Benefits & Risks of Immunizations, HPV Vaccine, Meningitis Shot – PediaCast 415
- This week we explore the real benefits and risks of immunizations. Have your children had their HPV vaccine? (They should… and that includes your boys!) What about the meningitis shot? And how many shots are too many? Dr Mike Brady stops by as we consider common vaccine questions asked by parents. We hope you can join us!
- Benefits & Risks of Immunizations
- HPV Vaccine
- Meningitis Shot
- eTeen Health Site from Nationwide Children’s
- Childhood Vaccines Part 1 – PediaCast 351
- Childhood Vaccines Part 2 – PediaCast 352
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.
It is Episode 415 for September 19th, 2018. We're calling this one "Benefits & Risks of Immunizations, HPV Vaccine, and the Meningitis Shot."
I want to welcome all of you to the program.
I have a little bit of a different show for you this week, and I know last week's episode was also a little bit different as we listen in on a recent Facebook live production that I did with our local CBS affiliate, 10TV, on a variety of back-to-school topics.
If you have had a chance to listen to that one and if you have kids in school, I would recommend that we've covered so much during that production. And the interesting thing is this, they were not the back-to-school topics that I had in mind, but they were the questions that the audience, made up of moms and dads, like you. They were the questions that the audience had in mind.
So the interview, and I actually played the role of guest instead of host last week. As the host was really one of the anchors from our CBS affiliate, 10TV, Tracy Townsend.
But anyway, the interview really became organic and granular as we just took questions from audience, and there were lots of them. And I knew we would not be able to recreate that, as a recorded podcast. It really helped that the parents were watching and asking questions, and sometimes asking questions that kind of played in the other questions.
So, I replayed and shared that Facebook Live event on this program last week, the audio of it.
But this week, my plan had been to cover a few select pediatric news items for you because we've not had news parents can use addition of the program in a while.
But then, I received a question from a long-time listener. That gave me pause and really motivated to shift gears this week.
And just like last week, when we had all those questions from parents. This one too, I hadn't really considered that this is an issue for parents until this question came up from a listener writing in.
So I love when you guys ask questions, and this really did shape this particular show for me.
She asked, and I'll get to her own words in a moment, but in that show, she asked what I thought of the HPV Vaccine. She wanted to know if I would have any reservations. Giving it, did I, or would I give it to my own kids, and she pointed out that I hadn't really talked about HPV Vaccine since 2011, so seven years ago.
So that got me thinking, you know, I probably don't cover vaccines as often as I should on PediaCast.
And so, for some folks listening, you know that may come across as "He doesn't care about them," or "The HPV Vaccine, you must not think it's important since he hasn't talked about it in seven years."
Now to be fair, we did have a two-week back-to-back episodes, sort of a Vaccine Special back in 2016 with Pediatric Infectious Disease and Immunization Expert Dr. Michael Brady, who also happens to be a past chairman of the Department of Pediatrics at the Ohio State University – College of Medicine. Also, a previous chairman of the Committee on Infectious Disease for the American Academy of Pediatrics.
And that one enough, he is also an associate editor of the red book, which is the go-to reference for all things related to infectious disease and immunizations in kids. So, he is a respective expert in the field.
Perhaps more importantly, he is someone that I have known for a very long time. And whose opinion I trust very much. So, he joined me two years ago and we did a two-episode extravaganza on the entire immunization schedule. I mean, literally, we covered every vaccine in detail.
Including the HPV vaccine, so it's not really been since 2011 when I last talked about HPV but it was sort of that conversation was buried, you know, in a couple of hours or little more in programming.
Those episodes, by the way, if you're interested in listening to those, I would highly recommend them. It's Episode 351 and 352. And I hope it links to them in the show notes for this Episode 415 of pediacast.org so you can find them easily.
But if you are interested in any particular vaccine, we covered them all in those two shows, that would be great ones to listen to.
In addition to sort of doing a round-up of all the vaccines, we covered immunizations in general.
So you know, how do they work?
Why are they important?
Are they still relevant and beneficial today given the fact that medicine has improved?
You know, could we just treat these diseases?
Do we really have to prevent them with vaccines?
So we talked about that.
We also considered what risks do they pose. And I mean, the real risks, you know, bad things that are truly associated with vaccines.
Turns out, there aren't very many of those things and the ones that do exist are incredibly rare, meaning that it's more dangerous to drive your child to the doctor's office than to have your child vaccinated at the office. The trip there and back is more dangerous.
But there are some risks, smallest they may be, so we discuss them with the transparency.
We talked about aluminum in vaccines, and mercury, and other chemicals.
We talked about so-called alternate vaccine schedules, are those good or bad? Do they somehow make a difference?
We talked about the number of vaccines that kids get, you know, are there too many shots?
If so, what can we do about that?
If not, how many would be too many?
So it was an honest discussion with someone I trust and an expert in the field.
Sort of like setting down with your uncle who might be a Bridge Engineer, or work for the Automotive Industry, or an Aviation Safety Expert, and you know, just someone that you know that has an interesting job and you can sit down with them on a picnic and just get the inside scoop, you know, I love doing that. How do bridges and cars and airplanes work? You know. Why should we trust the science behind them? Rather than packing a covered wagon, and venturing through ravines and mountains as we attempt to make it safely from Ohio to Oregon.
And if you've ever played the Oregon Trail, you know, how that journey can go. You know, give me cars and bridges and airplanes any day, because I truly believe my family is safer with science.
And that includes Medical Science in vaccines which at the end of the day are even safer than cars.
But don't take my word for it. Let's talk to someone who has spent his career dedicated that the noble task of helping kids achieve health and wellness and keeping them safe in the process.
And by the way, someone who is paid by you, parents and taxpayers, and not by the Pharmaceutical Industry.
So it was a terrific couple of episodes. And because it's been a couple of years, I feel like those shows have gotten a little lost in the feed. And in particular, the discussion on HPV Vaccine was even lost within all of that great content.
So I gave those shows a listen the other day, they're still up to date with the fantastic information on vaccines, in general, and on the HPV Vaccine, in particular.
So as I was sort of motivated by this listener question.
And let me share that with you now just to sort of give you an idea of what it was that motivated me to do this.
This was from a listener, Jessica, here in Ohio. I don't know Jessica personally, we just happen to live in the same state.
And Jessica said,
"Dr. Mike, I was surprised at my son's 12-year appointment to have my pediatrician recommend the Gardasil 9 Vaccine for him, which is the HPV Vaccine. My first reaction was "Isn't that for girls?" And she explained that the cancer prevention of the HPV Vaccine also applies to boys. And she seemed really excited by the fact that we could prevent cancers with this vaccine. I look through your old shows and found nothing later than 2011, and nothing on your view about this vaccine for boys, and the related cancers that it prevents for them. Of course, my mind went immediately to all the stir around the vaccines, causing irreparable damage to young girls. Which I think hasn't tied down. So shoot me straight Dr. Mike, your boy's 12 do you give him the Gardasil 9? Super super long time listener and welcome back, Jessica."
So as always, Jessica, you know, thanks for your question.
The quick answer, because I think that this deserves a quick answer and then a much longer explanation. But the quick answer is yes, I would give the HPV Vaccine to my children. In fact, I did give the HPV Vaccine to my kids. Because I don't want them to get cancer and we have a vaccine to prevent these cancers, so it's a very important vaccine.
There has been a no cause and effect association with any sort of irreparable damage to girls. So there is no evidence that the HPV Vaccine causes any particular problem, any more so than other vaccines.
I mean, if they were, there's no way I wouldn't give it to my kids. And there's no way I would recommend it for your kids, cause I care about kids.
And I want to prevent cancer, I want them to be healthy.
And the benefits of HPV Vaccine far far out way any risk that is associated with vaccination, just like the benefits of driving across bridges and cars with the latest safety features, or flying an airplane from Ohio to Oregon far out way.
The risks that bridges and cars and airplanes pose. The risks are not zero, you know, the risk of flying in an airplane, going across that bridge, driving in a car. Those risks are not zero. But they're very very very close to zero. As specialists, we consider any particular trip. You know while trusting covered wagons on unpaved roads or going without immunizations, those things have been proven to be particularly dangerous.
But how exactly did I arrived at this conclusion? You know, sort of what goes into the consideration of risks and benefits, and comparing those as we think about vaccines.
The answer to that question is an important one and it actually was illustrated pretty well in my 2016 conversation with Dr. Brady.
It's so important that I really stop in my tracks in order to show that again with you this week, rather than covering some pediatric news stories that I hadn't actually picked out yet.
So what will follow today is gonna be four segments, from PediaCast 351 and 352.
First, we're gonna cover the benefits and risks of vaccines. Just you know, why do we recommend them and what risks are you taking on when you have your child vaccinated?
We'll talk about how they work, we're not gonna skirt the risks, we'll give you a trustworthy analysis as Jessica says you can expect us to shoot straight with you as we consider the benefits and the risks of vaccines.
Then we'll talk about the HPV vaccine hopefully in enough detail to get all your questions answered about that.
And then I'm also gonna throw in our discussion on Meningitis Shot, so that would be segment number 3.
Because this is another one that we give a round of time that we're talking about HPV, you know, teenagers, the sort of the preteen years when you're almost a teenager. They sort to go together.
And in many cases, these vaccines do so we'll talk about the Meningitis Shot in addition to the HPV Vaccine.
And then finally we'll wrap things up with the discussion on the number of shots that we give kids.
Does that number matter?
Is it too many?
Can your immune system handle it?
What's the effect?
Why can't we just combine them all into one?
So a little bit of a rerun on PediaCast this week.
But it's a rerun based on a listener question and I really feel like this is a topic on the minds of many many parents today, as I consider my social media feeds and varies other online sites where parents and pediatricians hang out.
Before I play my conversation with Dr. Brady, I do want to remind you about something that I talked about last week. And that is a new site from Nationwide Children's called the eTeen Health Site, which is really aimed to help literacy for teenagers, and in particular, teenage girls.
Because we all use the internet to search for health and wellness information, right? It's like our very first go-to place. You do google search, even before you talk to family or ask your doctor.
But it is important to search well because you know, there's great trustworthy evidence-based good information out there. And then there's information that's not really so trustworthy, you know, based on a loose associations and misconceptions and myths and there's really no science behind it.
Science is not perfect, you know, sometimes we think one thing is best but then future study shows no, that was not right.
And that we kind of change our thinking, you know, recommendations change over time based on new evidence, and that some of those recommendations will also end up changing.
But at least we're basing it on something real. Something true.
Whereas sometimes we can let our emotions get away with us, and sometimes also personal agendas that are associated with this.
And we can uncover information that's really not accurate. That is not based on science or evidence.
And so, as you just do a general google search, you're gonna come across both good information and bad information.
So how do you evaluate it? You, know.
How do you test it?
And then how can you practically use it if you do determinate, yes this is good information.
So this eTeen Health Site actually walks teenagers. And again, it's sort of aimed more teenage girls but it walks you through searching, testing, and then deciding how you're going to use the information.
Really helps to increase health literacy. I think it's a fabulous site.
And if you have teenagers, you are a teenager, you work with teenagers in any capacity, please do share this site with them. And I will include a link to it in the show notes for this Episode 415 over pediacast.org.
Again, it's called the eTeen Health Site from Nationwide Children's. Also, I want to remind you that if there is a topic that you would like us to discuss. If you want to hear about some particular thing, just ask.
Jessica wanted to hear about the HPV Vaccine or you have a question for me on any topic, related to pediatric health or parenting, please do let me know. It's easy to get in touch as head of the pediacast.org and use the contact link.
Also, I want to remind you the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
So if you do have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
So let's take a quick break and I will be back to talk more about immunizations, benefits, risks, safety, HPV Vaccine, and the Meningitis Shot. That's all coming up right after this.
Dr. Mike Brady: Vaccines are a biological product that are designed to prevent diseases by prophylactically or sometimes therapeutically stimulating the body's own immune response to the different diseases, so that if somebody comes exposed to one of these diseases, the immune system has already developed the ability to protect the individual from whatever the disease is.
Most vaccines are currently addressing issues of infectious diseases, but vaccines can be considered for a lot of other things, and there's a lot of interest in time in developing vaccines for cancers even.
Dr. Mike Patrick: Yeah. So, with regard to childhood vaccines, we're trying to make memory with the immune system and providing a safe way for the immune system to remember, so when the actual disease, whether it's a virus or bacteria comes along, that the immune system gets revved up and will fight that because it has memory for it from the vaccine that we gave.
Is that the pretty accurate summary?
Dr. Mike Brady: It's a very accurate summary and again one of the advantages of the vaccine is it tries to develop this immune response without having the patient or the person actually have to go undergo the disease, and so it's a much safer way to develop protection.
Dr. Mike Patrick: Yeah. Now, one of the things that folks hear about with regard to the benefit of vaccines is not only that it helps to protect the individual child but there's also a concept of Herd immunity. What exactly is that?
Dr. Mike Brady: So, actually we're trying to move to the term "Herd Immunity" to "Community protection."
Dr. Mike Patrick: Because it's a better description of what's happening.
Dr. Mike Brady: And so, what happens is most of these infectious diseases that we're considering are transmitted from person to person.
So, you can reduce kind of outbreaks if you have very limited numbers of people who are capable of transmitting the particular virus or the bacteria to another individual.
So the concept of community protection is you have to have a certain level of individuals who are protected so they can eliminate further transmission.
And a very good example is what happened at Disneyland last year with measles.
Measles is one of the most contagious diseases that we have, and they were a number of people at Disneyland who hadn't been immunized.
They were exposed to measles, developed measles, and unfortunately, many situations were these people are not immunized. They were coming from communities where they are clusters of other people who are not immunized against measles.
And so we had many pockets of outbreaks that were related to the fact that the number of people in the different communities was at such a low level of being vaccinated. That they were able to continue transmission.
But it didn't actually get transmitted very much in other areas around the country. Because we did have this community protection with enough people who were immunized against measles.
And this is particularly important because we have some of our children who are either too young or because their immune systems are not strong enough, unable to either respond to the vaccine or get the vaccines. And one of the things we'd like to do is make sure that there's enough people in the communities that are immunized so that they can protect this kind of more vulnerable children.
Dr. Mike Patrick: Because, if the other folks are immunized then you have fewer people to get the disease from, that which makes us safer for those kids.
So one of the folks that we're trying to protect with this are those who can't get immunization. So if they have cancer for instance or other immune problems, they can't have vaccines.
But also sometimes vaccines don't work in a specific individual.
Dr. Mike Brady: No vaccine is perfect. What happens is the vaccine is to designed to try to stimulate the immune system, and there are some children whose immune systems may not be able to respond to that particular vaccine, one that's given.
So we have some children with immune deficiencies. We may have some children who are on medications, that alter the immune system. Most people think about cancer patients and chemotherapy but probably one of the more common medications would be some of the Corticosteroids like Prednisone, which can influence the ability of the immune system to respond.
So we have some children who can't respond to the vaccines because their immune system either naturally or through the use of medications is modified.
But the other thing, we have some children who are too young to respond to certain vaccines. And so under those circumstances, again, we would like to make sure that the people that are around them, kind of cocoon them, and protect them.
Dr. Mike Patrick: And it can even in healthy individuals, were you don't have a hundred percent, what we cause zero conversion from the vaccine. But it's pretty, it's a rare occurrence but you just don't know if your kid is one of the ones that didn't convert.
So even if your child has had vaccines and seems healthy, it's still nice to sort of cocoon them, with folks who are immunized so they don't have someone to get the disease from.
Dr. Mike Brady: Right. And again, a good example is the Measles Vaccine where we know that about 95% of healthy children have received the vaccine will develop protection. But that means 5% won't.
And when you have 4 million children every year being immunized, that becomes a large number over time.
And we did find out in the late 1980s that we needed to immunize with the second dose to try to get to that 5% because we had a kind of an outbreak of measles in the United States. That was occurring because we did have that 5% who are unable to respond or didn't respond for some reason.
And now again we've been able to control measles by using two doses.
Dr. Mike Patrick: And I think, in terms of covering childhood vaccines, we've talked about the benefits of vaccines and protecting kids from these diseases in a way that they don't have to get the disease first and protecting whole communities with the community protection or what's called Herd Immunity.
Let's discuss real quick before we go through the vaccines, actual risks. Because we want to, you know, sort of being transparent about what the real risks are. Sometimes, physicians sort of get blamed for skirting over any risks that are associated with immunizations and just trying to push them.
But I want to just take a step back and address what the risks are and then put that into perspective, and then we'll compare risks and benefits. You know, as folks are making decisions about vaccines.
So I think, first risk would be allergic reactions to the component, but this isn't something that you see very often, correct?
Dr. Mike Brady: No, fortunately. Actually, as you've mentioned, there are, you know, the vaccines contain not only the agent that you're trying to immunize against but also some other chemicals for stabilization and trying to avoid contamination.
And so people can be allergic to those, but those probably occur less than one in a million immunizations so they are something we have to be aware of. And if the child does develop an allergic reaction to a specific vaccine, we have to be careful that other vaccines that may have similar components are not given to that child.
Dr. Mike Patrick: Another thing that some folks will come across in reading and researching vaccines, is something called Guillain-Barre Syndrome. And we actually, if you do, if folks want to know more about this, you can do a google search for PediaCast and Guillain-Barre. So we've covered this in the past.
But this is also something that can happen after the influenza vaccine, in particular. But it's still, you know, one in a million kind of situation, correct?
Dr. Mike Brady: So, the Guillain-Barre Syndrome was kind of first identified as a potential adverse event associated with immunizations back in 1976, with the initial kind of Swine Flu Influenza vaccine.
And for the most part, that was the only year whether it was a significant amount of Guillain-Barre associated with administering the Influenza Vaccine.
Most other seasons with exception of maybe one or two, there really hasn't been any significant relationship between Influenza Vaccine and Guillain-Barre.
But again, since you're using a biological product to try to stimulate the immune system to provide protection, and Guillain-Barre is kind of an immune-mediated phenomenon. It is something that the Centers for Disease Control and the FDA are very interested in, and make sure that there's adequate monitoring kind of post-licensure experiences of people who received vaccines.
And so Guillain-Barre is really something that we recognized as a possibility. It has happened very rarely, but it is something constantly being monitored to make sure that we can understand whether it is a real effect or not.
A good example in 2005 when the first Meningococcal Conjugate Vaccine became available. There were reported to VAERS (which is kind of a passive reporting system) a number of children had received the vaccine who got Guillain-Barre Syndrome.
After further kind of evaluations, it was determined that these were just temporarily related and not constantly related to the vaccine. In other words, Guillain-Barre does happen in otherwise healthy people. And it just so happened that these healthy people who got Guillain-Barre also got the vaccine, but there was no relationship.
And that was determined by looking at large databases of children who did and did not receive the Meningococcal Conjugate Vaccine.
And it actually turned out that in that particular large study, with more than 20 million adolescents, that Guillain-Barre actually occurred more frequently in those who didn't get the vaccine.
Now, the vaccines certainly should not protect you from Guillain-Barre. But does suggest that it was not associated with the vaccine.
Dr. Mike Patrick: Because, just because, and we've talked about this on PediaCast many times. Just because two events are associated in time, doesn't mean that one caused the other.
You mentioned, there's which is the vaccine adverse event reporting system. And this is just a system that anyone can report any event following the vaccine but it certainly doesn't mean that the vaccine caused any of those events.
Dr. Mike Brady: Yeah, that's definitely true. So what happens is there is this kind of like early warning system. And what we want is for people to provide any kind of information on any kind of adverse event that occurs following the administration of a vaccine.
And as you've mentioned, it doesn't necessarily mean that there's a cause and effect, but it does require than additional evaluations to try to assess, whether there is a cause and effect.
And so again, VAERS is something that we want people to actively submit information to, but then there's other kind of mechanism.
So there's VSD, which is the Vaccine Safety Datalink network, where they have large numbers of people that they can monitor. Kind of on a more perspective basis and that can either support or refute a connection between a particular adverse event and the vaccine.
Dr. Mike Patrick: Sometimes, those numbers get reported and as "Oh, look, vaccines are causing all of these things," those numbers from VAERS are like get reported.
So a parent, you know, comes across this information that looks like the vaccine is causing every single one of these things. But a lot of the time wants the studies are done and folks look into it. That's not the case at all.
Dr. Mike Brady: Yeah, that's true.
Dr. Mike Patrick: There's another condition folks will come across, and this one is, you know, can be devastating, called Subacute Sclerosing Panencephalitis. That sometimes you'll see out there as associated with the Measles Vaccine.
But, the association is really with more the wild measles virus rather than the vaccine itself. Is that correct?
Dr. Mike Brady: That's very true. So, one of the conditions that was fortunately very rare but was seen after natural measles was, as you mentioned, SSP, the Subacute Sclerosing Panencephalitis.
But again, because we're giving a live virus with the Measles Vaccine, there has been tremendous interest to try to assess whether or not this was a complication of giving the live measles virus as part of the vaccine. And, you know, there is very good data to support the fact that Subacute Sclerosing Panencephalitis is not associated with receiving the live Measles Vaccine, but it is associated with measles.
So that gives us one more reason to actually use the vaccine.
Dr. Mike Patrick: And, as it turns out it's like one case per 70 million people. So this is, even more, not even one in a million, it's much rare even than that.
But again, I wanted to mention that because, you know, folks will come across that as they're looking into these things.
And then another is mercury, so Thimerosal was a preservative in multi-dose vials of vaccines that help prevent the bacteria from contaminating the vial. But for the most part, vaccines are single-served now. And do not contain Thimerosal. Is that correct?
Dr. Mike Brady: That's correct. The only vaccines in the United States that still may contain Thimerosal are the multi-dose vials for the Influenza Vaccine.
And multi-dose vials for the Influenza Vaccine are particularly valuable when you are trying to have large numbers of people immunized that one particular location.
But that's the current, only current vaccine in the United States.
However, around the world, there are still many vaccines that contain Thimerosal. And, the important thing that you need to understand is people get concerned about mercury poisoning and they have good reason to.
But that's not Methylmercury which accumulates in the body. Thimerosal is Ethylmercury, which can be metabolized. And therefore, does not accumulate in the body.
And there really is no kind of evidence that Thimerosal has caused any adverse consequences in any of the children who are immunized.
However, it was removed from the vaccines not because it was concerned that it was harmful. It was concerned that it was reducing acceptance of vaccines. And in order to try to enhance people's acceptance of vaccines, it was removed in the United States.
Dr. Mike Patrick: So we just didn't want to give folks another reason to be concerned even though that really wasn't a concern.
And as I recall when they first went to taking the Thimerosal out of the vaccines, they were shortages in lots of the vaccines because the production to make all these single-served ones was kind of lagging behind.
Of course, that's not an issue now. But I remember that was kind of a consequence of taking the Thimerosal out that they were some unprotected kids because they were shortages of vaccines there for a while.
What about specific additives to vaccines? Why is aluminum in immunizations?
Dr. Mike Brady: So, sometimes when you're trying to stimulate the immune system, you may need to have some kind of a chemical that can jumpstart the immune system. And that's called an adjuvant.
And aluminum, it turns out in certain aluminum salts is a very good adjuvant. That means, that with a smaller amount of whatever the vaccine component is, if you add the adjuvant, you can get a much stronger immune response. And that's very valuable when you're getting exposed to a particular pathogen, for the immune system to be really robust and be able to respond very rapidly and very strongly against the agent. So there are certain vaccines that contain this adjuvant.
And there's no question that they make a vaccine a much better vaccine.
Now again, because you're adding some additional chemicals, the people who create the vaccines and then all the people that are responsible for monitoring the vaccines, are constantly kind of trying to evaluate whether or not there's any evidence that adding any of these chemicals might be causing problems. And to date, there's no evidence to suggest that they are causing a problem.
One of the nice things is the Institute of Medicine which is probably the premiere organization trying to look at the immunizations and any potential harm has come out, and said that they currently don't have any evidence that any of these additional or adjuvant chemicals are causing problems for children.
Dr. Mike Patrick: Other additives that folks would come across, formaldehyde or formalin in trace amounts. And that just inactivates, that's used to inactivate the virus for some viral vaccines. Correct?
Dr. Mike Brady: Yes, so again, what we're trying to do is stimulate the immune system without having to expose somebody to potential harmful organisms. And so, yes, some of the vaccines are taking the live organism and killing it with formalin.
But then, the process is continued when it tried to remove as much formalin as possible. And that usually ends up being in trace amounts. And far less than what you'd be exposed to in almost daily activities. Because like it or not, we get exposed to formalin in a lot of things that we eat and experience on a daily basis.
Dr. Mike Patrick: So these things do have a purpose! That makes sense. And helps the vaccines to work.
Also, antibiotics, antifungals, in trace amounts to prevent contamination of certain vaccines.
But again, none of these things have been shown to be a problem. And if a problem does arise, we have this early warning system in place to evaluate. And as we go through the individual vaccines, there have been times when vaccines have been removed from the market, or when change have been made because we have seen that there are issues.
So it's not just a gung-ho, we're going to do this without really being thoughtful and watching for issues and then reacting to issues when they do occur.
So let's walk through just real quick.
When you do have parents who are concerned about these things that we've talked about, how would you walk through sort of the risk-benefit analysis for vaccines? I think most pediatricians, and most of the parents are going to expect that most pediatricians are going to say the benefits far out with the risks. Would you agree with that?
Dr. Mike Brady: I definitely would agree with that. And one of the, I think, the major challenges of the pediatrician in 2016 is that many of the diseases that are being prevented had been prevented for such a long time, that many parents have no understanding of the real potential impact of these diseases.
And so, that probably the biggest challenge. When you're trying to discuss the difference between the risks and the benefits is that if they don't understand what the benefit is, any risk may be unacceptable.
And I think that's one of the major challenges, to try to make it very clear that many of these diseases could happen again if we don't immunize and that many of them are very very serious.
People discuss the issues sometimes that why get the chickenpox facts, I mean chickenpox is not that big of a deal. And yet, you know, if you were to look at what have happened prior to the availability of the vaccine, there were hundreds of deaths related to Varicella, children will get Varicella Encephalitis, there will be significant cellulitis when they got infected and they were very difficult to treat.
So that average child may have Benign Disease but there were actually some significant consequences. So it is kind of a challenge trying to get people to understand that the benefits are truly outweighing the risk.
Dr. Mike Patrick: And when it's your child who gets Encephalitis from chickenpox, and especially if you had intentionally exposed them to chickenpox, then that happens. Just, you know, really tragic.
Dr. Mike Patrick: Why would we want to protect kids against human Human Papillomavirus? What is it? What is the cause?
Dr. Mike Brady: So Human Papillomavirus, again, it has a number of different kind of strains or types. And the primary thing that we're really concerned about is the possibility that it would cause cancers.
And the CDC just recently put out a report and said that each year in the United States, there are about 28,500 cases of HPV-associated cancer.
So it is a significant cause of cancer, and it causes cancer. Believe it or not, the most common HPV-associate cancer now is Oropharyngeal Cancer. So 15,000 of the 28,000 are, did Oropharyngeal Cancer, which kind of occur in both males and females.
Second most common is Cervical Cancer.
Followed by Vulvar Cancer.
So those are primarily seen in women.
And then, the next highest would be Anal and Rectal Cancers, and then Penile Cancer.
And so, it is a significant cause of cancer. And obviously would like to prevent that.
Dr. Mike Patrick: In boys and girls.
Dr. Mike Brady: In boys and girls.
Dr. Mike Patrick: I think this is another, we've talked about PediaCast many times, about sexual activity in teenagers. And the numbers are really pretty probably higher than what most parents would think.
With that 47% of all high school students admit they're having had sexual intercourse at least once in the past.
34% admit they're having had sexual intercourse within the past three months.
So even though you think, "My kid is not going to sexually active," nearly half of teenagers are.
And so, it is, I mean, it is really important to get your kids protected against this to prevent cancer down the road. Would you agree with that?
Dr. Mike Brady: There's no question. And the other thing that's very important, as I should mention, most parents would not necessarily have thought the numbers would be as high as they are.
But many parents also believe that they could predict when's going to happen in their own children. And you know, I think that the fact that they probably would be amazed at the information, which suggests that they probably can't.
Dr. Mike Patrick: What timeframe would you give this vaccine?
Dr. Mike Brady: Okay. So currently, the recommendation is to give it at age 11 to 12 years of age. But it can be given down to age 9, and actually here at Nationwide Children's Hospital are primarily caring that work and start giving it at age 9. And has had increased acceptance of the vaccine. And giving it at age 9 is actually kind of supported by some of the immunologic data that suggests that children between 9 and 13 have much higher levels of antibodies and children and adults over age 13.
So one of the things that giving it at an earlier age thus, is it makes less likely that the parents are going to have the back of their mind the issue of sexual activity?
Once you get to the fact, you get to the point where the child starts going through puberty, that becomes much more of a concern. So if you give it at age 9, I think that it is more highly accepted because you've kind of taken away one of the concerns that the parents might have.
Dr. Mike Patrick: One of the confusing things with this vaccine is it there are several types and they're different strains that were involved. So with each one that comes out, there was originally a two-strain one, and then a four-strain one, so different stereotypes we're talking about that it protects against.
And now there's a nine-strain one that's out there.
What if someone had the two or four-strain one and now they want to be protected against those other ones.
Can you get the nine-strain one after you've had the other ones? Or that's not doable?
Dr. Mike Brady: It's very doable. So if somebody has received the false series, either the HPV2 or the HPV4. They can safely receive the HPV9.
Now, neither the CDC or the AAP routinely recommends that, because the additional five strains represent less than 10% of the remaining causes of HPV-associated cancers. And kind of from a Cause Effective Perspective, it doesn't necessarily kind of add up.
However, there are people who are kind of interested in protecting their children as best as possible, and so there'll be no reason to not get the other vaccine.
And so, you know, again it's not routinely recommended but there'll be no reason not to do it.
Dr. Mike Patrick: Is that just the one-booster dose that you would do or would you have to do the whole series?
Dr. Mike Brady: Okay, so,
Dr. Mike Patrick: Or is it just two or no, three, three doses.
Dr. Mike Brady: So currently it's three. And hopefully, in the not too distant future, it will be two. But you would have to give the full series in order to provide protection.
Dr. Mike Patrick: Okay. And I think that the HPV Vaccine has really been sort of a victim of the vaccine hysteria that is out there. There've been a lot of claimed associations with Guillain-Barre Syndrome, Multiple Sclerosis, POTS (Postural Orthostatic Tachycardia Syndrome), I mean lots of things that folks would come across. But again, it's being monitored, just as all the other vaccines that we've talked about.
Has there been anything that really does stand up? That this could be an association that's concerning right now?
Dr. Michael Brady: Yeah, so probably the major concern is the issue of syncope. You're giving this vaccine to adolescents. We have known for a long time, back when I was training and we used to give a shot of penicillin to treat strep throat, adolescents would faint with that shot as well.
So syncope is probably the biggest risk. And there have been reports of children fainting and hitting their head, hitting their teeth, et cetera.
So that's probably the clearest and most significant adverse event associated with giving adolescents any vaccine. But it seems to occur more commonly with HPV vaccine.
And HPV vaccine hurts more than some of the other vaccines, so that's probably the reason. And, you know, I can't say for sure but I think that part of the fainting occurs because the adolescent wants to appear strong, and unlike the young child who screams and cries,
I think that kind of increases their likelihood that they're going to develop a fainting spell. But that's probably it.
Now, as you mentioned about the monitoring situation, there have been tremendous efforts by the CDC, by the FDA, and a number of different situations to try to see if they could identify any associations with many of the different conditions that you've mentioned. And it really turns out that those are sometimes temporally related but not causally related by the vaccine.
That's a tremendously difficult situation for people to understand if they had a child who seemed to be healthy, got a vaccine and then developed that condition.
If they didn't get the vaccine, it probably would have happened anyway. But they didn't have this kind of point in time where they could blame something.
And unless you can, so many of the different conditions you mentioned are things where we may not know exactly why they're caused.
So it's a lot easier for people to kind of jump on blaming the vaccine when their child experiences a change in their health, and they don't have a good explanation.
But, again, using a particularly some very large kind of population databases, the CDC and the FDA can review and take a look at it, and make sure that we're not missing something.
Dr. Mike Patrick: So the benefits far outweigh the risks with the HPV vaccine in terms of preventing cancers, which is, you know, such an important thing to do.
The meningococcal vaccine, then this is one that we think about kids getting before 7th grade, you know, 11 to 12 years old, and then or before college. Tell us about that one.
Dr. Michael Brady: There are actually two types of meningococcal vaccines.
The meningococcus has a number of different serogroups. The different capsules on the bacteria kind of determine what the serogroup is. And in the United States, the three that are the most common are B, C, and Y. It was relatively obvious, looking at the data, that in young infants, B was the most common. And when you got to adolescence, it was C and Y serogroups that were the most common causes of meningococcal disease.
So, the first vaccines that became available for meningococcus were vaccines that protected against serogroups A, C, W and Y. And there are reasons for that, I mentioned that C and Y caused a lot of disease in adolescents. It causes a little bit of disease in younger children, but it's very high in the adolescents. A, which is not something we see in the United States, is actually a serogroup that's present in a number of countries around the world, particularly in Africa. And again, people travel, so it was reasonable to kind of include that.
And so, the original intent of the vaccine when it was created was to try to provide protection to two different groups.
There are certain groups of people who are at high risk for meningococcal disease, people with complement deficiencies, people whose cells are not working well, people who don't have spleens or people with sickle cell disease.
There are certain other situations. There might be outbreaks. It turns out microbiologists who work with the organism are at increased risk. And then, if you travel to certain areas, you'd be at an increased risk.
So, the original vaccine was kind of designed for that population.
In addition, we recognized that adolescents had a higher rate of meningococcal disease compared to the general population. And when they kind of looked at it, it turned out that college students, particularly those who as freshmen lived in dorms, and as college students frequented areas where there was lots of smoking and alcohol consumption, and so that kind of defines many college students, that they were at increased risk.
So, the original vaccine was going to be given as part of the adolescent platform at 11 to 12 years of age. And there was a hope, based on experience from the other conjugate vaccines that protection would last for about 10 to 12 years at least. And that will get people through that peak.
Later, it was determined that the immunity waned in about half the people after about four or five years.
So it was necessary to have a booster dose. So now what happens is the recommendation is for 11 and then at 16 years of age, and that should cover that increased risk at the time for C and Y, because this is a vaccine with A, C, W and Y.
And that has been very very impactful. We just continued to see a decline in meningococcal disease in that age group.
What's kind of been interesting is B, which I mentioned was the most common serogroup causing meningococcal disease in young infants but was kind of less common in adolescents, there had been at least seven outbreaks on college campuses over the last five years of B. And that was unusual because most of the outbreaks before were C or Y.
So probably, the meningococcal conjugate vaccine is protecting college students. And so that means that what's left over is B.
Now, even with those outbreaks on college campuses, there still isn't any increased risk for college students to get meningococcal B disease compared to the general population. Actually, it's slightly lower than the general population. But that's what the outbreaks are, that's what serogroup is causing the outbreaks and it's got a lot of attention.
Dr. Mike Patrick: Yeah. So will B be added with all the others?
Dr. Michael Brady: So, there currently are two licensed meningococcal B vaccines. And again, they are licensed routinely to be given to individuals who are at increased risk from meningococcal disease. They are not routinely recommended for, and the vaccines are proof for age 10 and above, they are not routinely recommended for any other populations.
But the CDC and the American Academy of Pediatrics are going to say that they may be given if the family and the physician feel that it's prudent to give the child the vaccine.
Now, this received a kind of a complicated recommendation from the CDC. So the CDC has category A recommendations. Those are recommendations that are routine for either an age group or population.
So as I mentioned for the meningococcal B, for the high-risk group, got a Category A.
For the non-high risk group, they gave it a Category B recommendation, which means that again, if the family and/or the physician feel it would be prudent to give it, the vaccine can be given. And the reason that's important is the Affordable Care Act requires both federal and commercial insurance to pay for any vaccine that has a CDC recommendation.
Dr. Mike Patrick: Whether that's A or B category?
Dr. Michael Brady: Right. So, it's a situation where the B vaccine now is available and cost should not be a consideration as to whether or not somebody does or doesn't receive the vaccine. So that's been taken of. And it's just a discussion about, you know, kind of again risk-benefits and kind of worth it.
Dr. Mike Patrick: So if B outbreaks are now occurring on college campuses and you have a teen who's heading off to college, then that would seem that could be a prudent reason to do it.
Okay. Do you think that B will be added to the vaccine with A, C, and Y?
Dr. Michael Brady: They probably won't be incorporated into the current ones.
So, the serogroups A, C, W, and Y, the vaccines are polysaccharide conjugate vaccines where the polysaccharide is part of the capsule, which makes it an A, C, W, or Y.
The polysaccharide capsule of B actually looks very similar to polysaccharides that are found in humans. So, the body, fortunately, will not react to the polysaccharide in meningococcus by developing antibodies because that could damage the person. So they had to come up with a completely different approach, and so they took proteins that were in the different meningococcal B strains and develop vaccines from that. And it's unlikely that they would make a good kind of combination with the polysaccharide vaccines.
Dr. Mike Patrick: So that's the reason that there are two different ones and will probably continue to be different ones.
The meningococcal disease itself is not just meningitis. It really can be more severe and rapidly life-threatening. Tell us a little bit about meningococcal disease, why this is an important thing to protect against.
Dr. Michael Brady: I've mentioned before the term kind of 'invasive'. So when we talk about invasive disease, that means that usually, we're concerned about the bacteria getting into the bloodstream, and then potentially going to other vital areas such as the brain, meningitis or the lungs, pneumonia.
With the meningococcus, what happens is the kind of usual preceding situation is that somebody will end up getting exposed to somebody else with a meningococcal strain. It ends up getting into their nose. And for reasons that we don't know exactly why that the bacteria will then invade and get in the bloodstream.
Well, it turns out that when this bacteria gets in the bloodstream, it gets very aggressive. It grows very quickly. It releases a lot of chemicals that can modify your blood pressure, can modify your heart's ability to function. The bacteria can even go on to damage your adrenal glands and it can also go up to the meninges or around the brain and cause meningitis.
It turns out that probably the thing that is most life-threatening is when the bacteria's in the bloodstream and creating all these chemicals that are kind of damaging your blood vessels and your heart. We call that meningococcemia, and that's where you get this tremendous amount of difficulty maintaining somebody's blood pressure. It's a very rapid process, and it's probably responsible for almost all of the deaths.
Now, some children will also go on to develop meningitis. And, as we mentioned last week, meningitis can result in a lot of significant long-term sequelae, and that can happen with meningococcal disease as well. And so, that's again something that we'd like to prevent.
The other thing that can happen that is really kind of a life-changing is that many of the children who have this kind of meningococcemia will also have the bacteria, as well as the impact on the blood vessels cause damage to either the skin or the muscles. And, we have seen situations where children had to have complete amputations of fingers, toes, but even the whole arms or legs.
So this is a disease that definitely deserves a lot of concern.
And if a pediatrician walks in and sees a child with fever, and what we call petechiae, their blood pressure is up too. Because it's something that you recognize as potential from meningococcemia and you've seen patients with meningococcemia, you realize how severe the disease can be.
Dr. Mike Patrick: And you have to react quickly. The mortality rate ends up being about 15% within 12 hours of infection onset, you know, without any intervention at all.
So it can be rapidly serious and definitely something that you want to protect your kids against.
Let's kind of shift gears here a little bit.
One of the things that you hear parents say is that are these diseases really still a problem today?
So given, in particular, the diseases that we don't really see anymore, when we did see them it was before the era of modern medicine. So would diphtheria, pertussis, measles, would these things really still be dangerous today? What's your response to that question?
Dr. Michael Brady: So there's no question they would still be as dangerous. Many other things, some of the viral infection that you mentioned as we have no specific anti-virals to treat them, we would have slightly better kind of supportive care.
And yes, probably there would be a high number of children who would survive, but they may still go through a pretty tremendous poor experience and could still end up with significant health complications even if they did survive.
So I think that you know, we're more capable of managing things. But let's take something like meningococcal disease and we talk about how serious it is, the mortality rate hasn't declined despite the fact that we have much better supportive care. And part of the reason is that the disease that really progresses so rapidly, that before we'd have the ability to kind of use some of our very valuable supportive care mechanisms, the situations already become to a point where it can't be reversed or, you know, the child comes in to the emergency room pretty much dead.
Dr. Mike Patrick: So these really are diseases that we don't want to come back and have to deal with. And there's a cost involved that goes beyond just the mortality rate whether a child dies from a disease, but really, you know, what the child goes through just comfort-wise, what the family goes through, there's a financial cost to the disease itself.
And so, really, these vaccines are still very important today.
Are we giving too many vaccines? That's another common complaint of parents, that there are just too many of them that the kids are getting. Well, how do you address that?
Dr. Michael Brady: As a person who has seen the value of vaccines, I'm actually excited that we may be able to give more vaccines.
There's some promising information about the potential RSV vaccine.
So, the situation that the parents are concerned about is two-fold.
One is the number of shots. And there's no question, parents don't want to see their children get stuck. It hurts. But there's actually been some nice studies where they've shown that using kind of cortisol and some other kind of markers of stress, that if a child gets three shots or one shot, they actually have the same amount of stress.
And so, spreading the vaccines out and given them only shot each time just causes them to have stress more often than giving them multiple shots at one time.
So I can understand why parents are not excited about their child getting stuck at different places, but fortunately, you know, they go through a stressful period but then they recover very quickly, and it's over. And if they were to get the disease that's prevented, they wouldn't be that lucky.
The other situation is they think about these vaccines having, you know, these antigens which is what stimulates the immune system. And that maybe we're getting exposed to too many of these at one time and it's going to overwhelm the immune system of that child.
Well, if anybody has taken a look at an immunology textbook in 2016, they would realize that the immune system is a very, very intricate but very, very capable system that can actually multi-task much better than anybody.
And what happens is the immune system has the capability of recognizing thousands and thousands of antigens at one particular time and making the right decisions about what it needs to do.
If you go back and take a look, I mentioned about the pertussis vaccine where we used the whole pertussis organism, if you go back and look at how many antigens that we were exposing children in the 1960s. And then you take a look at how many antigens were exposed into in 2016, we are many, many times lower amount of antigens, because of the processing of the vaccines now allows them to kind of reduce the number of antigens, make them cleaner, et cetera.
So their immune system wasn't getting overwhelmed in the 1960s when we didn't get that many vaccines. It certainly isn't getting overwhelmed now.
The other thing is, if somebody gets a strep throat, the amount of antigens that they get exposed to by the streptococcus being there actually far exceeds how many antigens with all the vaccines we have together put in one.
So the body has developed the ability to be exposed to multiple antigens, to be able to figure out how to address each one independently and come up with an immune response.
Now, the other thing we have to recognize is when we give these vaccines, the schedule is made after the companies that make the vaccines, have done studies showing that when you give a single vaccine, and then when you add a new one to it, or two or three or four, that the immune response for each one of them is not changed by being in the same schedule that they would be if they were independent and were given one at a time.
So there's no advantage of separating the vaccines out with respect to the ability for the body to see them and develop a protective response.
And as I mentioned, if you do spread them out, you're just making your child stressed more frequently.
So, it really is done with a good amount of information to support the fact that the vaccines, when given together, result in the same level of response as if they were given separately.
Dr. Mike Patrick: And when you do give them separately, so if you're talking about an alternative immunization schedule that kind of spreads things out more, not only are your kids getting shots more often, but also you're allowing them to be susceptible to whatever disease for a longer period of time before they have good full protection.
Dr. Michael Brady: Right. We're trying to get away from alternative schedule because that would suggest that it's an option. And we're trying to see that there is a proven recommended schedule and all other schedules are therefore unproven and not recommended.
And so, you know, that is, what you said is exactly the reason that if you space out the vaccines, you actually increase the amount of time that somebody might be susceptible. Because, the schedule is made based on understanding the epidemiology of the diseases, and when you would like to get protection and how you can get protection in the most effective way to try to protect the child.
Now, the other thing is many of the people who are opposed to vaccines have recommended that the proven recommended schedule be compared to another schedule.
And the Institute of Medicine actually specifically said that would be unethical because any schedule that does expand the time of risk would not be appropriate to do a study.
So we aren't going to see that study because it wouldn't be ethical. And that I think supports the fact the proven recommended schedule is the right schedule.
Dr. Mike Patrick: Yeah. Because in order to show that the alternate schedule is dangerous is to put kids at risk. And then the kid gets meningitis, you know, from Haemophilus, for instance, or gets measles and has a bad outcome, then that's the reason it's unethical.
Because we don't want to put those kids' lives at risk, which is what parents are doing when they go with alternate schedules.
Dr. Michael Brady: Right. And you know, again, we saw what the situation in Disneyland with measles. But in 2010 or '11, when California had a large pertussis outbreak, that's exactly what they saw. Was that the pertussis disease was occurring in those children who are unimmunized or under-immunized. And so anytime that you prolong a period of risk, you're going to accept that risk.
Dr. Mike Patrick: We are back with just enough time to once again say thanks to all of you for taking time of your day in making PediaCast a part of it, we really do appreciate that.
Also, thanks, even though we did it a couple of years ago, thanks to Dr. Michael Brady, a Pediatric Infectious Diseases Specialist here in Nationwide Children's. We really appreciate him sharing his expertise with us on vaccines, in particular, HPV and the Meningitis Shot.
If you would like to hear more of that, we actually go through a similar fashion, all the vaccines. Right from the two-month, actually, right from the delivery room when we talk about Hepatitis B Vaccine, or at least the newborn nursery.
And all the childhood vaccines through infancy, through the school years, teen years, we talk about all of them in PediaCast 351 and 352. And I hope that links to both of those programs and the show notes for this episode 415, so you can find them easily over pediacast.org.
Also, I want to remind you; I talked about this in the show intro, also talked about it last week, the eTeen Health Site from Nationwide Children's. Really trying to help teenage girls do a great job of searching for health information online, testing that information, see if it's a good information or not so good information. Can you trust it? And then if it is trustworthy, what do you do with it? And even allows teenage girls to have the opportunity to try this process with some examples, and then they can apply what they learned to their own internet searches, as we consider health and wellness for teenage girls.
So, I'll put a link to the site in the show notes for this episode 415 for pediacast.org.
Again, eTeen Health Site from Nationwide Children's.
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This is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids.
So long everybody!
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