What's New This Flu Season

Flu vaccines are already available at many retail pharmacy locations, though the flu season typically startts on October 1st. 

The nasal spray flu vaccine is not recommended this year, much to the dismay of many children over the age of 2. Mine, included. 

Leaving the Anti-Vaccine Movement

The anti-vaccine movement had me in its grips after the early birth of my first child In 2008. My son's lungs were not fully developed, and he needed the NICU. My husband and I had signed up for a "natural" childbirth class where epidurals were evil and rupture of membranes did not mean go to the hospital. We were also told to forgo the hepatitis B vaccine for our newborns because "babies don't have sex or do illicit drugs by injection." I am a hospital pharmacist and was falling for it all.

Jenny McCarthy and Dr. Andrew Wakefield were regularly in the news for the connection between vaccines and autism, and I was fearful for my son. After all, Dr Wakefield was a physician with a research paper in support of the connection between vaccines and autism. Also it was a little bit popular to be anti-vax.

Herd immunity is a form of immunity that results when the vaccination of a significant portion of the population provides a measure of protection for those who have not developed immunity. Herd immunity disrupts normal transmission of diseases covered by vaccination. The anti-vax movement directly compromises this immunity resulting in less people becoming vaccinated and increases in diseases that were virtually eradicated.

Measles is on the rise. Dr. Mark Grabowsky, a health official with the United Nations, wrote last year in the Journal of the American Medical Association-Pediatrics. “Many measles outbreaks can be traced to people refusing to be vaccinated; a recent large measles outbreak was attributable to a church advocating the refusal of measles vaccination.” Measles was once considered eradicated. For every 1,000 children who get the measles, one or two will die from it, and one will get brain swelling so severe it can lead to convulsions and leave the child deaf or mentally impaired, the U.S. Centers for Disease Control and Prevention said. In contrast the fears parents have to vaccinate in relation to autism and MMR according to the Wakefield study continues to rise even though the study was proven false. Wakefield was stripped of his license to practice medicine, and numerous conflicts of interest surrounding the study were discovered. Once upon a time before vaccinations, nearly everyone in the U.S. got measles before there was a vaccine, and hundreds died from it each year. Today, most doctors have never seen a case of measles, but cases keep popping up, the latest starting in Disneyland.

Still the anti-vax movement continues. 

Mumps have also made a comeback. Before widespread vaccination, there were about 200,000 cases of mumps and 20 to 30 deaths reported each year in the USA. Mumps can in some cases lead to encephalitis and deafness. Herd immunity is important because the mumps vaccine is just 88% effective, explaining why someone can easily contract the disease even if they have been vaccinated as I did back in 9th grade from a foreign exchange student. I was vaccinated, but for whatever reason was infected from someone overseas. The CDC reports that the number of mumps cases doubled in the past year - affecting more than 1,000 people nationwide.

Mumps in the United States from 1970-2005

Mumps in the United States from 1980-2005

Pertussis or whooping cough was a universal disease in the pre-vaccination era was almost always seen in children. Between 1940 and 1945, before widespread vaccination, as many as 147,000 cases of pertussis were reported in the USA each year, with approximately 8,000 deaths caused by the disease. It is estimated that at the beginning of the 20th century as many as 5 of every 1000 children born in the USA died from pertussis.

Pertussis in the US from 1940-2000

Pertussis in the US from 1980-2005 (on the rise)

Why don't parents vaccinate today? Parents today did not grow up with these diseases and see the thousands of children die. We are not afraid of these diseases because they have not been a part of our lives and take for granted how these diseases can cause death or severe consequences. Parents hear celebrities like Jenny McCarthy, Alicia Silverstone and Kristin Cavallari cite fear as a reason not to vaccinate. But what many don't realize is that those against vaccines and not vaccinating their children depend on the rest of us to vaccinate to stay safe. The more people that join in the crusade that vaccines are evil, the higher the risk their own children will succumb to diseases that were virtually gone just a few years ago. 

Side effects of vaccines are mild according to the CDC. And while there are very rare cases of vaccine-related issues, the benefit far outweighs the risk if you compare the numbers pre-vaccination era vs. after vaccinations were introduced.

Why should parents vaccinate? Parents should vaccinate because vaccines are preventing complications from preventable childhood illnesses that can cause deafness, blindness, hospitalization, other life altering effects and death. Parents should become informed and become critical thinkers about the decisions made to increase the risk of these diseases to their children and others who are unable to fight infection (elderly, immunodeficiencies, and the very young). Parents should not, as I did, make decisions by fear and paranoia and look at the facts. We should also as a society consider public health and realize that vaccines are safe and very effective and not vaccinating is irresponsible.

Fortunately, I woke up from the "anti-vax movement" before endangering my son further. Although his vaccines were spaced out individually and further apart, he ended up receiving them all. My daugther, on the other hand, received them all on time as outlined by the CDC. I do have much greater peace of mind knowing the numbers don't lie, vaccines save lives and have since they were first introduced years ago. I am glad I did not let the fear of the unknown and debunked guide my choices to put them in harm's way.

BCPS 2013: Vaccines

Vaccines:  the memorization of when and what and when not to if the patient has certain conditions.  Imagine questions that are simple but complicated.  For example, perhaps an age is given and you need to know what vaccinations were due by that age or if the child had never had vaccines what could be given as catch-up?  It is really not complicated and again if you are a parent this may be an easier topic if you are of the pro-vax crowd (as I am). Below see the schedule from the CDC that is also approved by the American Pediatric Association along with the recommended schedule for catching up on vaccines if missed.

Special Population Considerations

1. Preterm infants

• Immunize on the basis of chronologic age.
• Do not reduce vaccine doses.
• If birth weight is less than 2 kg, delay HepB vaccine because of reduced immune response until the patient is 30 days old or at hospital discharge if it occurs before 30 days of age (unless the mother is positive for HepB surface antigen).

2. Children who are immunocompromised

• No live vaccines
• Inactivated vaccines and immune globulins are appropriate
• Household contacts should not receive oral polio vaccine
• MMR, influenza, varicella, and rotavirus vaccines are recommended

3. Patients receiving corticosteroids

a. Live vaccines may be administered to patients receiving the following:

• Topical corticosteroids
• Physiologic maintenance doses
• Low or moderate doses (less than 2 mg/kg/day of prednisone equivalent)

b. Live vaccines may be given immediately after discontinuation of high doses (2 mg/kg/day or more      of prednisone equivalent) of systemic steroids given for less than 14 days.

c. Live vaccines should be delayed at least 1 month after discontinuing high doses (2 mg/kg/day or more      of prednisone equivalent) of systemic steroids given for more than 14 days.

4.  HIV Positive Patients

a. MMR should be administered unless patient is severely immunocompromised. b. Varicella should be considered for asymptomatic or mildly symptomatic patients. c. Inactivated vaccines should be administered routinely.

BCPS 2013: Pediatrics

I feel I have a bit of insight into the test and can attest to what is needed to know in each section.  Keep in mind the guidelines could change between 2012 and 2013 along with the test questions, but for the most part I found the test to be incredibly fair though stressing areas more than others that I would have not expected. I want you to pass!  First attempt!

So what do you need to do to pass?  Start now.  I especially am talking to those with families and/or children and very little time to spare for sitting down and studying the traditional way.  Again, I did fail this past year, so I will disclose that immediately, but I do believe I have insight into the test and very much plan to pass it this fall.  It's a goal at this point for my own personal development.

So, ahead I will have some material presented that does come from the ACCP study material though reworded and simplified in more study form and perhaps some hints as to what was important on the test in each particular section.  I am hoping to not get in any sort of trouble by doing this as far as with the BPS, so if this is not appropriate, would someone from there contact me?  I do not plan on giving test questions per se' and I couldn't if I tried as there were far too many to memorize.

After two children I am convinced parts of my brain were delivered with the children as it is.

First up!  PEDIATRICS!

This was always the topic that would terrify me prior to having children, but at this point besides missing one of the most common concepts of children and the very small amount of data on the test regarding pediatrics (at least in my opinion), pediatrics just doesn't seem so daunting.

Know the common pathogens of children in sepsis and meningitis.

0–1 month  

• Group B streptococcus
• Escherichia coli
• Listeria monocytogenes
• Viral (e.g., herpes simplex virus)
• Coagulase-negative staphylococcus—nosocomial
• Gram (−) bacteria (e.g., Pseudomonas spp., Enterobacter spp.)
• nosocomial

1–3 months

• Neonatal pathogens (see above)
• Haemophilus influenzae type B
• Neisseria meningitidis
• Streptococcus pneumoniae

3 months–12 years

• H. influenzae type Ba
• N. meningitidis
• S. pneumoniae

> 12 years

• N. meningitidis
• S. pneumonia

Not to hard to figure out correct?  Keep in mind that H. flu is less and less due to immunizations.  I suppose if you live in an area where vaccination is the devil, you may find more of this organism.

Potential Antibiotic Regimens

Age                                                                         Regimen

0–1 month                                                            Ampicillin + gentamicin OR ampicillin + cefotaxime

1–3 months                                                          Ampicillin + cefotaxime/ceftriaxone

3 months–12 years                                             Ceftriaxone ± vancomycina

> 12 years                                                             Ceftriaxone ± vancomycina

**Addition of vancomycin should be based on the regional incidence of resistant S. pneumoniae.

Regimens for Chemoprophylaxis  (I will have to reformat this later)

Drug                      Neisseria meningitidis                                                                       Haemophilus influenzae

Rifampin            < 1 month old: 5 mg/kg/dose PO every 12 hours × 2 days                       20 mg/kg/dose (maximum 600 mg)

> 1 month old: 10 mg/kg/dose PO every 12 hours × 2 days                   daily x 4 days

Adults: 600 mg PO every 12 hours × 2 days

Ceftriaxone             < 15 years old: 125 mg IM × 1 dose                                                               Not indicated

> 15 years old: 250 mg IM × 1 dose

**Ciprofloxacin and azithromycin are possible alternatives although not routinely recommended.

RSV - Identify the drugs available for preventing and treating respiratory syncytial virus.

Prophylaxis

1. Nonpharmacologic: Avoid crowds during RSV season and conscientiously use good hand-washing practice.
2. RSV IVIG (RespiGam): No longer marketed in the United States (didn't see on the test ;))
3. Palivizumab (Synagis)

• a. Dosing: 15 mg/kg/dose intramuscularly; given monthly during RSV season
• b. Effects on outcomes

i. A 55% reduction in hospitalizations for RSV

ii. Safe in patients with cyanotic congenital heart disease

iii. No reduction in overall mortality

iv. Does not interfere with the response to vaccines

v. Not recommended for the prevention of nosocomial transmission of RSV

Know this:  Supportive care.  Treatment is supportive care only.

American Academy of Pediatrics Palivizumab approval:  (you WILL see this)

i. Premature infants born before 32 weeks’ gestation (i.e., 31 weeks, 6 days or earlier) who are 6 months old or younger at the beginning of RSV season

(a) Infants born at less than 28 weeks’ gestation may benefit up to 12 months of age.

(b) Eligible for a maximum of five doses of palivizumab during RSV season

ii. Infants with chronic lung disease who are 2 years or younger and who required medical management of their chronic lung disease in the previous 6 months – Eligible for a maximum of five doses of palivizumab during RSV season

iii. 32 and 35 weeks’ gestation (i.e., 32 weeks, 0 days through 34 weeks, 6 days) who are 3 months or younger at the beginning of RSV season

(a) With at least one of the following risk factors may benefit: infant attends childcare or sibling younger than 5 yo in same household

(b) Eligible for a maximum of three doses of palivizumab during RSV season

iv. Infants 24 months and younger with hemodynamically significant congenital heart disease

(a) Eligible for a maximum of five doses of palivizumab during RSV season

(b) There is a 58% decrease in palivizumab serum concentration after cardiopulmonary bypass; therefore, a postoperative dose of palivizumab is recommended as soon as the patient is medically stable.

v. Infants 12 months and younger with congenital abnormalities of the airway or neuromuscular disease that compromises the handling of respiratory tract secretions – Eligible for a maximum of five doses of palivizumab during RSV

Tomorrow will continue with otitis media...

Pertussis and New Recommendation

It is a well know fact that I support vaccinations. I become irritated when I think about the cases of pertussis that takes the life of an infant because herd immunity is losing its protection. These gaps allow these vaccine preventable diseases to find their way back into the general population. Just the other day on my Facebook wall, there was a comment from someone who is against vaccines. They were told their insurance would no longer cover well visits because she doesn't vaccinate her children. I believe this is the directions insurance companies will go. Vaccinate or no coverage. I do not agree with taking away choice. But truly, if we didn't need insurance and paid for our own healthcare (who does that?) we could make our own decisions.

The CDC now recommends that pregnant women get a dose of the Tdap every time they are pregnant rather than the one time booster if they had not previously received the vaccine. Dr. William Schaffner, who is the chair of the department of preventative medicine at Vanderbilt School of Medicine, suspects that a proportion of babies who die of Sudden Infant Death Syndrome are caused by pertussis.

Whooping Cough

So this is the year where the glorious United States reaches the highest levels of pertussis (whooping cough) in 50 years! Is that enough to stop the crazy anti acclimation rhetoric that continues to flow? Sadly, no. So far the CDC has recorded nearly 18,000 cases this year alone. Pertussis is caused by the bacteria Bordetella pertussis. It is highly contagious and spreads from person to person by coughing or sneezing. Young children are the highest at risk and can lead to death as it has with nine children this year.

It is preventable. So,please stop listening to Jenny McCarthy and protect your children!

Whooping Cough Reaching Record Levels

I remember how I felt about vaccines prior to becoming a mother. They were effective. They were needed. They saved lives. However, my thinking changed the first time I stared at my newborn son seconds after birth, and the reports of the possibility of a link between autism and vaccines and the higher rate in males vs females really challenged my thinking. I ran to the bookstore buying all of Dr. Sears' books, scoured the Internet for information, and joined forums where it was cool to be a home birthing, baby wearing, baby led weaning, crunchy, baby food making, raw milk drinking and cloth diapering momma. I suddenly felt like the worst mother in the world, and all my sense about science left as the prolactin levels rose.

I declined hepatitis B vaccine for my infant. Hell, he was not a IV drug user and wasn't having sex yet.

Over time, he is finally up-to-date, and my daughter received all as scheduled (though I did delay hepatitis B with her as well until she reached three months, I believe. I have definitely been more laid back this time. And I have also seen the stories of the prevalence of diseases previously almost eradicated making a huge comeback. Unfortunately herd immunity is only good if all subscribe. Sporadic cases are becoming more normal... and with that deaths.

Last month, Washington state had 640 confirmed cases of whooping cough (or pertussis) compared to only 94 in the same period last year.

The connection between autism and vaccines have never been confirmed. I cannot think of anything more responsible as a parent than getting your kids vaccinated. I guess you can say my thinking was challenged, but I have reached full circle.

Integrity is Lost in Wakefield

Hypothesis testing and the outcome, all part of the scientific process, shows integrity whether positive OR negative. In the Wakefield study, he focused his attention on 12 children who had been referred to for GI problems. Dr. Wakefield had already been toying with the idea of a connection between bowel problems and the MMR vaccine. At the same time Dr. Wakefield was paid to find out if children who had already had the MMR vaccine and a corresponding decline had a case. Some of these children were in both studies. That in itself is called "conflict of interest." Dr. Wakefield did admit that more research was needed but that he insisted on the MMR being administered individually rather than the 3-in-1 jab. Today, this study has been retracted as an elaborate fraud with Dr. Wakefield vehemently denying such an accusation. The British medical journal BMJ, which published the results of its investigation, concluded Dr. Andrew Wakefield misrepresented or altered the medical histories of all 12 of the patients whose cases formed the basis of the 1998 study - and that there was "no doubt" Wakefield was responsible. The journalist who wrote the BMJ articles said Thursday he believes Wakefield should face criminal charges.

Is this an example of a doctor who wanted recognition and to be the pariah in the medical community for autism OR is this an example of Big Pharma winning out and going on a witch hunt?

Because of this article, I have personally witnessed the attitude toward vaccinations shift from lifesaving to poison even so far as one parent telling me that she would not vaccinate her three children because it was wrong and if I did the same I was a bad parent. Tell that to the parents of the infants, babies, and children who have died since 1998 when Dr. Wakefield's study appeared.

In the prevaccination era, pertussis (ie, whooping cough) was a leading cause of infant death. The number of cases reported had decreased by more than 99% from the 1930s to the 1980s. However, because of many local outbreaks, the number cases reported in the United States increased by more than 2300% between 1976 and 2005, when the recent peak of 25,616 cases were reported.¹ The disease is still a significant cause of morbidity and mortality in infants younger than 2 years. Pertussis should be included in the differential diagnosis of protracted cough with cyanosis or vomiting, persistent rhinorrhea, and marked lymphocytosis. (link)

In the prevaccination era, pertussis caused more than 270,000 cases and nearly 10,000 deaths annually. This rate reached a low of 4 reported deaths in the United States in 1982 and has recently risen to an average of about 25 deaths annually, with 39 being reported in 2005.

It's not so much that if you don't vaccinate your child that your child will die. It's that you are now taking advantage of herd immunity. You are taking advantage of a scenerio where most follow the rules and thus pertussis was on the decline. You are saying, "I don't have to vaccinate my child because pertussis isn't here." It is here. You are helping to carry it along. I am grateful for the recent push to booster dTaP in the adult community.

MMR was the focus of the study, though. I did cringe as both my children received the MMR and watched them like a hawk for the next six months wondering if "the light bulb would turn off suddenly." It did not. I do feel relieved that I don't have to worry about mumps. Mumps is back, folks. Ask those who are deaf now how THEY feel about those parents that will not vaccinate their children.

Read this post from back in May. Exactly. I couldn't have written it any better.

Please, for the love of God, stop putting our children at risk. Vaccinate your children. I truly believe that those that don't are negligent.

Lancet retracts statement about the link between MMR and autism

Link I'm not surprised.  Here we are watching the rates for many of the diseases that these vaccines have eradicated increase dramatically not only putting those that have not vaccinated at risk, but also putting those of us with lower titers at risk.  I have been quite tired of Jenny McCarthy touting her lack of any education, research, etc... giving false hope to those that do have autistic children with a "cure" and pointing her finger at the vaccines.  All the while, I'm watching as one mother who is a friend of a friend burying her son who contracted pertussis in an area where the disease is on the rise due to the lack of vaccinations.

I will say here, where I live, it is almost POPULAR to not vaccinate.  The ones that DO vaccinate are scrutinized and looked at as though we are harming our children.  It's really a shame because the information out there is all scare tactics.  I even had a friend cite a study from another country but when I looked at the study, it was incredibly flawed.  Mercury was to blame.  California watched as the autism rates continue to rise as the thimerosol was removed.  The same can be said for so many other things.  I'm quite tired of all of the banter about the anti-vaccination movement.

The movement should be called the reintroduction of mumps, measles, and rubella into our normal population where the rates of death are much higher than the uninformed scare of the antivaccination movement.

Vacinatons and the Trend Grows to "Opt Out"

If you are tempted to delay any vaccinations for your children, it’s critical that you educate yourself about the diseases those vaccinations are intended to prevent. As an increasing number of parents are delaying or forgoing certain vaccinations, it’s no longer possible to simply assume these diseases will remain so rare that they are not a threat. Exit herd immunity. Find out about the diseases themselves.... tetanus not spread person to person but spores in dirt as a source. Mumps can cause issues with males later on.