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.

 

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.

Vaccine Side Effects

It has been said that pro-vaxers (i.e. docs, especially pediatricians), always talk about vaccine benefits and rarely about side effects.  I agree!  So today I want to talk about some of the side effects most commonly encountered with the routine vaccines we give to children.

Overall I think the reason that we accentuate the positive with vaccines is for 2 reasons: time and odds.  Time is the biggest reason, at least for me.  In my usual 15 minutes for a well visit, I need to take a history, discuss concerns, examine my patient, show parents growth charts, discuss any abnormal findings, AND then talk about labs and vaccines that are due.  As we already give out a Vaccine Information Statement (aka VIS) that lists individual vaccine side effects with each vaccine, most docs, me included, are a little fast and loose with discussing vaccine side effects in detail unless a parent has specific questions.

Odds are a different story.  Doctors are trained in thinking about risk:benefit ratios, making choices that serve the greatest good, and taking a global perspective of a patient’s health.  This means (I hope) that we presume that a parent will share our perspective of, say, the value of receiving a measles, mumps and rubella vaccine despite the pain of vaccination, the chance of rash and fever, and the small possibility of more severe side effects such as a febrile seizure.

Some side effects of vaccination are common to almost all vaccines given, while some are particular to a certain vaccine or when certain vaccines are given together.  Also, due to how side effects are monitored, almost any symptom might occur after a vaccine, whether it was an actual side effect or just a coincidence.  Some definite side effects are very serious but also very rare, which makes the vaccine “worth” giving to people in general although horrible for those who experience the severe side effect (see “odds” above).

So in no particular order, here is my take on some vaccine side effects.

Side effects of most most or all vaccines:

Pain: ok, I know this is obvious, but it’s also by far the biggest factor for all young children and lots of older ones as well.  Any injection is likely to cause pain although some kids seem not to care very much, even after the shot has been given.  Pain is most commonly present for up to a day or two after vaccination, at the site of the injection.  Pain meds like acetaminophen and/or ibuprofen work well.  If one is averse to medication, an ice pack can help.

Fever: also a biggie; timing varies by vaccine but commonly one should expect a fever in the 1-3 days following most vaccines.  The big exception is the measles vaccine (either MMR or MMRV), which can cause fever starting anywhere from 5-12 days after vaccination and can last several days from then.  Just like with pain, normally the best treatment for this is acetaminophen and/or ibuprofen.  Also you can consider cool cloths draped onto your child.  Do not try to put a child with a fever into a cold bath, because if he/she does have a febrile seizure (see below) that is the last place you want him or her to be, at risk for hitting the head or inhaling  bath water or both.

Fussiness: many children are more fussy in the day or two after a vaccine; often it is hard to tell if this is due to fever or pain or the vaccine itself

Rash: common after MMR and varicella (aka chickenpox) vaccines or the two combined as MMRV, rash usually happens in a similar time period as fever. There’s not much to do about it unless it itches, in which case a topical anti-itch medicine or moisturizing lotion may help.

 

 

More uncommon side effects:

Febrile seizure: this is an uncommon side effect but one that can occur after vaccination.  Febrile seizures usually occur as a child’s temperature is rising, and the is usually not any warning beforehand.  They are most common in children from 6 months to 5 or 6 years old, which is also an age range when lots of vaccines are given.  Thankfully, febrile seizures are usually very brief (under a minute) and almost always stop on their own.  If this occurs, after making sure the child is in a safe place (safe from falls, sharp objects and other dangers) you should call you child’s doctor but there is usually not much to do as the seizure is usually over before you reach anyone.  Of course, a prolonged seizure should prompt a call for an ambulance.  See below for a reference about this.  *It has been found that in 12-15 month olds, febrile seizures are more common when the MMR and varicella vaccines are given at the same time, so many doctors give them at different visits, say one at 12 months and the other at 15 months old.

 

Fainting: fainting, if it occurs, is most common in the 10-30 minutes right after a vaccination.  It seems to happen much more commonly with teens than with younger children.  The biggest worries are getting injured during a fall, especially head injuries.  Some people are prone to faint after vaccines, so with them a period of waiting while sitting down for 15 or 20 minutes after being vaccinated is advised.

 

A rare one but a big deal:

Guilian-Barre Syndrome: this is a rare but serious condition that usually occurs after infections but can also rarely occur after influenza vaccination.  It is a rapidly worsening tingling of nerves and weakness of muscles and can be life-threatening for some.  Again, rare but very serious.  People with a history of GBS are not given flu vaccine.

 

Whew!  That is a quick summary of some more common vaccine side effects.  There are many more as well, feel free to comment if you like.

 

 

This reference on measles-contains vaccines is from the CDC; it’s long but pretty comprehensive; with an excerpt below:

https://www.cdc.gov/mmwr/preview/mmwrhtml/00046738.htm

The following recommendations concerning adverse events associated with measles vaccination update those applicable sections in “Measles Prevention: Recommendations of the Immunization Practices Advisory Committee” (MMWR 1989; 38{No. S-9}), and they apply regardless of whether the vaccine is administered as a single antigen or as a component of measles-rubella (MR) or measles-mumps-rubella (MMR) vaccine. Information concerning adverse events associated with the mumps component of MMR vaccine is reviewed later in this document (see Mumps Prevention), and information concerning the rubella component is located in the previously published ACIP statement for rubella (18).

Side Effects and Adverse Reactions

More than 240 million doses of measles vaccine were distributed in the United States from 1963 through 1993. The vaccine has an excellent record of safety. From 5% to 15% of vaccinees may develop a temperature of greater than or equal to 103 F ( greater than or equal to 39.4 C) beginning 5-12 days after vaccination and usually lasting several days (19). Most persons with fever are otherwise asymptomatic. Transient rashes have been reported for approximately 5% of vaccinees. Central nervous system (CNS) conditions, including encephalitis and encephalopathy, have been reported with a frequency of less than one per million doses administered. The incidence of encephalitis or encephalopathy after measles vaccination of healthy children is lower than the observed incidence of encephalitis of unknown etiology. This finding suggests that the reported severe neurologic disorders temporally associated with measles vaccination were not caused by the vaccine. These adverse events should be anticipated only in susceptible vaccinees and do not appear to be age-related. After revaccination, most reactions should be expected to occur only among the small proportion of persons who failed to respond to the first dose. Personal and Family History of Convulsions

As with the administration of any agent that can produce fever, some children may have a febrile seizure. Although children with a personal or family history of seizures are at increased risk for developing idiopathic epilepsy, febrile seizures following vaccinations do not in themselves increase the probability of subsequent epilepsy or other neurologic disorders. Most convulsions following measles vaccination are simple febrile seizures, and they affect children without known risk factors.

An increased risk of these convulsions may occur among children with a prior history of convulsions or those with a history of convulsions in first-degree family members (i.e., siblings or parents) (20). Although the precise risk cannot be determined, it appears to be low.

Influenza – almost gone but back again soon

Flu shot poster

This is a piece on obtaining flu vaccines in pharmacies and other non-physician’s office locations.  As you can see, I’m in favor…

This year’s influenza season was a long and hard one. We had a longer season with more complications and more hospitalizations than usual. As we are just about finished with flu this time around, one looks back and wonders why. Doctors always complain that too few people get vaccinated and that too many patients call for antivirals (like Tamiflu) at the first sign of a respiratory infection. Patients are unhappy that it’s so hard to get to see their doctor on short notice, whether they are sick or trying to prevent an illness.
Some numbers: each year about 30,000 people in the U.S. die from influenza or its complications. These are usually the very old or the very young, and often those with heart, lung, or immune system conditions. Many more get sick and miss work or school. By early November 2017, less than 40% of U.S. infants, children and adults had received a flu vaccine, which was in line with recent years. Finally, in the past 10 years, the effectiveness of the influenza vaccine has ranged from 37 to 60% according to the CDC. As it is always hard to estimate this until a season is over or close to over, let’s agree on an average 50% vaccine effectiveness against “real” influenza (not against colds and stomach viruses). This means that for every 2 people who get the vaccine, one will not get the flu (and the other person will) if they are exposed. To get this 50% benefit, you have to: make an appointment with your doctor, likely miss some work, show up (although you may have to wait anyway), and get a shot, unless you qualify for a nasal spray. Or you could go to CVS, Walgreen or one of the many other places that offer flu vaccines. These are called retail clinics, or what I like to call quick-serve healthcare and immunization providers, or Q-SHIPs. Here, you still get your shot or spray, but it’s on your own time, and likely will still be covered by your health insurance. Some lucky employees may even have flu vaccine provided by their workplace.

Docs much prefer that patients get vaccinated. Why? First, it works on our schedules and we get paid (a little) to provide the service. Second, given the duration of illness of about a week, there is no question that preventing flu with a vaccine costs much less that treating it with medication or missing work, or both. Also, the flu vaccine is very good at preventing severe illness, and vaccinating people helps to prevent epidemic outbreaks in places where people congregate, such as at school, work, daycare, nursing homes, hospitals, etc.

On the other hand, patients often prefer the “I’ll take the risk” approach. Why? First, the patient decision-makers are usually adults, and they are often employed. This means that scheduling a visit to a doctor’s office usually involves missing work. So even if the vaccination is free, there is an opportunity cost associated with lost work or vacation time. Second, the effectiveness of about 50% leaves a lot of people underwhelmed. Also, many people who get vaccinated may later get a seasonal cold virus, which flu vaccine does NOT prevent. This may lead one to presume that the vaccine didn’t work for them. Also, many otherwise healthy adults feel that medication can be used instead, IF they get sick, and this can often be gotten over the phone, without the pain, time or expense of vaccination. Although the cost of a course of an antiviral for influenza may be hundreds of dollars, an insured patient’s much lower copay insulates them from this cost, so that medication costs are a tiny consideration for many. Of course, all those who got vaccinated and don’t get sick don’t really know if this was due to vaccination or just luck. Due to these issues, overall many patients feel that the value they get from a flu vaccine is low. When a busy doctor looks at it from the busy patient point of view, it makes sense.

So how to meet in the middle? A few simple suggestions to reduce the pain for everyone, both literally and figuratively:
1. Many pediatric offices offer flu vaccines on weekends. Offices serving adults should consider doing the same.
2. Medical offices should offer flu vaccines at ALL appointments to ALL patients during flu vaccination season (August through May). Vaccinating today means that your patient need not come through the office again for a vaccination visit this season.
3. Patients should accept this offer of vaccination if possible (and no, August is not too early).
4. Medical offices should use the nasal spray influenza vaccine when possible. This was not used for the past 2 years due to effectiveness issues, but it has been placed on the list of likely vaccines for the upcoming 2018-2019 season. It is approved for use in people from 2 to 49 years old.
5. Doctors should encourage patients to use Q-SHIPS, and should work to get documentation of their vaccination. Rather than worry about lost business, we should be HAPPY when a patient receives a vaccine at CVS or another pharmacy – it preserves office supply for others who will need it. Instead of worrying that business is going elsewhere, seek more of these partnerships and make sure that you have a system in place to document the vaccination. Remember, in the end the goal is more vaccinated patients and less influenza along with its complications.

 

 

Mumps Booster for College?

mumps neck swelling CDC

Photo above: a child with mumps (with swelling of the parotid glands in the neck)

 

There has been a lot of press in the vaccine community about recent outbreaks of mumps on college campuses.  This caused a debate over whether students should receive a booster of MMR vaccine prior to starting college.

The Facts:

1. In the U.S. children receive MMR vaccine routinely at 12-15 months old and again at 4-6 years old.

2. By college age most people are still protected (but not everyone).

3. Outbreaks of mumps are uncommon but they do happen.

4. Current CDC recommendation is to consider an MMR booster in people at high risk of exposure to mumps in consultation with local health authorities.  **This means that a graduating high school senior will NOT routinely need an MMR booster but it may be recommended if her/his college experiences an outbreak.  This vaccination would likely happen on campus.  This would be safe and would make sense.

5. Given medical privacy rules and the fact that most college students are over 18, families may or may not be notified of an event such as this (just like the fact that you will normally not get a copy of your child’s grades directly from the school).

Any thoughts???


Usual Pediatric Schedule:

  • 1st dose (as part of MMR vaccine) at 12-15 months old
  • 2nd dose (as part of MMR vaccine) at 4-6 years old

Vaccines and other Pediatric topics (but mostly vaccines)

 

Stethoscope graphic

Hi all – this is my first post on my new blog!  Will be adding something of substance in the next few days.  Hopefully everyone who finds their way here will either leave with new information, or (even better) leave something for the rest of us.

Marc Grella