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Last-Modified: December 2, 1994

=====================================================================
Collection maintained by: Lynn Gazis-Sax ([e-mail])
Last updated: December 2, 1994

To contribute to this collection, please send e-mail to the address
given above, and ask me to add your comments to the FAQ file on
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Copyright 1994, Lynn Gazis-Sax.  All rights reserved.  Use and copying
of this information are permitted as long as (1) no fees or compensation
are charged for use, copies or access to this information, and (2) this
copyright notice is included intact.

For a list of other FAQ topics, ftp to the pub/usenet/misc.kids directory
  of rtfm.mit.edu or tune in to misc.kids.info.
=====================================================================
[NOTE: this is information collected from many sources and while I
have strived to be accurate and complete, I cannot guarantee that I
have succeeded.  This is not medical advice.  For that, see your
doctor or other health care provider.]
===============================================================================

Contents

Section 1. Introduction and General Information
Q1.1    What is vaccination?
Q1.2    What are active and passive vaccination?
Q1.3    What is herd immunity?
Q1.4    How effective is vaccination at producing immunity?
Q1.5    What are some of the risks of vaccination?
Q1.6    What are some contraindications to vaccinations?
Q1.7    How common are the diseases vaccinated against?
Q1.8    What percentage of children are vaccinated?
Q1.9    What are some sources of further information about
vaccinations?

Section 2. The recommended vaccination schedule
Q2.1    What is the recommended vaccination schedule in the US for
infants?
Q2.2    What is the recommended vaccination schedule in the US for
older children who were not vaccinated in infancy?
Q2.3    What is the recommended vaccination schedule in the US for
adults?
Q2.4    Who determines this schedule?
Q2.5    What vaccination schedules are used in other countries?
Q2.6    What international bodies are concerned with vaccinations?

Section 3. Specific vaccines
Section 3a. DTP (diptheria, tetanus, and pertussis) and DT
Q3a.1    What is diptheria, and what are the risks of the disease?
Q3a.2    How common was diptheria before routine vaccination, and how
common is it now?
Q3a.3    How effective is the diptheria vaccine?
Q3a.4    How long does the diptheria vaccine last?
Q3a.5    What is pertussis, and what are the risks of the disease?
Q3a.6    How common was pertussis before routine vaccination, and how
common is it now?
Q3a.7    How effective is the pertussis vaccine?
Q3a.8    How long does the pertussis vaccine last?
Q3a.9    What is tetanus, and what are the risks of the disease?
Q3a.10    How common was tetanus before routine vaccination, and how
common is it now?
Q3a.11    How effective is the tetanus vaccine?
Q3a.12    How long does the tetanus vaccine last?
Q3a.13    What are some of the risks of the DTP vaccine?
Q3a.14    When is the DTP vaccine contraindicated?
Q3a.15    What are the advantages and disadvantages of the new acellular
pertussis vaccine?
Q3a.16    What are some of the risks of the DT (diptheria and tetanus)
vaccine?
Q3a.17    When is the DT vaccine contraindicated?
Q3a.18    Under what circumstances is tetanus toxoid given to pregnant
women?

Section 3b. Polio
Q3b.1    What is polio, and what are the risks of the disease?
Q3b.2    How common was polio before routine vaccination, and how
common is it now?
Q3b.3    How effective is the polio vaccine?
Q3b.4    How long does the polio vaccine last?
Q3b.5    What is the difference between oral polio vaccine (OPV) and
inactivated polio vaccine (IPV)?
Q3b.6    I've heard that it is possible to contract polio from handling
the diapers of recently immunized infants.  How long after receiving
the vaccine does the child's excrement continue to contain the virus?
Q3b.7    What are some other risks of the polio vaccine?
Q3b.8    When is the polio vaccine contraindicated?
Q3b.9    Isn't it true that wild polio has been eliminated in the US?
Q3b.10    Why are we still vaccinating for polio, then?

Section 3c. MMR (measles, mumps, and rubella)
Q3c.1    What is measles, and what are the risks of the disease?
Q3c.2    How common was measles before routine vaccination, and how
common is it now?
Q3c.3    How effective is the measles vaccine?
Q3c.4    How long does the measles vaccine last?
Q3c.5    What are some of the risks of the measles vaccine?
Q3c.6    What is mumps, and what are the risks of the disease?
Q3c.7    How common was mumps before routine vaccination, and how
common is it now?
Q3c.8    How effective is the mumps vaccine?
Q3c.9    How long does the mumps vaccine last?
Q3c.10    What are some of the risks of the mumps vaccine?
Q3c.11    What is rubella, and what are the risks of the disease?
Q3c.12    How common was rubella before routine vaccination, and how
common is it now?
Q3c.13    How effective is the rubella vaccine?
Q3c.14    How long does the rubella vaccine last?
Q3c.15    What are the pros and cons of vaccinating all infants for
rubella versus vaccinating females only at puberty?
Q3c.16    What are some of the risks of the rubella vaccine?
Q3c.17    When is the MMR vaccine contraindicated?

Section 3d. HiB (Hemophilus influenze B)
Q3d.1    What is hemophilus influenze B, and what are the risks of the
disease?
Q3d.2    How common was HiB before routine vaccination, and how
common is it now?
Q3d.3    How effective is the HiB vaccine?
Q3d.4    How long does the HiB vaccine last?
Q3d.5    What are some of the risks of the HiB vaccine?
Q3d.6    When is the HiB vaccine contraindicated?
Q3d.7    What about rifampin prophylaxis?

Section 3e. Hepatitis B gamma globulin and hepatitis B vaccine
Q3e.1    What is hepatitis B, and what are the risks of the disease?
Q3e.2    How common is hepatitis B?
Q3e.3    What is hepatitis B gamma globulin, and when is it given?
Q3e.4    How long does the immunity provided by hepatitis B gamma
globulin last?
Q3e.5    What are the risks and contraindications of hepatitis B gamma
globulin?
Q3e.6    How effective is the hepatitis B vaccine?
Q3e.7    How long does the hepatitis B vaccine last?
Q3e.8    What are some of the risks of the hepatitis B vaccine?
Q3e.9    When is the hepatitis B vaccine contraindicated?
Q3e.10    Why did the ACIP and AAP change their recommendation about the
hepatitis B vaccine?
Q3e.11    Does vaccination for hepatitis B affect one's ability to
donate blood?
Q3e.12    Do people who have showed up positive on the blood banks' tests
for hepatitis B exposure still need to be vaccinated?
Q3e.13    I will be travelling to an area where hepatitis B shots are
recommended, but I have less than six months before I leave.  Is there
an accelerated schedule for hepatitis B vaccination?

Section 3f. Influenza
Q3f.1    What is influenza, and what are the risks of the disease?
Q3f.2    How common is influenza?
Q3f.3    How effective is the influenza vaccine?
Q3f.4    How long does the influenza vaccine last?
Q3f.5    What are some of the risks of the influenza vaccine?
Q3f.6    When is the influenza vaccine recommended?
Q3f.7    When is the influenza vaccine contraindicated?
Q3f.8    Is it OK to be vaccinated for influenza during pregnancy?

Section 3g. Pneumococcal vaccine
Q3g.1    What is pneumococcal disease, and what are the risks of the
disease?
Q3g.2    How common is pneumococcal disease?
Q3g.3    How effective is the pneumococcal vaccine?
Q3g.4    How long does the pneumococcal vaccine last?
Q3g.5    What are some of the risks of the pneumococcal vaccine?
Q3g.6    When is the pneumococcal vaccine recommended?
Q3g.7    When is the pneumococcal vaccine contraindicated?

Section 3h. Meningococcal vaccine
Q3h.1    What is meningococcal disease, and what are the risks of the
disease?
Q3h.2    How common is meningococcal disease?
Q3h.3    How effective is the meningococcal vaccine?
Q3h.4    How long does the meningococcal vaccine last?
Q3h.5    What are some of the risks of the meningococcal vaccine?
Q3h.6    When is the meningococcal vaccine recommended?
Q3h.7    When is the meningococcal vaccine contraindicated?

Section 3i. Varicella (chicken pox) vaccine
Q3i.1    What is chicken pox, and what are the risks of the disease?
Q3i.2    How common is chicken pox?
Q3i.3    When will the chicken pox vaccine be available?
Q3i.4    Will the chicken pox vaccine be part of the regular schedule
of vaccinations?
Q3i.5    Will older children who have not had chicken pox be able to
get the chicken pox vaccine?
Q3i.6    Will adults be able to get the chicken pox vaccine?
Q3i.7    How effective is the chicken pox vaccine?
Q3i.8    How long does the chicken pox vaccine last?
Q3i.9    What are some of the risks of the chicken pox vaccine?
Q3i.10    For which groups is the chicken pox vaccine especially
recommended?
Q3i.11    When is the chicken pox vaccine contraindicated?
Q3i.12    Is there a gamma globulin for chicken pox?

Section 3j. BCG (tuberculosis) vaccine
Q3j.1    What is tuberculosis, and what are the risks of the disease?
Q3j.2    How common is tuberculosis?
Q3j.3    How effective is the BCG vaccine?
Q3j.4    How long does the BCG vaccine last?
Q3j.5    What are some of the risks of the BCG vaccine?
Q3j.6    When is the BCG vaccine recommended?
Q3j.7    When is the BCG vaccine contraindicated?
Q3j.8    What are some other methods of controlling tuberculosis?

Section 3k. Other vaccines which are available
Q3k.1    What other vaccines are available and when are they given?

Section 3l. Vaccines under development
Q3l.1    What vaccines are currently under development?
Q3l.2    What other research is being done to improve vaccines?

Section 4. References

Section 5. Stories of Parents

===============================================================================

Section 1. Introduction and General Information

Q1.1    What is vaccination?

The basic principle of vaccination is that a disease-causing agent is
given to a person in a killed or weakened form (or in the form of
proteins genetically engineered to look like a disease-causing agent),
in order to stimulate the production of antibodies to fight off the
disease.

Q1.2    What are active and passive vaccination?

Active immunization involves trying to stimulate antibodies by giving a
person a killed or weakened form of a disease-causing agent. Passive
immunization involves giving a person antibodies from someone who was
infected with the disease (these are called gamma globulins). Passive
immunization doesn't last very long, but can be useful for someone who
expects to be exposed to a disease (e.g. someone travelling to another
country who takes hepatitis A gamma globulin right before leaving), or to
someone who has just been exposed to a disease.  Most of the vaccinations
discussed in this FAQ fall under the active vaccination category.

Q1.3    What is herd immunity?

If a large enough percentage of a population is immune to a disease,
their immunity protects the rest of the "herd."

Some discussion of this concept from misc.kids follows:

*************************************************************************
From: [e-mail] (Paula Burch)

|> >Paula Burch ([e-mail]) wrote:
|> >: If one child remains unvaccinated, but all other children are
|> >: vaccinated, the one child who does not get vaccinated is pretty safe
|> >: from getting the disease. If many children remain unvaccinated,
|> >: epidemics occur, and children die needlessly.

|> [e-mail] (Mark Dolson) writes:
|> >This is exactly what occured with measles in the 80's, BTW.  Fewer
|> >vaccinated, and the incidence skyrocketed, with resulting complications
|> >of eye problems, etc, and even some deaths.  I agree that people who
|> >let their children remain unvaccinated are riding on the backs of
|> >everyone that does vaccinate, and I resent it.

[e-mail] (Cerebus) writes:
|> To be fair, most of the major outbreaks (as well as most of the
|> serious complications) were and are on college campuses, and occurred *not*
|> because of failure to vaccinate, but because the vaccine that was given
|> to kids between '69-'76 turned out not to give total immunity.  Many kids
|> who were vaccinated were victims of measles, before people became conscious
|> that it was necessary for many teens and young adults to be re-vaccinated.
|>
|> I had measles my first year in college, after vaccination at the appropriate
|> age.  After that outbreak my college began requiring re-vaccination.  But it
|> is not technically correct to blame the measles outbreak on the failure of
|> parents to vaccinate.

It's true that that's what happended in that case, but it's not true for
other cases, in which failure to vaccinate has been a major factor:

   "The nation [U.S.] has experienced a marked increase in measles cases
   during 1989 and 1990.  Almost one half of all cases have occurred in
   *unvaccinated* preschool children." (JAMA.  1991 Sep 18.  266(11).
   P 1547-52.)

   "Beginning in October, 1990, a large measles outbreak involving
   predominantly *unvaccinated* preschool age children occurred in
   Philadelphia.  By June, 1991, 938 measles cases had been reported to
   the Philadelphia Health Department.  In addition to these cases, 486
   cases and 6 measles-associated *deaths* occurred between November 4,
   1990, and March 24, 1991, among members of 2 Philadelphia church
   groups that do not accept vaccination." (Pediatr-Infect-Dis-J.  1993 Apr.
   12(4).  P 288-92.)

   "In 1989 and 1990 the United States experienced a measles epidemic with
   more than 18,000 and 27,000 reported cases. Nearly half of all persons
   with measles were *unvaccinated* preschool children under 5 years of age."
   (Am-J-Public-Health.  1993 Jun.  83(6).  P 862-7.)

Measles is bad, but I'm more concerned myself about pertussis (whooping cough):

   "From 1980 through 1989, 27,826 cases of pertussis were reported to
   the Centers for Disease Control....Infants less than 2 months of age
   had the highest reported rates of pertussis-associated hospitalization
   (82%), pneumonia (25%), seizures (4%), encephalopathy (1%), and *death*
   (1%)." (Clin-Infect-Dis.  1992 Mar.  14(3).  P 708-19.) [Many of these
   infants would not have caught the disease if enough older children were
   appropriately vaccinated.]

   "Two large *epidemics* of pertussis occurred in Britain during 1977-79
   and 1981-83." (Commun-Dis-Rep-CDR-Rev.  1992 Dec 4.  2(13).  P R155-6.)

This explains the herd immunity concept rather well:

   "The epidemiology of whooping cough [pertussis] in Denmark is described
   on the basis of the notified cases of the disease.  The frequency of
   whooping cough has decreased to approximately one sixteenth of the
   previous level in children following the introduction of vaccination
   for whooping cough in 1961....deaths from whooping cough still
   occurred in the eighties, all of these among *unvaccinated* infants.
   The risk of whooping cough in an *unvaccinated* child is approximately
   one sixth of the risk prior to introduction of vaccination.  In a
   vaccinated child, the risk, as judged from the notified cases, is one
   twentieth of the risk during the time prior to introduction of
   vaccination.  In all age groups "herd immunity" is considered to have
   contributed considerably to the reduced incidence.  The incidence in
   Denmark is, however, high compared with the incidence in some other
   industrialized countries.  A vaccination programme with more numerous
   whooping cough vaccinations...may be recommended on the basis of the
   strategy aimed at keeping the incidence of whooping cough, and thus the
   risk of exposure, as low as possible." (Ugeskr-Laeger.  1990 Feb 26.
   152(9).  P 597-604.)

Paula Burch
[e-mail]
not speaking for Baylor College of Medicine
*************************************************************************

Q1.4    How effective is vaccination at producing immunity?

Vaccination does not always work.  For one thing, vaccines can lose
effectiveness when they aren't stored properly.  And even if they are
stored effectively, they will fail to stimulate immunity a certain
percentage of the time.  The effectiveness of vaccines varies,
depending on the vaccine.  Effectiveness can also vary depending on
the age, sex, and health of the recipient.  Sometimes different
strains of a vaccine can have different effectiveness.

Vaccine effectiveness is measured in two ways.  First, antibody levels
are measured after a vaccine is given.  Second, people are vaccinated
and then followed to see whether they get the disease when they are
exposed to it.  Estimates of effectiveness can vary in some cases
depending on the level of antibodies which is considered as passing,
and the criteria for measuring whether someone has the disease (for
instance, pertussis vaccine is more effective at preventing full-blown
pertussis than at preventing a mild cough).  Also, some sources give
estimates of field effectiveness which take into account difficulties in
storing vaccines in some areas; these estimates tend to be lower than
estimates based on studies of vaccination in the US or other developed
countries.

Estimates of effectiveness of individual vaccines are given in the
section for each vaccine (and, where I have found variations in estimates
of effectiveness, I have noted that as well).

Q1.5    What are some of the risks of vaccination?

Again, these risks vary with the vaccine.  However, there are some
risks which are common to several vaccines.  People may be allergic to
a component of the vaccine, such as eggs or neomycin.  Occasionally,
these allergies can lead to anaphylactic shock (doctors keep
epinephrine on hand when giving vaccinations to guard against this
risk).  Vaccines can produce the same symptoms as the disease
(in a milder form, and with less frequent incidence of the risks
associated with the disease).  Live vaccines in particular can be
risky for people with weakened immune systems, who have less ability
to resist even the weakened form of the disease.  Common minor adverse
reactions include soreness or swelling at the injection site and
fever.  Because of the latter, vaccinations are often postponed if the
recipient already has a fever.

Another risk is the risk that the vaccination will wear off, and the
recipient will get the disease later.  Depending on the illness, the
disease could be either less or more harmful to adults.  While this
risk can be dealt with by giving boosters, it is worth bearing in mind
in setting vaccination policies and making vaccination dscisions,
because in some case getting the vaccine and then *not* getting the
booster might lead to increased risk.

Further information related to vaccination risks follows:

From Cyndy Brunken:

I posted this for Kathleen over on sci.med then I realized that
misc.kidders might also benefit from the info contained herein.
*****************************************************************

DISCLAIMER:  THIS MESSAGE IS BEING POSTED FOR KATHLEEN STRATTON BY
SOMEONE NOT AFFILIATED WITH THE MESSAGE.  I have read-only access to
USENET and have followed the immunization discussions in the last few
weeks.  I think some of the participants will have an interest in the
following information.

An Institute of Medicine (IOM) committee has concluded in a new report
that a causal relation exists between certain common childhood vaccines
and specific, but rare, health problems.  The committee also determined
that there appears to be no causal relation between some of those same
vaccines and other specific health problems.  The vaccines studied
include those used against tetanus, diphtheria, measles, mumps, polio,
hepatitis B, and Haemophilus influenzae type b (Hib).

The IOM is a private, non-profit organization that provides health
policy advice under a congressional charter granted to the National
Academy of Sciences.  The IOM committee was NOT asked to assess risk-
benefit or cost-benefit relations.  Rather, the task was to evaluate all
medical and scientific evidence bearing on the causal relation between
childhood vaccines and specific, serious health outcomes.

The report is entitled "Adverse Events Associated with Childhood
Vaccines:  Evidence Bearing on Causality".  A previous IOM committee
submitted a report in 1991 entitled "Adverse Effects of Pertussis and
Rubella Vaccines".  Both reports were mandated by the U.S. Congress in
the 1986 National Childhood Vaccine Injury Act (P.L. 99-660).  This law
addressed many aspects of childhood immunization.  Notably, it
established a federal compensation program for those who have been
injured by mandated childhood vaccines.

The IOM committee reported that the evidence established a causal
relation between diphtheria, tetanus, measles-mumps-and-rubella, and
hepatitis B vaccines and anaphylaxis.  The evidence established a causal
relation between measles-mumps-and rubella vaccine and thrombocytopenia;
between measles vaccine and death from measles infection (primarily in
immunocompromised individuals); between oral polio vaccine and death
from poliovirus infection (primarily in immunocompromised individuals);
and between the oral polio vaccine and poliomyelitis disease.

On the other hand, the committee found that the evidence favored
rejection of a causal relation between diphtheria and tetanus vaccines
and encephalopathy, infantile spasms, and SIDS.  The committee found
similarly regarding certain Hib vaccines and increased susceptibility to
Hib disease.  The committee investigated other serious health problems
and classified their relation to vaccines in three other categories:  no
evidence, inadequate evidence to accept or reject a causal relation, and
evidence favors acceptance of a causal relation.  The specific relations
are too numerous to list here.

The committee noted that in most cases it was impossible to calculate an
incidence rate or relative risk for these reactions, but that they were,
on the whole, extremely rare.

The final report will be available in late October or early November
from National Academy Press, 1-800-624-6242.  It will cost approximately
$60.00.  (The report on pertussis and rubella is still available)  A few
prepublication copies of the Executive Summary of the new, 1993 report
are available from the project director at no cost on a first come-first
served basis.  Anyone wishing specific information about this report can
email me, Kathleen Stratton, directly.  I am the study director for this
project.  My internet address is [e-mail]

*************************************************************************

From Mike Dedek:

*************************************************************************
New England Journal of Medicine 1987; 316: 1283-1288, May 14, 1987,
"Compensating Children with Vaccine-Related Injuries", Iglehart, John K.

   The federal immunization program, by virtually all economic, medical, and
political measures, is a stunning success story because of its record of
protecting millions of children against the common infectious diseases of the
young. But in recent years the program has come under a legal cloud that is
threatening its stability, slowing the development of  new vaccines,  and
sending vaccine prices sharply upward. To address these problems, Congress has
created a new federal program to compensate children who suffer vaccine-related
injuries, but how it will be funded and whether it will achieve its goals remain
open questions.

   The legal cloud has formed because, even when the best vaccine products are
properly administered and used, vaccines pose minute risks to those who receive
them, and an increasing number of lawsuits are seeking damages on behalf of
injured persons. Dr. Louis Z. Cooper, representing the American Academy of
Pediatrics, testified before Congress on March 5 about the nature of these
risks. Cooper stated:

    One case of polio-like disease will result from each 2.6 million doses of
oral polio vaccine OPV , and a serious, permanent neurological injury will
result from every 310,000 doses of DTP diphtheria, tetanus, and  pertussis
vaccine . In extremely rare cases, an encephalitis or nerve deafness will
develop from MMR measles, mumps, and rubella vaccine . Approximately 75
vaccine-related injuries per year are the price we pay to protect the more than
3.8 million children born each year in this country.

   For five years, Congress has struggled to fashion legislation that addresses
he complex issues related to the compensation of children injured by vaccines;
in the process, it has explored virtually every conceivable policy option.

<additional text deleted>

*************************************************************************

Q1.6    What are some contraindications to vaccinations?

Contraindications vary with the vaccine, so contraindications for each
specific vaccine are given in the appropriate sections.  Some common ones
are: allergy to some substance contained in the vaccine (such as eggs or
thimerosal, a preservative used in some vaccines), a weakened immune
system (which may make attenuated live vaccines more risky), and
pregnancy.

The allergies to worry about, in particular, are those with an
anaphylactic or anaphylactoid reaction, e.g. hives, swelling of
mouth and throat, difficulty breathing, hypotension, or shock.

Q1.7    How common are the diseases vaccinated against?

I have extracted from table number 190, in _Statistical Abstracts of
the United States_, the following table, showing the frequency, in the
US, of some diseases for which vaccinations are either available and
diseases for which I knew a vaccine was being developed or researched
(obviously with more success in some cases than in others).  Table
information extracted from:

No. 190. Specific Reportable Diseases - Cases Reported: 1970 to 1990

Disease                  1970       1980       1983       1984    1985
AIDS                 (N/A)      (N/A)      2,117      4,445    8,249
Chickenpox (1000)        (N/A)    190.9    177.5    222.0    178.2
Diptheria            435    3    5    1    3
Hepatitis B (serum) (1000)    8.3    19.0    24.3    26.1    26.6
  A (infectious) (1000)        56.8    29.1    21.5    22.0    23.2
Measles (1000)            47.4    13.5    1.5    2.6    2.8
Meningococcal infections    2,505    2,840    2,736    2,746    2,479
Mumps (1000)            105.0    8.6    3.4    3.0    3.0
Pertussis (1000)        4.2    1.7    2.5    2.3    3.6
Plague                13    18    40    31    17
Poliomyelitis, acute        33    9    15    8    7
Rabies, animal            3,224    6,421    5,878    5,567    5,565
Rabies, human            3    _    2    3    1
Rubella (1000)            56.6    3.9    1.0    1.0    0.6
Tetanus                148    95    91    74    83
Tuberculosis (1000)        37.1    27.7    23.8    22.3    22.2
Typhoid fever            346    510    507    390    402

Disease                1986    1987    1988    1989    1990
AIDS                13,166    21,070    31,001    33,722    41,595
Chickenpox (1000)        183.2    213.2    192.9    185.4    173.1
Diptheria            _    3    2    3    4
Hepatitis B (serum) (1000)    26.1    25.9    23.2    23.4    21.1
  A (infectious) (1000)        23.4    25.3    28.5    35.8    31.4
Measles (1000)            6.3    3.7    3.4    18.2    27.8
Meningococcal infections    2,594    2,930    2,964    2,727    2,451
Mumps (1000)            7.8    12.8    4.9    5.7    5.3
Pertussis (1000)        4.2    2.8    3.5    4.2    4.6
Plague                10    12    15    4    2
Poliomyelitis, acute        8    6    9    5    7
Rabies, animal            5,504    4,658    4,651    4,724    4,826
Rabies, human            _    1    _    1    1
Rubella (1000)            0.6    0.3    0.2    0.4    1.1
Tetanus                64    48    53    53    64
Tuberculosis (1000)        22.8    22.5    22.4    23.5    25.7
Typhoid fever            362    400    436    460    552

Some estimates on the number of cases worldwide, drawn from several
articles in World Health Statistics Quarterly, 45, 1992:

Measles: 45 million cases and around 1 million deaths estimated in
developing countries in 1990. (Clements, Strassburg, Cutts, and Torel)

Polio: 16,435 cases reported by 46 countries to the Expanded Programme
on Immunization in 1990, a 39% decrease from 1989 when 26,916 cases
were reported. (Hull and Ward)

"Neonatal tetanus claimed the lives of over 433,000 infants in 1991.
It is endemic in over 90 countries throughout the world." (Whitman,
Belgharbi, Gasse, Torel, Mattei, and Zoffman)

Pertussis (whooping cough): 659,973 cases reported in 1987. (Galazka)

Q1.8    What percentage of children are vaccinated?

Some estimates of vaccination rates, from articles in World Health
Statistics Quarterly, 45, 1992:

Measles: About 80% of the world's children aged < 1 were reported to
have received measles vaccine (a dramatic increase from 1983, when the
figure was less than 20%).  (Clements, Strassburg, Cutts, and Torel)

Polio: Estimated vaccination rate of 85% worldwide in 1990.  This rate
isn't equally distributed, though.  The Western Pacific Region had a
coverage rate of 95%, and the South-East Asia Region 91%, but the
Africa Region had a coverage rate of only 56%. (Hull and Ward)

DTP: Varies widely from country to country.  The US, Canada, France,
Norway, Poland, Australia, China were among the countries with
coverage rates over 80% in 1987-1989.  (The article gives Yugoslavia
as also being in this category, but in view of the breakup of the
country and the civil war there, I would suspect that level hasn't
been maintained.)  England, Spain, Mexico, Turkey, and most of the
countries in South America, as well as the Soviet Union (now defunct)
were in the 50-80% category.  Sweden and many African countries had
coverage rates of under 50%.  Coverage rates in the WHO regions were
as follows: Africa 57%, Americas 75%, Eastern Mediterranean 80%,
South-East Asia 89%, Western Pacific 94%. (Galazka)

From _Statistical Abstracts of the United States, tables no. 189,
Percent of Children Immunized Against Specific Diseases, by Age Group:
1980 to 1985 (I am including the totals only, but the table also
includes a breakdown by race)

Disease                All Respondents
                1 to 4 years old
                1980    1984    1985
Diptheria-tetanus-pertussis    66.3    65.7    64.9
Polio                58.8    54.8    55.3
Measles                63.5    62.8    60.8
Rubella                63.5    60.9    58.9
Mumps                56.6    58.7    58.9

Disease                All Respondents
                5 to 14 years old
                1980    1984    1985
Diptheria-tetanus-pertussis    74.0    73.8    73.7
Polio                70.0    70.2    69.7
Measles                71.0    73.5    71.5
Rubella                74.0    72.4    70.2
Mumps                63.2    70.9    71.6

Respondents consulting records, 1985 (29 percent of white and 15
percent of black or other respondents who consulted records for some
or all vaccination questions)

Disease                1 to 4 years    5 to 14 years

Diptheria-tetanus-pertussis    87.0        93.0
Polio                75.7        88.4
Measles                76.9        87.4
Rubella                73.8        85.3
Mumps                75.5        87.1

According to the California Morbidity for May 21, 1993, about one third
of infants were found not to be vaccinated, and more than half of all
toddlers were behind schedule at their second birthday.  Vaccination
rates were lower among black and Hispanic children.  Only at school entry
age did vaccination levels really rise, the result of school
requirements.  By 1990, more than 90% of school age children were
vaccinated.  Immigration was cited as one factor keeping vaccination
rates low.

The May 1, 1994 HICNet Medical News, citing MMWR, reports on vaccination
coverage of 2 year old children in the US from 1992-1993,

     "Vaccination coverage increased for three vaccines from 1992 to 1993:
for three or more doses of Hib, from 28.0% to 49.9% (p <0.05); for three or
more doses of poliomyelitis vaccine, from 72.4% to 78.4% (p <0.05); and for
three or more doses of DTP/ diphtheria and tetanus toxoids (DT), from 83.0%
to 87.2% (p greater than 0.05). Coverage with measles-containing vaccine
decreased from 82.5% to 80.8% (p greater than 0.05). Among
19-35-month-olds, 12.7% had received three or more doses of Hep B.
     From 1992 to 1993, the proportion of children who had received a
combined series of four or more doses of DTP/DT, three or more doses of
polio vaccine, and one dose of MMR increased from 55.3% to 64.8% (p <0.05),
primarily because of increased coverage with the fourth DTP/DT dose (from
59.0% to 71.1% [p <0.05])."

(More details on these statistics in that issue of HICNet Medical News.)

Q1.9    What are some sources of further information about
vaccinations?

I don't have any addresses for information outside the US (except for the
WHO book on travel vaccinations); if people contribute them I'll add them.

Information on vaccinations is available from: The Academy of
Pediatrics, Committee on Infectious Diseases, Evanston, Illinois
60204; Centers for Disease Control, Atlanta, Georgia 30333; Council on
Environmental Health, American Medical Association, Chicago, Illinois
60610.

Not specific to vaccinations, but useful in general for the effects
of drugs, illnesses, etc., during pregnancy is the UCSD Teratogen
Registry (1-800-532-3749).  Another general source of information on
illnesses is the National Foundation for Infectious Diseases, 4733
Bethesda Ave., Suite 750, Bethesda, Maryland 20814 (USA).

Critics of routine vaccination have set up their own information
center; it is called the National Center for Information on Vaccination
and is based in Virginia.  Their telephone number is 1-800-909-SHOT.

Information on travel vaccinations is available from _Health Information
for International Travel_, published annually by the Centers for Disease
Control, and available from: Superintendent of Documents, US Government
Printing Office, Washington, DC 20402.  This publication also has a lot of
other information on health-related travel issues, and some information on
the regular childhood vaccinations as well (it also includes a table, for
all vaccinations, of which are contraindicated during pregnancy).  It is
also available in some public libraries. The CDC informs all state and many
city and county health departments twice monthly about changing risks and
requirements.  Another source is _INTERNATIONAL TRAVEL AND HEALTH:
Vaccination Requirements and Health Advice_, copies of which may be ordered
from WHO Distribution and Sales, CH-1211, Geneva 27, telephone
(41 22) 791 2476;  fax [phone].  (More sources of information
about travel vaccinations can be found in the section of this FAQ which
covers them.)

The reference section of this FAQ lists the sources I used in putting
together the FAQ.  Some of the ones I used most heavily include Harrison's
Principles of Internal Medicine, The Merck Manual, _Taking Care of Your
Child: A Parents' Guide to Medical Care_, by Pantell, Fries, and Vickery,
The Physician's Desk Reference, The American Hospital Formulary Service
Drug Information, and _The Wellness Encyclopedia_ From the editors of the
UC Berkeley Wellness Letter.  Here is a list of other people's suggestions
(to which people are welcome to add):

Robert Mendelsohn _How to Raise a Healthy Child_
George Wootan _Take Charge of Your Child's Health_

===============================================================================
Section 2. The recommended vaccination schedule

Q2.1    What is the recommended vaccination schedule in the US for
infants?

Recommended Age        Vaccine(s)    Comments
Newborn            Hepatitis B    Sometimes given at 2 months
2 mo            DTP,OPV,HbCV
4 mo            DTP,OPV,HbCV
6 mo            DTP (OPV), HbCV    (OPV optional except in
                    high-risk areas)
12 mo            TB skin test    Sometimes given at 15 months
15 mo            MMR
            DTP,OPV,HbCV    (At same time as MMR or 18 mo)
4-6 yr            DTP,OPV,MMR
14-16 yr        Td        (Repeat every 10 years for
                    lifetime)

DTP = Diptheria and tetanus toxoids with pertussis vaccine
OPV = Oral, attenuated polio vaccine
HbCV = Haemophilus influenzae type b polysaccharide vaccine,
conjugated
MMR = Live measles, mumps, and rubella in a combined vaccine
Td = Adult tetanus and diptheria booster

There is an alternate schedule for HiB vaccination: 2, 4, and 12 months,
for a different type of HiB vaccine.  Depending on whether hepatitis B
vaccine is started at birth or at two months, the schedule for that
vaccine is either birth, 1-2 months, and 12 months, or 1-2 months, 4
months, and 12 months.

There is a difference of opinion about when the second dose of MMR
should be given.  ACIP recommends 4-6 years, but the AAP recommends at
entry to middle or junior high school.  Health authorities in
different states in the US have adopted one or the other of these
requirements.  The advantage of giving the second dose at 4-6 years is
that compliance may be higher if it is made a requirement of entrance
to public schools.  The advantage of giving the second dose later is
that it will be closer in time to the age at which measles outbreaks
have been occuring, and may increase immunity at that time.

This schedule is subject to change, and so, if you look at different
medical and childcare books, you may see slightly different schedules.
Recent changes include the addition of a new vaccine for haemophilus
influenzae B, the addition of the hepatitis B vaccine to the schedule,
and the addition of a second dose of MMR at entry to primary or middle
school, in response to an increased incidence in measles among
teenagers.  A vaccine for chicken pox (not yet approved by the FDA)
may be added to the schedule soon, ppossibly combined with the MMR
shot.  The FDA did approve a couple of new vaccines in 1993 a
combination of Haemophilus influenzae B vaccine and DTP vaccine,
and a new dosage for the hepatitis B vaccine.  In 1992, a new acellular
pertussis vaccine was approved.

Q2.2    What is the recommended vaccination schedule in the US for
older children who were not vaccinated in infancy?

Schedules for people not vaccinated in infancy can be found, among
other places, in the Merck Manual and in AMA Drug Evaluations Annual.
There are two schedules, one for children under 7, and one for people
(children or adults) over 7.  The reason is that pertussis vaccine
should not be given to anyone over 7.  Pertussis is a mild disease
over the age of 7, but a serious one for the very young.  For that
reason, the risks of the vaccine outweigh the risks of the disease
after the age of 7.

Q2.3    What is the recommended vaccination schedule in the US for
adults?

If they haven't been vaccinated at all, see the answer to question
2.2.  If they have been vaccinated, then a tetanus and diptheria
booster is recommended every ten years (or five years in case of a
very dirty wound).  People in certain high risk groups are advised to
get flu shots annually (see the section on the flu vaccine).

Q2.4    Who determines this schedule?

Two bodies set these schedules.  They are the Immunization Practices
Advisory Committee (ACIP) of the Public Health Service, and the
American Academy of Pediatrics Committee on Infectious Diseases.

Q2.5    What vaccination schedules are used in other countries?

Routine vaccination is practiced in many countries, but specific schedules
vary from country to country.  The vaccine for tuberculosis is given in
some countries where tuberculosis is common, but is not given in the US.
Tetanus toxoid is given to pregnant women in countries where neonatal
tetanus is common.  Some countries, like the US, vaccinate all infants
against rubella, while others choose instead to vaccinate adolescent
girls.  Italy and Sweden do not routinely give pertussis vaccine to
infants (or at least they didn't when my source was written, in 1992)
(Galazka).  Germany, the former USSR, Ireland, Spain, and the United
Kingdom do use pertussis vaccine, but the rates of vaccination are lower
than in the US.

There is also some variation in the schedules at which vaccines are
given.  For example, schedules for DTP vaccine include 2, 3, and 4
months, or 3, 4, and 5 months, or 3, 5-6, and 7-15 months, and booster
doses are given in some countries at 12-14 months, and in some countries
at 3-6 years (Galazka - two charts in this article give DTP schedules for
various countries in Europe and percentages of countries following
different schedules in different regions of the world).

People outside the US are advised to consult their doctors about the
specifics of vaccination schedules in their countries (keeping
vaccination schedules for all the countries represented in misc.kids
current is probably too big a job for one FAQ maintainer).

Q2.6    What international bodies are concerned with vaccinations?

The World Health Service Expanded Programme on Immunization works to
increase the percentage of the world's children vaccinated against certain
target diseases: poliomyelitis, measles, tuberculosis, diptheria, and
tetanus.  The WHO/UNDP (United Nations Development Programme) Programme
for Vaccine Development promoted research into new and improved vaccines.
The Children's Vaccine Initiative, founded in 1990 by UNICEF, UNDP, the
Rockefeller Institute, the World Bank, and WHO, promoted new and better
vaccines for the world's children, cooperating with the Programme for
Vaccine Development and the EPI. (Hartveldt) WHO also has three centers
which cooperate with organizations in 79 countries to formulate the annual
flu vaccine. (Ghendon)

Archive-name: misc-kids/vaccinations/part2
Posting-Frequency: monthly
Last-Modified: August 8, 1994

===============================================================================
Section 3. Specific vaccines
-------------------------------------------------------------------------------
Section 3a. DTP (diptheria, pertussis, and tetanus) and DT

Q3a.1    What is diptheria, and what are the risks of the disease?

Diptheria is a contagious disease affecting the nose, throat, and
skin.  Complications include paralysis (about 20% of patients) and
heart damage (about 50%) (Pantell, Fries, and Vickery).  The Merck
manual has a very long list of complications, mostly involving the
heart, and says that complications are likely if antitoxin isn't
administered properly.  The death rate was 35% before antitoxin was
available, and is now 10% (Harrison).

Q3a.2    How common was diptheria before routine vaccination, and how
common is it now?

In 1900, there were 40.3 deaths per 100,000 population from diptheria
in the US.  There was a sharp decline in the number of deaths per 100,000
both before and after routine vaccination was instituted in the 1940s, and
in 1990 there were 4 cases of diptheria reported in the US. (_Historical
Statistics of the United States, Colonial Times to 1970_ and _Statistical
Abstracts of the United States_.

Q3a.3    How effective is the diptheria vaccine?

"The fatality rate in immunized populations is one-tenth that in the
unimmunized population.  Paralysis is 5 times and 'malignant' disease
15 times less common in immune than in nonimmune individuals."
(Harrison)

Q3a.4    How long does the diptheria vaccine last?

Ten years.

Q3a.5    What is pertussis, and what are the risks of the disease?

Pertussis, or whooping cough, is a very contagious disease of the
respiratory tract.  Its attack rate in unvaccinated household contacts
is over 90% (PDR) or up to 90 and in some cases 100% (Harrison).

Pertussis is very serious in children under 2, with a mortality rate
on about 1 to 2%. (Merck)  "Prior to the availability of a vaccine,
pertussis caused as many deaths as all other contagious disease
_combined_." (Harrison, p. 607)  Complications include various lung
complications (The Merck Manual has a long list of these), cerebral
complications, hemorrage into the brain, eyes, skin, and mucuous
membranes.  In addition to killing, it can leave surviving infants
with lasting lung damage and neurological diseases.

The mortality rate is higher in developing countries, partly because
children in these countries contract pertussis at a younger age (and
mortality is higher at younger ages), and partly due to an association
with protein-energy malnutrition (Galazka).  This same article estimated
that in the industrialized world, 0.04% of infected children die from
pertussis and complications, usually pneumonia  "Among vaccine-preventable
diseases, pertussis rivals measles and neonatal tentanus in importance
and severity in young children in developing countries and is third only
to measles and neonatal tetanus as a cause of death.  It is estimated
that pertussis is still causing some 340,000 deaths of children in the
world each year." (Galazka)

Q3a.6    How common was pertussis before routine vaccination, and how
common is it now?

"Since immunization against pertussis (whooping cough) became
widespread, the number of reported cases and associated mortality
declined from about 120,000 cases and 1,100 deaths in 1950, to an
annual rate of about 3,500 cases and 10 fatalities in recent years."
(PDR)  For unknown reasons, there has been an increase in the US recently.
"Over 6000 cases of pertussis were reported in the U.S.  in 1993, the
highest number in 25 years." (N Engl J Med 1994 Jul 7; 331:16-21,
summarized in Journal Watch for July 22, 1994.)

In some other countries, pertussis is more common (most of the following
information is taken from Galazka).  "Before the introduction of
widespread immunization of young children with pertussis vaccine, the
incidence rates in Europe and the United States were very high.  The
reported rates per 100,000 population ranged from 200-300 in England and
Wales and Sweden, to more than 1,000 in Denmark and Norway." (Galazka)
Annual incidence in the US and Canada before the introduction of pertussis
vaccine in the 1940s ranged from 98 to 210 per 100,000 population.  After
the introduction and widespread use of DTP vaccine, incidence declined
dramatically in most countries, and this trend continued for about 20
years. For example, in England and Wales, more than 150,000 cases of
pertussis were reported a year in the 1950s; by 1973, when vaccine
acceptance was over 80%, only about 2,400 cases were reported.

However, in the late 1970s and the 1980s, different trends began to
appear in different European countries.  In one group of countries,
reported incidence is between 10 and >100 per 100,000.  This group
includes Sweden and Italy, which don't routinely give pertussis vaccine
to infants.  It also includes Germany, the former USSR, Ireland, Spain,
and the United Kingdom, where infants are routinely vaccinated, but
coverage is less than 80%.  In Denmark, incidence is high despite high
coverage, but Denmark uses a different vaccination schedule from the
other countries.  Countries with a moderate reported incidence (between 1
and 10 per 100,000) include Austria, Finland, Greece, Israel, Norway, the
Netherlands, Portugal, Romania, and Yugoslavia.  Countries with a low
incidence (<1 per 100,000) include Hungary, Switzerland, Bulgaria,
Czechoslovakia, Poland, and Turkey.

Q3a.7    How effective is the pertussis vaccine?

It's one of the less effective childhood vaccinations.  The PDR
estimates its effectiveness at 70-80%.  It's effectiveness rating
depends on the severity of the cases of pertussis being observed.  One
study of 1797 households found the vaccine to be 64% effective against
a mild cough, 81% effective against a paroxysmal cough, and 95%
effective against severe clinical illness.  "Requiring laboratory
confirmation improved efficacy to 95 to 98% for culture-positive
children and to 77% to 95% for culture- or serology-confirmed cases,
depending on disease severity.  Vaccine efficacy for typical
paroxysmal cough increased from 44% for one diptheria, tetanus, and
pertussis vaccine to 80% for four or more doses." (Onorato, Wassilak,
and Meade)  The variation in estimates of efficacy may be because the
more severe cases were more likely to actually be pertussis, or it may
be that the vaccine protects better against severe pertussis than
against a mild form of the disease.

Q3a.8    How long does the pertussis vaccine last?

It doesn't.  According to _Harrison's Internal Medicine_, "the
protection ... is transient, with minimal resistance being evident a
decade later."  However, the critical years for pertussis immunity are
when a child is young; the disease is not dangerous for adults.

Q3a.9    What is tetanus, and what are the risks of the disease?

Tetanus is very dangerous.  Even with antibiotics, mortality can be 40%
or higher (Pantell, Fries, and Vickery, Harrison).  Tetanus bacteria and
its spores are everywhere.  Because tetanus is so ubiquitous, the only
way to counter it is widespread vaccination.

Q3a.10    How common was tetanus before routine vaccination, and how
common is it now?

300,000 to 500,000 cases are reported worldwide, with a mortality of about
45%.  In the US, there are about 100 cases a year, with a mortality of
40-60% (Harrison).

Q3a.11    How effective is the tetanus vaccine?

According to Taking Care of Your Child, "Tetanus is one of our best
immunizations.... Of all the vaccines available, tetanus comes closest
to 100 percent effectiveness after the initial series of shots."

Q3a.12    How long does the tetanus vaccine last?

Generally ten years.  In the case of a really dirty wound, a booster
is recommended if the person hasn't been vaccinated for tetanus within
the last five years.

Q3a.13    What are some of the risks of the DTP vaccine?

DTP is probably the most controversial of the childhood vaccines,
because of risks associated with its pertussis component.  Anecdotal
evidence has linked the vaccine with a variety of problems, including
convulsions, physical collapse, brain damage and SIDS.  Supporters of
the vaccine have argued that these problems are common in any case at
the age at which children are vaccinated for pertussis, and therefore
are not necessarily effects of the vaccine.

The association between DTP and SIDS has not been confirmed by further
study (see Q1.5 for a study which found the evidence to be against such an
association).  The story on brain damage is somewhat different.  Criticism
of the pertussis vaccine received some confirmation in 1976, when a large
British study of all children 2 to 36 months old in Britain found that 1
in 310,000 doses resulted in permanent brain damage.

Critics argue that the rate of complications from the pertussis
vaccine is too high, and the effectiveness too low.  Some argue that
the decline in pertussis cases in this century has been an effect more
of improved sanitation than of the pertussis vaccine.  The side
effects of this vaccine have inspired groups critical of vaccination
in several countries, including the US, where the group Dissatisfied
Parents Together (DPT) has lobbied Congress for changes to laws about
vaccination and set up its own vaccine information center.

Supporters of the pertussis vaccine differ in their response to the
British study which linked pertussis to brain damage.  Some say that
further analysis indicates that a link between the vaccine and brain
damage is not so clear.  "Meticulous reexamination of the data from this
study led to the conclusion that the preliminary results were due to a
systematic bias that favored finding an association between the vaccine
and serious neurological sequelae.  In fact, there was no valid evidence
from the study that the vaccine was associated with permanent
neurological damage." (Shapiro)

Some smaller studies done since the British study didn't find a connection
between DTP vaccine and neurological damage, and a new study was just
published in the Journal of the American Medical Association which finds
no increased risk of serious neurological illness.  I haven't seen the
article yet, so my information comes from the January 11, 1994 San Jose
Mercury (from the New York Times news service), which reports that the
study is in the current (as of 1/11/94) issue of JAMA.  According to the
article, "The federally financed study, the largest of its kind in the
United States, involved 218,000 children up to 24 months old in Oregon and
Washington who were studied for a one-year period, beginning Aug. 1,
1987." However, the study is also described as "not intended to give a
definitive answer to the question of whether whooping cough vaccine causes
neurological illness."

Others do not dispute the 1976 British study, but argue that a 1 in
310,000 risk of brain damage is still much smaller than the risk of
actually getting pertussis.  Supporters agree that it is important to
maintain high vaccination levels against pertussis, lest we see a
resurgence in the disease.  In Great Britain, Japan, and Sweden, there
were sharp increases in the number of cases of pertussis when vaccination
levels fell.  Routine use was discontinued in Sweden as a result of
reports of side effects, while acceptance in Great Britain declined to 30%
(Harrison), and vaccination declined in Japan as well.  "Within two years,
one hundred thousand cases (with twenty-eight deaths) appeared in Great
Britain and thirteen thousand cases (with forty-one deaths) in Japan.
Even in the US, the disease has by no means been wiped out; there are
still about fifteen hundred to two thousand cases (with four to ten
deaths) each year. That is why virtually all health care authorities
recommend that we keep using this vaccine." (UC Berkeley)

Known and non-controversial (i.e. everyone agrees that they occur) side
effects of DTP vaccine include redness and tenderness at the injection
site, fever, drowsiness, fretfulness, vomiting, and convulsions. (A
vaccine information pamphlet from Kaiser gave the frequency as being 1 in
100 to 1 in 1000 for crying without stopping for three hours or longer, a
temperature of 105 F or greater, or an unusual, high-pitched cry, and 1 in
1,750 for convulsions, generally from high fever, or shock collapse.  I
didn't see any frequencies in the PDR, other than describing these side
effects as rare.) It is a good idea to give acetaminophen to children
being vaccinated for pertussis, to reduce the chance of fever and febrile
convulsions.

From Mike Dedek:

*************************************************************************
American Journal of Diseases of Children 1992; 146: 173-176, February 1992,
"Pertussis outbreaks in Groups Claiming Religious Exemptions to Vaccinations",
Etkind, Lett, et. al.:

<my summary; 4 outbreaks between 1986 and 1988, although <= 1% of children
are not vaccinated, they provide pockets in which outbreaks can occur;
schools containing >2% non-vaccinated students are monitored>
<direct quote follows>:
 Key measures in preventing pertussis are immunization and judicious use of
 prophylactic antibiotics.  Pertussis can be prevented in children by
 immunization.  Unfortunately, controversy over the safety of the pertussis
 vaccine has reduced acceptance.  Highly publicized accounts of reactions to the
 vaccine and a dramatic increase in the number of malpractice lawsuits have made
 physicians and parents wary of using the diphtheria-tetanus toxoid and pertussis
 vaccine. {n4-n6} This publicity may have caused overinterpretation of the
 guidelines for medical contraindications. {n7} However, this overinterpretation
 creates its own risk for malpractice if a child given an inappropriate medical
 contraindication suffers damage due to disease.
*************************************************************************

Q3a.14    When is the DTP vaccine contraindicated?

Hypersensitivity to a vaccine component, including thimerosal, a
mercury derivative.  Defer vaccination in case of fever or acute
infection (but not nececcarily for a mild cold without a fever).
A history of convulsions is generally a contraindication to
pertussis vaccination, but "The ACIP and AAP recognize certain
circumstances in which children with stable central nervous system
disorders, including well-controlled seizures or satisfactorily
explained single seizures, may receive pertussis vaccine.  The ACIP
and AAP do not consider a family history of seizures to be a
contraindication to pertussis vaccine." (PDR)

The following reactions to a previous dose are contraindications:
An immediate anapylactic reaction.  Encephalopathy occuring within
7 days following DTP vaccination.  Precautions include a fever of
>= 40.5 C (105 F) within 48 hours, collapse of shocklike state
within 48 hours, persistent inconsolable crying for more than 3 hours
within 48 hours, convulsions with or without fever within 3 days.
(These  latter are precautions rather than contraindications, because
there might be circumstances, such as a pertussis epidemic, where you
would still want to give the vaccine.)

Pertussis vaccine should not be given to anyone over seven years old.

Vaccine components capable of causing adverse reactions: for diptheria,
thimerosal and toxoid; for tetanus, thimerosal and toxoid; for pertussis,
bacterial components (Travel Medicine Advisor).

Q3a.15    What are the advantages and disadvantages of the new acellular
pertussis vaccine?

The big advantage is that the acellular vaccine has fewer side effects.
There is still some uncertainty as to whether it is as effective.
Reports from Japan say that it is, but a Swedish clinical trial indicated
efficacy of 59% for one, and 64% for the other acellular vaccine.
However, even this trial did show >90% efficacy against severe
pertussis.  (Shapiro)  Further research is under way to establish how
effective the acellular vaccine is.

From Mike Dedek:

This next one indicates there's a better vaccine that may soon become
available:

*************************************************************************
In Pediatrics 1992; 89; 882-887, May 1992, "Acellular Pertussis Vaccination
of 2-Month Old Infants in the United States", Pichichero, Francis, et. at.:

ABSTRACT: This is the first study in children from the United States that
evaluates the immunogenicity of and adverse reactions to the Connaught/Biken
two-component acellular  pertussis  vaccine compared with whole-cell  pertussis
vaccine when given as a primary immunization series at 2, 4, and 6 months of
age.  Three hundred eighty infants were studied; 285 received acellular
diphtheria-tetanus toxoids- pertussis  (DTP (ADTP)) and 95 received whole-cell
DTP (WDTP).  Following the third dose, ADTP vaccination produced higher antibody
responses than WDTP to lymphocytosis-promoting factor (enzyme-linked
immunosorbent assay IgG geometric mean titer (GMT) = 131 vs 9 and Chinese
hamster ovary cell assay GMT = 273 vs 16) and to filamentous hemagglutinin (IgG
GMT = 73 vs 10) (all P < .0001).  Agglutinin responses were higher in WDTP
compared with ADTP recipients (GMT = 50 vs 37; P = .02).  Local reactions were
fewer for all three doses following ADTP vaccination.  Fever, irritability,
drowsiness, anorexia, vomiting, and unusual crying all occurred less frequently
in ADTP compared with WDTP recipients for one or more of the three doses.  We
conclude that this two-component ADTP vaccine when given as a primary series
produces greater immunogenicity and fewer adverse effects than the currently
licensed WDTP vaccine.

...A large case-control study
in Britain (National Childhood Encephalopathy Study) estimated that permanent
neurologic deficits may occur after its administration in 1 in 310000 doses
of WDTP.  However, a reanalysis of this and similar studies recently has led
to the widely held conclusion that a causal association between WDTP vaccination
and permanent brain damage has not been demonstrated....

*************************************************************************
Public Health Rep 1992; 107: 365-366, May 1992/June 1992, "FDA Approves New
Whooping Cough Vaccine"

    The Food and Drug Administration (FDA) has licensed a  new  whooping cough
 vaccine  that may cause fewer side effects in children.

    The  new vaccine  is being approved at this time only for the fourth and
 fifth shots.  The current vaccine will continue to be used for the first three
 shots.  Additional research has been undertaken to ascertain whether it will be
 effective for preventing  pertussis  when used for primary inmunization -- the
 first three shots -- in infants.

   The  new vaccine  is acellular, meaning that it is made from only part of the
 pertussis  organism, as opposed to the whole organism from which the current
 vaccine is derived.

   Whooping cough ( pertussis)  is a highly contagious disease.  As many as 90
 percent of nonimmune household contacts acquire the infection.  Since routine
 immunization against  pertussis  became common in the United States, the number
 of reported cases of disease and deaths from it has declined from about 120,000
 cases with 1,100 deaths in 1950 to an annual average in recent years of about
 3,500 cases with 10 fatalities.

   The  new vaccine  appears to be as effective in older children as the current
 vaccine and to cause fewer adverse reactions.  It has been widely used in Japan
 -- where it was developed -- with apparent success in children older than 2
 years.  It will be combined with diphtheria and tetanus toxoids (DTP) and sold
 under the brand name Acel-Imune.

   Gerald Quinnan, MD, acting director of FDA's Center for Biologics, where the
 vaccine was evaluated and licensed, said that the availability of an acellular
 vaccine is a significant step forward in infectious disease control.

  The most common adverse reactions seen in clinical trials of the acellular
 pertussis  vaccine included tenderness, redness, and swelling at the injection
 site, fever, drowsiness, fretfulness, and vomiting.

  The  new pertussis vaccine  component is produced by Takeda Chemical
 Industries Ltd. of Osaka, Japan, and is combined with diphtheria and tetanus
 toxoids manufactured by Lederle Laboratories of Wayne, NJ.  Lederle will also
 distribute the product in the United States.  The vaccine is administered by
 injection.

  The approval of the  new vaccine  comes at a time when the Federal Government
is emphasizing early childhood immunizations in the wake of the largest reported
measles outbreak in the nation in 20 years -- with more than 27,600 cases and 89
deaths reported in 1990.

  The aim is to reach a goal of full immunization for 90 percent of children by
 the time they are 2 years old.
*************************************************************************

Q3a.16    What are some of the risks of the DT (diptheria and tetanus)
vaccine?

Most of the risk in the DTP vaccine comes from its pertussis component;
the diptheria and tetanus vaccines are quite safe. Reactions to the
diptheria vaccine are quite rare.  Most reactions are local, limited to
swelling at the injection site.  The same is true of the tetanus shot.
"Severe local reactions can occur if too many shots are received; this
phenomenon was frequently seen in military recruits who received unneeded
immunizations." (Pantell, Fries, and Vickery)

Q3a.17    When is the DT vaccine contraindicated?

Should be avoided during the first trimester of pregnancy.  People
who have had a reaction (which is very rare) should avoid it.

Vaccine components capable of causing adverse reactions: for diptheria,
thimerosal and toxoid; for tetanus, thimerosal and toxoid (Travel Medicine
Advisor).

Q3a.18    Under what circumstances is tetanus toxoid given to pregnant
women?

Tetanus toxoid is given to pregnant women in countries where there is
a high risk of neonatal tetanus (due to factors which enhance the risk
of cord contamination in these countries).

===============================================================================
Section 3b. Polio

Q3b.1    What is polio, and what are the risks of the disease?

Polio is a contagious viral disease which crippled tens of thousands
in the 1950s, and killed more than a thousand a year.  Because it is a
mild gastrointestinal illness in young children and a serious
paralytic illness in older people, it had an unusual epidemiology,
with more cases of paralytic polio turning up in wealthy areas and as
sanitation improved.  80-90% of cases of polio are the minor illness;
the rest are paralytic poliomyelitis.  In paralytic poliomyelitis, <
25% suffer permanent severe disability, about 25% have mild
disabilities, and > 50% recover with no residual paralysis.  Mortality
is 1 to 4%.  "Recently, a post poliomyelitis syndrome has been
described, characterized by muscle fatigue and decreased endurance...
The syndrome occurs many years after an attack of paralytic
poliomyelitis..." (Merck).

Q3b.2    How effective is the polio vaccine?

The Merck Manual and the Physician's Desk Reference give its
effectiveness as 95%.  An article in a WHO publication (Hull and Ward)
estimates effectiveness at 80%.  (As with other WHO estimates, the
lower effectiveness rating reflects an estimate of effectiveness in
the field in a variety of countries, including countries in the Third
World.  Polio vaccine effectiveness can deteriorate if it is exposed
to too much heat, which can happen in vaccination programs in some
countries.)

Q3b.3    How long does the polio vaccine last?

It provides lifelong immunity.

Q3b.4    What is the difference between oral polio vaccine (OPV) and
inactivated polio vaccine (IPV)?

Oral polio vaccine provides better immunity, and is usually the
recommended form, "because induces intestinal immunity, is simple to
administer, is well accepted by patients, results in immunization of
some contacts of vaccinated persons, and has a record of having
essentially eliminated disease associated with wild poliovirus in this
country." (PDR)  However, it carries a small risk of paralysis (see
the answer to the next question for details).

Q3b.5    I've heard that it is possible to contract polio from handling
the diapers of recently immunized infants.  How long after receiving
the vaccine does the child's excrement continue to contain the virus?

*************************************************************************
From Caren Feldman:

> Speaking of this, I know there has been mention in the past of contracting
> polio from handling diapers of recently immunized infants.  Does anyone
> know how long after receiving the vaccine the child's excrement continues to
> contain the virus?  The reason I ask is because sean got his polio booster
> and Rachel has only received the first vaccine in the series.  The doctor's
> office said she wain no danger of contracting poliofrom him since they don't
> come in contact with each other *that* closely.  However, I have to be extra
> careful after helping Sean clean up (he needs help sometimes) or handling his
> underwear to make sure I wash my hands thoroughly.  So, how long until I
> can stop being paranoid about remembering to wash my hands after handling
> the laundry?  (I forgot to ask)
>
The short answer is 6 weeks. But since you brought up the subject...here's what
I fond out about polio immunizations:

When I had read one poster's response that the live polio virus from feces
was actually weakened virus that would in fact help immunize unimmunized kids
they'd come in contact with it, naturally I didn't believe it. Well, not at
first. But I had enough doubts of my disbelief to start asking around, and came
up with some (at least to me) little known facts about polio and polio
immunizations. I am presenting it to misc.kids for everyone's edification.

Indeed, live virus from a recently immunized child's feces is weakened virus
that health officials actually hope unimmunized kids  come in contact with to
provide them with individual immunity and the general population with "herd"
immunity.

Now here's the tricky part. One of the attenuated strains used to make the
vaccine has a very low but existing back mutation rate, back to the "wild
type", i.e. back to "regular" polio. If the weakened virus the child has been
given mutates back to wild-type polio, any adult with no immunity to it (or
an immunized adult for whom the immunization series did not "take") is
potentially at risk for full blown polio. Of course, people with weak immune
systems may be at risk even from  weakened virus. Steroid use may also cause
the immune system to weaken (besides the usual anti-rejection drugs, HIV,
leukemia) and thus increase susceptibility for contracting the virus.

Polio in young children manifests itself as a mild gastrointestinal ailment.
Polio in older children and adults starts as a mild gastroenteritis but with
complications that may lead to paralysis. Before the advent of improved public
sanitation, most young children were exposed to and probably contracted the
polio virus, so by adulthood, chances were everyone had immunity to it. It
was only when public sanitation improved to where exposure to the virus was
delayed until later childhood that polio epidemics became prevelant. Polio
outbreaks in the US were less frequent among poor children than among more
affluent families.

The CDC estimates the chances of getting polio from a first immunization (I
presume this means gastroenteritis symptoms in babies, not paralytic polio)
is one in half million. The chances of getting polio from subsequent
immunizations is 1 in 12 million. I assume the chances of secondarily
contracting polio from feces are even rarer.

These rare cases probably account for the supermarket tabloid (not to mention
"60 Minutes") stories of adults catching polio from recently immunized kids
who'd been given oral vaccine. For those in the US, you will be glad to
hear that a federal compensation program exists, called the National Vaccine
Injury Compensation Program, to help those stricken with paralytic polio as a
result of coming into contact with a recipient of the oral polio vaccine.


Thanks go to two posters on sci.med for answering my questions regarding this
subject.
*************************************************************************

The 1993 Physician's Desk Reference confirms Caren Feldman's account,
with two small modifications.  First, it gives the time when the virus
is shed as 6-8 weeks, rather than six.  Second, the CDC estimates which
she gives are the estimates for cases of paralysis in *both* vaccine
recipients and contacts of vaccine recipients combined, not for recipients
alone.

Q3b.6    What are some other risks of the polio vaccine?

A small risk of anaphylactic shock.

Q3b.7    When is the polio vaccine contraindicated?

Because of the small risk of paralytic polio in recipients and contact
of recipients of OPV, it should not be given to anyone who is
immune-compromised or who has immune-compromised family members.  (The
PDR has a really long list of immune deficiencies involved, which you
can check if you think anyone in your family falls in this category.)
In these cases, IPV should be given instead.  IPV is also recommended
for adults who are at risk for polio (such as unvaccinated adults
travelling to an area where polio is endemic).  Both vaccines are
contraindicated for people with an anaphylactic allergy to neomycin or
streptomycin.

Vaccine components capable of causing adverse reactions: for both OPV
and IPV, streptomycin, neomycin, and phenol red; for IPV, animal
protein, formaldehyde, and polymyxin B (Travel Medicine Advisor).

Q3b.8    Isn't it true that wild polio has been eliminated in the US?

From Mike Dedek:

*************************************************************************
>From The Reuter Library Report, 2/26/93, "U.N. Warns on need for Polio
Immunisation" copyright 1993 Reuters:

 The last  outbreak of polio  took place in the Netherlands 15 years ago. The
 virus was carried to Canada and the United States by infected people visiting
 their relatives, the WHO said. This caused the United States' last  polio
  outbreak  which hit the Amish community in the state of Pennsylvania in 1979.

*************************************************************************
>From The [London] Independent, 2/9/93, pg. 12, "Why child vaccines may be a
shot in the dark", by Tessa Thomas:

 After numerous  cases  in which the ''live'' oral  polio  vaccination was
 found to have caused the disease, the American government is considering
 reintroducing the inactivated injectable version. In the UK, the Department of
 Health advocates the live version on the basis that it deactivates any wild
 polio  virus that reaches the gut, preventing it being excreted into the
 community, thus conferring community protection. The injectable vaccine acts
 only on the bloodstream, protecting the individual but not breaking the chain of
 infection. Lobbying by the Association of Parents of Vaccine Damaged Children
 has prompted an acknowledgement by Virginia Bottomley, the Secretary of State
 for Health, that the live vaccine is responsible for 50 per cent of recent new
 cases of polio.  Between 1978 and 1991 there were 42  cases of polio,  18 of
 which followed vaccination and nine of which followed infection through contact
 with the vaccinated child.

*************************************************************************
The Atlanta Journal and Constitution, 12/19/92, "Cases in Netherlands put
Americas at risk for polio", by Steve Sternberg, Section E; pg. 1

  The last polio case in the Americas emerged on Aug. 23, 1991 in the remote
  Peruvian highlands village of Pichinaki...

*************************************************************************
UPI 12/10/92:

  Except for a few rare vaccine-associated  cases,  there have been no  cases
  of polio  in the United States since 1986 when there was one imported  case.
  The current vaccine, Sutter said, is close to 100 percent effective in
  preventing the disease.

*************************************************************************

Q3b.9    Why are we still vaccinating for polio, then?

The AAP and ACIP continue to recommend vaccination for polio for
several reasons.  First, the risk of the disease is much higher than
the risk of the vaccine.  Second, though there is no wild polio in the
US *now*, with high levels of vaccination, there is still polio
elsewhere in the world.  148,000 cases were reported to WHO in 1990.
China reported 5,065 cases.  The USSR reported 337 cases.  India
reported 7,340. (Hull and Ward)  There is a concern that if levels of
vaccination were reduced in the US, polio could be reintroduced, and
we could see polio epidemics here again.

Encouraged by the worldwide elimination of smallpox, WHO, in 1988, set
a goal of eradicating polio from the world by 2000.  Since then, the
number of cases in the world has declined dramatically (29,916 in 1989
and 16,435 in 1990), and the number of countries reporting 0 cases has
increased (74 countries in 1985 and 116 countries in 1990).  As of 1993,
the number of cases worldwide has falled to 9714, and nearly 70 percent
of all countries reported no cases. (Progress toward global eradication of
poliomyelitis, 1988-1993. MMWR 1994 Jul 15; 43:499-503.  Summarized in
Journal Watch Summaries for July 22, 1994.) So another factor in the
decision to continue vaccinating for polio is the hope that it can be
eliminated for good.

There has been some discussion in the US of the possibility of
switching to IPV instead of OPV for the second two doses (IPV being
less effective, but lower in side effects).  The decision to date has
been to continue with OPV because it has been so successful, the
rate of side effects is still considered very low, and because of
various advantages in producing immunity (see above).  According to
the 1993 PDR, "The choice of OPV as the preferred poliovirus vaccine
for primary administration to children in the United States has been
made by the ACIP, the Committee on Infectious Diseases of the American
Academy of Pediatrics, and a special expert committee of the Institute
of Medicine, National Academy of Sciences."

===============================================================================
Section 3c. MMR (measles, mumps, and rubella)

Q3c.1    What is measles, and what are the risks of the disease?

Measles is one of the most contagious infectious diseases. "A child can
catch measles by breathing the air in a doctor's waiting room two hours
after an infected child has left." (Fettner)  90% of susceptible
household contacts get the disease (Harrison).  Measles spreads very
rapidly in unexposed populations.  In 1951, it was introduced to
Greenland by a recently arriaved visitor who went to a dance as he was
coming down with it, and in three months it spread to more than 4000
cases and 72 deaths.  The attack rate was 999 cases per 1000 people. In
1875, measles was introduced to Fiji and killed 30 percent of the
population (Smith).

In areas where it was endemic, before the measles vaccine, measles
epidemics used to occur at regular intervals of two to three years,
usually in the spring, with small local outbreaks in intervening years.
Mortality is low in healthy, well-nourished children unless complications
ensue (Merck), but nevertheless there were 400 deaths a year before an
improved measles vaccine was introduced in 1966 (Pantell, Fries, and
Vickery).  Complications include brain infection, pneumonia, convulsions,
blindness, various bacterial infections, encephalitis, and SSPE (a fatal
complication which can occur years after a person has had measles).
Pregnant women who get measles have a 20% chance of miscarriage.

Worldwide, measles is one of the leading causes of childhood mortality.
"Measles has been called the greatest killer of children in history."
(Clements, Strassburg, Cutts, and Torel)  In 1990, "45 million cases and
around 1 million deaths were estimated to occur in developing countries.
Thus measles is still responsible for more deaths than any other EPI
target diseases. The true number dying as a result of measles may be
twice the estimated 1 million if the recently documented delayed effect
of the disease is taken into account." (Ibid.)  Mortality is higher in
developing countries due to a difference in the age at which most people
catch it (measles is a more dangerous disease in the very young), poorer
nutrition, less availability of treatment for bacterial chest infections,
and other environmental factors.  However, "Even in countries with
adequate health care and healthy child populations, the complication rate
can reach 10%." (Ibid.)

More information on the incidence of measles complications is found in
the answer to Q3c.2.

Q3c.2    How common was measles before routine vaccination, and how
common is it now?

*************************************************************************
From Anthony C.:

I havent finished reading this thread so pardon if someone else has
already posted this information

Rates of complications of measles and measles immunization
            Measles per 10^5 Vaccine per 10^5
Encephalomylelitis    50-400        .1
sspe            .5-2.0        .05-.1
Pneumonia        3800-1000
Seizures        500-1000    .02-19
Deaths            10-10000    .01

These statistics are worldwide, hence the variablility in numbers.  The
higher rates of pneumonia and death represent figures collected from
India, Nambia, Nigeria, bangladesh and other countries with developing
health care industries.

As far as the number of people afflicted with measles in the US
    Cases        Deaths
1963    385,566        364     Inactivated measles type vaccine available
1964    458,093        421
1966    204,136        261    public health administration of vaccine
1967    62,705        81
1968    22,231        24
.
.hovers around 20-70,000
.
1977    57,345        15
1978    26,871        11
1979    13,597        6
1980    13,506        11
1981    3,032        2
1982    1,697        2
1983    1,497        4
1984    2,587        1
1985    2,822        4
1986    6,273        2
1987    3,588         2
1988    2,933        not available
1989    16,236        41
1990    26,520        97

iMajor foci of retransmission barring the complete elimination of measles:
1) unimmunized indigent, inner city youngsters.
2) illegal aliens.

I hope this is useful.  My source is Zinsser microbiology, 20th edition
pages 1013-1015, joklik et al.
*************************************************************************

Q3c.3    How effective is the measles vaccine?

The Merck Manual and the Physician's Desk Reference estimate its
effectiveness at 95%.  This estimate is based on studies of the
immunity induced by a series of vaccinations beginning at 15 months.
Another article, estimating the immunity induced in field conditions
(including some Third World countries, which may have less reliable
vaccine storage) by a series of injections beginning at 9 months (the
injections are started earlier in areas where measles is widespread),
estimated effectiveness as 85% (Clements, Strassburg, Cutts, and
Torel).

Q3c.4    How long does the measles vaccine last?

The Merck Manual describes it as "durable."  The PDR says that all of the
antibody levels induced by MMR have been shown to last up to 11 years
without substantial decline, and "continued surveillance will be
necessary to determine further duration of antibody persistance."

Q3c.5    What are some of the risks of the measles vaccine?

There is a small chance of complications similar to the complications of
measles (pneumonia, encephalitis, SSPE).  Information on the frequency of
these complications is included in the answer to Q3c.2. There is some
risk of anaphylaxis for people allergic to eggs or neomycin.

Q3c.6    What is mumps, and what are the risks of the disease?

Mumps is a viral disease which is less contagious than measles or chicken
pox.  It causes swollen salivary glands.  The most common complication is
swelling of the testes (in about 20 percent of males post puberty) and,
less commonly, ovaries.  Rarely, it can lead to sterility.  Other
complications are meningitis (less common than in measles) and acute
pancreatitits.  (A much longer list of complications can be found in the
Merck Manual.)

Q3c.7    How common was mumps before routine vaccination, and how
common is it now?

105,00 cases were reported in 1970; by 1990 the rate of reported cases
was down to 5,300.

Q3c.8    How effective is the mumps vaccine?

The Merck Manual estimates its effectiveness at 95%.  The Physician's
Desk Reference gives its effectiveness as 96%.

Q3c.9    How long does the mumps vaccine last?

The Merck Manual describes it as "durable." "Mumps immunization provides
protection through the blood serum antibodies for at least 12 years, and
possibly much longer." (Pantell, Fries, and Vickery) (See also Q3.4 for
the PDR's description of the duration of all the MMR-induced antibodies.)

Q3c.10    What are some of the risks of the mumps vaccine?

"Rarely, side effects of mumps vaccination have been reported, including
encephalitis, seizures, nerve deafness, parotits, purpura, rash, and
prurittis." (Merck. Encephalitis and convulsions were also on Merck's
list of complications for mumps itself.)

Q3c.11    What is rubella, and what are the risks of the disease?

Rubella is a mild illness, consisting of a mild fever and rash.  Rare
complications include ear infections and encephalitis, but the real
danger is to pregnant women.  During the last rubella epidemic, in 1964,
20,000 children were born with birth defects caused by rubella.  Birth
defects include deafness, cataracts, microcephaly, and mental
retardation.  Children born with congenital rubella are als susceptible
to rubella panencephalitis in their early teens.

Q3c.12    How common was rubella before routine vaccination, and how
common is it now?

Before the development of the rubella vaccine, epidemics used to occur at
irregular intervals in the spring, with major epidemics at 6 to 9 year
intervals.  (This means that one was just about due when the vaccine came
out in 1969.) There have been no major epidemics since 1969, but the
number of cases of rubella and congenital rubella syndrome increased
starting in 1989 (Merck, also California Morbidity for November 19, 1993).
(It was still a small fraction of the pre-vaccine number, though, see table
of disease frequencies in section 1.)  "Serological surveys conducted in
the late 1970s and the 1980s indicated that 10 to 25 percent of United
States women of child-bearing age were shown to be susceptible to
rubella." (California Morbidity, November 19, 1993)  It now appears to be
declining again: "Following a resurgence of rubella and congenital rubella
syndrome (CRS) during 1989-1991, the reported number of rubella cases during
1992 and 1993 was the lowest ever recorded." (MMWR, cited in June 9, 1994
HICNet Medical News Digest.)

Q3c.13    How effective is the rubella vaccine?

The Merck Manual estimates its effectiveness at 95%.  The Physician's
Desk Reference gives its effectiveness as 99%.

Q3c.14    How long does the rubella vaccine last?

The Merck Manual describes it as "sustained." (See also Q3.4 for the PDR's
description of the duration of all the MMR-induced antibodies.)

Another reference, from Heather Madrone:

*************************************************************************
D. M. Horstmann "Controlling Rubella:  Problems and Perspectives"
_Annals of Internal Medicine_, vol. 83, no. 3, pg. 412

Horstmann found reduced antibody formation 3-5 years after administering
the vaccine and 25% of those tested showed no immunity to rubella at
all.
*************************************************************************

Q3c.15    What are the pros and cons of vaccinating all infants for
rubella versus vaccinating females only at puberty?

There is still some uncertainty about the most desirable rubella
vaccination policy.  In 1969, when the vaccine came out, it was decided
to avert the expected epidemic by vaccinating all children over one year,
so that they would not spread rubella to their possible pregnant mothers
- the first time one group of people was vaccinated to avoid having them
spread a disease to a different group of people.  Supporters of this
policy point out that the expected epidemic didn't occur.  The possible
disadvantage is that we aren't sure how long the immunity lasts.  Now
that generation of children is old enough to have children, and some of
them may no longer be immune.  In the past, 80% of the population was
immune due to having had rubella in childhood.

Some countries follow a policy of vaccinating girls at puberty if they
don't have rubella antibodies (Pantell, Fries, and Vickery).  The
disadvantage is that vaccine side effects are more common at this age.
The most common is joint pain, which occurs in 10% of women who are
vaccinated in adolescence or later.  In some cases, it has lasted as long
as 24 months.  (Pantell, Fries, and Vickery) The PDR describes this same
side effect in somewhat milder terms, saying that it generally does not
last very long and "Even in older women (35-45 years), these reactions are
generally well tolerated and rarely interfere with normal activities." It
does agree with Pantell, Fries, and Vickery that the incidence of this side
effect increases with age: 0-3% of children and 12-20% of women have joint
pain, and the pain is more marked and of longer duration in the adult
women.  A few women (between 1 in 500 and 1 in 10,000) experience
peripheral neuropathy (tingling hands).  Another risk of vaccinating later
is the risk that a woman may be pregnant.  So far, no connection with
birth defects has been demonstrated, but women are advised to avoid
pregnancy for three months after getting the vaccination.

Current US policy is to vaccinate all children at 15 months, and give a
booster during school years.  Adult women are advised to get an antibody
test before becoming pregnant, and, if it comes up negative, get
vaccinated and wait three months before getting pregnant.

There has not been a rubella epidemic since 1964, either in countries
which vaccinate all children at 15 months, or in countries which
vaccinate girls only at puberty.

Q3c.16    What are some of the risks of the rubella vaccine?

The PDR has a long list of possible adverse reactions (besides arthritis
and arthralgia, usually short-lived, see above).  Most of them are either
mild or rare.

Q3c.17    When is the MMR vaccine contraindicated?

People with an anaphylactic or anaphylactoid allergy to eggs or neomycin
should not get the vaccine.  Other allergies or chicken or feather allergies
are not a contraindication.  Vaccination should be deferred in case of
fever.  The PDR give active untreated tuberculosis as a contraindication,
but the AHFS says that there is no evidence of a need to worry about TB.
Both give immune deficiency as a contraindication (see PDR for a long
list of immune deficiencies involved).  Immune globulin preparation or
blood/blood product received in the preceding 3 months.  The same
contraindications apply individually to measles and mumps vaccines, but
the rubella vaccine can be given by itself to people with an anaphylactic
egg allergy.  The other contraindications still apply to the rubella
vaccine alone.  (California Morbidity, October 31, 1987)

Vaccine components capable of causing adverse reactions: for mumps
and measles, chick fibroblast components; for mump, measles, and
rubella, neomycin (Travel Medicine Advisor).

===============================================================================
Section 3d. HiB (Hemophilus influenze B)

Q3d.1    What is hemophilus influenze B, and what are the risks of the
disease?

HiB is a bacteria which is one of the leading causes of meningitis in
young children.  About 60% of cases are meningitis.  The remaining 40%
are cellulitis, epiglottis, pericarditis, pneumonia, sepsis, and septic
arthritis.  Mortality rate can be about 5%, and there are neurologic
sequelae in up to 38% of survivors.

Q3d.2    How common was HiB before routine vaccination, and how
common is it now?

Before routine vaccination, about 12,000 cases a year in the US, with a
cumulative risk of 1 in 200 that a child would get the disease by age 5.
A vaccine was introduced in 1985.  Since the introduction of the Hib conjugate
vaccine in 1988, the race-adjusted incidence of Hib among children less than 5,
has declined from 41 cases per 100,000 in 1987 to two cases per 100,000 in
1993.  (The incidence for people five or older remained stable.  Hib is most
serious in children under 5.)  (A decline of 95%, despite the fact that the
National Health Interview Survey showed only 67% of children 12-23 months
had received at least one dose, and 36% three or more doses.  This decline
is attributed to the elimination of carriage, which reduces Hib exposure
even in unvaccinated children.) The CDC has a goal of eliminating Hib in
the US by 1996.  (HICN708 Medical News, "[MMWR] Progress Elimination
Haemophilus influenzae type b")

Q3d.3    How effective is the HiB vaccine?

Estimates from different labs vary a lot.  AHFS Drug Information,
after noting this variability, and the uncertainty as to what antibody
level is adequate for protection, says that in one study, 75% of
children 18-23 months and 85% of children 24-29 months had serum
anticapsular antibody levels of one microgram per milliliter or
greater.  The PDR lists numerous studies, with results ranging from
100% efficacy to one study in which vaccinated children had more cases
of HiB than the unvaccinated group.  With the exception of the latter
study, all of the studies showed significant positive results, often
with efficacy estimates over 90%.

According to a NY Times article of 12/18/90, HiB vaccine produces
lower antibody response among Native Americans, but the new conjugated
vaccine seems to produce higher antibody response in Native  American
children and may protect all children at a younger age.

Q3d.4    How long does the HiB vaccine last?

The duration of immunity is unknown.  However, the disease is only
dangerous to very small children.

Q3d.5    What are some of the risks of the HiB vaccine?

In a study of 401 infants, fever occurred in 2%, and redness, warmth, or
swelling in 3.3%.  All adverse reactions were infrequent and transient.
(PDR)

Q3d.6    When is the HiB vaccine contraindicated?

Hypersensitivity to any component of the vaccine, including diptheria
toxoid and thimerosal in the multi-dose presentation.

Vaccine components capable of causing adverse reactions: phenol,
bacterial polysaccharides, thimerosal (Travel Medicine Advisor).

Q3d.7    What about rifampin prophylaxis?

An alternative to HiB vaccination is rifampin prophylaxis, but it
could be unwieldy to administer.  AHFS Drug Information says that it
is "effective for eradicating nasopharyngeal carriage of HiB, but the
efficacy of the drug for prevention of secondary disease has not been
firmly established."

===============================================================================
Section 3e. Hepatitis B gamma globulin and hepatitis B vaccine

Q3e.1    What is hepatitis B, and what are the risks of the disease?

There are several forms of hepatitis, infections of the liver which
cause jaundice, nausea, and weakness.  Hepatitis B is spread mainly by
contact with infected blood and by intimate contact with bodily fluids,
such as in sexual intercourse and childbirth.  However, the hepatitis
B virus is far more resilient than, for example, the AIDS virus, and
the disease is not strictly a venereal disease, and can be caught even
by people who are not sexually active.  Hepatitis B becomes chronic
in 5-10% of those infected.  Complications include hepatic necrosis,
cirrhosis of the liver, chronic active hepatitis, and hepatocellular
carcinoma.  Hepatitis B is endemic throughout the world, and a serious
problem in groups at increased risk.  Information about hepatitis B
is available by calling 1-800-HEP-B-873.  Another source of information
about hepatitis B and many other forms of liver disease is:

           American Liver Foundation
           1425 Pompton Avenue
           Cedar Grove, NJ  07009

Hepatitis B should not be confused with hepatitis A, which is more
contagious but less serious.  Hepatitis A is spread through contaminated
food and water.  Symptoms can be mild flulike symptoms or severe nausea
lasting for weeks.  Hepatitis A does not become chronic and is rarely
fatal.

Q3e.2    How common is hepatitis B?

"The estimated lifetime risk of HBV infection in the United States
varies from almost 100% for the highest risk groups to approximately
5% for the population as a whole." (PDR)  The CDC estimates about
0.75 - 1 million chronic carriers in the US, and more than 170 million
are estimated worldwide.

Q3e.3    What is hepatitis B gamma globulin, and when is it given?

It is given to people who have already been exposed to hepatitis B, to
boost their immunity.  In particular, it is given to children born to
mothers with hepatitis B.  It should be given as soon as possible
after birth for the best results.

Q3e.4    How long does the immunity provided by hepatitis B gamma
globulin last?

Two months, maybe longer.

Q3e.5    What are the risks and contraindications of hepatitis B gamma
globulin?

No known contraindications.  A couple of diseases (see PDR for more
information) are listed under precautions (a weaker form of warning than
contraindication - in the case of precautions gamma globulin may be given,
but the extra risks of giving the gamma globulin have to be weighed against
the benefits).  These diseases, though, aren't ones a newborn is likely to
have, so they would probably not apply in the case of giving it to
the newborn of a mother infected with hepatitis B.

Q3e.6    How effective is the hepatitis B vaccine?

It varies depending on the age, sex, and general health of the
recipient.  About 96-100% in infants and children 19 and under, 94-99%
in adults 20-39, 88-91% in adults 40 or older.  May be lower in men
than women.  Lower (only 64% in one study) in hemodialysis patients.
(AHFS Drug Information 1992)  The PDR estimated 95-96% for infants,
and agrees with AHFS about the conditions which reduce effectiveness.

Q3e.7    How long does the hepatitis B vaccine last?

There is evidence that immunity lasts up to ten years, but beyond that,
the duration is uncertain, and the need for booster doses not defined.
(My source for the duration is Journal Watch, 9/1/93.)

Q3e.8    What are some of the risks of the hepatitis B vaccine?

"During clinical studies involving over 10,000 individuals distributed
over all age groups, no serious adverse reactions attributable to vaccine
administration were reported." (PDR)  The most common adverse reactions
were injection site soreness (22%) and fatigue (14%).  A longer list of
adverse reactions can be found in the PDR.

Q3e.9    When is the hepatitis B vaccine contraindicated?

Sensitivity to yeast or any other component of the vaccine.
Pregnancy is not a contraindication to hepatitis B vaccination.

Vaccine components capable of causing adverse reactions: aluminum
phosphate, thimerosal, and formaldehyde (Travel Medicine Advisor).

Q3e.10    Why did the ACIP and AAP change their recommendation about the
hepatitis B vaccine?

Up until 1992, the recommendation was that hepatitis B vaccine be given
only to people in high risk groups for hepatitis B: people whose
professions exposed them to blood, people at extra risk due to their
sexual practices or intravenous drug use, and certain populations (such
as Southeast Asian immigrants) with a high incidence of the disease.  The
chief reason was cost; it was felt to be not cost-effective to vaccinate
low-risk groups.

Unfortunately, this policy was not successful in checking the spread of
hepatitis B.  It proved difficult to identify high-risk people, and
high-risk people did not volunteer in large numbers to be vaccinated.
For this reason, in 1992, the ACIP recommendation was switched to
vaccination of teens and adults in high-risk groups and universal
vaccination of infants.  The AAP made a similar recommendation but would
also like to extend hepatitis B vaccination to all adolescents, if possible.

The American Liver Foundation also supports hepatitis B vaccination of
infants, and their pamphlet on the subject suggests a variety of ways
in which even young children could come in contact with the virus (through
contact with blood, etc.).  Though young children are at low risk of
catching hepatitis B, their risk of developing the chronic form of the
disease if they do catch it is higher than for adults.

The new policy was well-received internationally, and 30 countries now
have universal infant HBV vaccination programs.  Many physicians remain
skeptical, however, and a survey in North Carolina showed one third of
pediatricians and <20% of family physicians supporting the new guidelines
(Journal Watch).

Why the resistance? One reason is a reluctance to give low-risk infants
yet another vaccination.  Another is doubt about the duration of HBV
vaccine.  There is evidence that it lasts up to 10 years, but we do not
know yet whether it wears off beyond that point.  There is concern that
infants vaccinated for HBV may lose immunity during adolescence, when the
risk of catching the disease is greatest.  An alternative would be to
vaccinate all children at age 10 and give a booster at age 20.  But
compliance would likely be lower at age 10 than in infancy.  Hepatitis B
vaccine is administered in three shots over the course of six months, and
it would be difficult to get preteens to all come in for the full series.
Also, 8% of hepatitis B infections occur before age 10, and the deadly
form is three times greater in children (NY Times, 3/3/93:B8).  Boosters
could be given later to infants vaccinated for HBV if immunity proves to
lapse.

Hepatitis B vaccine is also often recommended for travel purposes.

Q3e.11  Does vaccination for hepatitis B affect one's ability to
donate blood?

*************************************************************************
From Gregory Froehlich, MD (from a posting to sci.med):

First, hepatitis B *antigen* is used to make Hep B vaccine.  The
antigen is grown in yeast culture; formerly, it was purified from the
blood of people who were chronic hepatitis carriers. Antibodies are
used in the gamma globulin shots used for hepatitis A or for passive
immunization against hepatitis B if you're exposed.

The local blood bank does not specifically test for exposure to
hepatitis A (the kind you'd get from contaminated water).  If a person
has an active hep A infection, it will be picked up by elevated liver
enzymes; if the person had such an infection in the past, it's over and
done with--hep A doesn't give you a chronic, subclinical infection.
Antibodies to hepatitis A should not preclude blood donation.

They check for chronic hep B carriers by testing for hep B surface
antigen.  They test for recent hep B infection by testing for hep B
core antibody.  This antibody does not carry disease, but rather
indicates that the person was recently infected and might or might not
still be infectious.  They do not test for surface *antibody*, which
would indicate either (a) former hep B infection which was cleared, or
(b) immunization against hep B--in either case, not infectious.  I've
got hep B surface antibody, because I was immunized; I can still donate
blood.

Blood banks also test for hepatitis C antibody; people with this
antibody can still be infectious.
*************************************************************************

Q3e.12  Do people who have showed up positive on the blood banks' tests
for hepatitis B exposure still need to be vaccinated?

It is still useful to be vaccinated, because some of the people who show
up positive on the blood bank tests are false positive.

Q3e.13  I will be travelling to an area where hepatitis B shots are
recommended, but I have less than six months before I leave.  Is there
an accelerated schedule for hepatitis B vaccination?

_Travel Medicine Advisor_ lists an accelerated schedule, with 3 doses
at 0, 30, and 60 days.  With this schedule, a fourth dose is recommended
at 12 months if there is still a risk for hepatitis B exposure.

Archive-name: misc-kids/vaccinations/part3
Posting-Frequency: monthly
Last-Modified: August 8, 1994

===============================================================================
Section 3f. Influenza

Q3f.1    What is influenza, and what are the risks of the disease?

Influenza has a fairly high mortality rate among the elderly and the
chronically ill.  Complications include pneumonia, neurological
complications, myocardia, heart block, and peripheral vasoconstriction.

Q3f.2    How common is influenza?

Outbreaks of flu occur almost every year, generally in the winter,
and can cause thousands to be hospitalized.

Q3f.3    How effective is the influenza vaccine?

About 70-80%.

Note that influenza vaccine protects against influenza only, and not
against other respiratory infections.

Q3f.4    How long does the influenza vaccine last?

It has to be repeated every year, as the strains of influenza vary
from year to year.

Q3f.5    What are some of the risks of the influenza vaccine?

Public confidence in flu shots was reduced by the swine flu controversy
of 1976-9177.  Of the nearly 48 million people who were vaccinated
that year, about 500 came down with a rare paralytic condition called
Guillaine-Barre syndrome.  This was many more than could normally be
expected to come down with this disease (though still a small percentage
of all the vaccinated people).  After this year, there were changes to
the vaccine, and medical sources (Berkeley, PDR) report that the vaccine
has not been clearly associated with Guillaine-Barr syndrome since that
time.

Adverse reactions include local tenderness, and, infrequently, fever,
"most often [affecting] people who have had no exposure to the
influenza virus antigens in the vaccine (e.g. small children)." (PDR)
Allergic reactions also occur.

Q3f.6    When is the influenza vaccine recommended?

It is recommended for people who are over 65 and for people with
various chronic illnesses, particularly those affecting the lungs
(including asthma) or the heart.  Candidates among children include
similar groups to those for pneumococcal vaccine: sickle cell, chronic
renal and metabolic disease, diabetes, chronic pulmonary disease,
long-term aspirin therapy, and significant cardiac disease (Catalana).

In the US, the rate of vaccination for influenza in the groups for
whom the vaccine is recommended is only 20%.  Among children, the
rate is 1-7% (Catalana).

The antiviral drugs amantadine and rimantadine are also effective against
influenza A, but not influenza B.

Q3f.7    When is the influenza vaccine contraindicated?

Egg allergy, hypersensitivity to thimerosal.  Delay in case of an
active neurological disease or fever. (PDR)  The AHFS gives the
same contraindications, but adds a history of Guillaine-Barre
syndrome and bleeding disorders which would contraindicate
intramuscular injection.

Vaccine components capable of causing adverse reactions: chick embryo
components, formaldehyde, thimerosal (Travel Medicine Advisor).

Q3f.8    Is it OK to be vaccinated for influenza during pregnancy?

It depends.  When this topic has come up on misc.kids, people have
reported different recommendations from their doctors.  And, when I
consulted the PDR, I found the same result: the PDR says that the
risks of the vaccine (especially during the first trimester) have to
be weighed against the risks of a particular patient getting the flu,
and that "The clinical judgment of the attending physician should
prevail at all times in determining whether to administer the vaccine
to a pregnant woman."

===============================================================================
Section 3g. Pneumococcal vaccine

Q3g.1    What is pneumococcal disease, and what are the risks of the
disease?

It causes ear infections and sinusitis in children, and sometimes
meningitis and pneumonia.

Q3g.2    How common is pneumococcal disease?

>From Nelson Textbook of Pediatrics, Behrman and Vaughn, eds.,14th edition,
1992:

Pneumococcus (_Streptococcus pneumoniae_) is a normal inhabitant of the
upper respiratory tract (as many as 91% of children between 6 mo and 4
1/2 yr of age carry this bacterium at some time). Pneumococcus is the most
common cause of bacteremia (bacteria in the blood), bacterial pneumonia,
and bacterial otitis media (middle ear infections). Pneumococcus causes
25-30% of acute middle ear infections. It is also high on the list for
bacterial causes of meningitis.

Q3g.3    How effective is the pneumococcal vaccine?

It protects against 23 strains of pneumococcus, 85% of those which cause
ear infections and almost all of those which cause pneumonia and
meningitis.

Q3g.4    How long does the pneumococcal vaccine last?

According to a chart I got from Kaiser, one dose is good for life,
except for immune suppressed or immunodeficient patients, who should get
a booster two years later.  _Travel Medicine Advisor_ also says that
no booster is required.  _AHFS Drug Information_, however, says that
antibodies are elevated at least five years in healthy adults, but
decline to prevaccination levels after ten years in some (if anyone
can clarify this apparent contradiction in my sources, let me know).

Q3g.5    What are some of the risks of the pneumococcal vaccine?

Discomfort at injection in 30-40% of recipients, and fever in 5-20% of
recipients. (Catalana)

Q3g.6    When is the pneumococcal vaccine recommended?

It is recommended for children 2 or older who are at increased risk of
pneumococcal infection.  Conditions which increase risk of pneumoccoal
infection include HIV positive status, functional or anatomic asplenia,
and sickle cell or other hemoglobinopathies.  It is also recommended for
adults 65 or older and adults with significant cardiovascular or
pulmonary disorders, splenic dysfunction, asplenia, Hodgkin's Disease,
multiple myeloma, cirrhosis, alcoholism, renal failure, CSF leaks, or
immunosuppressive conditions.

Work is underway now to develop and test a pneumococcal conjugate vaccine
(analogous to the HiB conjugate vaccine) to allow immunization of those
younger than 24 months (which is the age group most affected by S.
pneumoniae). This might open up a new indication for pneumococcal vaccine:
prevention of middle ear infections.

Q3g.7    When is the pneumococcal vaccine contraindicated?

It should not be given to children under 2.  It also shouldn't be given
to people who have already been vaccinated.

Vaccine components capable of causing adverse reactions: phenol,
polysaccharides, thimerosal (Travel Medicine Advisor).

===============================================================================
Section 3h. Meningococcal vaccine

Q3h.1    What is meningococcal disease, and what are the risks of the
disease?

Meningococcal disease is a rare disease which causes meningitis as well
as widespread blood infection, leading to shock and death.

Q3h.2 How common is meningococcal disease?

About 2,500 cases a year in the US.

Q3h.3    How effective is the meningococcal vaccine?

I don't have this information.

Q3h.4    How long does the meningococcal vaccine last?

I don't have this information.

Q3h.5    What are some of the risks of the meningococcal vaccine?

Adverse reactions are infrequent and mild, mostly redness at the
injection site for 1-2 days.  Up to 2% of children vaccinated will
experience transient fever (Health Information for the International
Traveller, 1992).

Q3h.6    When is the meningococcal vaccine recommended?

For children with certain types of immune disorders and during epidemic
outbreaks.  It is also given to children travelling to certain areas,
and is required for pilgrims to Mecca for the annual Haj (as of 1992,
according to the CDC).

Q3h.7    When is the meningococcal vaccine contraindicated?

I haven't found any, except pregnancy (when it should be given only
in case of an outbreak).

Vaccine components capable of causing adverse reactions: phenol,
polysaccharides, thimerosal (Travel Medicine Advisor).

===============================================================================
Section 3i. Varicella (chicken pox) vaccine

Q3i.1    What is chicken pox, and what are the risks of the disease?

Complications are rare in normal children, but more common in children
with immune deficiencies.  The disease is somewhat more severe in
adults, and can be serious for newborns and pregnant women.  Possible
(infrequent) complications include hemorrhagic varicella, encephalitis,
pneumonia, and bacterial skin infection.  Possible complications in
pregnancy include premature birth and congenital varicella, and mortality
(of the infant, not the mother) is high.  "It is estimated that there are
about 9,600 chicken-pox related hospitalizations annually, with 50 to
100 deaths." (FDA announcement, January 28, 1994)

A study of the effects of congenital varicella and herpes zoster (Enders G;
et al. Consequences of varicella and herpes zoster in pregnancy: prospective
study of 1739 cases.  Lancet 1994 Jun 18; 343:1548-51., summarized in Journal
Watch Summaries for July 1, 1994.) followed 1373 women with varicella and 366
women with herpes zoster acquired during the first 36 weeks of pregnancy.
Nine of the infants had congenital varicella syndrome, with defects ranging
from "multisystem involvement to limb hypoplasia and skin scars."  There were
no cases of congenital varicella syndrome among infants whose mothers had
varicella after 20 weeks or among those whose mothers received anti-varicella-
zoster immunoglobulin after they were exposed.

Q3i.2    How common is chicken pox?

Over the past decade, about 177 to 222 thousand people a year got it
in the US.  It's one of the most contagious diseases known, and most
people get it while growing up.  33% of cases are estimated to occur
in children ages 1 to 4, and 44% in children ages 5 to 9 (estimates
from January 28, 1994 FDA announcement).

Q3i.3    When will the chicken pox vaccine be available?

Sometime soon; estimates keep changing.  In the fall of 1993, an article
in the San Jose Mercury predicted it would be available March-April 1994,
but in January 1994, a San Francisco Chronicle article predicted summer
of 1994.  On January 27, 1994, an advisory committee to the FDA concluded
"that an experimental chickenpox vaccine is safe and effective but advised
FDA to look into several issues before making a final decision on
approval."  Questions remaining included "whether the vaccine provides
long-term immunity; whether extensive vaccinations in children will
shift the disease to adults where it is more severe; whether to give
children one inoculation or two; and whether chicken pox immunizations
should be given simultaneously or with other vaccines.  Another question
about the vaccine is how it will affect the occurrence of shingles, a
painful rash caused when the chickenpox virus continues to live within
its victims and resurfaces in nerve endings later in life." (January 28,
1994 FDA announcement)  The committee's recommendation isn't binding on
the FDA.

Q3i.4    Will the chicken pox vaccine be part of the regular schedule
of vaccinations?

Possibly.  It may be combined with the measles, mumps, and rubella
vaccine.

Q3i.5    Will older children who have not had chicken pox be able to
get the chicken pox vaccine?

*************************************************************************
From Andy Spooner, MD:

This from "Pediatric Notes: the Weekly Pediatric Commentary" by Sydney
S. Gellis, MD:

"In anticipation of the approval by the FDA of the chicken pox vaccine,
the ACIP [Advisory Committee on Immunization Practices] will be
recommending the vaccine at 12-18 months and for all older susceptible
children (those with no history of chicken pox) at ages 18 months to
12 years (at entry to day care, or to elementary school, or during the
middle school years). (Marwick C. Journal of the American Medical
Association 270: 2154, Nov 10, 1993)"

There has been some discussion in this group about varicella (chicken
pox) vaccinations for older children.  I surmise from the above that
the vaccine will be offered to older children as well as the 12-18
month age range.

*************************************************************************

Q3i.6    Will adults be able to get the chicken pox vaccine?

It might be limited to immune-compromised adults for reasons of cost.
Health care workers without previous history of chicken pox would also be
good candidates for this vaccine. For example, nurses with no history of
chicken pox must routinely take two weeks off work if they are exposed.
This creates problems which could be avoided if the vaccine were
available.

Q3i.7    How effective is the chicken pox vaccine?

95-100% effective in healthy children.  Lower in children with
leukemia, but a second dose can bring effectiveness to 90%. (Catalana)

Q3i.8    How long does the chicken pox vaccine last?

We don't know yet.

Q3i.9    What are some of the risks of the chicken pox vaccine?

Mainly, the risk that it will wear off.  Chicken pox is more serious
in adults than in children.  The vaccine itself is very well
tolerated.  About 5% of recipients get a chicken pox rash.  The
incidence of herpes zoster isn't any higher than in those who haven't
been vaccinated. (Catalana)

Q3i.10    For which groups is the chicken pox vaccine especially
recommended?

People with HIV, nephrosis, severe asthma, and similar chronic
diseases, but especially leukemia.  Conditions for vaccination of
leukemic children are: remission for at least a year, off maintenance
therapy for a week before and a week after getting the vaccine, and
cellular immunity intact. (Catalana)

Q3i.11    When is the chicken pox vaccine contraindicated?

I haven't found any contraindications yet.  (Contributions are
welcome.)

Q3i.12    Is there a gamma globulin for chicken pox?

Yes, but it is only available to people at especially high risk from
chicken pox.  It needs to be given within 72 hours of exposure.  More
common on misc.kids is the concern of adults who haven't had chicken pox,
but aren't otherwise at high risk from exposure.  The varicella immune
globulin isn't likely to be available to these people, but something else
is available: acyclovir.  This antiviral drug will lessen the severity of
chicken pox if it is given promptly, as soon as the rash first begins to
appear.

===============================================================================
Section 3j. BCG (tuberculosis) vaccine

Q3j.1    What is tuberculosis, and what are the risks of the disease?

Tuberculosis is a chronic bacterial infection that is spread by inhaling
droplets sprayed into the air by someone infected with TB (it can also be
spread through unpasteurized milk).  It isn't as contagious as a cold
(you need to inhale a higher concentration of the droplets to catch it).
The disease most commonly affects the lungs, the bones of the spine or
large joints, and the kidneys, but can reach almost any organ of the body.

Q3j.2    How common is tuberculosis?

In 1930, mortality was 101.5 per 100,000 population in the US.  It
declined steadily, and in 1970 was 18.3 per 100,1000 population
(Historical Statistics). 37.1 thousand cases were reported in 1970, and
the number was down to 25.7 thousand in 1990 (Statistical Abstracts).
Unfortunately, while that number represents a decrease from 1970,
it represents an *increase* from 1985.  In 1985, after decades of
decline, TB cases began to rise again in the US, and have continued
to rise ever since.  A similar increase has occurred in several
other industrialized countries (TB was never really brought under
control in the Third World).  Moreover, new, multi-drug-resistant
strains of TB have emerged.  The AIDS epidemic has worsened the TB
situation. (Ryan)  The percentage of cases of drug-resistant TB varies
in different areas.  An Morbidity and Mortality Weekly Report article
summarized in the June 15, 1994 HICN726 Medical News gives the incidence
overall in New Jersey as 5% of the state's TB patients, the incidence in
Jersey City as 13%, and the incidence in New York City as 19%.

Q3j.3    How effective is the BCG vaccine?

The AHFS Drug Information, 1992 says that its effectiveness is unknown,
"Diagnostic and clinical evidence has generally demonstrated a reduction`
in the incidence of tuberculosis."  Tuberculin sensitivity is highly
variable, depending on the strain, and the relationship between tuberculin
sensitivity and immunity has not been adequately studied.

_The Forgotten Plague_ says that results of research varied in different
countries.  In Great Britain, a Medical Research Council survey of
50,000 children showed an 80% reduction in the infection rate after
vaccination, leading Great Britain to introduce BCG vaccination of
school children in the 1950s.  In the US, the results were the opposite,
so the US has not used the vaccine.

A New York Times article ("Tuberculosis Vaccine Found Surprisingly
Effective in Studies", New York Times, 03/02/94,  P. C14), recently
reported that "A new statistical study by the Centers for Disease
Control and Prevention reports that the vaccine, known as BCG,
reduced the risk of full-fledged tuberculosis of the lung by 50
percent and death by 71 percent."

Q3j.4    How long does the BCG vaccine last?

It is of limited duration (Ryan).  _AHFS Drug Information_ says that
several studies showed tuberculin sensitivity lasting 7-10 years.

Q3j.5    What are some of the risks of the BCG vaccine?

It rarely has serious side effects.  (See _AHFS Drug Information_
for a list.)

Q3j.6    When is the BCG vaccine recommended?

BCG vaccine is given in developing countries because it is easy to
administer, inexpensive, and rarely has serious side effects.
Some industrialized countries (e.g. Great Britain, France, Scandinavia)
have also used it, for vaccination of children in general and of
household contacts of people with TB.  Others (e.g. the US, the
Netherlands) have not.

Because of the low rate of new infections, the availability of low-cost
isoniazid prophylaxis for people who are exposed, and the availability
of effective treatment which quickly make patients non-contagious and
cures them, the BCG vaccine hasn't been considered necessary in the US.
There might be some changes in these recommendations with the increase in
multiple-drug-resistant strains (one misc.kids poster reports that her city
college system is now requiring TB shots).  In the meantime, the FDA has
approved a new combination tuberculosis drug, Rifater, which combines
isoniazid, rifampin, and pyrazinamide, in hopes of making it easier for
patients to take their medication and thus increasing patient compliance
(antibiotic treatment which is discontinued too early increases the development
of drug resistant TB strains).

In the US, the AAP, ACIP, and the American Thoracic Society recommend
BCG for infants and children intimately exposed to TB that is
"persistently untreated, ineffectively treated, or resistant to
isoniazid and rifampin and who cannot be removed from the source of
exposure or placed on long-term preventive therapy." The AAP and ACIP also
recommend it for children in groups with a rate of new TB infections
greater than 1% annually "and for whom the usual surveillance and
treatment programs have failed or are not feasible." (_AHFS Drug
Information_)  It is recommended for travel only for people who will
be in a high risk environment for a long time without access to TB skin
testing.  It is currently not recommended for health care workers (skin
testing and isoniazid is considered to be enough), but this recommendation
is periodically reevaluated because of the incidence of TB in AIDS
patients.

BCG also has some use against certain tumors (in particular, bladder
cancer).

Q3j.7    When is the BCG vaccine contraindicated?

Hypersensitivity to the vaccine, positive TB skin test, recent smallpox
vaccination, burn patients, various immune deficiencies or
immunosuppressive therapy (see _AHFS Drug Information_ for a list).
In case of eczema or other skin disease, give it in a different area
of the skin.

Vaccine components capable of causing adverse reactions: Triton WR 1339
(Travel Medicine Advisor).

Q3j.8    What are some other methods of controlling tuberculosis?

Tuberculin skin screening and use of drugs such as isoniazid.
Pasteurization of milk and testing of cows for tuberculosis
are also useful.

===============================================================================
Section 3k. Other vaccines which are available

Q3k.1    What other vaccines are available and when are they given?

Other vaccines available include vaccines for cholera, typhoid, yellow
fever, rabies, and plague.  Hepatitis A vaccine is available in some
countries, though not yet in the US.  _Travel Medicine Advisor_ also
mentions vaccines for Japanese encephalitis B virus and for typhus; I
haven't collected information on either of these yet.  Immune globulins
are also available for a variety of diseases.  For more information on
these other vaccines, check the _American Hospital Formulary Service
Drug Information_ (a better source than the PDR in this case) and
_Health Information for Travelers_, which is put out by the CDC every
year (vaccination and booster schedules for all of these vaccines can be
found there, as can information on where these diseases are common and
what vaccination requirements various countries have for entrance).  The
latter can be purchased from the Superintendent of Documents, U.S.
Government Printing Office, Washington, D.C. 20402, and most local health
departments have a copy which can be consulted, sometimes by telephone.
It can also be found in some public libraries.  The International
Association for Medical Assistance to Travellers (IAMAT), which has
affiliated institutions in over 115 countries, puts out a _World
Immunization Chart_.  The address of the U.S. affiliate is IAMAT, 736
Center Street, Lewiston, N.Y. 14092.  The World Health Organization
produces a publication on international travel; it is called _INTERNATIONAL
TRAVEL AND HEALTH: Vaccination Requirements and Health Advice_, and
copies may be ordered from WHO Distribution and Sales, CH-1211, Geneva 27,
telephone [phone];  fax [phone].  The price is 15 Swiss
Francs;  in developing countries: 10.50 Swiss Francs.  Further information
about rabies can be found in books on mountaineering and spelunking (the
one I consulted is _Medicine for Mountaineering_, by James A. Wilkerson,
M.D.).  Hepatitis B and meningococcus vaccines are given for travel, so
people interested in travel vaccinations may want to check the sections of
this FAQ dealing with those vaccines.

Cholera is an intestinal infection spread by contaminated food and
water.  Cholera vaccination is about 25-50% effective in reducing clinical
illness for 3-6 months after vaccination (with the greatest protection
during the first two months).  (_Health Information for Travellers_ gives
the effectiveness as 50%, and AHFS Drug Information gives it as 25-50%.)
Boosters are every six months for travelers who will be staying for a
long time in cholera-endemic areas.  Serious reactions are rare.
Since the effectiveness is so low, neither the CDC nor the WHO actually
recommends the vaccine, but some countries require it.  According to
AHFS Drug Information, "_Cholera vaccine does not prevent transmission
of infection_, and should not be used to manage contacts of imported
cholera cases or to control the spread of infection."

Vaccine components capable of causing adverse reactions: bacterial
components (Travel Medicine Advisor).  The vaccine should not be given
to children under 6 months.

Hepatitis A is also spread through contaminated food and water.  There is
no vaccine (yet) available in the US, but immune globulin provides temporary
protection.  People traveling to endemic areas for less than five months
are advised to get one dose right (i.e. days) before leaving.  Travelers
staying for longer are advised to get a dose every five months.  Immune
globulins prepared in the US have few side effects and no risk of AIDS
transmission.

A hepatitis A vaccine is under development, and results have been positive.
It is expected that the FDA will approve it not too long from now.  I
haven't found much information on this vaccine in my reading (since it
isn't available in the US yet), but, according to posters on sci.med,
it is now available in Great Britain, Germany, and the Netherlands.  It
involves three injections, two one month apart (after which you can travel),
and the third one year later.  One posting gave the length of protection
as 10 years.

It is unlikely that your child will ever need a plague vaccination.  The
disease is found among rural rodents in some areas, including the Western
third of the US, but urban outbreaks are now rare.  Vaccination is only
recommended for people at increased risk due to research or field
activities in epizootic areas.  An alternative for people at increased
risk is tetracycline prophylaxis.  _AHFS Drug Information_ gives the
vaccine's effectiveness as 90% for 6-12 months.  Other measures for
avoiding plague in epizootic areas are getting rid of wild rodent food
and shelter, defleaing dogs and cats weekly, avoiding sick or dead
rodents, and routine bacteriologic precautions in labs.

Vaccine components capable of causing adverse reactions: phenol, beef
protein, soya, casein (Travel Medicine Advisor).

Rabies, an almost universally fatal disease transmitted by saliva and
brain tissue of infected animals, is rare in the US but more common in
some countries where pet vaccination is not common.  Dogs are the main
reservoir in developing countries, but all animal bites should be evaluated.
The most common animal vectors in the US are carnivorous small animals
(such as skunks, racoons, foxes, coyotes, and bobcats) and bats.  There
has been a recent increase in racoon rabies in the mid-Atlantic and
northeastern states of the US (MMWR 29 Apr 1994), and programs to institute
oral rabies vaccination of racoons, foxes and coyotes have been initiated
in some state (similar programs have been used to control fox rabies in
Canada and Europe).  More than 50% of rabies cases in the US come from
exposure to rabid dogs outside the US.  The disease is most commonly spread
by animal bites, but can also be caught through non-bute exposure, including
contact between infected saliva or brain tissue and pre-existing cuts,
scratches, open wounds, or mucuous membranes.  There are also cases of
aerosolized transmission in medical laboratories and caves inhabited by
rabid bats, and transmission through cornea transplants from people who had
died of undiagnosed (before the transplant) cases of rabies.  The chance of
infection is more likely in case of bite or non-bite exposure to the head,
neck, face, shoulders, or hands, than with similar exposure to the trunk
or legs.

In case of exposure to rabies, the wound should be immediately and
thoroughly cleaned with soap and water.  "Although not included in the
ACIP recommendations, some clinicians also rinse the wound thoroughly
with water or 0.9% sodium chloride solution and then cleanse with a
topical antiseptic (e.g. povidone-iodine)." (AHFS Drug Information 1992)
It is also important to promptly vaccinate anyone exposed to rabies
(and give rabies immune globulin if the person has not been previously
vaccinated), as the disease is, for all practical purposes, always
fatal once rabies symptoms begin to show up.  (A few people have recently
survived after symptoms appeared, but they all had serious brain damage.)
Pre-exposure vaccination is given to people who live in or visit rabies
endemic areas and to people whose professions or activities put them at
extra risk, such as lab workers, veterinarians, and spelunkers.  The
highest travel risk is where dog rabies is still endemic.

There is some drug interference between chloroquine (an anti-malarial
drug) and rabies vaccine, but intramuscular injection can take care of
the problem.  Need for boosters depends on risk category, and ranges from
regular tests of antibody levels every six months, with vaccination when
they drop, for rabies lab workers, to no pre-exposure vaccination for
most people.  Post-exposure, unvaccinated people get rabies immune
globulin and rabies vaccine, while previously vaccinated people get
rabies vaccine alone, in a smaller amount.  Adverse effects include local
reactions (30-74% of vaccinees) and mild systemic reactions (e.g. headache,
nausea, 5-40% of vaccinees).  About 6% of vaccinees have a reaction
characterized by urticaria, pruritis, and malaise.  Rarely, anaphylactic
shock may occur.  Because rabies is so deadly, pregnancy is *not* a
contraindication to postexposure vaccination.

Vaccine components capable of causing adverse reactions: neomycin, phenol
red, thimerosal (Travel Medicine Advisor).

The following posting from sci.med, by Achim Lohse, provides further
information about rabies vaccine (the side effect under discussion is
anaphylactic shock):

----------------------------Original message----------------------------
...

In Canada (at least as of two years ago) there is only one rabies
vaccine availble, and the manufacturer supplies it only in one-millitre
vials, with strict instructions to use the entire vial for one injection
only.  At $60 + per vial, the series of three costs over $180.  I was
fortunate to have a physician who had worked among fur trappers up north,
and had some familiarity with the vaccine.  He informed me that  if
injected  _intra_dermally, a dose of only 0.1 millilitre is enough.
I confirmed this with the local public health nurse, who showed me that it
had been standard public health procedure in British Columbia for five
years to use the 10% dose intradermally (10 trappers would arrange to
share the contents of a standard vial).

Later investigation via Medline showed that this particular vaccine
human diploid cell (HDCV) is not only the most expensive to produce,
but may also have a significantly higher rate of side-effects when
compared to the much less expensive purified chick embryo vaccine.

I had a taste of physician non-acceptance when my physician was away
after administering the first in the series of three shots.  He assumed
any of the other five doctors in the rural practice could and would complete
the series.  NOT!  I was turned down flat by the two experienced doctors
on duty, and had to get my shot from the public health nurse.

Rabies antibodies (assuming the initial titres are adequate) are considered
to be reliably adequate for only three years, after which a booster is
required (and with the HDVC adverse reactions have most often been
experienced with the booster).  The alternative is to get a Rabies titre
test, but I understand (anyone have figures?) that this is quite expensive,
and in Canada's health system, may simply not be available on demand in
some provinces (unless you can persuade a sympathetic public health official
of the need).

>However, since it's unusual for people to get rabies and the
>vaccine does work fine after exposure, it will probably not be
>part of the usual childhood vaccines.
>
>Mike K

As someone noted in a previous post, the urgency of treatment depends on
the proximity of the infection site to the brain.  A report from a
researcher from pre-war Yugoslavia (Zagreb) indicated that there wolf
attacks resulting in bites to the face and neck have resulted in death,
due to inability to get the antibody titres high enough in time. One possible
strategy to improve this situation (suggested to me by Richard Passwater's
book "Selenium as Food and Medicine") is to take a large dose of selenium
concurrent with or within a few hours of vaccination.  He reports that this
 has greatly increased antibody titres  with other vaccines.

Finally, aside from the risk of not being able to get to treatment in time
after clear exposure, there is the very real danger of unnoticed infection,
expecially in children, by having a cut  finger or lip, etc. come in contact
with saliva from the tongue or coat of an infected animal.  There is even
one reported instance of a spelunker dying after supposedly no other exposure
than inhaling  saliva droplets from rabid bats.  Since unvaccinated victims
can't be treated successfully once symptoms appear, pre-vaccination is the
only available protection for this last type of exposure.

Achim

[e-mail]   [e-mail]
------------------------------------------------------------------------

From: Achim Lohse <LOHSEACH@UREGINA1>
Subject:      rabies vaccine - update

Hi Lynn. I did a little more reasearch on rabies vaccine in the past two
days, and learned that the Canadian manufacturer - Connaught Labs, also
markets the vaccine in the U.S..  In fact, it markets two versions in the
U.S., both are human deploid cell vaccines (HDCV), but one, called
"Merieux" is marketed in a 0.1 ml format for intradermal injection.  In
Canada, ironically, this form is not available, and only the 1 ml
intramuscular form is marketed (suggested retail about CDN$75 per vial).

I wasn't able to get any us prices, but was given a U.S. information number:

1-800-VACCINE , which of course, doesn't work from my (Canadian) calling area.

I wasn't able to learn whether HDCV is the still the _only_ type of rabies
vaccine available in the U.S. (it is the  only typpe in Canada).

Finally, I learned that there are two methods of testing rabies antibody titre
(to find out if you need a booster).  The preferred one is the
neutralization assay type, in which diluted serum is mixed with infected
cell culture and checked for reaction.  The titre is reported as the highest
dilution ratio that provokes a reaction, with 1:32 being the minimal
acceptable titre.  If titre is at 1:32, then retesting or boosting is
adviseable in a year to maintain adequate protection.  I couldn't get
any details about the other method, called complement fixation, except that
the local expert considered it less reliable. BTW - for Alberta and
Saskatchewan (and possibly other Canadian provinces) all rabies titre testing
is done by the _Ontario_ Provincial Laboratory, so it's a slow and costly
undertaking.

regards,

Achim

[e-mail]

------------------------------------------------------------------------

Smallpox vaccine is no longer given, because smallpox has been eliminated
by vaccination.  The virus is currently kept in labs in the US and
Russia, just in case it is needed at some point (there has been talk of
destroying the last samples, but the virus recently got a reprieve).
Since the elimination of smallpox is one of the major triumphs of
vaccination, which is mentioned in many medical texts which I consulted
as an argument in favor of vaccination, I'll also mention at this point
that smallpox mortality was 25-30%, that it infected 90% of the
population at risk, and that there were 10-15 million cases worldwide as
recently as 1967.  The last natural case was reported in 1977, and the
last cases were reported in 1978, as a result of an escape of the virus
from a lab (the lab director committed suicide while under quarantine).
(Kiple)  The only people who still need to be vaccinated for smallpox are
the people who work in the labs where the virus is kept.

Vaccine components capable of causing adverse reactions: polymyxin B,
streptomycin, chlortetracycline, neomycin, phenol, brilliant green
dye, glycerin (Travel Medicine Advisor).

Typhoid is spread by contaminated food and water.  The vaccine protects
70-90% of recipients.  There are two forms of the vaccine: oral (live),
and parenteral (killed).  The oral vaccine shouldn't be given to
immune-compromised people.  Otherwise, there are few adverse reactions,
mostly local discomfort and sometimes fever and malaise.  Boosters are
every three years for parenteral and five years for oral vaccine.

Vaccine components capable of causing adverse reactions: phenol,
bacterial components (Travel Medicine Advisor).

The following posting from sci.med gives further information on
typhoid vaccine:

------------------------------------------------------------------------
From: "Mark A. Shelly" <[e-mail]>
Subject: Re: Oral form of typhoid vaccine

>A typhoid vaccination is recommended for a trip to Costa Rica.  My family
>doctor said that the last time she gave someone a prescription for the
>vaccine they came back with an oral vaccine.  Since then she hasn't been
>able to find any information comparing the oral to the injectable form:
> - efficacy
> - scheduling (the injectable form requires 2 doses, the first a month
>   before the trip)
> - side effects (she says that the injectable form tends to make you feel
>   sick, the oral form may be an improvement).

Oral typhoid vaccine is a live but weakened (attenuated) strain (Ty21a) of
the Salmonella germ that causes typhoid fever.

The oral vaccine is probably equal to the injected vaccine in efficacy, at
about 80%.

It is given orally on an empty stomach every other day for 4 doses (total
elapsed time 6 days). It must be kept refrigerated but not frozen, a significant
limitation to use in other countries. You can't be taking antibiotics at the
same time.

It is very well tolerated. (The injected form has 80+% side effects). If you
have weakened immunity, or if you are too young to take pills, you shouldn't
use this vaccine.

I almost never recommend the injected form of typhoid vaccine. Typhoid
vaccine is recommended for travel to areas with poor water supplies when
the trip is over 3 weeks and when your eating will be "high risk".

Hope this helps

Mark Shelly
[e-mail]
------------------------------------------------------------------------

Yellow fever is a viral infection which is spread by mosquitos.  Yellow
fever vaccine is a live vaccine which can be given only at certain
vaccination centers.  Many countries require this vaccination for entry.
A booster is needed every ten years.  Contraindications include egg
allergy and immune deficiency.  Reactions are mostly mild.

Vaccine components capable of causing adverse reactions: chick embryo
components (Travel Medicine Advisor).

Travelers may also want to take anti-malarial drugs, bring insect
repellant containing N,N diethylmethylbenzamide, and avoid unboiled
water, raw vegetables, fruit they haven't peeled themselves, undercooked
fish and shellfish, and food kept at room temperature.  Other sources of
travel health information are _Fielding's Travelers' Medical Companion_
and the US State Department Citizen's Emergency Center, which provides
information on a variety of foreign travel risks 24 hours a day at
202-647-5225.  CDC Travelers' Health Section, 404-332-4559, and
Immunization Alert, 203-487-0611, have up-to-date information on
vaccinations for international travel.

===============================================================================
Section 3l. Vaccines under development

Q3l.1    What vaccines are currently under development?

In addition to the chicken pox vaccine, new vaccines under development
include vaccines for HIV (vaccines are being tested both to improve
the immune response in those already infected and to resist infection),
rotavirus, hepatitis A, and respiratory syncytial virus (Rathone),
malaria, leprosy, gum disease, Lyme disease, herpes and other illnesses.

While at least 15 candidate vaccines are being developed for AIDS,
the variation of retroviruses and the virus transmission directly
from cell to cell by fusion pose significant obstacles.  It's anyone's
guess when (and if) an AIDS vaccine will be ready.  Two articles which
discuss AIDS vaccine development are "Vaccine Against AIDS?" in the
British medical journal Lancet ((02/26/94) Vol. 343, No. 8896, P. 493)
and "AIDS Vaccine: Shooting Blanks or Loaded for Bear?" in Men's Fitness
((03/94) Vol. 10, No. 3, P. 118).  Information about efforts to produce
an AIDS vaccine is sometimes posted in sci.med.aids, and references,
updates, and current information is available by gophering to
odie.niaid.nih.gov.  If you have gopher, gopher odie.niaid.nih.gov will
get you there.  The AIDS FAQ (available from the pub/usenet/sci.med.aids
directory of rtfm.mit.edu) describes some other Internet resources with
information about AIDS.

The malaria vaccine has shown positive results in Phase I/II trials, which
were reported on February 18, 1994 issue in the British medical journal
_Vaccine_ (volume 12 no. 4, pp 328-336; 1994). (A report on an earlier
trial can be found in the medical journal Lancet, volume 341, pp 705-710;
l993).  More details can also be found in a WHO press release kept on
gopher.who.ch.  The first results of Phase III trials are expected to be
available in October 1994.

The vaccine for periodontitis (gum disease) has shown some positive
results in macaque monkeys (less bacterially induced bone loss in the
vaccinated monkeys), indicating that a human periodontitis vaccine is
feasiable.  Full-fledged clinical trials, however, may be a decade away.

The hepatitis A vaccine has shown positive results, and may be close to
being ready for approval (in fact, it is approved in some European
countries).  I don't know how far developed the other vaccines are.

Q3l.2    What other research is being done to improve vaccines?

Research is being done to improve existing vaccines (such as the
research which resulted in the new acellular pertussis vaccine).  One
area being explored is whether it is possible to combine more vaccines
in a single shot.  Micro-encapsulation is an attempt to encase
vaccines in microcapsules which will be released over time, mimicking
repeated injections.  Trans-disease vaccinology is an attempt, by
genetic engineering, to create vaccines which protect against more
than one disease.  Efforts are also under way to produce a
heat-resistant polio vaccine.  (Hartveldt)  (There is also a United Press
International article from 3/25/94, included in the CDC AIDS Daily
Summary for March 28, 1994, which discusses the effort to make a vaccine
which will be effective against a variety of different viruses.)

===============================================================================
Section 4. References

AMA Drug Evaluations Annual, 1993.

The American Medical Association Family Medical Guide. Random House, New
York. 1987.

The American Hospital Formulary Service Drug Information, 1992.
Published by the American Society of Hospital Pharmacists.

California Morbidity, a Biweekly Report from the Division of Communicable
Disease Control, part of the State of California Health and Welfare
Agency. Issues from October 31, 1987, May 21, 1993, and November 19,
1993.

Catalana, Paul, MD. "The 'Other' Childhood Immunizations." Emergency
Medicine, October 15, 1992.

Center for Disease Control. _Health Information for International
Travel_, 1992.

Clements, C. John, Strassburg, Marc, Cutts, Felicity T. and Torel, Carol.
"The epidemiology of measles." In _World Health Statistics Quarterly, Vol
45, No 2/3, 1992.

FDA. "Advisory Committee Discusses Chickenpox Vaccine." January 28, 1994.
(Pulled off of fdabbs.fda.gov. Connect with login bbs to find this and
other FDA information.)

Fettner, Ann Giuici. _The Science of Viruses._ Quill. William Morrow, New
York, 1990.

Galazka, Artur. "Control of Pertussis in the World." In _World Health
Statistics Quarterly_, Vol 45, No 2/3, 1992.

Ghendon, Y. "Influenza - its impact and control." In _World Health
Statistics Quarterly, Vol 45, No 2/3, 1992.

Harrison's Principles of Internal Medicine, Eleventh Edition.  McGraw
Hill Book Company, 1987.

Hartveldt, Frank. "The Children's Vaccine Initiative." World Health 46th
year, No. 2, March-April 1993.

Historical Statistics of the United States, Colonial Times to 1970.
Bicentennial Edition. US Department of Commerce, Bureau of the Census.

Hull, Harry F. and Ward, Nicholas A. "Progress towards the global
eradication of poliomyelitis." In _World Health Statistics Quarterly, Vol
45, No 2/3, 1992.

Journal Watch, 9-1-93. "Infant HBV Vaccination: Doubts Remain."

Kiple, Kenneth E., Editor. _The Cambridge World History of Human
Disease_.

The Lippincott Manual of Nursing Practice, Fourth Edition. 1986.

The Medical Letter on Drugs and Therapeutics, Vol. 34 (Issue 875), July
24, 1992.

The Merck Manual, Sixteenth Edition.  Merck Research Laboratories, 1992.

Nossal, Sir Gustav. "Prospects for new vaccines." World Health 46th year,
No. 2, March-April 1993.

Onorato, Ida M., MD, Wassilak, Steven G. Md, Meade, Bruce, PhD. "Efficacy
of Whole-Cell Pertussis vaccine in Preschool Children in the United
States." JAMA, May 27, 1992, Vol. 267, No. 20.

Pantell, Robert H., MD, Fries, James F., MD, and Vickery, Donald M., MD.
_Taking Care of Your Child: A Parents' Guide to Medical Care._ Third
Edition.

The Physician's Desk Reference, 1993.

Rathone, Mobeen H., MD. "Childhood Immunizations: An Update." Infections
in Medicine, June 1992.

Ryan, Frank, M.D. _The Forgotten Plague: How the Battle Against
Tuberculosis Was Won - And Lost_. Little, Brown, and Company, 1993.

Shapiro, Eugene D., MD "Editorial: Pertussis Vaccines: Seeking a Better
Mousetrap." JAMA, May 27, 1992, Vol. 267, No. 20.

Smith, Alice Lorraine. Principles of Microbiology. The C. V. Mosby
company. St. Louis, Toronto, and London, 1992.

Statistical Abstracts of the United States, 1992.

Travel Medicine Advisor. May 1993.

University of California, Berkeley. _The Wellness Encyclopedia._ From the
editors of the UC Berkeley Wellness Letter. Houghton Mifflin Company,
Boston, 1991.

Whitman, Cynthia, Belgharbi, Lahevari, Gasse, Francois, Torel, Carol,
Mattei, Vittoria, and Zoffman, Henrik. "Progress towards the global
elimination of poliomyelitis." In _World Health Statistics Quarterly, Vol
45, No 2/3, 1992.

WHO. The Work of WHO 1990-1991. Biennial Report of the Director General.

Wilkerson, James A., M.D.  Medicine for Mountaineering, Third Edition.
The Mountaineers, Seattle, Washington, 1985.

Electronic resources consulted:

CDC AIDS DAILY SUMMARY (regularly posted on sci.med.aids)

fdabbs.fda.gov (login using name "bbs")

gopher.who.ch (gopher gopher.who.ch, also:

telnet gopher.who.ch  login:gopher)

HICNet Medical News Digest (available from [e-mail];
regularly posted to sci.med)

Journal Watch Summaries (regularly posted to sci.med by [e-mail])

(A list of Internet and Bitnet Health Sciences resources, compiled by
Lee Hancock, can be ftped from the pub/nic directory of ftp.sura.net.)

Archive-name: misc-kids/vaccinations/part4
Posting-Frequency: monthly
Last-Modified: August 8, 1994

===============================================================================
Section 5. Stories of Parents

The questions asked were as follows:

Now, the questions for parents (or parents to be) about vaccination.  The
following questions refer both to the regular vaccinations which are
recommended for all children, and to any optional vaccinations which your
child may have gotten (such as hepatitis B or flu shots).  (This list of
questions has been slightly modified from the first posting, to correct
a typing mistake which made some questions appear to be addressed only
to vaccinators.)

These first questions are meant for people anywhere on the spectrum
as far as what vaccinations they chose to give or not give their
children.  What vaccines did you (will you) choose to give or not give
your children?  What were your reasons for making the choices you did?
How did you go about making your decisions, and what resources did you
find helpful in getting the information you needed?

For parents who have vaccinated your children, do you have any advice for
parents who are about to have their children vaccinated about things they
should be prepared for?

For parents who have not given the recommended infant vaccinations, are
you planning to have your children vaccinated later?  Why or why not?
In particular, would you vaccinate your daughter for rubella when she hits
puberty?  Why or why not?

===============================================================================

From: Paula Burch <[e-mail]>

We choose to give our son all of his vaccinations as recommended by the
pediatrician. Vaccinations are one of the few true successes of modern
medicine, and despite some extremely small risks prevent far, far more
agony than they ever cause.

Some who would otherwise choose to have their children vaccinated cannot,
for odd medical reasons. These individuals depend absolutely on the rest
of the population's being vaccinated. Parents who elect to refuse
vaccination for their children, for no better reason than that they've
been listening to some quack, put not only themselves but these other
children in danger. When a child who cannot be vaccinated dies due to
infection from a child who could have been vaccinated but wasn't, the
parents of the latter child are morally though not legally guilty of the
dead child's murder. When only a small number of children are
unvaccinated, the risk is small, but when many elect to refuse
vaccinations, the risk of an epidemic becomes quite high, and in some
cases this has already been seen on a small scale.

Almost all problems blamed upon the pertussis vaccine actually have had
nothing to due with the vaccine, but were observed coincidentally in
children who would have had the problems even in the absence of the
vaccination.

In no case has our child shown any reaction at all to any of the
vaccinations he has received, through 18 months, except for pain
immediately after the injection. Even if he had shown some problem,
however, I would still be convinced of the necessity of the immunization.
A one in a million risk of a side effect is a whole lot better than a one
in twenty, or worse, chance of dying. It is my duty as a mother to do what
I can to improve my child's chances of good health, and it is extremely
clear that immunizations improve the odds tremendously.

At the turn of the century, no more than one or two out of five children
could be expected to survive to maturity. Vaccinations are one of the
primary reasons why our own children can expect to grow up.

Having said that, I saw no reason to give the hepatitis B vaccine to my
newborn. My peditrician gives it when the child is several months older,
which seemed preferable to me, as there was so little risk of exposure
before that time. The need for vaccination against hepatitis is much lower
than the need for immunization against the diseases of childhood, but, as
the hepatitis vaccine is genetically engineered, there is essentially zero
risk of ill effects, so I felt it was well worth getting.

Paula Burch
[e-mail]

===============================================================================
From: [e-mail] (Rayaz Jagani)

(It would be easier to answer/comment if the questions were
enumerated, I hope the following does not further confuse the issue)

I tend not to allow my child to be vaccinated.

My HMO (Kaiser Permanente), has not given me actual numbers of
efficacy/side effects over the life of an average person. I understand
that the definition of side effects is what happens within 6 weeks.
If the effects are known to be longer, why should side effects be of
shorter duration?

My wife, who is an M.D. thinks differently. Our son got all the
recommended shots. I had my fingers crossed.
He also got the works for our recent trip to India/Pakistan.
I don't think it worked as he did land up with stools etc.,
was prescribed some anti-biotic (Bactrin or something).

I dont take any shots when I visit that region; but then, I grew
up there, not that I was vaccinated regularly there :-)

About the hepatitis B shots, not enough is known. Also, should
babies be given this or more likely adolescents... if they are
becoming sexually active. Apparently, they do get some residual
effects from their infancy vaccines.

My conclusion is, that if you are looking for answers, a long
term view, and hard numbers, there is a lot of gray area.
All the numbers are based on samples, statistics, control groups,
duration of followup, etc. You decide what you want to bet on, in
this russian roulette.

There may also be a legal requirement in public schools, private
schools can probably do anything they wish. I think
you can get around public school limitations, however, you may
have to go to court.

You may wish to hunt the sci.med archives for more discussion;
I dont know how enlightening you will find it :-).
Below is an example:


EX:From: [e-mail] (J. D. McDonald)
EX:Newsgroups: sci.med
EX:Subject: Re: infant seizures after vaccination
EX:Date: Fri, 3 Sep 1993 13:52:43 GMT
[deleted rest of header]
EX:In article <[e-mail]> <[e-mail]> writes:
EX:>Date: Thu, 2 Sep 1993 16:13:04 MST
EX:>From: <[e-mail]>
EX:>Subject: Re: infant seizures after vaccination
EX:
EX:>nnget 93245.161304
EX:>In article <[e-mail]>, [e-mail] (Gordon Banks) says:
EX:>>
EX:>>
EX:>>Seizures and epilepsy are not uncommon in children.  They often begin
EX:>>about the age that the child is vaccinated.  No correlation has
EX:>>been shown between the vaccine and the development of epilepsy.
EX:>>It is likely just coicidence.  The child needs a good pediatric
EX:>>neurologist.  Denver is likely the only place in the State of
EX:>>COlorado that has one.
EX:>>
EX:>>--
EX:>Given that a large portion of children are vaccinated; and that seizures and
EX:>epilepsy occur around the same time as vaccination; how could one possible say
EX:>that no correlation has been shown. Where are the controls in this study?
EX:
EX:>Certainly not every vaccinated child has seizures. And not every child will be
EX:>allergic to milk, either. The fact that not every child has a reaction to
EX:>vaccinations is no argument against the notion that they may cause reactions
EX:>in
EX:>some. Unlike the milk allergy, where one can eliminate milk from the diet and
EX:>see if the condition gets better, it is not possible to unvaccinate someone.
EX:>While the connection is not absolute, there are **NO** grounds for dismissing
EX:>vaccinations as a possible source of health complications.
EX:
EX:
EX:There is NO reasonable doubt that vaccination with the pertussis vacine
EX:can cause permanent and serious neurological harm. That has been
EX:proven again and again in court cases in the US. In fact, just this
EX:last week another child was awarded millions of dollars in damages
EX:after being brain-damaged by this vaccine. Note that one need
EX:not make any qualifications about that .. not "may have been", but
EX:"was". This is simply no longer debateable. It is only this one vaccine thaty
EX:does this. It is often given in combination with two other vaccines.
EX:If those are given alone, the vaccine is safe.
EX:
EX:The vaccine is still required in some places EVEN THOUGH it is known
EX:that it can cause SERIOUS harm to children.
EX:
EX:Doug McDonald

Best of luck.
--
Usual disclaimers/caveats apply.
It is impossible for a man to learn what he thinks he
already knows.  -Epictetus

===============================================================================
From: [e-mail]

In article <[e-mail]> you write:
>These first questions are meant for people anywhere on the spectrum
>as far as what vaccinations they chose to give or not give their
>children.  What vaccines did you (will you) choose to give or not give
>your children?

Morganne received 1 dose of DPT, 2 doses of DT, 3 doses of oral polio
and 1 dose of MMR.  Matisse has received 1 dose of tetanus vaccine
and we plan to vaccinate her for polio.  Both girls will receive
rubella vaccinations at puberty (if they show no immunity at that
time).

>What were your reasons for making the choices you did?

I was undecided with Morganne but decided to vaccinate her anyway.
After she had severe reactions to the pertussis and MMR vaccines,
I did more reading and consulted with the doctor.  We came up with
the following:

1)  Additional doses of pertussis or MMR could be dangerous or deadly
    for Morganne and were not advised for siblings, either.
2)  The side effects of the diptheria, pertussis, measles, mumps
    and rubella vaccines are a greater health risk to healthy
    children than the diseases themselves.
3)  There are concerns about vaccines wearing off.  I would rather
    my children contract mild illnesses (mumps, rubella, chicken pox,
    measles) as children.  I am haunted by the prospect of a population
    of young women whose immunity to rubella may wear off just as
    they begin to bear children.
4)  The risks of tetanus and polio (and the safety of the vaccines)
    are greater than the risks of the vaccines.  So my children will
    receive these vaccines.
5)  The risk of rubella in a pregnant woman is very troublesome.
    Therefore, I will delay this vaccine until puberty.  This will
    give them a chance to receive more effective immunity from the
    natural disease and will also put them at lower risk for
    reduced vaccine immunity in their childbearing years.

>How did you go about making your decisions, and what resources did you
>find helpful in getting the information you needed?

Our family doctor was very helpful.  I also found the writings of
Robert Mendelsohn and George Wootan (both MDs) very helpful.  Mothering
magazine was another good source of information.  George Wootan's book
has an especially good section on the risks and benefits of the various
vaccines.

>For parents who have vaccinated your children, do you have any advice for
>parents who are about to have their children vaccinated about things they
>should be prepared for?

Know what severe reactions to watch out for and take any unusual reactions
seriously.  I didn't know until later that Morganne's reaction could
have resulted in brain damage or death.  Report the reactions to your
doctor.

Prepare for mild illness for 1 week to 10 days after the vaccination.
It can and does happen.

>For parents who have not given the recommended infant vaccinations, are
>you planning to have your children vaccinated later?  Why or why not?

I covered this above, but will summarize.

1)  The effectiveness of some vaccines (particularly pertussis) is
    questionable.
2)  The incidence of diptheria is quite low and diptheria is now
    treatable.
3)  Measles, mumps, rubella and chickenpox are mild childhood diseases
    with few side effects for healthy children.  (These diseases are
    dangerous for malnourished children, however).
4)  Each vaccine carries certain risks.
5)  The immunity conferred by a vaccine is generally shorter-lived and
    less complete than the immunity conferred by the natural disease.

Note that we are choosing to vaccinate for polio and tetanus.

>In particular, would you vaccinate your daughter for rubella when she hits
>puberty?  Why or why not?

Yes.  Childhood rubella vaccinations seem short-sighted to me in light
of the tendency for the rubella vaccine to wear off.  But young women
need immunity to rubella to protect their unconceived children.

>(Please mail responses to this account.  Your name will be included inthe
>FAQ unless you specify otherwise.)
>
>If anyone is interested in reviewing the FAQ when I have written a draft,
>send me email (I have one person reviewing it already).  I have found
>some information about vaccinations in other countries, so I no longer
>need that question answered, but if anyone on sci.med (or on misc.kids,
>for that matter) can suggest good resources to check to keep this FAQ
>current after I have written it, I'd welcome them (one thing I've noticed
>in my research is that there are lots of changes happening).
>
>Lynn Gazis-Sax
>
>
>
>


--
Heather Madrone
[e-mail] (WAS [e-mail])

===============================================================================
From: [e-mail] (Margaret T Kelliher)

Lynn,
Here's my 2 cents. Hope it's what you're looking for.
Margaret

We've given all recommended vaccinations so far (15 mos
and 4 years) We did delay certain of Colleen's shots
because she had a very rough neonatal period and we
couldn't see stressing her system more than necessary.

Why did we do this? All these things are a bet. Given
the relative rates of disease, and the seemingly bad
effects of these diseases, and the relatively low risks
of the shots, it seemed a good bet to take the shots.
(And it makes it easier to get into school and day care.)

I did a little reading (Parents, and a few articles my
doctor gave me at my request), but in large part, I
trusted my doctor, who has always answered my questions
to my satisfaction. With the hepatitis B, I also talked
to several other doctors: ob/gyn & pediatric neurologist
in particular, and read some articles on the subject.

Advice:

Give them tylenol immediately after the DPT shot.

For all shots, leave extra cuddle time in the schedule.
If nursing, try to make an opportunity to nurse the baby
immediately after the shot. Once they are verbal, prepare
them for it (but not too graphically).

Always ask questions about the shots effects and what to
look for. DPT especially; I believe that the first
adverse reaction is supposed to be somewhat mild; while
subsequent ones are more likely to be devastating. I would
not allow a second one if the first one raised a question.

===============================================================================
From: [e-mail] (Carolyn Peterson)

Pertussis vaccine.

This vaccine is one that many parents worry about giving their children.
They do so for good reason.  There is a lot of information out saying that
the vaccine could cause problems with their child's health.  Who wouldn't
worry!

Unfortunately, the possibility of getting the illness and problems from the
illness does not seem to be publicized as much as the potential
complications from the vaccine are.  Pertussis, or whooping cough, is still
present today and can easily be transmitted.  The last booster for the
illness is given around 4-6 years, after that the illness isn't severe, so
boosters aren't given.  Adults can have the disease and just think they
have a bad cold.  It's a completely different story for infants.

Friends of ours came down with colds and a bad cough.  They continued their
normal routine.  Their 3 month old daughter also came down with the "cold".
The disease reached the pertussis stage while the mother and child were
thousands of miles from home.  The baby had horrible coughing spells,
projectile vomiting and apnea attacks after the coughing.  She was
hospitalized for 3 weeks, with 8 days of that in ICU due to whooping
cough (or pertussis).

Our 3 month old child and several other infants that age had all been
exposed to the disease at a play group.  The infants received their second
vaccination early and were put on erythromycin for 10 days as a precaution.
That stuff is wicked for young children.  After one day, our daughter
started screaming at the sight of the antibiotic bottle.  It took two of us
to get the medicine down her and we were fortunate that she only needed two
doses a day.   The only thing that gave us the strength to force her to
take the medicine was the knowledge that our friends' child was so ill many
miles away.

During this time, we learned that whooping cough is still quite active in
the United States.  Countries that don't vaccinate against it have children
dying from the disease each year (I don't have the numbers any more.)  The
immunization isn't complete until after the 3rd shot at six months.  Even
then, there is a small chance they could come down with the disease.  The
only other case of pertussis that our pediatrician had seen at the time was
from a child who had been vaccinated, but still came down with the disease.
--
Carolyn Peterson
[e-mail]

===============================================================================
From: Diane Lin <[e-mail]>

Our son has been given the full range of immunizations--polio, DPT
(diphtheria, pertussis, tetanus), MMR (measles, mumps, rubella),
Hib (meningitis), and Hepatitis-B.  We made the decision to have our
son vaccinated for all of these because (a) we felt there was a moral duty
to have him vaccinated, both to escape the free-rider problem, and
to contribute to the herd immunity**, (b) the risk of serious side-effects
did not outweigh the benefits of immunization, and (c) the increased
numbers of children who are not immunized is steadily going up,
which increases the chances of an epidemic, and while most of the
diseases are fairly minor, we didn't see the point in exposing our son
unnecessarily.  In making our decision, we spoke to our
pediatrician, other parents, and read the views expressed in misc.kids :-).

When our son got his first DPT shot, he cried for about 4 hours
afterwards, and I was at a loss to comfort him.  After calling my
husband to come home, we were finally able to get a little bit of
Infant Tylenol into our son's system.  That helped tremendously so
that he could nurse and be comforted.  After that, we made sure we
gave him some Infant Tylenol just before he got his shots, to ease
the discomfort.  Also, after his first MMR shot, I had forgotten
that some kids display symptoms of measles anywhere from a few days
to a week after the immunization.  I didn't panic, but I wish I had
kept that in mind!

--
Diane C. Lin            "The only rational way of educating
[e-mail]             is to be an example."
(Dylan's mom, 2-3/4 years)                    --  Albert Einstein

===============================================================================