Great News About the HPV Vaccine!

The HPV vaccine has been a controversial vaccine on social media, but anyone who knows me knows that I agree with the recommendations and wholeheartedly endorse it for the reasons given in my favorite HPV Vaccine article.

Photo Source: Jan Christian via Wikimedia

To add to the confusion and misinformation that circulates regarding the safety of the vaccine (which I don't have room to go into here, but is discussed here, here, here, and visually here), the vaccine itself has changed (covering 9 strains now compared to the initial 4 strains) and the dosing schedule is changing.

Don't presume the change in vaccine schedule is to answer the calls of the anti-HPV vaccine crowd. That isn't needed because their claims have been debunked (see all the articles referenced above).

Dosing schedule ~ Happy News!

HPV vaccines were initially approved to be administered as a 3-dose series: dose #2 given two months after the first and the 3rd dose at least 4 months after the second. Giving doses later is acceptable, but they cannot be given too early.

There is research that supports giving just two doses at least 6 months apart. A two dose schedule was approved earlier in Europe and this week was approved by the FDA in the US for children 9 to 14 years of age. The two doses should be given 6-12 months apart, which means for most kids they can get the vaccine at two regularly scheduled well visits (such as the 11 year exam and the 12 year exam) and not have to come in for additional visits.

The data support continuing a 3 dose series in those 15 years and up. This means they can get the 2nd dose 2 months after the 1st dose and then a 3rd dose at least 4 months after the 2nd dose and 6 months after the 1st dose.

The official ACIP Meeting Information is not yet available, but will be posed within 90 days of the October 19-20 meeting. (Note: I originally stated this was an October 11 meeting.)

I know that the two dose series will make many kids happy ~ one less shot for the same protection!

If two doses have already been given at less than 6 months apart or if the teen is 15 years and older, the third dose will still be needed.

Addendum: 

I don't want to confuse everyone... the FDA has approved a new schedule, but the Advisory Committee on Immunization Practices (ACIP) will need to give their input before the schedule actually changes. That will be decided at their October 19-20 meeting.

One last addendum:

The ACIP approved the changes! Talk to your doctor about your child's vaccine needs. In short, the new recommendations state:

• Kids who get the first HPV vaccine before their 15th birthday need two doses 6-12 months apart.
• Kids who have turned 15 years old before the first dose should use the 3 dose series.
• Kids who have gotten a 2nd dose less than 6 months after the first (regardless of age) need the 3rd dose.

Vaccines don't have to hurt as much as some fear

Many kids are scared of shots. Some even fight parents and nurses when it's time to get shots. The more they fight and worry, the worse it gets. But it doesn't have to be that way.

In general there are some things that increase anxiety about shots or just make them seem bad. Lying about shots or threatening them as a punishment are never a healthy approach to the situation.

• Never tell kids they won't get a shot at the doctor's office. They might be due for one (or more) and if they were specifically told they won't get one, they are usually more upset.
• Do not threaten kids with shots if they misbehave. This makes kids see shots as a negative.
• Siblings can increase anxiety with their teasing. Don't share the need for shots with siblings and if it's possible to leave siblings at home when one child will need shots, that might work best. 
• Some kids worry more because parents are worried or presume the child will be worried. When the parent starts talking about shots in a worrisome manner it feeds into the fear. Try to be factual. Don't start telling them it's okay and not to worry. That tells them there's something to worry about.

Oh, no!

Some kids do best if they don't know shots are coming. If they ask if they'll get shots at an upcoming visit, you can say you don't know. If you think your child will lose sleep for days worrying about the shots, this is often the best way to handle it. Then the doctor and nurse at the office can deliver the news and it isn't your fault.

Just kidding. It's not bad getting my flu shot!

Some kids do better with advance warning. If you want to prepare your kids before bringing them in for shots or if you just need some help when you're at the office, follow these tips:

• Do not tell kids it won't hurt. Shots can hurt. Lying doesn't help. It just minimizes their fear and makes things worse. It might hurt, but how much is variable. Pain is a very individualized feeling. You can describe it as a pinch. 
• I often ask kids if they've ever gotten hurt playing outside. They usually say yes. Then I ask if they still wanted to play outside again. They usually say yes. I might sound surprised that even though they know that they can get hurt, they still want to play, but then I "realize" that it was because the benefit (playing) outweighs the risk (getting hurt). Then we talk about the benefits of the shot are so much more than the quick poke and a little pinch feeling. This works really well for the middle school shots because they're old enough to get the connection.
• Don't pre-treat with an oral pain reliever. Studies have shown that acetaminophen and ibuprofen decrease the immune response, which might make the vaccines less effective.
• Don't tell kids to not cry. It's okay to be scared and to feel pain. Let them know what is and is not okay. If they cry it's okay. It is not okay to kick, hit, run, or do anything that can harm others or themselves.
• Educate kids about how vaccines help us. There are many resources available. When they understand why the shots are good for them, it helps them to accept them.
• Practice what happens when we get shots. Have them practice sitting still and making their arms loose. Wipe the arm with a tissue as you explain the person giving the shot will clean the area with a very cold wet tissue to clean the area. (I avoid the term alcohol swab because the term alcohol confuses younger kids who learn about drug prevention in school.) Pinch the arm to show them there will be a small pinching feeling. Put a bandaid on the area if they like or just explain that they can get a bandaid when it's over. (If your child hates bandaids, tell the person giving shots that they prefer to not have them.) Let them practice giving you a "shot" too. 
• Let kids know that the poke will be fast and they can move their arms up and down afterwards to make the sting go away. 
• Bring a comfort item from home, such as a stuffed animal or blankie.
• There is evidence that blowing out or coughing during the injection helps decrease the pain. We often recommend this for kids old enough to blow or cough. Sometimes we'll entice preschoolers with bubbles or pinwheels. It really helps!
• Other forms of distraction can help too. Telling stories, reading books, or watching a video on a smart phone or tablet are great distractions. 
• Studies have shown that allowing kids to sit (rather than force laying down) during shots is perceived as less painful. The less restraining the child needs, the better. It makes sense that if they need to be held down they will be more scared and it will be perceived as more painful.
• Ask the person giving the vaccines to save the most painful vaccine for last, if applicable. (Our nurses do this routinely.)
• Our office sometimes uses Buzzy when kids are especially afraid of shot pain. As long as the child isn't overly worked up and they aren't opposed to the coldness of the ice, Buzzy works fantastically! If kids have worked themselves into a frenzy it isn't sufficient to distract in this way.  
• I used to think bribery was not a good parenting technique... until I had kids. It can be very effective. If you can promise a reward for being brave, such as stopping for a smoothie or getting a favorite treat, that can work wonders. 

Help with anxieties in general (great for life worries, not just shots!):

• After kids do things that they were afraid of, congratulate them for the attempt. Remind them that even though they were scared they did it. This helps set the pattern that they can be brave when faced with any fear. They can even keep a list of things that they did despite being scared to try. They can use the list whenever a new fear pops up to see how many things they've already done and how brave they really are. I've started recommending that parents take a video of kids to show their future self if they can say it didn't hurt as much as they worried it would. They tend to remember the anxious phase of excessive worry, but forget that it wasn't that bad. Show the video the next time shots are due. Their own self stating it wasn't bad can be reassuring!

• Use a meditation app, such as Stop, Breathe & Think. It's free and helps with general anxieties as well as mindfulness. Download it and use it at home several times to let them get comfortable using it. 
• Some great articles: 

• 18 Important Things That Kids With Anxiety Need to Know
• 5 Ways Caring Parents Make Teen Anxiety Worse
• 9 Things Every Parent with an Anxious Child Should Try 

• Understand Your Child's Anxiety (with infographic) 
• Anxiety and Social Competencies ("The Spirals")
• It Doesn't Have To Hurt  

Resources

Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline

Vaccines are a pain: What to do about it (This includes a link to this parent tip sheet.)

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Flu Vaccine 2016-2017 Season

Flu Vaccine Drama. Every Year It's Something!

Every year since I've been in practice there has been a hitch of some sort or another with flu vaccine production and/or administration. This year it's a big hitch. The Advisory Committee on Immunization Practices (ACIP) has recommended that the FluMist not be given to children.

Wow. That will make a lot of kids unhappy.

Dr Mellick and many of our staff have used FluMist over the years.

I always say we should never promise "no shots until ____".

This season' vaccine isn't here yet, but here's me getting a flu shot a few years ago. (I've gotten the FluMist for the past few years...)

Nasal Flu Vaccine (FluMist) Update

• The ACIP has advised that the attenuated influenza vaccine (LAIV), AKA “nasal spray” flu vaccine (FluMist), should not be used in kids during the 2016-2017 flu season. 
• About 8% of all flu vaccines were projected to be FluMist this year.
• FluMist uses live but weakened strains of flu virus to stimulate the immune system to protect against the flu virus strains in the vaccine.
• Initially FluMist was thought to work better than the injectable flu vaccine -- until the 2013/14 season. 
• The 2015-2016 FluMist is estimated to have been only 3% effective protecting against any strain of flu in children 2 years to 17 years of age. The injectable flu vaccine is estimated to have been 63% effective in this age group.
• The H1N1 component of the vaccine is the part that has not maintained effectiveness and has led to serious illness among people who have had the FluMist.
• The reason for the poor effectiveness of FluMist in recent seasons is not known. One thought is that the same strain in the vaccine year after year does not give the body the boost it needs since it already recognizes the flu strain.
• It has taken several years of data to show a pattern, which is why after the first year the nasal spray didn't seem as effective it was not pulled from the market. 
• There are many things to take into consideration when making flu vaccine recommendations. 

• It is difficult to know the overall number of cases of influenza since many people do not see a doctor when sick. This makes it difficult to assess effectiveness of flu vaccines in general. 

•  Flu vaccine effectiveness varies year to year because the strains of virus that circulate change.

• It could be one lot that wasn’t effective from a process problem, such as poor refrigeration. This is a fixable problem, so does not affect future lots if addressed properly. This was what vaccine manufacturers thought happened in 2014.  

• Studies in the UK do not show the same poor effectiveness in children, so it might be only US FluMist stock that was less effective for an unknown reason. Ongoing surveillance and studies will continue.

• It is possible that the FluMist will once again be recommended. It depends on what they find out most likely caused the decline in effectiveness and if they can overcome that obstacle.

Isn't something better than nothing? (In other words, my child hates shots... can't we just do the nose spray?)

I know many parents will wonder if their child can still get the nose spray because they hate shots. After all, they've had the nasal spray vaccine for several years and have been okay, so it should be fine for them, right? 

While one could argue that if the choice is a flu vaccine that might be less effective is better than no vaccine at all, most of us can see that 3% effectiveness isn't much to rely upon - especially if the injectable vaccine has a better track record. A few minutes of hearing a child cry due to a shot is preferable to watching them get seriously ill or die. I don't want to sound like a fear-monger, but death can be the consequence of influenza. My friend's niece was sadly one of the healthy children who died of flu last season after being vaccinated with the FluMist. Her family will forever wonder if the shot would have saved her life. 

We need to use the information we have to make the best decisions, and that is to use the injectable flu vaccine this season.

If your child fears shots, have them learn why they're important. Don’t Just Vaccinate Your Kids, Teach Them the Science Behind Vaccines has a number of links to games and booklets that can help. Knowledge is power. If your kids know why they're getting a shot, they are more likely to go willingly.

And if that doesn't help, teach them to blow out or cough during the shot. Those tricks really help! More shot survival tips are on Kid's Health.

Flu Vaccine General Facts

• Influenza virus kills between 4,000 and 50,000 people per year in the US. 
• Most deaths from influenza are among infants, elderly, pregnant women, or people with underlying illnesses (such as asthma and immune deficiencies). Some healthy children, teens, and young adults without known risks die from influenza.
• The flu vaccine continues to be recommended for everyone over 6 months of age.
• Every year the flu vaccine targets the anticipated types of flu for the season. This year’s strains are:

o A/California/7/2009 (H1N1)pdm09-like virus
o A/Hong Kong/4801/2014 (H3N2)-like virus
o B/Brisbane/60/2008-like virus (B/Victoria lineage)
o B/Phuket/3073/2013-like virus (B/Yamagata lineage) (quadrivalent vaccine only)

• The CDC does not expect any shortages of flu vaccine at this time despite the FluMist not being used.

Does this prove flu vaccines are not safe or worthwhile? Does our system work?

Many people wonder if this finding and recommendation supports that the flu vaccine in general is not effective and shouldn't be used. I don't think so at all.  

This shows that the continuous monitoring of vaccine safety and effectiveness allows changes to be made to make them more safe and effective. The process works. It takes time and isn't perfect, but it helps to continuously improve the vaccines we have.

I know some are angry that it took "so long" for this to come out. As mentioned above, the process takes time. The government wasn't hiding anything. They had to collect enough data to make an informed decision. Knee jerk reactions with limited information would cause its own problems. 

Scientists are working on a universal flu vaccine. Hopefully that will soon be available and the yearly flu vaccine won't be needed!

Until we know more or have a universal flu vaccine, please follow the ACIP recommendations and get everyone over 6 months of age vaccinated against the flu each season. The more people vaccinated, the better the herd immunity and the better we are all protected!

Travelling around the world? Stay safe and healthy!

Spring Break is around the corner, which means many of my patients will be travelling to various areas of the world for vacation or mission trips. Many of these areas require vaccines prior to travel, so plan ahead and schedule a travel appointment with your doctor (if they do them) or at a travel clinic. Many insurance companies do not cover the cost of travel medicine visits, medications, or vaccines, but they are important and are a small cost in comparison to getting sick when on your trip.

Vaccinate when you can!

Immunization records will need to be reviewed, so if you are going to a travel clinic outside your medical home (doctor's office) be sure to bring the records with you. Vaccines work best when they are given in advance, so do not schedule the pre-travel visit the week you leave! Some vaccines that are recommended are easily available at your medical office but others are not commonly given so might require a trip to a local health department, large medical center, or travel clinic. Check with your insurance company to see if the cost of the vaccine will be covered or not so you can include your cost in your travel budget if needed.

Watch the food and drinks

Many diseases are spread through eating and drinking contaminated foods. If in doubt: do not eat! Cooked foods are generally safer. Any fresh fruits or vegetables should be washed in clean water before eating. Be sure all dairy products are pasteurized. Avoid street vendors, undercooked foods (especially eggs, meats, and fish), salads and salsas made from fresh ingredients, unpeeled fruits, and wild game. Drink bottled water or water that has been boiled, filtered or treated in a way that is known to be reliable. Use the same water to brush teeth. Do not use ice unless you know it is from safe water because freezing does not kill the germs that cause illness. As always, wash hands often, use sanitizer as needed when washing is not available, and avoid touching the "T" zone of your face (eyes, nose, and mouth). Do not share utensils or foods. Avoid people who are obviously ill.

From: http://wwwnc.cdc.gov/travel/page/infographic-food-water-whats-safer

Many companies that schedule international travel recommend bringing antibiotics for prevention or treatment of diarrhea. This is not recommended by many experts due to the rise of "superbugs" with the use of unnecessary antibiotics. In general, the use of antibiotic prophylaxis is recommended only for high-risk travelers, and then only for short periods. The average duration of illness when untreated will be 4 to 5 days, with the worst of the symptoms usually lasting less than a day. Antibiotics might lead to yeast infections, allergic reactions, or even a chronic carrier state (colonization) or irritable bowel syndrome. Antibiotics should be reserved for the treatment of more serious illnesses that include fever and significant associated symptoms such as severe abdominal pain, bloody stools, cramping, and vomiting. Bismuth subsalicylate is available over the counter for adults and can reduce traveler’s diarrhea rates by approximately 65% if taken four times daily. Risks of bismuth products are that it can turn the tongue and stool black and they contain salicylate. Salicylate carries a theoretical risk of Reye syndrome in children, so should be avoided in children. Probiotics and prebiotics have been shown to help prevent and treat diarrheal illnesses safely in most people with intact immune systems.

Mosquitos...

Many diseases are spread by mosquitos. Contact with mosquitoes can be reduced by using mosquito netting and screens (preferably insecticide-treated nets), using an effective insecticide spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. Everyone at risk for mosquito bites should apply mosquito repellant.

Non-Infectious Risks

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page.

Learn local laws prior to travelling.

Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.

Remind everyone to stay in groups and to not venture out alone.

Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.

Wear sunscreen! It doesn't matter if you're on the beach or on the slopes, you need to wear sunscreen every time you're outside. Don't ruin a vacation with a sunburn.

For more safety tips, see this helpful brochure.

Keep records

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

• your name, address, and phone number
• emergency contact name(s) and phone number(s)
• immunization record
• your doctor's name, address, and office and emergency phone numbers
• the name, address, and phone number of your health insurance carrier, including your policy number
• a list of any known health problems or recent illnesses
• a list of current medications and supplements you are taking and pharmacy name and phone number
• a list of allergies to medications, food, insects, and animals
• a prescription for glasses or contact lenses

Specific Diseases to Prevent

Risks of illness vary depending on where you will be travelling and what time of year it will be. I refer to the CDC's travel pages and the Yellow Book for information on recommendations. Some of the most common issues to address are discussed below in alphabetical order.

Dengue Fever

Dengue is a mosquito-borne viral illness. It is seen in parts of the Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa. There is no vaccine or specific treatment. Mosquito bite prevention measures are important.

Hepatitis

Infants should begin vaccinations against Hepatitis B starting at birth and against Hepatitis A starting at a year of age. Be sure these vaccines are up to date. Hepatitis A is spread through food and water, so be sure to follow the above precautions even if vaccinated.

Malaria 

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be travelling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication.

• Atovaquone-proguanil should begin 1–2 days before travel, daily during travel, and 7 days after leaving the areas. Atovaquone-proguanil is well tolerated, and side effects are rare but include abdominal pain, nausea, vomiting, and headache. Atovaquone-proguanil is not recommended for prophylaxis in children weighing <5 kg (11 lb).
• Mefloquine prophylaxis should begin at least 2 weeks before travel. It should be continued once a week, on the same day of the week, during travel and for 4 weeks upon return. Mefloquine has been associated with rare but serious adverse reactions (such as psychoses or seizures) at prophylactic doses but are more frequent with the higher doses used for treatment. It should be used with caution in people with psychiatric disturbances or a history of depression. 
• Primaquine should be taken 1–2 days before travel, daily during travel, and daily for 7 days after leaving the areas. The most common side effect is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized if primaquine is taken with food. In G6PD-deficient people, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by laboratory testing.
• Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas. Doxycycline can cause photosensitivity so sun protection is required.  It also is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal and it should be swallowed with a large amount of fluid and should not be taken before bed. Doxycycline is not used in children under 8 years. Vaccination with the oral typhoid vaccine should be delayed for 24 hours after taking a dose of doxycycline.
• Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present. Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week during travel and for 4 weeks after a traveler leaves these areas. Side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and itching, but generally these effects do not require that the drug be discontinued.  

Measles

We routinely give the first vaccine against measles (MMR or MMRV) at 12-15 months of age, but the MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks. Under 6 months of age, an infant is considered protected from his mother's antibodies. These antibodies leave the baby between 6 and 12 months. The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday. Any vaccine dose given before the first birthday does not count toward the two doses required after the first birthday, but might help protect against exposure if the immunity from the mother is waning. It is safe for a child to get extra doses of the vaccine if needed for travel between 6 and 12 months.

Meningitis

Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States. In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but can be given as young as 9 months of age. MenACWY-CRM is newly approved for children 2 months and older. 

There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel. 

Meningitis vaccines should be given at least 7-10 days prior to potential exposure.

Travellers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. The vaccine is available for children 9 months and older in my office and a newer vaccine is approved for 2 months and up. Boosters for people travelling to these areas are recommended every 5 years. 

Tuberculosis

Tuberculosis (TB) occurs worldwide, but travelers who go to areas of sub-Saharan Africa, Asia, and parts of Central and South America are at greatest risk. Travelers should avoid exposure to TB in crowded and enclosed environments and avoid eating or drinking unpasteurized dairy products. The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States. Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure. It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body's immune system is compromised, as with old age or another illness. Appropriately treating the TB before it causes active disease is beneficial for the long term.

Typhoid

Typhoid fever is caused by a bacteria found in contaminated food and water. It is common in most parts of the world except in industrialized regions (United States, Canada, western Europe, Australia, and Japan) so travelers to the developing world should consider taking precautions. There are two vaccines to prevent typhoid.

• Children over 2 years of age can be vaccinated with the injectable form. It must be given at least 2 weeks prior to travel and lasts 2 years. 
• The oral vaccine for children over 5 years and adults is given in 4 doses over a week's time and should be completed at least a week prior to travel. The oral vaccine lasts 5 years. 
• Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Yellow Fever

Yellow fever is another mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Zika Virus

At this time it is advised that pregnant women and women who might become pregnant avoid areas in which the zika virus is found. For up to date travel advisories due to this virus, see the CDC's Zika page.

Flu Shot Information 2013-14 Season

Dr. Mellick getting FluMist

Dr. Stuppy getting a flu shot

Many parents are already asking about this year's flu vaccine, which means we've done a great job in the past making them aware that they need to think about getting the vaccine before they start seeing people get sick!

We feel so strongly that the vaccine is effective at protecting not only the person vaccinated but also the community around them that our office requires all staff to get a vaccine. We made the Honor Roll for Patient Safety from the Immunization Action Coalition for this requirement!

What's new this year?

Every year scientists predict which strains of Influenza A and Influenza B will likely be prevalent. The World Health Organization makes the recommendations for the vaccine based on these predictions. The strains chosen are the same for every company that makes the vaccine. The difference this year is that some will have three strains (trivalent) with two A and one B, others will have four strains (quadrivalent) with two A and two B.

Flu shot season causes headaches for doctor's offices. 

We must anticipate our need many months in advance and get our orders in. Each year the vaccine demand varies (a lot based on press reports on how badly people are getting sick, which we don't know when ordering). As more places offer vaccines (such as offices and pharmacies) the numbers of people getting vaccines at their doctor's office might go down. (I am biased, but of course believe getting them at your doctor's office is superior since we keep all your medical records in one place.)

From a business perspective, no one wants to be stuck with thousands of dollars of unused vaccine-- we can't stay in business if we lose money. We also don't want to have kids at risk of disease because they're unprotected and unable to find an appropriate vaccine when we run out. We certainly don't want parents yelling at our staff because we run out. Sometimes we've ordered enough overall, but our shipping allotments don't come fast enough for the demand. Shortages have happened over the years, something beyond anyone's control.

Scheduling mass flu vaccine clinics is often the best way to vaccinate large numbers of patients, but they are fraught with complications: how many people will show up, what flu vaccine (injectable vs nose spray) will they need? How many doses do we need on hand to hold a clinic? In times of shortages or low stock, how do you prioritize who gets the vaccine -- or do you want to just keep giving to anyone until it is gone so the office isn't stuck with unused vaccine at the end of the season? Do you give one dose to a 6 month old who you know won't be able to get the 2nd dose due to your supply running out?

This year there's a new spin to the variety of headaches: different vaccines will be available. Not just injectable vs nose spray. There will be some with 3 strains of virus, others with 4 strains. (For a review of how strains get into vaccine and how this year is different, see Quadrivalent Flu Vaccines: Four Means More Protection.)

So this year we have new questions: How are we supposed to order the different types, who gets which type, and are they interchangeable? How will the public perceive the difference and will they demand one or the other? Will insurance companies reimburse the cost appropriately, given that one is more expensive than the other? While in health care our goal is to keep everyone as healthy as can be, no office can afford to lose money on vaccines and stay in business.

What kinds of vaccine will be available this season?

There are many companies that make influenza vaccine, each with their own indications. For a complete list, see the chart on the CDC website. Our office has pre-ordered the FluMist and the Fluzone products (both forms) in part because we didn't know which would be available at the start of the season. We do not purchase the brands that are only available for older children or adults. Ask your doctor what they order.

All FluMist will be quadrivalent (4 strains) and is for children over 2 years without high risk conditions, such as asthma (presumed based on previous recommendations, this year's statement has not been released yet). It is expected to start shipping in July or August, though any individual office may not receive their order with the first shipping dates.

Fluzone Quadrivalent (4 strains) is an injectable vaccine for everyone over 6 months of age. It has already sold out  based on pre-season orders and will be available in limited quantities. Shipping dates will begin in August or September.

Fluzone Trivalent (3 strains) is an injectable vaccine for everyone over 6 months of age. It is expected to begin shipping in July and August. I have not heard of shortages.

Is adding a new strain dangerous?

Based on the chaos in the year of H1N1, I know that many parents fear "new" strains added to a flu shot. In actuality, every year the vaccine changes with very rare exception. That is because the flu strains predicted to cause disease change year to year. Adding a new strain does not make the vaccine less safe, just more effective.

Who needs the flu vaccines and how will they be given?

As of today, the finalized recommendations have not been approved. The preliminary recommendations  continue to recommend flu vaccine for all people over 6 months of age. (The link should update to the final recommendations as they become available.)

Last year it was recommended to start giving the vaccine as soon as it was received (previously it was suggested to wait until October so it remained effective throughout the season, but the vaccine is effective longer than previously thought so earlier vaccine is effective.) I presume this will remain the same.

If a child under 9 years of age has not had flu vaccine before, they need 2 doses in the same season to "prime" and "boost" immunity. If only one vaccine was given, the next season the child needs 2 doses unless they have gotten 2 of the same strain before. (This was easier last year because it was a rare year that the vaccine didn't change, so they could have gotten one the season prior, and the booster last year.) For children over 9 years, only one dose is needed, even if never received previously. After that first year of 2 doses, each year everyone just needs one dose unless it dramatically changes (as in the H1N1 year). I suspect since 3 of the 4 strains are the same this year, if a child needs 2 doses because they have not had 2 doses of the same strains, the vaccines are interchangeable. We will all find out when the final recommendation is given.

At this point I have not heard if high risk people should get preference for the quadrivalent vaccine. I don't think this will be possible in many cases, since many of the high risk are under 2 years old, and not eligible for FluMist. The injectable quadrivalent vaccine is in short supply, and many offices are likely to not get it at all. I personally feel it would be bad to wait for the quadrivalent vaccine if we have the trivalent vaccine in stock and an eligible patient is in the office. I'd rather vaccinate than potentially miss the opportunity all together. I'm sure others will differ in opinion since the quadrivalent vaccine is better protection. Talk to your pediatrician about their preference.

Although we cannot require all patients to get vaccinated, we certainly encourage it and try to make it as painless as possible (though the kids who get shots don't always agree). We will once again allow any patient in the office to get a flu vaccine (even if just there with a sibling for an appointment) and we will offer on line sign up for our clinics. On line sign up has proved very popular, both among our nurses and the families who come. It has really made the process run much more smoothly. There will not be a co pay collected at those clinics. (After we submit the claim to your insurance company if they tell us differently we will send a bill, but do not expect that in most cases.) Be sure you have registered for our e-Newsletter so you will be among the first to know when sign ups are ready for our patients. (No dates are set yet because we have not gotten verification on shipping dates. Please don't call the office to ask-- staff have no idea.) We will put information on our website as it becomes available in addition to posting on our Facebook page and sending the e-Newsletter.

We will all have to wait to see how this plays out! Every year something is new with the flu vaccine. What will be next?

Vaccine timing... is it too late?

It is common in the summer months for parents to worry about their child's vaccines being delayed by summer travel or simply scheduling conflicts.

The typical question I am asked is along the lines of, "He is due for his 4 month shots on July 5th, but we are on vacation. Is it okay to wait until the end of July?"

or

"Tweeny is getting her first HPV vaccine today, but she has a big out of town tournament the week she is due for the 2nd dose. Can she come later?"

The answer to both questions: yes.

Vaccines are recommended with minimal intervals (you can't give them too soon) but if there is a delay for whatever reason (missed appointments, scheduling conflicts, immune compromise-such as cancer in a child or their caregiver) it is recommended to catch up as soon as possible.  Doses do not need to be repeated if the interval has been longer than recommended.

Conversely, it is not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in Kansas.  Some states have a leeway for giving doses early, but Kansas does not. This is an issue with some children moving to our state from a more lenient state. Maybe they get their MMR a couple days before their first birthday. Does this protect them against measles, mumps, and rubella? Probably. Does the school count it? No. They need to repeat it.

Another scenario is children traveling outside the US. It is recommended for international travelers over 6 months to get an MMR early due to worldwide outbreaks. This dose does not count toward the 2 doses typically given because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Another common scenario involves Hepatitis A and B vaccines due to the ages given and the intervals required.

The dosing interval for Hepatitis A is a minimum of 6 months. We typically give it at 12 months and 18 months, but if these appointments are scheduled with less than 6 months between, we typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine. This delay is okay. 

Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.  If a newborn does not get the first Hepatitis B vaccine on the date of birth for whatever reason (too ill, parental preference, prematurity) and the one month well check is less than 28 days from the first dose, we delay the 2nd Hepatitis B vaccine until a future visit. This will push the 3rd dose back in most cases.

Each year the CDC updates the recommended vaccine schedule. We know it is confusing to parents, but we will help keep your kids on track!