Vaccines: The Logic behind Alternative Vaccination
by Tara Zandvliet, MD
I have two main sayings in medicine: "Just because you can, doesn't mean you should", and "Everything is a medical intervention, so consider the consequences". I view vaccines the same way. I wouldn't do a tonsillectomy on every entering kindergartener (even though it would eliminate strep throat), nor would I vaccinate with a vaccine I don't feel they need. I think most parents are of the same mind. The confusion comes when we all believe the recommended schedule of vaccines put forth by the CDC and the AAP includes only the minimum vaccines truly needed. But the reality is that not all vaccines are created equal. Just like not all diseases are created equal. A cold is not Flu, and Chicken pox is not Measles.
The standard vaccine schedule is now being disputed by many pediatricians, including yours truly, because it recommends too many shots all at once, especially at the one year mark, which is when the measles vaccine (MMR) is first given. Historically, it was given alone at one year old. Rates of complications were low. When the schedule was changed - for parent convenience, not for any medical benefit - it changed that single shot to 6 different injections with 10 disease proteins all given at the same time. Side effects rose, mainly involving fevers, infections at the site, and seizures. Children with hyper immune systems, such as those with eczema or food allergies, do not handle that many shots well. Because of this, many pediatricians are advocating for a slower schedule. In my opinion, viewing the historical data, the MMR should only ever be given alone. As we see the news stories about the MMR being weaker and less effective and we see the call for booster shots, remember that its effectiveness was fine when we used to give it alone. No background chatter to dilute the immune response. This was also seen in the DTaP vaccine for whooping cough - Studies have shown it to be less effective since we moved it from 15 months down to 12 months for parent convenience.
Because of this, and because of the difference in importance of the different diseases involved, many parents have chosen to give the most important vaccines to their children one at a time, and to delay others that are not relevant until later. For example, they often do the classics - DTaP and MMR, but delay the Hepatitis B and Chicken pox vaccines until the teen years, when medically they become more of a risk. But even if they have most of these vaccines, the schools still require the exemption form if even only one is missing or delayed. So when you hear about a 20 % vaccine exemption form rate at your child's school, that doesn't mean that 20 % have had NO vaccines. Several years ago there was a shortage of the HIB vaccine, so the CDC recommended skipping the booster dose at 18 months. But 4 years later, those children entered kindergarten and the school required the shot. The disease is not a risk to that age group, but the schedule groups 1-6 year olds all together. Question: Do you give an unneeded shot because the school says so? Or do you have your doctor sign the exemption form because of that one missing shot and be labeled a "non-vaccinator".
No vaccine is ever "Perfectly safe", but in general, the vaccine is much safer than getting the disease. There are exceptions, but that is generally the case. Considering that, I feel all the vaccines have their place and have their time to be given. Below is how I generally view the vaccines.
DTaP - probably the most important vaccine for San Diego and especially for the first year of life. We have a high rate of Pertussis, and it is deadliest in the first year of life. Antibiotics can improve survival and prevent spread, but it does not stop the swelling in the lungs and the cough that can cause them to gasp for air. There are still deaths every year in San Diego and across the nation. This is a serious disease even for those over 1 year of age, and continues to plague children and adolescents with months of severe cough, gasping, and gagging. My daughter had it at age 10. I recognized it was a mild case, as she had been vaccinated and had the antibiotics, but it was still frightening to hear her gasp and gag and only be able to rub her back and hold a bowl. Doctors are fairly powerless against Pertussis, so the vaccine is our best defense. Diphtheria is extremely deadly, and it is important to have immunity as well, along with tetanus. Tetanus lives in the dirt, and infects wounds. What child never gets a skinned knee?
HIB - H. Flu is the bacteria this protects against, and it causes meningitis. It is most severe and deadly in the first 2 years of life, and tapers off by about 5. It can still cause walking pneumonia and ear infections after that age, but is not usually deadly. Very important as an infant vaccine. Don't bother giving after age 4.
PCV - Strep Pneumonia is the bacteria, and there are many strains. It causes severe pneumonia and Meningitis. Every 7-10 years, they will mutate and evade the protection of the vaccine, but for those first years, the vaccine is very effective in protecting infants and children up to about 10 years old. Important as a childhood vaccine.
Rotavirus - severe diarrhea illness that can dehydrate an infant in fewer than 4 hours! The children get lethargic and won't drink, and they can die if not hydrated by IV quickly. It is the Cholera or Dysentery of San Diego. This version of the vaccine is very safe now, and it is considered important up to about 1 year of age. After that, children get very ill with 7-10 days of diarrhea, but are not likely to die of it. Important as an infant vaccine. Don't bother with a vaccine after they are 8 months old.
MMR - Measles is a deadly disease causing rash that can infect the brain and cause pneumonia. 1 out of 1000 dies. No treatment. The vaccine is extremely important now that there is an upswing in cases in the US. Given at 12-14 months or after 2 years. Boost needed at 4-6 years old, but you can do a blood test to see if the first one was fully protective. Mumps causes infection of the glands, especially around the face and the salivary glands. Can cause meningitis and sterility in boys. Rubella is not dangerous to children, but can cause miscarriage, stillbirth, deafness and mental retardation if a pregnant mother gets it.
Hepatitis B - causes severe liver infection and death especially in young children. It is passed through body fluids, like saliva, and blood. It is mainly transmitted in the US through bites, sex, birth, blood transfusions, and drug use involving needles. In the past, we did this at birth because there was not a way to test all mothers giving birth. We gave it to all newborns because we didn't know which ones were at risk. Now we test all mothers, so we know who needs it. This vaccine is still on the schedule for birth, with 2 more in infancy. I feel this is not needed until they are at risk of being bitten - like at daycare with toddlers - or as a teen. If you test negative for Hepatitis B, then you can choose to do the standard schedule or you can do them at 2 years old or as a teen.
Hepatitis A - causes severe liver infection. It is spread by contaminated food. We have had outbreaks recently in washed lettuce, frozen berries, and seafood. The key is to wash all your own raw food. For example, if you buy prewashed spinach, wash it again. If you use frozen berries for smoothies, wash them before you put them into the blender. And get vaccinated. I saw a 5 year old that got it from eating salad in a restaurant years ago, and he needed a liver transplant. He survived about 4 years after that, but 9 is too young to die. This is scheduled at 1 year old, but kids are not usually at risk until they are eating raw food their parents didn't wash, like salads at a restaurant, or smoothies at the juice place. It could be delayed until 2 years old.
Polio - bad diarrhea disease that can paralyze. Often the paralysis involves the breathing muscles as well, and the child then needs a respirator forever (in the past, they were in Iron Lungs) Very important vaccine. However it is eradicated in the US for now, and in most of Western Europe and Canada, so it may be considered a travel vaccine, like Yellow Fever. The vaccine is much safer now that it is an injection and not live, but it does not prevent the infection, only the paralysis. So, some of "Montezuma's Revenge" traveler's diarrhea may actually be Polio. But as long as the paralysis is prevented, the disease is not life threatening. Currently on the schedule to be given at 2, 4, and 6 months old, may be delayed until travel.
Chicken Pox (Varicella) - common childhood rash, causes a lot of discomfort and lost school and work days. Can be deadly if the skin gets infected with staph or after the age of 14, when it can infect the lungs and brain and cause death. Even then, not that deadly. Currently on the schedule for 1 year old. Because the disease is not very deadly until adulthood, I feel this can be delayed until the teen years, if the child has not had regular chicken pox by then. A very interesting fact is that this vaccine may have eliminated a natural immunity boost against Shingles. The virus of chicken pox stays in your body forever, and that includes the virus from the vaccine. It can come out along a nerve, causing blisters and severe pain as Shingles later in life, traditionally when you were old or immune suppressed, like with a lot of stress. Recently we have had a rise in Shingles, with cases being very young - 30 and 40 year olds instead of 60 and 70 year olds. They have developed a shingles vaccine because of it. It appears as though the presence of chicken pox in our communities - lots of kids with early contagious chicken pox at the schools, libraries, Wal-mart and restaurants - actually boosted our immune systems to keep the virus hidden away, thus preventing shingles. In this manner, parents were "immunized" by their children with chicken pox, and grandparents were "immunized" by their grandchildren they cared for while their parents went to work. Only the very old were not exposed much, as they did not leave home much, and so lost their immune control of the virus and got shingles. Without children getting chicken pox, parents and grandparents are now getting shingles. One vaccine created the need for another vaccine.
Meningococcal - important for adolescents. Causes a meningitis with a rash that is so deadly the teen could die within 4 hours of the spots showing up. Highest risk is those in close quarters, like a boarding school, dormitories, camp, college and the military.
HPV - The first vaccine that can prevent cancer! Cervical cancer is mainly caused by the HPV virus. A healthy body can usually fight it off and cure itself. If there is a decrease in the immune system, it can then cause abnormalities in the cells of the cervix, and causes a slow progression to cancer, averaging 5-7 years for it to become a cancer. Pap smears detect it and can catch it early, even before it is a cancer. 87% of women clear it without help. The vaccine is to catch the other 13%. Since this is a sexually transmitted virus, and almost all women who are or become sexually active will contract the virus, it is recommended for all girls starting at age 9. I think this is a little young. I like the conversation that it opens up when they are a little older - about sex, protection, abstinence, good nutrition and caring for yourself with sleep and stress management to boost the immune system, etc. This is a very personal choice for families. Many feel they are strong enough to fight it off. Many don't want to worry about getting pap smears. I think it is important for some girls and women. It is now recommended for boys, since they transmit to the girls, but I feel this is overstepping the parameters of the vaccine.
One last important point: Unvaccinated children are really only a risk to other unvaccinated children, and only if ill. If you or your children have had your vaccines, rest easy.