well as people who have been convicted of crimes. And most of my encounters with all of these people are pleasant interactions with folks with good hearts. And some of them are absolute saints.

Unfortunately I do also see the effects of poverty, violence, mental illness, and lack of education and they are sobering. When I get home and start going around hugging everyone in my family, one of my kids will say “Did you see something sad today, Dad?” In my experience, neither sainthood nor sadness is confined by demographics.

As a middle-aged, white professional, I certainly have advantages in my dealings with society. I know this not only from the stories of those who do not share those advantages, but also by objective psychological data that reveal our biases, biases that we do not even know we have and that we find offensive when we recognize them in ourselves. Some of my advantages were earned and some were bestowed upon me by outside forces. But even the ones that were earned were more easily obtainable for me than they would have been for some others who started with a different set of conditions.

People are just people. If you are religious, we were all created in the image of God. If you are not religious, we all share the same cosmic chemical origins. Either way, we are all just people, related to each other and deserving of each other’s respect. But we are people whose experiences and identities are unique and it is important to acknowledge that my experience is not your experience and vice versa. The only way we understand another’s experience is to listen. Pretty much every religion has some version of the Golden Rule: “Do unto others as you would have them do unto you.” In order to do that, you first need to see that other person as a person, just like you.

Last week a little African-American boy wandered into my office and struck up a conversation. He was intrigued by a picture of my children and asked me all sorts of questions. And yesterday at the end of the visit, two African-American children gave me hugs as they exited the exam room. Those children simply treated me like a human being, not like some alien from another demographic. We would all do well to follow their example.

PS – I like hugs from brown and white children as well.

The Upside of the Recent News on Flumist

Many of you have probably heard that the nasal flu vaccine (Flumist) is not being recommended for use in children for the upcoming flu season due to lack of efficacy over the past several years. While it is certainly disappointing that this particular vaccine has been found to not be very effective, I also find it oddly reassuring.

I find it reassuring because from my own observations, I would not have known that it was not working. I see a small slice of the whole picture from my perspective in one setting in Augusta County, Virginia. My limited personal observations could lead me to develop erroneous conclusions. But by analyzing large populations of people who received the vaccine, the doctors and scientists who monitor these things were able to reach this conclusion.

I find it comforting that the safety and efficacy of vaccines are being monitored in a systematic way that compiles information from patients all over the country. That way I can be confident that I am providing the safest, most effective treatment based on the evidence, not just on my impressions from the relatively few patients I see.

The beauty of approaching these questions scientifically is that it allows self-correction when the evidence suggests something different than what we thought we were seeing. To me, that is evidence that the system is working.

On Being a Father and a Doctor

Sometimes things that seem routine to medical professionals can cause a lot of anxiety for patients and their families.

Last summer one of our teenaged children had his wisdom teeth removed. From a medical standpoint, everything went smoothly and there were no complications. However, being the one who cared for him the rest of the day reminded me why parents worry. He was so helpless, drifting in and out of sleep and hallucinating about elephants on the drive home. I had this big surge of a paternal protection instinct. And when his local anesthesia took longer to wear off than I expected, I started imagining permanent nerve damage. From a medical perspective, he did great. But from a parental perspective, it was an anxious day.

I have also had the experience of almost fainting while watching a routine procedure on a family member. Something that I had seen many times had a completely different effect on me when it was being done to a loved one, much to the amusement of the nurses who were there and knew me professionally.

Our family has also dealt with a genetic, metabolic disorder. It is extra work, expensive, and a pain to have to deal with. But it has not caused any real medical problems and the treatment is a huge medical success story. But as a parent, one worries about all of the “what ifs.”

I even had some of that protective feeling when I recently took one of our beagles in for a procedure. Even though he often drives me crazy barking at night, I was surprised to find myself worrying about him.

Sometimes the best thing I can do for a patient and her family is remind myself what it is like to be on the patient side, what it is like to be a parent with a sick child who you love more than anything.

Lyme Disease

I enjoy outdoor activities and pulled the first tick of 2016 off of myself last week so I guess it is that time of year again. Removing ticks from myself is a normal part of my warm weather routine.

Lyme disease is a not uncommon concern leading to visits with us. It is an infection caused by the bacteria Borrelia burgdorferi acquired through the bite of a deer tick. Although it has increased in our area in recent years, it is still relatively uncommon. While it is important to be aware of Lyme disease and evaluate and treat appropriately, it is also important to remember that the vast majority of tick bites do not result in any type of illness and that there are many other illnesses that remain far more common than Lyme disease. Even in areas with high rates of Lyme disease, the chance of catching it from a confirmed deer tick bite is 1-3%. So a child’s illness is much more likely to be from something more mundane.

Lyme disease most often presents as a characteristic target-like rash. Less often it can present as a single, swollen, painful joint (usually a knee), or a facial droop, or some combination of these symptoms. In cases when the presentation is clear, we will usually treat without doing any further testing. If the diagnosis is not clear, we will often do a blood test for Lyme disease. When we order the test, the state of Virginia requires us to inform patients that the test is not always accurate. Of course, no test we do gives a correct answer 100% of the time and diagnosing an illness is always based on a combination of history, physical exam findings, and other studies if indicated. As we have all been taught, it is important to treat the patient not the lab result.

Lyme disease is generally easily-treated with a course of oral antibiotics. If it is at a more advanced stage, occasionally a course of IV antibiotics is needed.

So be aware of the signs of Lyme disease and check yourself and your children for ticks after outdoor activities. Get checked if you develop any of the potential signs of Lyme disease. But don’t let concern of Lyme disease prevent you from getting outside and being active!

 

The Benefits of Exercise (and a caution)

Around the time our daughter was born, we had blood pressure screening one day at church and mine was surprisingly high. I had been very fit as a youngster and played a lot of sports. But in my mid 30s, I had gained weight and was not exercising. I was working too much, sleeping too little, and generally not being very healthy. The juxtaposition of the birth of our second child and the high blood pressure reading made me consider my responsibilities and resolve to do something about it. So I took up running.

It has been said that if exercise were a medication, it would be the most-prescribed drug of all because it is good for almost everything. Regular exercise decreases the risk of heart disease, high blood pressure, diabetes, some types of cancer, strokes, and arthritis. It increases bone strength, elevates mood, and improves energy levels and sleep.

So I started running, a little at first, then more. I eventually ran some 5Ks, then 10Ks, and then 10 milers. I lost weight, my blood pressure returned to normal, and I felt great. This progressed to a few half marathons and then some marathons (PR 3:16:04 for the runners out there). My training often required getting up in the wee hours of the morning to run or running with a head lamp at night. When I was on call, I would sometimes run laps around the hospital at night because I had to be able to get there within minutes if there was an emergency. In the process, I started getting more tired again, and then my leg started hurting. An MRI revealed a stress reaction in my tibia, the main bone in the lower leg.

What had started as an attempt to get healthy by exercising resulted in me exercising so much I harmed myself. My leg healed with rest and I started running again, now in smaller amounts. There is nothing wrong with running marathons, but in my particular situation, running had led to a different kind of unhealthy. I haven’t raced since that injury but try to run a few times a week. My blood pressure remains fine (110/74 earlier this week) and I think I am in pretty good shape for a guy my age (though I certainly can't keep up with my teenage children). Sometimes my exercise for the day is simply walking the mile to and from our mailbox to get the mail. Even that little bit makes me feel better. Or if I have had a stressful day, a quick five mile run is the best way to burn that stress away.

You don’t have to be an athlete or compete in things to benefit from exercise. Find something you enjoy – walking, hiking, riding bike, working in the garden, playing basketball or soccer, kayaking, chopping wood, etc. and do it regularly. Or better yet, do some combination of several different activities. You will feel better and decrease your risk of a variety of health problems.

Whatever Happened to Rotavirus?

We are in the midst of what used to be Rotavirus season. Rotavirus is a viral intestinal infection which causes fever, vomiting, and diarrhea and generally lasts 3-8 days. In some cases, it can lead to dehydration and hospitalization, particularly in infants.

In the “old days,” meaning before 2006, it was not unusual for us to have several infants with Rotavirus admitted to the hospital at the same time at this time of year. Rotavirus was part of the reason that our pediatric ward was often full in the winter, sometimes causing our patients to overflow onto the adjacent adult ward. We dealt with Rotavirus so often that the nurses on the pediatric ward could usually predict a positive test for it before we had the results based on the smell of the stool. In contrast, that same pediatric ward now rarely houses more than a couple of patients at a time, though the decrease is certainly not due only to fewer cases of Rotavirus.

The difference is that we now have an oral vaccine for Rotavirus that is given at two, four, and six months of age. Just two years after introduction of this vaccine, there was an 85% reduction in ER visits and hospitalizations due to Rotavirus nationwide.

Prior to the currently available vaccines, there was another Rotavirus vaccine on the market. It was quickly discovered that there was a small increase in cases of intussusception, a type of intestinal obstruction, in children who had received the vaccine and it was quickly withdrawn from the market.

The currently available vaccines have been watched closely for this same association and no increased risk of intussusception has been found. The successful reduction of Rotavirus infections is evidence for the efficacy of the vaccine as well as the mechanisms in place for detecting adverse reactions to immunizations.

Effects of Too Much Screen Time

Sometimes when there is a big weekend of sports on TV, I find myself watching for far too long. Not infrequently, this leads to a headache and general grumpiness. The same thing happens when I spend too much time on-line, whether I am just reading the news or watching something mindless. I do not think I am alone in this and there is plenty of evidence that TV and other screen time has deleterious effects on other people as well, including children.

Television watching in young children has been linked to an increased risk of ADHD and watching TV is associated with obesity and sleep problems in children as well. Think about what children are not doing while watching TV. Children need to be interacting with others, playing outside, solving problems while building forts with things they find, playing games, etc. Play is how children learn about the world and learn to interact with others. Some of my best childhood memories are of building dams in a pasture stream, exploring the woods, and baseball games in the back yard that lasted for hours. Debating a close call at first base and coming to a conclusion together is practicing for real life.

TV also exposes children to scenes of violence, advertisements for unhealthy foods, lots of advertisements for alcohol (especially if you like to watch sports), and sex without consequences. The amount of sex that is implied on TV comes with remarkably low incidences of sexually transmitted diseases and unwanted pregnancies. In real life, people actually do get pregnant and pick up diseases. I remember once while watching TV with one of my children I was asked during a beer commercial “Why is she out in the snow in her bathing suit?” A reasonable question for which I had no reasonable answer.

The American Academy of Pediatrics recommends no screen time for children younger than two and a maximum of 1-2 hours per day for children older than that. With the ubiquity of TVs, computers, tablets, smart phones, etc., it is easy to exceed that without even noticing.

So turn off the electronics and get kids outside playing or building a house in the living room with chairs and a blanket or just exploring the world around them. I know for myself, getting away from the TV or computer and going for a run, walking the ½ mile to get the mail from our mailbox, shooting baskets in the driveway, or even just sitting on the porch and watching and listening to birds and lizards can really improve the way I feel both mentally and physically. And it probably makes me more pleasant to be around as well.