I know, I know, it's been months without a post. This is what happens when you're a pediatric intern trying to learn all the diseases. And working 12 hour days, 6 days a week really wears on you. I hardly ever feel like reading when I get home, let alone researching for a blog post. But I'm working on it. And given that this is the first anniversary of this blog, I thought it was fitting to pick things back up.
I saw a patient in clinic recently, there for a well visit, who had only seen a doctor once before, shortly after birth. Her parents had refused vaccines in the newborn nursery, and then hadn't seen anyone for the routine 2 month vaccines, and was now showing up for the four month visit. But, parents weren't sure which vaccines they wanted, and they claimed to want to follow Dr. Sears' modified vaccine schedule. So, I got the opportunity to wade through these treacherous waters to see how best to vaccinate this child.
Vaccine refusal, parents who tell us as pediatricians that they do not want to vaccinate their children, is more common than I'd like it. Ideally, all parents would understand the importance of vaccinations, and would follow the CDC schedule without concern. Then maybe we wouldn't see the outbreaks of measles that are currently occurring across the US.
There are some legitimate reasons for not vaccinating. Children with cancer generally cannot receive live vaccines. Other children with impaired immune systems, where they can't fight off certain bugs, may not respond well to vaccines. But for the generally healthy child? There's no overwhelming reason not to vaccinate. Thus, it usually comes down to the parent's ideas about vaccination.
I could spend hours on this topic, going over each of the arguments I've heard. In fact, I've touched on some of them before. In general, parents fall into a handful of categories:
1. Vaccines cause autism.
Without going into all the research, this has been disproven time and time again. But I'll explore the concept more related to the particular vaccine that this is used for: the MMR vaccine.
2. Vaccines contain harmful preservatives, including formaldehyde.
Again, I'll explore this with each individual component, but essentially, it comes down to the fact that the 0.5 mL vaccine contains such a small amount of these preservatives that it is less than an average person consumes in their diet on a day-to-day basis.
3. Vaccines cause disease.
I most often hear this related to the flu vaccine. There's a select few cases where the vaccine does cause disease, and I'll explore those when discussing those particular vaccines. But in general, there's no way for the vaccine to cause disease, because the bug used to create the vaccine has been torn up so much that it doesn't do anything anymore.
4. We are overwhelming our children's immune systems.
The vaccines we use today actually contain less material to stimulate children's immune systems than they did 20 years ago, and they cover more diseases. While not all the vaccines need to be given on the schedule recommended by the CDC, most children do just fine with the schedule, and aren't overwhelmed in the least.
5. The diseases aren't common anymore, so why should I vaccinate my child.
For this, I point out the measles outbreaks, particularly the current one in the Southwest US. These diseases still exist, even if they aren't that common in the US anymore, and we have vaccines because these diseases can be devastating to children. I'll explain more in each of the blogs I post here out.
So, this series is going to go over each of the individual vaccines available. It will be a long series, but in an effort to both learn new things myself, as well as teach others, I want to investigate each vaccine.
If you have any other blanket arguments against vaccines, either from yourself or that you've heard from others, please mention it in the comments, so I can attempt to address it. Maybe you'll convince me that I'm wrong.
Showing posts with label viruses. Show all posts
Showing posts with label viruses. Show all posts
Sunday, February 1, 2015
Sunday, May 11, 2014
Vaccines: Building Our Immunity One Shot at a Time
I hope I'm not just preaching to the choir with this post, but I feel like I can't have a blog written from the Pediatrician's perspective and NOT talk about vaccines. It's too big a part of our practice.
Vaccines truly form one of the cornerstones of a pediatric practice. They are among the few interventions that are cost-saving. One of the others is providing clean drinking water. In the US, we have a schedule of vaccines for all children, and will provide them to everyone because they are cost-saving. These include Hepatitis A and B, Diptheria, Tetanus, Pertussis, Measles, Mumps, Rubella, Polio, and Chicken Pox. It is because of these vaccinations that polio no longer exists in the Western Hemisphere (the reason it has not been eradicated in the Eastern Hemisphere is because there is resistance to vaccination efforts), and partly the reason smallpox only exists in labs.
And yet, despite all the data showing that vaccines work, there is a huge anti-vaccine movement in industrialized nations. Organizations such as the Vaccine Liberation and the Think Twice Global Vaccine Institute advocate to parents not to get their children vaccinated.
Don't get me wrong. I'm all about informed consent and vaccine safety. I think all vaccines should be rigorously tested before they are given to millions of children. I think vaccine reactions should continue to be monitored, and that vaccines aren't necessarily a one-size fits all thing. There are some children who can't get vaccines, either because they are allergic to something in the vaccine itself, or because they do not have a strong enough immune system to make the vaccine effective (or worse, they could contract the disease if a live vaccine is used). But, considering that, all children who are able to get vaccines should, in order to protect those who can't. When the healthy population doesn't get vaccinated, they serve as possible source of infection to those children.
Let's look a little more in depth into their arguments.
First, the supposed link with autism. While this could be a blog post in and of itself, let's run through a quick history of this argument. Back in 1998, Andrew Wakefield, a surgeon from the UK, published a paper in Lancet, a well renowned medical journal, claiming that MMR vaccines had a link to autism. Around this same time, the FDA published guidelines requesting the removal of mercury based products from foods. Thiomersal, a mercury-based solvent and preservative, was being used at that time in several vaccines, and the CDC and AAP requested vaccine manufacturers to remove it. Note that these two episodes were linked in time, but not by anything else. In the ensuing decade, thousands of studies have been done. None have been able to replicate Wakefield's results, and none have shown harm to thiomersal, though it is no longer used in vaccines. In 2004, the Lancet partially retracted Wakefield's paper, after Brian Deer (a reporter in London) demonstrated that there were conflicts of interest that were not disclosed. Then in 2009, Deer determined that Wakefield had actually falsified much of his data. In 2010, the Lancet fully retracted the paper, and Wakefield was banned from practicing medicine by the General Medical Council in the UK.
Moral of the story: vaccines do not cause autism. There has not been a single study that shows that it does. The vaccine schedule is set up in a way that children are going to have developmental changes shortly after administration of the vaccines. That's what happens when kids get older.
Vaccine Liberation makes the claim that cleanliness can prevent all diseases, and 'proves' this with graphs showing that the death rate of several vaccine-preventable diseases and several where there is no vaccine available. The primary problem with these graphs is that they only look at death rates. Death isn't what we're concerned about in most cases. Polio, for instance, causes paralysis. We can prevent death through a variety of interventions, including the ventilator. It's the paralysis that we want to prevent. Mumps? It rarely causes a complication resulting in death; we give the vaccine to prevent inflammation of the testicles or ovaries, which can result in infertility. It also just doesn't sound like a fun illness to have. Complications from measles are more common, but it's especially bad to be pregnant and exposed to measles (same with chicken pox; most complications are in pregnant women). The graphs don't take into account any of these complications; they just look at the death rate.
Think Twice claims "Recently vaccinated children do carry the disease germ and are able to spread it to other children. Many so-called epidemics are initiated and spread in this manner, even though the unvaccinated are blamed." It is true that some vaccines are live vaccines, meaning that the virus was altered to cause an immune response, but not disease, and the virus itself is still functional. These vaccines tend to be more effective than other vaccines, because they act more like a disease-causing virus than the segments that are used in the inactivated or subunit vaccines. These include the varicella (chicken pox), oral polio, and MMR vaccines.
However, the idea that children can spread disease after getting these vaccines, especially that this accounts for most of the cases of these diseases, is incorrect. Most measles cases are imported, meaning that they were brought back from people traveling overseas, usually to Asia. These were most commonly unvaccinated people who contracted the illness, though some vaccinated people remain susceptible. Of course, the recent outbreaks of measles may change that assumption in the near future.
This post is already getting long, so I'll end it here, but if you know of any other arguments against vaccines, please feel free to bring them to my attention and I will do my due diligence in examining the data. But in the meantime, please vaccinate your children. For the good of society, and for their own health.
Need more evidence that parents not vaccinating their children is causing harm? Check out this map. It shows the vaccine-preventable diseases Measles, Mumps, Rubella, Polio, and Whooping Cough (Pertussis) on a world map where all the epidemics are occurring, along with how many cases are in each epidemic.
Vaccines truly form one of the cornerstones of a pediatric practice. They are among the few interventions that are cost-saving. One of the others is providing clean drinking water. In the US, we have a schedule of vaccines for all children, and will provide them to everyone because they are cost-saving. These include Hepatitis A and B, Diptheria, Tetanus, Pertussis, Measles, Mumps, Rubella, Polio, and Chicken Pox. It is because of these vaccinations that polio no longer exists in the Western Hemisphere (the reason it has not been eradicated in the Eastern Hemisphere is because there is resistance to vaccination efforts), and partly the reason smallpox only exists in labs.
And yet, despite all the data showing that vaccines work, there is a huge anti-vaccine movement in industrialized nations. Organizations such as the Vaccine Liberation and the Think Twice Global Vaccine Institute advocate to parents not to get their children vaccinated.
Don't get me wrong. I'm all about informed consent and vaccine safety. I think all vaccines should be rigorously tested before they are given to millions of children. I think vaccine reactions should continue to be monitored, and that vaccines aren't necessarily a one-size fits all thing. There are some children who can't get vaccines, either because they are allergic to something in the vaccine itself, or because they do not have a strong enough immune system to make the vaccine effective (or worse, they could contract the disease if a live vaccine is used). But, considering that, all children who are able to get vaccines should, in order to protect those who can't. When the healthy population doesn't get vaccinated, they serve as possible source of infection to those children.
Let's look a little more in depth into their arguments.
First, the supposed link with autism. While this could be a blog post in and of itself, let's run through a quick history of this argument. Back in 1998, Andrew Wakefield, a surgeon from the UK, published a paper in Lancet, a well renowned medical journal, claiming that MMR vaccines had a link to autism. Around this same time, the FDA published guidelines requesting the removal of mercury based products from foods. Thiomersal, a mercury-based solvent and preservative, was being used at that time in several vaccines, and the CDC and AAP requested vaccine manufacturers to remove it. Note that these two episodes were linked in time, but not by anything else. In the ensuing decade, thousands of studies have been done. None have been able to replicate Wakefield's results, and none have shown harm to thiomersal, though it is no longer used in vaccines. In 2004, the Lancet partially retracted Wakefield's paper, after Brian Deer (a reporter in London) demonstrated that there were conflicts of interest that were not disclosed. Then in 2009, Deer determined that Wakefield had actually falsified much of his data. In 2010, the Lancet fully retracted the paper, and Wakefield was banned from practicing medicine by the General Medical Council in the UK.
Moral of the story: vaccines do not cause autism. There has not been a single study that shows that it does. The vaccine schedule is set up in a way that children are going to have developmental changes shortly after administration of the vaccines. That's what happens when kids get older.
Vaccine Liberation makes the claim that cleanliness can prevent all diseases, and 'proves' this with graphs showing that the death rate of several vaccine-preventable diseases and several where there is no vaccine available. The primary problem with these graphs is that they only look at death rates. Death isn't what we're concerned about in most cases. Polio, for instance, causes paralysis. We can prevent death through a variety of interventions, including the ventilator. It's the paralysis that we want to prevent. Mumps? It rarely causes a complication resulting in death; we give the vaccine to prevent inflammation of the testicles or ovaries, which can result in infertility. It also just doesn't sound like a fun illness to have. Complications from measles are more common, but it's especially bad to be pregnant and exposed to measles (same with chicken pox; most complications are in pregnant women). The graphs don't take into account any of these complications; they just look at the death rate.
Think Twice claims "Recently vaccinated children do carry the disease germ and are able to spread it to other children. Many so-called epidemics are initiated and spread in this manner, even though the unvaccinated are blamed." It is true that some vaccines are live vaccines, meaning that the virus was altered to cause an immune response, but not disease, and the virus itself is still functional. These vaccines tend to be more effective than other vaccines, because they act more like a disease-causing virus than the segments that are used in the inactivated or subunit vaccines. These include the varicella (chicken pox), oral polio, and MMR vaccines.
However, the idea that children can spread disease after getting these vaccines, especially that this accounts for most of the cases of these diseases, is incorrect. Most measles cases are imported, meaning that they were brought back from people traveling overseas, usually to Asia. These were most commonly unvaccinated people who contracted the illness, though some vaccinated people remain susceptible. Of course, the recent outbreaks of measles may change that assumption in the near future.
This post is already getting long, so I'll end it here, but if you know of any other arguments against vaccines, please feel free to bring them to my attention and I will do my due diligence in examining the data. But in the meantime, please vaccinate your children. For the good of society, and for their own health.
Need more evidence that parents not vaccinating their children is causing harm? Check out this map. It shows the vaccine-preventable diseases Measles, Mumps, Rubella, Polio, and Whooping Cough (Pertussis) on a world map where all the epidemics are occurring, along with how many cases are in each epidemic.
Sunday, March 9, 2014
Popping Pills: The Age of Antibiotics
Last week, we discussed how to take care of a sick child. Susie came in with a fever, cough, and runny nose, and we talked about the importance of treating the fever and keeping her hydrated. But gosh darnit, you want her illness to go away, for her to be able to go back to school or daycare, and so on. So, you demand a medication to make things go away. An antibiotic. Your pediatrician refuses, saying that it's not indicated.
Look, I understand why you want your child to feel better. You hate seeing them sick. I get it. Really, I do.
But antibiotic use with diseases like the one above is such an issue that the American Academy of Pediatrics has made it #1 on their list of 5 things pediatricians and parents need to discuss.
Let's take a step back a moment. As a kid, you certainly learned about germs. The germ theory of disease, that is, that germs cause disease, has been around since the mid-1800s. It is the reason that when you go into surgery now, any member of the staff touching your open wound is 'sterile', and the reason we wash our hands when going into and coming out of patient rooms. The reason you probably tell your children to wash their hands before dinner, and Lysol every surface in the house if you have a bad illness spread through.
There are four major types of 'germs': bacteria, viruses, parasites, and fungi. Bacteria causes diseases like strep throat (which is caused by a streptococcal bacteria), some pneumonias (infections of the lung), and some other, rarer infections of the brain, sinuses, and intestines. Parasites include malaria and pin worms. Fungi cause diseases like athlete's foot, yeast infections, and ringworm. Viruses can cause any number of different diseases, so many that we don't always know about them. The common cold is caused by a group of viruses called rhinoviruses. Herpes, chicken pox, the flu, cervical cancer, and any number of other respiratory or stomach bugs are also caused by viruses.
Statistically, you are more likely to come in with a disease caused by a virus than one caused by any of the other groups of germs. Antibiotics are not effective against viruses. We do have some medicines that are effective against some viruses; for instance, cold sores caused by the herpes virus can be treated with acyclovir to shorten the course of disease and the flu can be treated early on with Tamiflu (though it really doesn't help). But amoxicillin won't make your cold go away.
As with fevers, showing up to your doctor within the first few days of an upper respiratory infection (a cold) doesn't tell us a whole lot. It could be bacterial, but it is much more likely to be a virus. And if antibiotics aren't going to help you, then the risk of them doing harm outweighs the benefit. Any antibiotic, but particularly the penicillins, can cause life-threatening allergic reactions, or more mild side effects such as diarrhea and vomiting. Why chance it if you don't need it?
So when should you get antibiotics? The American Academy of Family Practitioners recommends antibiotic use for upper respiratory infections only if the symptoms have lasted 10 days. Viruses generally go away after 5-7 days (though the cough may last up to 2-3 weeks), but if you continue to have fevers, runny nose, etc after that period, or if you start to feel better and suddenly get worse, you're much more likely to have a bacterial infection. Note that the color of the snot or mucus has no bearing on whether or not it is bacterial or viral. Unless it's clear, then it's more likely to be allergic in nature, rather than infectious.
What about other things?
Ear infections should generally be treated, but the physician should see a bulging, red, and pus-filled ear-drum. An ear drum that just has fluid behind it is not a sign of a middle ear infection, and antibiotics should not be given in those cases. You can see some examples of what ear drums look like here.
Bronchitis (chest colds) should probably be evaluated by a physician, but generally follows the same concept as upper respiratory infections: no antibiotics until 10 days into the course, or if you get better and take a turn for the worse. There is one important exception: if a child has coughing spells so severe that he/she vomits at the end, or has a "whoop" trying to breathe during the spell, he or she should be seen, as these are indications of Pertussis, which can be life-threatening in very young children. There is an antibiotic treatment for it, but often once the coughing starts, the antibiotic is no longer effective.
There is some current debate over whether or not strep throat needs to be treated. Antibiotics do not shorten the course of strep throat. The reason we give them is to prevent the development of rheumatic fever, which can lead to permanent heart damage. It's a rare complication of strep throat, and studies have shown that treatment with antibiotics essentially eliminates the risk of rheumatic fever, but there has been some concern that the risk of complication from using antibiotics exceeds the risk of getting rheumatic fever in developed nations (David Newman, who is an awesome speaker, talks about this a bit in his book Hippocrates' Shadow). But, antibiotics should only be given in patients who have a positive strep test, or who have a high suspicion for strep throat, which is not the case in most instances of a sore throat.
Bottom line, those physicians who argue with you about the need for antibiotics are trying to help you. They are not trying to make your life more difficult. Instead, they are trying to eliminate the risk of a complication from taking an unnecessary medication. If they're doing their job right, they should provide you some information about how to treat your symptoms and get you back to your normal self, even without antibiotics.
If they aren't explaining to you why, ask. It's your right as a patient to know what your physician is thinking when deciding on treatment. And if you don't agree, talk about it. Don't get mad and run off to another physician who will just give you what you want--those aren't the type of physicians you want around when things get hairy because they truly don't have your best interests at heart.
Look, I understand why you want your child to feel better. You hate seeing them sick. I get it. Really, I do.
But antibiotic use with diseases like the one above is such an issue that the American Academy of Pediatrics has made it #1 on their list of 5 things pediatricians and parents need to discuss.
Let's take a step back a moment. As a kid, you certainly learned about germs. The germ theory of disease, that is, that germs cause disease, has been around since the mid-1800s. It is the reason that when you go into surgery now, any member of the staff touching your open wound is 'sterile', and the reason we wash our hands when going into and coming out of patient rooms. The reason you probably tell your children to wash their hands before dinner, and Lysol every surface in the house if you have a bad illness spread through.
There are four major types of 'germs': bacteria, viruses, parasites, and fungi. Bacteria causes diseases like strep throat (which is caused by a streptococcal bacteria), some pneumonias (infections of the lung), and some other, rarer infections of the brain, sinuses, and intestines. Parasites include malaria and pin worms. Fungi cause diseases like athlete's foot, yeast infections, and ringworm. Viruses can cause any number of different diseases, so many that we don't always know about them. The common cold is caused by a group of viruses called rhinoviruses. Herpes, chicken pox, the flu, cervical cancer, and any number of other respiratory or stomach bugs are also caused by viruses.
Statistically, you are more likely to come in with a disease caused by a virus than one caused by any of the other groups of germs. Antibiotics are not effective against viruses. We do have some medicines that are effective against some viruses; for instance, cold sores caused by the herpes virus can be treated with acyclovir to shorten the course of disease and the flu can be treated early on with Tamiflu (though it really doesn't help). But amoxicillin won't make your cold go away.
As with fevers, showing up to your doctor within the first few days of an upper respiratory infection (a cold) doesn't tell us a whole lot. It could be bacterial, but it is much more likely to be a virus. And if antibiotics aren't going to help you, then the risk of them doing harm outweighs the benefit. Any antibiotic, but particularly the penicillins, can cause life-threatening allergic reactions, or more mild side effects such as diarrhea and vomiting. Why chance it if you don't need it?
So when should you get antibiotics? The American Academy of Family Practitioners recommends antibiotic use for upper respiratory infections only if the symptoms have lasted 10 days. Viruses generally go away after 5-7 days (though the cough may last up to 2-3 weeks), but if you continue to have fevers, runny nose, etc after that period, or if you start to feel better and suddenly get worse, you're much more likely to have a bacterial infection. Note that the color of the snot or mucus has no bearing on whether or not it is bacterial or viral. Unless it's clear, then it's more likely to be allergic in nature, rather than infectious.
What about other things?
Ear infections should generally be treated, but the physician should see a bulging, red, and pus-filled ear-drum. An ear drum that just has fluid behind it is not a sign of a middle ear infection, and antibiotics should not be given in those cases. You can see some examples of what ear drums look like here.
Bronchitis (chest colds) should probably be evaluated by a physician, but generally follows the same concept as upper respiratory infections: no antibiotics until 10 days into the course, or if you get better and take a turn for the worse. There is one important exception: if a child has coughing spells so severe that he/she vomits at the end, or has a "whoop" trying to breathe during the spell, he or she should be seen, as these are indications of Pertussis, which can be life-threatening in very young children. There is an antibiotic treatment for it, but often once the coughing starts, the antibiotic is no longer effective.
There is some current debate over whether or not strep throat needs to be treated. Antibiotics do not shorten the course of strep throat. The reason we give them is to prevent the development of rheumatic fever, which can lead to permanent heart damage. It's a rare complication of strep throat, and studies have shown that treatment with antibiotics essentially eliminates the risk of rheumatic fever, but there has been some concern that the risk of complication from using antibiotics exceeds the risk of getting rheumatic fever in developed nations (David Newman, who is an awesome speaker, talks about this a bit in his book Hippocrates' Shadow). But, antibiotics should only be given in patients who have a positive strep test, or who have a high suspicion for strep throat, which is not the case in most instances of a sore throat.
Bottom line, those physicians who argue with you about the need for antibiotics are trying to help you. They are not trying to make your life more difficult. Instead, they are trying to eliminate the risk of a complication from taking an unnecessary medication. If they're doing their job right, they should provide you some information about how to treat your symptoms and get you back to your normal self, even without antibiotics.
If they aren't explaining to you why, ask. It's your right as a patient to know what your physician is thinking when deciding on treatment. And if you don't agree, talk about it. Don't get mad and run off to another physician who will just give you what you want--those aren't the type of physicians you want around when things get hairy because they truly don't have your best interests at heart.
Subscribe to:
Posts (Atom)