Vaccines a balanced discussion of what you need to know to make an informed decision

Transcription

1 Vaccines a balanced discussion of what you need to know to make an informed decision KOREN BARRETT ND

2 We will be discussing... Vaccines what it is and what they do Traditional vaccine schedule Detailed information on each vaccine and the diseases it protects against Alternate schedules How to vaccinate safely What do I do if I choose not to vaccinate?

3 Vaccines A small dose of an attenuated bacteria or virus Stimulates the immune system to react thereby creating memory primes the pump

4 Vaccine Benefits Large decrease in pertussis infections Polio eradicated from western hemisphere Small pox eradicated Measles at all time low Diptheria is rare Death from tetanus is rare

5 Vaccines - What is all the controversy? Concerns with safety. Testing Ingredients Too soon Too many Too many at once

6 Testing Vaccine studies are conducted to ensure they raise titer levels, the studies are too small to detect many potentially dangerous events All clinical trials only enroll healthy infants no studies where they are administered to sick kids

7 Ingredients - Mercury in vaccines? Thimerosal (ethyl mercury) was a preservative added to vaccines to inhibit the growth of bacteria

8 Thimerosal (mercury) Safe level of organic (methyl) mercury EPA 0.1 mcg/kg per day ASTDR 0.3 mcg/kg per day FDA 0.1 mcg/kg per day WHO 3.3 mcg/kg per week DTaP + Hib + Hep B was a total of 62.5 mcg This exceeds all safe levels for a 10 lb infant

9 Thimerosal (mercury) some infants could have been exposed to cumulative levels of mercury during the first six months of life that exceeded EPA recommended guidelines for safe intake of methylmercury urging vaccine manufacturers to reduce or eliminate thimerosal in vaccines as soon as possible Accessed

10 Mercury (mostly) removed 2001 Thimerosal was eliminated from most vaccines Flu vaccines, Meningococcal and Rho-gam may still contain the preservative

11 Aluminum Known neurotoxin, linked to autoimmune disease When several vaccines are given in combination possibly exceeds safe dosage Studies have been conducted on premature infants receiving aluminum in IV solutions to determine safe amounts 5 mcg/ kg/day was OK (no studies on healthy term infants with healthy kidneys we can assume they can handle a bit more but how much??) 12 lb baby can safely handle 30 mcg of aluminum 22 lb 50 mcg of aluminum Hib contains 225 mcg per shot, Pc 125 mcg

12 Other ingredients. Preservatives (must be in multi dose vials) Formaldehyde To inactivate the virus or bacteria Use of human or animal tissues Possible viral and mycoplasma contaminant Antibiotic residue

13 Too soon? Vaccines depend on creation of memory in the immune system to be effective Most immunological memory doesn t happen the first year of life immature immune system Immune activation different for an infant vs. a toddler (1 yo) TH1 vs TH2 Early immunization many shift the immune system creating more allergies/ asthma/ eczema/ autoimmunity

14 Immune system shift Canadian study showed that children who received the DTP at the recommended 2 months had a 14% asthma rate by age 7 but children receiving the vaccine at 4 months had a 6% asthma rate J Allergy Clin Immunol. 2008;121:

15 Japan s schedule From Japan had a minimum age of 2yo to start vaccines They had the worlds lowest infant mortality rate at that time Beginning in 1995 they have a much less aggressive immunization schedule than the US Japan currently ranks 3 rd in the worlds lowest infant mortality The US ranks 34 th

16 DAPTACEL insert - Link to SIDS? 5.7 Apnea in Premature Infants Apnea following intramuscular vaccination has been observed in some infants born prematurely. The decision about when to administer an intramuscular vaccine, including DAPTACEL, to an infant born prematurely should be based on consideration of the individual infant s medical status and the potential benefits and possible risks of vaccination. - accessed Feb 2014

17 Apnea ap ne a ˈapnēə,apˈnēə/ nounmedicine noun: apnoea; noun: apnea 1. temporary cessation of breathing, esp. during sleep.

18 Too Late? BUT if you vaccinate too late this can increase risk of autoimmunity Autoimmune triggering most often occurs in adults >40 yo If children are going to be vaccinated introduce vaccines between ages 2-9

19 Too Many?? Vaccine schedules are recommended by the CDC (center for disease control) and AAP (American academy of pediatrics) 1970 s Recommended children receive 23 doses of 7 vaccines by age 6 starting at 2 months old 2012 Recommend children receive 48 doses of 15 vaccines by age 6 starting at 12 hours old

20 Vaccine schedule months: DTP, Polio 4 months: DTP, Polio 6 months: DTP, Polio 1 year: Measles 1-12 years: Rubella, Mumps 1 1/2 years: DTP, Polio 4-6 years: DTP, Polio

21 Today s Schedule Birth - Hep B 1 month - Hep B 2 months - HIB, Pc, DTaP, arotavirus, Polio 4 months - HIB, Pc, DTaP, arotavirus, Polio 6 months HIB, Pc, DTaP, Rotavirus, Hep B, Flu 1 year MMR, chickenpox, Hep A, Flu 15 months HIB, Pc 18 months DtaP, Polio, Hep A, Flu 2 years - Flu 3 years - Flu 4 years - Flu 5 years DTaP, Polio, MMR, Flu, Chickenpox 12 years Tdap, Meningococcal, HPV (3x)

22 Too much at once??? At 2 months babies receive as many as 8 vaccines in one visit At months babies receive up to 13 in a single visit

23 One size fits all approach The focus of the immunization schedule is based on herd immunity Little allowance for individual immune status Preemie age adjusting is not taken into consideration Reason for giving vaccines at a young age Linked to pediatric wellness visits greatest chance to immunize the greatest portion of the population

24 A better way? Evaluating individual risk Determining which vaccine is appropriate Proper timing of vaccines Prevention and treatment of the diseases

25 What do I need to know about Hepatitis B? Standard schedule Given at birth, 1m, & 6m Virus Majority of hepatitis infections occur in people ages yo ½ of the people never develop symptoms Only 20% develop severe symptoms Can become chronic 10% risk Causes liver damage 25% of people eventually develop liver failure CDC Hep B Info sheet

26 Hepatitis B risk factors l Babies born to infected mothers (70-90% risk of transmission) l Vaccine should be considered later in life as Hepatitis B is primarily an adult disease transmitted through infected body fluids Drug addicts Sexual promiscuity Health care workers exposed to blood Persons who require repeat blood transfusions

27 Hepatitis B frequency l Is it common? 38,000 new cases in 2009 Only 360 cases reported yearly in infants prior to vaccine Less than 1% of cases occur in persons less than 15 yo

28 Hepatitis B vaccines Best choice Vaccine options; Recombivax HB 250 mcg aluminum, yeast, formaldehyde Engerix B 250 mcg aluminum, yeast, 0.5 mcg mercury Comvax 225 mcg aluminum (this is less than the 475 mcg if you give hep b and PedVaxHIB separately) Pediarix DTaP + Engerix + polio, many preservatives and additional ingredients!! 850 mcg aluminum Twinrix hep A + hep B for persons age 18 yo or older

29 Hep B Protection by age & dose Dose 1 Infants 16-40% Teens/adults 20-30% Dose 2 Infants 80-90% Teens/adults 75-80% Dose 3 Infants % Teens/adults 90-95% Preterm infants have less efficacy when <2 kg

30 Hep B vaccine Adverse reactions reported to CDC Pain at site of injection 0-20% of children - fatigue, headache, irritable.4-6.4% had a low grade fever Alleged to cause exacerbation / causative factor of multiple sclerosis New Zealand study found 60% increase of diabetes following a massive hepatitis B immunization campaign - Classen, J.B.: Diabetes epidemic follows hepatitis B immunization program. New Zealand Medical Journal, 109: 195, 1996

31 Hep B vaccine Who should get it? Not for children unless born to mother who is hepatitis B positive (my opinion) Consider in adolescents age 9-11 before they become sexually active Adults who are in a high risk group

32 What do I need to know about HIB Haemophilus Influenzae Type B l Standard schedule - Given at 2m, 4m, 6m, & 15m l Bacteria l Transmitted by respiratory droplet l Usually causes mild cold Severe (Invasive) cases cause meningitis l Peak incidence children age 3-18 months l Hib meningitis has a 5% fatality rate l 25% cause some brain damage l Difficult to recognize in the early stages l It is a treatable condition by IV antibiotics, will prevent fatalities but not all damage CDC Hib Info Sheet -

33 Hib risk factors Smoker in the house at most risk for being an asymptomatic carrier Highest risk ages 6-12 months Rare prior to age 6 m and never seen after 5 yo Not breast fed protection in infants from moms antibodies in breast milk for 6 months Daycare or school age siblings Greater than 4 in a household Chronic disease ill children at greater risk

34 Hib frequency Is it common? No 0.16 invasive cases in 100,000 yearly in children under the age of 5 yo, rare beyond 3 yo Prior to vaccines in the 80s 20,000 cases yearly 3-6% were fatal

35 Hib Vaccines est choice ActHIB no aluminum (3 doses in primary series) Hiberix no aluminum (booster dose only) PedVaxHIB contains 225 mcg aluminum (2 doses in series) Pentacel (in combo with DTaP and polio) contains 1500 mcg aluminum (more than the sum of its components separately 330 mcg) 3 doses in series Comvax (in combo with Hep B) contains 225 mcg aluminum (this is less than the 475 mcg if you give hep b and HIB separately) (2 doses in series)

36 Hib vaccine protection by age and dose Do not give prior to 6 weeks old may make future vaccines ineffective Most do not show a proper immune response before age 6 months Requires less dosages if given later Any previously unvaccinated child months only needs a single dose of the vaccine and no booster No need to vaccinate children older than 59 months

37 Hib vaccine Adverse reactions Local inflammation 5-30% Seizures, renal failure, guillain barre Recent research has linked an association with type 1 diabetes, the more vaccine doses the higher the risk - BMJ 1999;319:1133.1

38 Hib Who should get it? Major risk factors (second hand smoke, daycare, large family, poverty, not breast fed) Not needed after 5 yo Most children acquire natural immunity by this age

39 What do I need to know about Pc Pneumoccoccal Conjugate l Standard schedule Given at 2m, 4m, 6m, & 15m l Bacteria - Spread by respiratory droplet l Very common and virtually every child is a carrier the first year of life l Causes URI, otitis media, pneumonia l May cause meningitis (after 6 months of age) 10% fatality (mostly in elderly and those with underlying illness) l It is a treatable condition by IV antibiotics for severe infection, oral antibiotics for mild infection concern with emergence of antibiotic resistance CDC info sheet Pc- -

40 Pc Risk Factors Second hand smoke exposure Lack of breast feeding Daycare Poor nutrition and vitamin A deficiency

41 Pc - frequency Is it common? Yes in its mild form Most common cause of infant meningitis 10,000 cases yearly of severe infection in children under 5 yo in US and 20,000 in adults 60,000 yearly before introduction of the vaccine

42 Pc vaccines Only choice l Prevnar mcg of aluminum Protects against 13 strains l Pneumovax 23 for adults only

43 Pc protection by age and dose Age 6 wks to 7 months requires 4 doses Age 7-11 months requires 3 doses Age months requires 2 doses Age 24 + months requires 1 dose Removed from the schedule at 7 yo

44 Pc vaccine Adverse reactions Seizures Fever Tenderness at site of injection Prevnar 7 (older version) was temporarily removed from Japan s schedule after 4 infant deaths. No issues with current version

45 Pc vaccine Who should get it? Not effective prior to 6 months of age Any child with major risk factors

46 What do I need to know about Diptheria The D of DTaP ` DTaP standard schedule 2m, 4m, 6m, 18m & 5yo What is it? Bacteria Causes severe throat infection Infection through respiratory droplet What is the concern? Can cause closing of throat, difficulty breathing 5-10% fatality It is a treatable condition with an antitoxin and IV antibiotics CDC DTaP info sheet -

47 Diphtheria risk factors People who live in crowded areas with poor sanitation Alcohol addiction and drug use have higher rates of diphtheria

48 Diphtheria frequency Is it common? No Maximum 5 cases yearly There was only 1 case in 2002

49 Diptheria vaccine Adverse reactions Site tenderness Rare severe reactions Anaphylaxis Urticaria Neurological complications

50 What do I need to know about tetanus - T of DTaP DTaP standard schedule 2m, 4m, 6m, 18m & 5yo What is it? Bacteria that lives in the soil Can cause paralysis Enters body through contaminated wound Symptoms usually start 3 d to 3 weeks after injury Not contagious Treated with immunoglobulin What is the concern? Causes paralysis through out the body 15% fatality rate

51 Puncture wounds Tetanus risk factors

52 Tetanus frequency Is it common? NO CASES YEARLY virtually all in older adults who have not received a booster shot 15 cases in children from

53 Tetanus vaccine Adverse reactions Mild soreness at site of injection Rare allergic reaction or kidney problems Fatigue

54 Tetanus vaccine Who should get it? Consider in children older than 1 year

55 Tetanus vaccine protection by age and dose Children >1 yo 2 doses at 2 months apart then another 6-12 months later

56 What do I need to know about Pertussis? - P of DTaP DTaP standard schedule 2m, 4m, 6m, 18m & 5yo Bacteria - WHOOPING COUGH Coughing fits that last 30 sec to 2 min so severe the person has trouble breathing Toxin released irritates the lungs Illness can last 3 months Most serious in 1 st 6 months of life 1% fatality 2000 cases yearly 75% hospitalized 5-10 children die yearly (most before 2 months of age) Possible brain damage due to prolonged coughing

57 Pertussis risk factors Daycare Adolescent sibling between ages vaccine wears off (50% decline over 6-12 yrs) and they may not present with any symptoms Exposure to second hand smoke Parents who are health care workers or teachers are the most common vectors Highly communicable 80% of household will become infected

58 Pertussis frequency Is it common? cases reported each year in US In the US 5-10 children die every year most deaths occur in unvaccinated children or children too young to be vaccinated

59 Pertussis vaccine Adverse reactions Redness, swelling. Pain and vomiting No appetite Breast milk does not provide much protection (unlike Hib or Pc)

60 Pertussis vaccine Who should get it? Highest rates in inner cities Note: lowest vaccination rate in Ashland OR yet not the highest incidence of the disease Pertussis After 6 months fatality VERY rare but we vaccinate older children and adults to protect infants Pertussis Immunity only lasts 4-8 years

61 DTaP Vaccines Daptacel 330 mcg aluminum 4 doses = primary immunization for pertussis, the 5 th is a booster 3 doses = primary immunization for tetanus & diptheria, the 4 th & 5 th are boosters Tripedia 170 mcg aluminum, 0.3 mcg mercury Infanrix 625 mcg aluminum Pentacel contains 1500 mcg aluminum (more than the sum of its components separately 330 mcg) Pediarix (in combo with hep B and polio) 850 mcg aluminum TriHIBit (combined with Hib for 18 m only) 170 mcg aluminum There are no pertussis only vaccines Diptheria can be given separately from DTaP

62 DTaP protection by age On the CDC catch-up schedule All 4 vaccines are need in the series is you start anytime between age 6 weeks to 6 years You need 3 in the series is the child is 7 yo and the first dose was administered at 12 months or older. Titers are not accurate for pertussis downloads/child/catchup-schedule-pr.pdf

63 Tdap (Adacel or Boostrix) in pregnancy Recent addition based on less than 200 women who incidentally received the vaccine during pregnancy and did not experience any fetal harm rr5704a1.htm accessed Feb 2014 Antibodies to pertussis readily cross the placenta and are present in infants blood in concentrations comparable to maternal blood These disappear by 4 months of age

64 Tdap in pregnancy Aluminum is known to cross the placenta Adacel 1500 mcg aluminum Boostrix mcg aluminum There have been report of fetal harm with women using aluminum contain antacids long term (this was a much larger dose than that found in a vaccine) Gilbert-Barness E, Barness LA, Wolff J, Harding C. Aluminum toxicity. Arch Pediat Adolesc Med. 1998;152: Ideally get your booster BEFORE you get pregnant

65 What do I need to know about Rotavirus? Routine schedule Given at 2m, 4m, 6m, Virus Settles in the intestines Severe vomiting and diarrhea children die yearly due to dehydration Most severe in the first year of life There is no medication to treat the illness give fluids (IV if necessary)

66 Rotavirus risk factors Daycare!!! Easily spread in daycares due to resistance to antibacterial soaps

67 Rotavirus Frequency Is it common? 2 million people are hospitalized yearly for the disease ½ million Dr visits yearly for the disease Worst in late fall and winter By age 3 yo most kids will have had the virus once

68 Rotavirus vaccines RotaTeq 5 strains no aluminum

69 Rotavirus vaccine Adverse reactions Vaccine concerns; Viruses are whole and live, intended to create a small infection, live viruses are coming out of the diaper for 15 days after the first dose (10-50%) Concern with intussusception (concern with older version of vaccine)

70 Rotavirus vaccine Who should get it? High risk kids Daycare Older siblings Poor health

71 What do I need to know about Polio? Routine schedule given at 2m, 4m,18m, & 5yo What is it? Virus Most cases do not show any symptoms What is the concern? 1 in 250 cases muscle paralysis Maybe temporary but 2/3 have permanent muscle weakness Most often not fatal

72 Polio risk factors Breast feeding gives passive immunity A healthy GI tract is most likely protective If a child is traveling to a country where Polio is endemic then consider vaccinating.

73 Polio frequency Is it common? No No cases since 1985

74 Polio vaccines Best choice Ipol inactivated whole virus Ingredients - 2-phenoxyethanol, formaldehyde, neomycin, streptomycin, polymyxin B, monkey kidney cells, Eagle MEM modified medium, calf serum protein, Medium 199 Pediarix (in combo with hep B and DTaP) Pentacel (in combo with DTaP and HIB) No longer using live oral vaccine (can contaminate others or cause the disease in the recipient)

75 Polio protection by age and dose Highly effective in producing immunity >90% immune after 2 doses >99% immune after 3 doses Duration of immunity not know with certainty Breast feeding diminishes the child's immune response to the vaccine that s why 3 shots are given

76 Polio vaccine adverse reactions Previous live vaccine could cause polio or infect others (lots of problems!!) Pentacel contains 1500 mcg aluminum (more than the sum of its components separately 330 mcg) Minor local reaction redness and swelling SV40 and cancer SV40 is a virus found in the rhesus monkey kidney cells (how the virus was grown) that is a human carcinogen (causes cancer) Removed in 1990 s

77 Polio vaccine who should get it? Traveling out of the country Keep up healthy gut flora Breast feeding gives immunity Start vaccine after breastfeeding has stopped

78 What do I need to know about Flu Influenza? Routine schedule given at 6m, 12m, 18m, 2yo, 3yo, 4yo, etc.. What is it? Virus many strains Common cold symptoms Treatable with antiviral mediations if started in the first 48 hours What is the concern? Not usually serious 100,000 hospitalizations yearly usu in elderly 100 deaths yearly in children and young adults combined 1500 deaths yearly 90% in elderly May want to vaccinate family to protect those at risk

79 Flu frequency Is it common? VERY Millions of cases yearly

80 Flu Vaccines Best choice Flumist live virus for ages 5+ years can cause a flu infection Fluzone ages 6m and older. 25 mcg mercury in multi dose vials 0 mcg in single dose vial these were made in limited supply and difficult to find FluLaval ages 18 yo and older 25 mcg mercury Fluarix ages 18 years and older 1 microgram mercury Fluvirin ages 4 years and older trace amount mercury Flublok ages egg free Flucelvax grown on animal cells Package insert not known whether when given to pregnant women if it will cause fetal harm The influenza virus vaccine is an FDA pregnancy risk category C drug. The ability of Fluarix, Fluvirin, FluLaval, Afluria, or Fluzone to cause fetal harm or to affect reproductive capacity is unknown.

81 Flu - Pregnancy category C Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus."

82 Flu vaccine who should get it? Immuno-compromised people that need protection from other family members Consider carefully is you are pregnant

83 What do I need to know about Measles? M of MMR Routine schedule 1yo and 5yo What is it? Highly infectious virus Causes a fever, rash, runny nose and cough What is the concern? Many infected experience a milder disease but 19% require hospitalization 0.3% of cases are fatal CDC MMR information sheet -

84 Complications by age for reported measles cases, United States, Orenstein W A et al. J Infect Dis. 2004;189:S4-S by the Infectious Diseases Society of America

85 Measles risk factors Measles has an antibody that is transferred though the placenta and breast milk. - When a child stops breast feeding they are at increased risk Mothers have less antibody if they received the vaccine vs. having the disease Vitamin A deficiency and international travel are increased risk factors.

86 Vitamin A if you contract Measles The World Health Organization recommends vitamin A therapy for all children with measles - In countries with high measles mortality, treatment with vitamin A once daily for 2 days (200,000 IU for children 12 months of age or 100,000 IU for infants <12 months) is associated with an ~50% reduction in mortality. For hospitalized children <2 years old with measles in the United States, the American Academy of Pediatrics recommends a single dose of vitamin A (200,000 IU for children 12 months; 100,000 IU for those <12 months). J Infect Dis. (2004) 189 (supp 1): S4-S16

87 Measles frequency Is it common? NO??? (on the rise) Usually about 60 cases yearly, 189 in 2013 and 129 so far in cases in 2014 (jan-april) in California Often occurs people visiting a foreign country (Philippines) 1980s The majority of outbreaks occurred among middle, high, school and college student population As many as 95% of persons infected during these outbreaks had received one dose of the measles vaccine A second dose is now recommended for school age children

88 Measles vaccines Live virus Vaccines produce a mild non communicable infection

89 Measles protection by age and dose Antibodies develop in ~95% of children vaccinated at 12 months of age In ~98% of children vaccinated at 15 months of age Vaccine induced immunity appears to be long term but a booster seems to be needed

90 Measles vaccine adverse reactions Fever Rashes Thrombocytopenia (low platelet) within 2 months of the vaccine 1 in 30,000 Link to autism? Increased expression of IgE Possible link to rise in allergy and asthma

91 What should I know about Mumps? M #2 of MMR What is it? Virus Causes fever rash and swelling of the saliva glands in the cheeks What is the concern? Rarely infects the internal organs In adults rarely causes sterility No specific treatment is available

92 Mumps frequency Is it common? No 250 cases yearly in the US Can see higher rates in years of resurgence Many cases (97% in 2009) were in persons who had received 1-2 doses of the vaccine

93 Mumps protection by age and dose The first dose provides long-term protection (97%) Second doses of MMR are given because of the measles component (not because of the mumps or rubella components) Vaccine most effective when given after 16 months No effectiveness prior to 12 months of age Life long immunity

94 Mumps vaccine adverse reactions Very safe vaccine Most problems are due to the measles or rubella components

95 What do I need to know about Rubella? R of MMR What is it? Virus usually a mild childhood disease Fever rash and aching joints No specific treatment runs its course What is the concern? In pregnancy can infect the fetus and cause birth defects 4 babies born between with congenital rubella syndrome

96 Rubella risk factors A fetus is at risk of a pregnant woman who is not immune and contracts rubella

97 Rubella frequency Is it common? No Used to be 100,000 cases yearly 2005 CDC announced rubella eradicated in US

98 Rubella vaccine protection by age and dose 1st dosage provides long term immunity at least 15 years Second dose of MMR is given for the measles component (>95% immune after 1 st dose) Most effective when given after the age of 16 months

99 Rubella vaccine adverse reactions Do not vaccinate a breast feeding woman the infant may become infected Vaccine concerns; rare Do not give to people /infants with gelatin or egg allergies

100 MMR Vaccines Vaccine types MMR II measles, mumps and rubella Proquad MMR with chickenpox (insert states do not use tylenol at time of vaccination) Meruvax II (rubella alone no longer produced) Mumpsvax (mumps alone no longer produced Attenuvax (measles alone no longer produced)

101 What do I need to know about Chickenpox varicella? Routine schedule 1yo & 5yo Herpes virus - Causes fever and spots Not usually serious 1 in 65,000 cases is fatal More serious in those with compromised immune systems can cause birth defects if a pregnant woman contracts the disease in the first half of her pregnancy. Can be treated with acyclovir (antiviral medication if started within 72 hours of the rash appearance) In adults - reactivate to cause shingles (zoster)

102 Chickenpox frequency Is it common? Prior to 1990 and initiation of vaccine 3.5 million cases yearly 75-85% decrease since the vaccination began

103 Chickenpox vaccines Vaccine types Varivax live virus ProQuad (combined with MMR) I don t recommend, increased rates of high fever and febrile seizures better to give separately Zostavax (for adults only to prevent shingles) Do not give within 30 days of receiving MMR, increased risk of breakthrough chickenpox

104 Chickenpox vaccine adverse reactions Vaccine concerns; Unnecessary vaccine? Possible link to increased incidence of shingles in children? May make shingles in adults more likely Short lived immunity ~7 years, increased risk of dangers of adult chickenpox

105 Chickenpox vaccine who should get it? Adults and children 15 yo who did not get the disease Much more severe disease Immuno-compromised children Genetic disorder Disease Medical treatment 2 nd highest rate of death from chickenpox

106 What do I need to know about Hepatitis A? Routine schedule 12m &18m What is it? Virus Attacks the liver Most children do not have any symptoms What is the concern? Several weeks of illness Rarely will come and go for up to 6 months If underlying liver disease can suffer severe liver damage No specific treatment is available

107 Hepatitis A vaccines Vaccine types Vaqta mcg aluminum Havrix mcg aluminum Twinrix (combined with hep B for 18+years old)

108 Hepatitis A frequency Is it common? 10,000 cases yearly mostly kids age 5-14 yo

109 Hepatitis A adverse reactions Vaccine concerns; Recent addition to vaccine schedule (2006) Usually harmless disease in children

110 Travel Hepatitis A vaccine who should get it?

111 What do I need to know about Meningococcal? Standard schedule Receive at 12 yo Bacteria - Can cause meningitis What is the concern? Very serious illness - 10% are fatal 20% are fatal among teens and college age students (50 fatalities in 250 students contracting the disease) 15% of survivors have some permanent disability nerve damage or heating loss It is a treatable condition by IV antibiotics, but disease progresses VERY rapidly

112 Meningococcal frequency Is it common? 3000 cases yearly Most cases occur in infants 2 m to 2 years old, some in college freshman in dorms or men's military barracks

113 Meningococcal vaccines Vaccine types Menactra Menveo Menomune thimerasol in multi-dose vial

114 Meningococcal vaccine adverse reactions Vaccine concerns; Rare condition Guillian Barre Syndrome 19 cases reported in 2007 among adolescents

115 What do I need to know about HPV Human Papillo Virus? Standard schedule 3 doses starting at 12yo What is it? Virus Causes genital warts and cervical cancer Transmitted sexually What is the concern? Several strains can progress to cervical cancer If undiscovered can be fatal

116 HPV frequency Is it common? Very 80% of sexually active adults carry 1 or more strains of the virus Most common sexually transmitted infection 20 million people become infected with HPV yearly

117 HPV vaccine Vaccine types Gardasil aluminum Cerverix - aluminum

118 HPV adverse reactions Vaccine concerns; Only protects against the most common strains (6,11,16 &18) not ALL the strains. This protects for the stains causing 70% of cancers 225 mcg aluminum New vaccine may be slight increased risk of autoimmune disease Unsure how long it lasts at least 4 years This has become a VERY controversial vaccine 90% of HPV infections spontaneously resolve in 2 years Cervical cancer is very treatable if detected early

119 Travel considerations Yellow fever vaccine S America, sub Saharan Africa Typhoid vaccine Asia, Africa, C/S America Japanese encephalitis vaccine SE Asia, China, India, E Russia

120 Alternate schedule Dr Sears 2 month DTaP Rotavirus 3 months Pc, Hib 4 months DTaP, Rotavirus 5 months Pc, Hib 6 months DTap, Rotavirus 7 months Pc, Hib

121 Alternate schedule Dr Sears 9 month Polio, Flu (x2) 12 months Mumps Polio 15 months Pc Hib 18 months DTaP, chickenpox 21 months - Flu 2 years Rubella, Polio 2 ½ years Hep B, Hep A

122 Alternate schedule Dr Sears 3 years Hep B, Measles, Flu 3 1/2 years Hep B, Hep A 4 years DTaP, Polio, Flu 5 years MMR, Flu 6 years - Chickenpox 12 years Tdap, HPV 12 years 2 months - HPV 13 years HPV, Meningococcal

123 Select schedule Dr Sears 2 month DTaP Rotavirus 3 months Pc, Hib 4 months DTaP, Rotavirus 5 months Pc, Hib 6 months DTap, Rotavirus 7 months Pc, Hib

124 Select schedule Dr Sears 15 months Pc Hib 5 years tetanus booster 10 years Titers for MMR, chickenpox, hep A. Consider vaccination if not immune. Also consider 3 dose polio If travel to Africa or Asia is a possibility 11 years HPV (3 doses) 12 years Hep B (3 doses)

125 My current recommendations Parents with healthy children who want to; vaccinate early for the scary stuff, not do too many at one visit, minimize aluminum per visit, avoid mercury entirely, delay slightly to possibly avoid/minimize immune shift, delay much longer for vaccines of low/no risk diseases and avoid unnecessary vaccines

126 My current recommendations starting 4 m 4 months DTaP (Daptacel 330mcg aluminum) make sure to cocoon for pertussis before the baby's birth Ideally the mom was vaccinated against pertussis prior to pregnancy 5 months Hib* (ACTHib no aluminum) & Pc** (Prevnar mcg aluminum) 6 months DTaP 7 months Hib & Pc 8 months DTaP 9 months Hib & Pc 18 months Hib & Pc months DTaP 4-6 yo DTaP*** booster

127 **Notations for previous slide** *If you wait until 7 m for Hib you only need 2 doses then 18 m booster, at 12 m only 1 dose then 18 m booster and at 15 m 1 dose no booster. After 5 yo Hib is not needed **If you wait until 7 m for Pc you only need 2 doses then 18 m booster, at 12 m only 2 doses no booster, at 24 m 1 dose only ***this dose is not needed if the 4 th DTaP was administered at age 4 yo or older

128 My current recommendations cont Between age 5-12 yo consider polio (4 shots in series) to contribute to herd immunity Before school / to contribute to herd immunity consider MMR (2 shots in series) Separate MMR when available (if your pediatrician still has this available not likely maybe in Europe/Asia?) 12 yo varicella (1 shot) if they did not get the chickenpox (13 yo and older then need to get 2 in the series) Hep B when your child becomes a doctor Consider Hep A if you travel out of the country --- Still waiting on longer term safety/efficacy data on HPV vaccine ---

129 My current recommendations starting 12 m What if I wait until 12 months to start? 12 m Hib, Pc 13 m - DTaP 14 m Hib Pc 15 m DTaP 17 m run titers* for DTaP if necessary administer vaccine m run titer is previously neg for DTaP and administer if necessary 4-6 yo run titer for DTaP and administer if necessary *no evidence of a direct correlation between serum antibody titers for pertussis and disease protection other immunological mechanisms may be required for long lasting immunity (cellmediated)

130 My current recommendations starting 24 m What if I wait until 24 months to start? 24 m DTaP 25 m Pc, Hib 26 m run titer for DTaP if necessary administer vaccine 28 m if previously negative run titer for DTaP and if necessary administer vaccine m - if previously negative run titer for DTaP and if necessary administer vaccine 5-6 yo run titer for DTaP and administer if necessary

131 My current recommendations May consider starting at 2 m for children with risk factors Not breastfeeding Smoker in the house Daycare Health challenges Vector (someone from whom they may catch an infection) Another child age 4-10 yo Health care worker Teacher/educator

132 Titers Consider having your child s titers checked Many children will become immune even if they have not received the full course of vaccinations

133 Titers what to order Diptheria Diptheria antitoxoid antibodies Immune if >0.1 Tetanus Tetanus toxoid antibody Immune if >0.1 IU/ml Whooping cough Bordetella pertussis antibody IgG Immune if PT IgG >45 Unclear if this correlates with disease protection Measles rubeola antibody, IgG Immune if >1.09 Mumps Mumps antibodies IgG Immune if >1.09 Rubella - Rubella antibodies IgG Immune if >9 IU/ml Hib haemophilus influenzae B IgG Immune if >1 mcg/ml Pc Streptococcus pneumoniae IgG Antibody panel (14 serotypes) Immune depends on serotype Hepatitis B Hepatitis B surface antibody quantitative Immune if >10 miu/ml Chickenpox Varicella zoster antibody, IgG Immune if >1.09

134 What about pre-medicating? Parents often administer a pain reliever prior to the vaccination May mask symptoms May make vaccines more harmful NEVER give Tylenol!!!

135 How to safely immunize your child Separate vaccines in time Use thimerosal (mercury) free vaccines Use aluminum free or lowest aluminum vaccines

136 How to Safely Vaccinate Your Child Breast feed Never immunizing your child when they are sick, have diarrhea or on antibiotics Keep children on nutrient rich diets Minimize sugar and junk foods Minimize other chemical exposures Give before each vaccine Probiotics Vitamin A Zinc

137 I m choosing not to vaccinate what do I do? Make Immune Supportive Breast Milk Mother to consume the following Whey protein powder Contains Lactoferrin (I like Whey Cool by designs for health) Probiotics Helps Th1/Th2 response (I like HLC intensive by pharmax) Vitamin A 10,000 IU daily ( I like Klaire labs vitamin A drops) L Glutamine 5 grams daily Vitamin D dose to blood levels Dose to blood levels (I like orthomolecular vitamin D drops)

138 I m choosing not to vaccinate what do I do? Boost kid s Immune systems Probiotics (I like HLC Neonate) Vitamin D (I like Kid-D drops by orthomolecular) Zinc 10 mg infants and 20 mg in older kids Vitamin A Larch (I like Berry well by vital nutrients)

139 I m choosing not to vaccinate what do I do? Kids on nutrient rich diet NO SUGAR!!! Avoid exposure to disease Cocoon (taking one for the team) Stay at home with your child (if possible) Homeopathic vaccines (questionable efficacy)

140 Exemptions SB 277 Personal belief exemption Needs to be signed and on file by Jan Grade spans Infant through preschool Kindergarten through 6 th 7 th through 12th New law - California allows ONLY medical exemptions billnavclient.xhtml?bill_id= sb277

141 Vaccines required by SB 277 Diphtheria Hepatitis B Haemophilus influenzae type b Measles Mumps Pertussis (whooping cough) Poliomyelitis Rubella Tetanus Varicella (chickenpox) Any other disease deemed appropriate by the department

142 Vaccines Research vaccines and make informed choices Discuss concerns with your doctor Do not be intimidated by medical personal they are there to serve you You are the parent and you call the shots!

143 Koren Barrett ND Newport Integrative Health 1831 Orange Ave Ste A Costa Mesa CA (949) Website;