Australia set to ‘eliminate’ cervical cancer by 2028

Australia has just announced that it is on track to banish cervical cancer (caused by human papilloma virus infection) in the next 10 years!  As you likely know, this is the virus that causes most cases of cervical cancer, genital warts, anal cancers and many head and neck cancers.  You may also know that although we have had the same vaccines and screening tests for a while, in the U.S. our vaccination rates are dismally low compared with some other countries.  Not only will Australia save many lives and prevent many surgeries with this milestone, it will also save tremendous amounts of money on having to care for these illnesses.  Here’s the link:

 

AUSTRALIA IS A VACCINATION ROCK-STAR!

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Vaccines for Pregnancy (not strictly a pediatric topic)

For pregnant women, there are a number of vaccines to be thinking about during the pregnancy which can help protect your baby.   Although this is always at your pregnancy provider’s discretion, the most common vaccines to be talking about  would be influenza (especially from September through May), Tdap and (maybe) MMR.

  • Influenza vaccination is considered very important to receive if you will be delivering between September and June.  Pregnant women who get influenza have higher rates of premature labor and of influenza complications.  Just as importantly, some antibodies (immune proteins) are passed through the placenta to the fetus, helping to protect your baby from influenza after birth while he or she is still too young to get a flu vaccine. Also recommended for partners and others who will be spending a lot of time around the baby, such as family members (this concept is known as “cocooning” or surrounding the baby within a web of protected people to decrease possible infection).  Normally given once annually, September through April or May.

 

  • Tdap (tetanus, diphtheria and pertussis) vaccine is given to help to protect you and your baby from pertussis.  In adults, pertussis can cause a high fever and prolonged cough; in newborns the respiratory infection can be fatal.  As above, also recommended for partners and others who will be spending a lot of time around the baby, such as family members.  Given to pregnant women during the third trimester of EACH pregnancy; for all other adults, given only once.

 

  • MMR (measles, mumps and rubella) vaccine is actually not given during pregnancy but sometimes is given after delivery.  During pregnancy women are tested for immunity to rubella, since contracting rubella during pregnancy may lead to congenital rubella syndrome in infants, characterized by cataracts, heart disease, hearing problems, and developmental delays.  This is now rare in the U.S. due to universal vaccination of children at 1 and 4 years old.  However, if a woman is found to be “non-immune” to rubella during pregnancy, the standard is for her to receive MMR vaccine right after delivery to prevent possible infection during future pregnancies.  Given after delivery if not found to be immune during prenatal testing.

Has your child gotten a flu vaccine yet? Which one?

Let’s see which vaccine kids are getting and why.

Hi all – it’s September, which is the unofficial start of flu vaccine season!

Since this year we have flu vaccine choices again (shot or nasal spray), and different recommendations from different organizations (i.e. CDC and AAP), I wanted to survey people to see what their docs recommend and what their child(ren) receive.  With FluMist (nasal spray influenza vaccine) back on the scene but no data on its effectiveness until December 2018 at the earliest, this will be an interesting flu season.

Please use the comments box below to let us know.  I will tally results every week or so and post here, so check back for updates.

Remember, it is very important to have your child vaccinated, whichever method you choose.  Earlier is better, so just do it!

Also, if you are pregnant, please get a flu vaccine ASAP (although I’m sure your obstetrician or nurse midwife is already on top of this).  Also any partners or others who will be spending significant time with your baby (i.e. grandparents) should receive one as well.

 

Lead in Our Schools (ok, not a vaccine topic)

In the past few years there have been lots of reports of large cities finding lead in their drinking water.  Of course, Flint, MI comes to mind, and they are STILL working on that, but with the new school year come more reports about schools finding high levels of lead in their water fountains.  This necessitates turning off the water fountains and bringing in bottled water for students and faculty to drink (which, aside from being very expensive, is a landfill nightmare if they are using disposable plastic water bottles).

Here’s a story from this week’s Wall Street Journal and here’s another from last week.

Older pipes are much more likely to be lined with lead, and lead was also used to solder pipes together in the past.  This is why older cities with older building and older water supplies bear much of the lead burden (it is similar in homes with lead paint: old house=lead hazard).  Lead is a heavy, durable metal, which was used in the past in plumbing, paint, even fishing (in fact, lead “sinkers” are still made and sold).  When the problem in Flint emerged, it was discovered that officials making critically important decisions about water sourcing were well-informed about budgets, but not about the science of preventing lead leaching out of older pipes.  Since city water mains are very large and very buried, they are tremendously difficult and expensive to replace.  Luckily, most districts probably have water that is safe, and also luckily, most problems with lead in older city buildings come from water in the pipes within the buildings, not in the water mains under streets and highways, so the fixes are a little easier.  But you don’t know about any building unless you take the time and trouble to find out.

Part of the problem is that there is no federally mandated testing of schools, although some states require periodic testing.  Less than half of school districts in the U.S. reported testing their water for lead in the last 2 years.  The EPA (already a very leadership-challenged agency, as you may know) recommends testing and also recommends maximum safe cutoff levels of 20 parts per billion (or ppb), but there are no mandates and so school districts are left to create policies on their own.  Unfortunately, this is not what school officials are expert in, so everyone does things differently, and many, many districts are not even testing.  In fact, the recommended maximum lead level of 20 ppb was set over 20 years ago – and since then the recommended “action level” for lead in blood tests done on very young children has been lowered twice, without any changes to the recommended maximum levels found in school drinking water.  Lead is known to be toxic to humans at any level, and can affect most organs and body systems.  Some of its most dangerous effects are on the developing brain, especially in infants and young children.

I think this should be seen as a public health emergency – the fact that we are not seeing higher lead levels in many older children due to aging pipes in schools and home is because many children are not tested for lead after they become toddlers or preschoolers.  We would not accept this level of municipal neglect in our home drinking water (again, see Flint), so why is it ok in our schools?  As parents of children in school, we should be thrilled when our children make a choice to drink water from a water fountain, which is cheap, healthy, and environmentally thoughtful.  Parents should demand that their school districts both test the water in each school and make the results known to parents.  If levels are safe, great, but if not, we all need an action plan.

 

 

Varicella (Chickenpox) Vaccine

Many adults remember having had chickenpox as a child.  We considered it a mild disease, and everyone we knew got it as a young child.  Usually a whole family’s kids would get it in short order.  It was uncomfortable, but it passed pretty quickly and then you were done for life.  I remember having it on the way up to our summer house in upstate NY (complete with a potbelly stove for heat and an outhouse for the first few years until we installed a bathroom).

While all of this is mostly true, it misses some important details:

  • While most people have mild disease, about 1% of infected patients are hospitalized
  • About 1% of those hospitalized (or 1 in 10,000 patients who get it) die from a fatal complication
  • Immunocompromised patients (think newborns, cancer, chemo, the elderly, those on steroids) have high complication rates
  • Chickenpox in kids=home from school with a parent until the illness is gone
  • Now with less stay-at-home parents, 2 weeks at home with a sick child can cost a lot

The vaccine for varicella (chickenpox) was licensed in 1995.  Since then, we have seen varicella rates in the U.S. plummet, along with its complications.  It has also made life easier in pediatricians’ offices – children who have just developed the fever of chickenpox often have no other symptoms, and were commonly brought to the doctor to be checked (and often more than once).  Imagine all of those highly contagious children walking around newborns and sick children in our waiting rooms!

A lot of people were skeptical of the varicella vaccine at first, as many saw this as a “lifestyle” vaccine, not one that stopped serious illnesses, like polio.  In a way, that was true – although any fatalities are too awful to think about for the families affected, this vaccine was in part approved because it saved money: not money spent on medical care, but money in lost productivity (in terms of school and work missed).

Although this is one of the major vaccines that non-vaxxers object to (think “chicken pox parties”), the vaccine is safe and effective, and the series is completed in only 2 doses.  Since it is often combined wit MMR vaccine, children often get a 4-in-1 combo called MMRV.


U.S. Schedule

  • dose 1 at 12-15 months old (often combined with MMR as MMRV)
  • dose 2 at 4-6 years old (often combined with MMR as MMRV)

HPV Vaccine (updated 10-9-2018)

Gardasil

Today is HPV vaccine day!!  (I just decided it.)

I’m hoping to get to most of the vaccines commonly used in Pediatrics over time, but HPV vaccine is both an important and timely place to start.

Human papilloma virus is a scourge.  Previously felt to be only the cause of genital warts, it is now known to also cause the majority of cases of cervical cancer, most anal and penile cancers, and a large number of head and neck cancers.

Although treatments for HPV infection are only fairly effective, since 2006 we have had a licensed vaccine to prevent the most dangerous strains of HPV.  Initially, the vaccine covered either 2 or 4 strains of HPV.  In the past few years the vaccine has been improved and now prevents the 9 most commonly cancer-causing strains of HPV.

The basics:

-HPV vaccine, called Gardasil, which stands for “guard against squamous intraepithelial lesion”, the official designation of cervical precancer (yes, I know, terrible name – all drugmakers seem to have no talent for naming their products) is approved to use from ages 9-45 years old.

-Most doctors start giving it at age 11.

-If started at age 14 years or younger, a patient needs only 2 doses, at least 6 months apart.

-If started at age 15 or older one needs 3 doses, with at least 1 months  between the first 2 doses and with #3 given at least 6 months after #1.

-The vaccine is very safe and very effective.

-There is no link between getting HPV vaccine and initiating sexual activity, just like there is no link between getting a tetanus shot and playing with rusty nails.

Bottom line (literally): HPV vaccine is cancer prevention.

HPV vaccine has probably caused more discussion and controversy than any other vaccine after the MMR vaccine.  It seems to be inextricably tied up in an emotional battleground, with a lot of people scared both of the vaccine and of what its use means to them – the fact that their child will likely be intimate with other people in the future.  Whether parents who resist this vaccine do it on the basis of what they have read on the scaremonger websites, or whether they feel it goes against their religious beliefs to use it, or whether they just plain don’t want to think about this, our results in protecting our children from HPV are pretty dismal: only about 55% of boys and 65% of girls from 13-17 years old had received even a single dose.  This is FAR below every other routine pediatric vaccination used in the U.S.

The really painful part of this awful statistic is that HPV it not a disease of the young and  promiscuous; it takes women when they are in their 40s and 50s; when they may be wives, mothers, or grandmothers.  For those unlucky enough to develop cancers of the head and neck, many people need disfiguring surgery or worse.

Hepatitis B, which is also mainly spread by intimate contact, is also prevented by a highly effective vaccine.  This vaccine is given during infancy and has much better vaccination rates, with very little argument over its importance.  This is due in large part to the “Hep B message” being about preventing chronic liver disease and liver cancer, while the “HPV message” seems stuck on sex.


For my own patients and their parents: this is the part I told you about!!

In discussions in my office, I find that a lot of parents fall into 2 categories: those that know a lot about the HPV vaccine and want their child to get it, and those who are sure they do not want their child to get it before I even mention it.  Many of the second group are already dug in, but I’m wondering if we would have a different conversation if their child was not present, or if we had emailed about the issue prior to the appointment.  I say this because it seems that what many of these parents really don’t want is to be talking about their child and sex, especially in front of their 10- or 11-year old child.  I’m thinking that if this conversation came up in a coffee shop, not when we are all painfully pressed for time, the discussion might go a different way.   In the end, I think getting the HPV vaccine is REALLY important for your kids, of BOTH genders, and at the right age, not just “maybe next year”.  I don’t get anything out of your child’s vaccination except knowing that he or she is protected against a cancer that can be debilitating or worse.  Doctors do not get paid for giving vaccines, and we don’t collude with vaccine manufacturers to make sure they sell a lot of their products.

Now, I’m not suggesting that we all need to do a pre-physical-exam prep session at Starbucks, but in the end what a lot of people need most is information, delivered in a low-stress setting, with plenty of time for give and take.  I also happen to be a big fan of Starbucks and would love to have a session with a group of parents outside the office some time.  Any takers????


June 18, 2018: for more perspective on the marketing of vaccines, see this article from the medical/science/tech site STAT on the new, hipper approach that Gardasil’s maker (Merck) is using in its direct to consumer ads:

August 2018: a new CDC report indicates that by age 13-15 years, only half of U.S. teens have received the full series of HPV vaccines (either 2 or 3 doses, depending on age and immune system status).  Again, this is a vaccine, uniformly recommended and covered by insurance (as well as for the uninsured), without side effects on fertility, immune system function, or sexual activity/habits, that prevents multiple cancers (many of which have few or no symptoms until they spread), which are caused by a virus that most people WILL be exposed to in their lifetimes.  How does this add up???

October 9, 2018: Gardasil 9 now approved for men and women up to 45 years old!  The FDA announced on October 5 that it has approved an amendment to the labeling for Gardasil 9 to include older men and women, and now the vaccine can be given up until age 45.  This is a big deal because although we presume that most or all people are sexually active (and thus exposed to HPV) by their early 20s, this will allow uninfected people (who may be abstinent or not very sexually active) to receive protection until a much higher age.  Here’s the link:


Usual Pediatric Schedule:

  • 1st dose between 9 and 11 years old
  • 2nd dose 6-12 months later
  • If for some reason the series has not been started before age 15, a total of 3 doses are needed over a 6-12 month period)

Shingles Vaccine (This one’s for Parents and Grandparents; updated 8/2018)

Shingrix

Most of my posts will be about vaccines used in childhood, but there is an important one for many parents to be aware of that I’ve just become eligible for and many people are not yet clued into.  This is the newer version of the shingles vaccine.

What is it?

Shingles (i.e. zoster virus infection) is caused by the same virus that causes chickenpox in children, although we see a lot less of it now that there is an effective vaccine, available since the 1980s.

About varicella:

For most children, varicella is a mild but uncomfortable illness, causing fever, fatigue and blistering rash for most who still get it.  A small number of children are hospitalized for dehydration and a tiny number (about 1 in 10,000 of those infected) have a fatal complication.  Most of these fatal cases already have immune system problems before the infection develops.  Luckily, there is a very effective vaccine that almost all children get at 12-18 months old and again at 4-6 years old.  Receiving both doses of the vaccination is 88-98% effective in preventing any form of chickenpox and about 100% effective in preventing severe chickenpox.  It is routinely recommended and required for licensed daycare and school attendance, among other activities.

About shingles (hint: same virus but different symptoms in adults):

Once you get chickenpox, as most adults over 40 did as a child, the virus stays in your body but is kept dormant by your immune system.  As we age, our immune system slowly weakens and infectious conditions start to occur more easily.  Shingles is the condition that develops as the varicella-zoster (i.e. chickenpox) virus reactivates.  Initially one may have only severe pain, often in the abdominal region, chest or back.  Sometimes the pain may be so severe it is confused with appendicitis or a heart attack.  After several days, the pain improves but a rash develops in a particular pattern – it develops along the path of the sensory nerve that was harboring the virus for all those years.  The rash is most commonly red bumps and blisters, on only one side of the body, which can be painful, itchy or both.  The rash fades over time but the pain can be intense enough to need opiates.  After recovery, many people afterwards develop persistent pain, called post-herpetic neuralgia for months or years.  A family friend had this about 2 years ago and she still has fairly severe pain at times.

The older vaccine for adults (called Zostavax) was the same vaccine as we use to prevent chickenpox in children, only about 14 times stronger.  It was fairly effective and usually recommended for adults over 60.  For this reason, many people think of the shingles (or more properly the zoster) vaccine as a vaccine for the elderly.  Not true!!  The previous version was indeed generally recommended for those 60 and over but there is a newer, more effective version that is now recommended for adults age 50 and over (like my wife and me).  In fact, when given earlier, one has a more robust immune response, which means it works better when you receive it at a younger age.  The new vaccine is called “Shingrix” (ok, so no points for the name).  This is a new recommendation, so when calling your doctor’s office you may have to gently remind them that this is the new vaccine which is now given at a younger age (you can even send them the link below).  I strongly recommend this vaccine for all adults who are 50 and over.  It is safe and effective and should be covered by everyone’s medical insurance if they are over 50, even if they have already received Zostavax (the older version) in the past.

**Be aware, many doctors’ offices and retail pharmacies STILL do not have this in stock, even a year after its licensure.  I’m sure GSK (GlaxoSmithKlineBeecham) is doing everything in its power to increase their output, so hopefully it will not be long, but it would make sense to make a call to your doctor now, just to get onto a waiting list if possible.

See below for the excerpt from the CDC website at https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html

Here’s a post from the excellent blog Shotofprevention.com about needing this vaccine and how few adults are aware of it.

Summary of Recommendations

Routine Vaccination of People 50 Years Old and Older

CDC recommends Shingrix® (recombinant zoster vaccine) as preferred over Zostavax® (zoster vaccine live) for the prevention of herpes zoster (shingles) and related complications. CDC recommends two doses of Shingrix separated by 2 to 6 months for immunocompetent adults age 50 years and older:

CDC Expert Commentary with Medscape

Medscape video; Dr. Kathleen Dooling

Everything You Need to Know About Shingrix
[3:58 mins]
Dr. Kathleen Dooling discusses storage, administration, and patient counseling for the new shingles vaccine
Released: 4/30/18

  • Whether or not they report a prior episode of herpes zoster
  • Whether or not they report a prior dose of Zostavax
  • Who have chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease), unless a contraindication or precaution exists. Similar to Zostavax, Shingrix may be used for adults who are
    • are taking low-dose immunosuppressive therapy
    • are anticipating immunosuppression
    • have recovered from an immunocompromising illness
  • Who are getting other adult vaccines in the same doctor’s visit, including those routinely recommended for adults age 50 years and older, such as influenza and pneumococcal vaccines. The safety and efficacy of concomitant administration of two adjuvanted vaccines, such as Shingrix and Fluad, have not been evaluated.
  • It is not necessary to screen, either verbally or by laboratory serology, for evidence of prior varicella infection.

 

See this nice table from the CDC Website!

TABLE. Recommended storage, use, and administration of currently licensed herpes zoster (shingles) vaccines — United States, 2018Return to your place in the text
Characteristic Brand name (manufacturer)
Shingrix (GSK) Zostavax (Merck)
Vaccine type Recombinant adjuvanted (RZV, licensed 2017)* Live attenuated virus (ZVL, licensed 2006)
Packaging Supplied as 2 components: 1) single-dose vial of lyophilized varicella zoster virus glycoprotein E antigen and 2) a single-dose vial of AS01B adjuvant suspension Single-dose vial of lyophilized vaccine and a vial of sterile water diluent
Storage Antigen and adjuvant should be stored refrigerated between 2°C and 8°C (36°F and 46°F); discard antigen or adjuvant components if frozen; discard reconstituted vaccine if frozen Vaccine should be stored frozen between -50°C and -15°C (-58°F and +5°F),§ diluent should be stored separately at room temperature or refrigerated between 2° and 8°C (36°F and 46°F); do not freeze reconstituted vaccine
Reconstitution Reconstitute the lyophilized varicella zoster virus glycoprotein E antigen component with the accompanying AS01B adjuvant suspension component (single reconstituted dose is 0.5 mL) Reconstitute lyophilized vaccine with the supplied diluent (single reconstituted dose is 0.65 mL)
Use Administer immediately after reconstitution or refrigerate and use within 6 hours; discard reconstituted vaccine if not used within 6 hours Reconstitute immediately upon removal of vaccine from the freezer and administer immediately after reconstitution; discard reconstituted vaccine if not used within 30 minutes
Route Intramuscular (IM) injection Subcutaneous (SQ) injection
Dose/Schedule 2 doses; second dose 2–6 months after the first dose 1 dose
Indication Prevention of herpes zoster in adults aged ≥50 years Prevention of herpes zoster in adults aged ≥50 years
ACIP recommendation Immunocompetent adults aged ≥50 years, including those who previously received ZVL, RZV is preferred over ZVL for the prevention of herpes zoster and related complications Immunocompetent adults aged ≥60 years**

Abbreviations: ACIP = Advisory Committee on Immunization Practices, GSK = GlaxoSmithKline; RZV = recombinant zoster vaccine; ZVL = zoster vaccine live.