What Every Parent Needs to Know About Vaccinations Dr Clare Thompson 7 November, 2016 Baby, Expert, Features, Kids, Parenting We’ve asked Dr Clare Thompson to do an extensive piece for us covering everything to do with vaccinations. Why, how and when? This is a fascinating read, and it also includes a very helpful download which keeps you up-to-date with everything. Dear Parents, Taking your child to the Doctor to get his or her vaccinations can be a fraught – filled 30 minutes full of inadequate explanations to your child followed by outright bribery that often leave you, as a parent, feeling even more confused at the whole effort. When faced with the extensive list of vaccinations in the ‘Red-Book’ it can seem an impossible task, especially for your older child who will often put up quite a fight and ask why on earth must they go through this process. And quite rightly so! The vaccination uptake rate is really rather high in the UK and yet despite Doctors reassurances and mounting evidence that underscores the safety and value of vaccinating, many educated and dedicated parents are still incredibly wary or even passionately opposed to them. As a doctor there is an ethical responsibility to extol the virtues of vaccinating our children. However, we must appreciate that vaccinations can often become a personal decision amongst parents and one that polarises people’s opinion so greatly. Here is a succinct account of the vaccinations available in the UK with a concise summary of the National Screening Programme. Also included is information on some of the other vaccines which are still only available privately which you may find helpful. I hope to highlight different cultures and countries attitudes to vaccinations and spark debate about how we should approach these decisions in an educated and considered manner. Why should we vaccinate our children? Ultimately we have the responsibility to make sensible decisions for our children based on the evidence provided by extensive research. As educated parents and care- givers we must act in the best interests of our children who are unable to decide for themselves and protect them from serious childhood disease. What is a vaccine? A vaccine is a biological preparation (a shot or oral solution) which is given to stimulate a person’s immune system to produce antibodies (proteins produced by your immune system) which recognise the disease and will then mount an immune response to protect them from that disease in the future. Most vaccines take about 3 weeks for the immune system to process and start producing enough antibodies for a protective response. This process is called ‘Seroconversion’. Vaccines can be ‘live’ or ‘killed’. A live vaccine means that part of the disease is still active in the preparation. So in essence you are actually exposed to a small amount of that actual disease in order for your immune system to activate a protective response in the future. Examples of live vaccines: MMR Chickenpox Shingles Oral Polio Killed vaccines have had the active part of the disease removed. However, your immune system still recognises them as foreign and will mount a protective response. Smallpox – the success story of vaccinating Smallpox is an example of the success of large scale, global vaccination programmes. It was previously one the most devastating diseases known to humanity but was declared ‘eradicated’ in the 1980s following a global immunisation campaign led by the World Health Organisation. The MMR Vaccine Controversy Ask parents what scares them the most about their child receiving all these shots and you’ll most likely get one answer: Autism. The MMR was introduced in the UK in 1988 to protect children from Measles, Mumps and Rubella. The uptake was initially very good until the late 1990’s following the controversy surrounding a fraudulent publication in the medical journal, The Lancet, that lent support to the later discredited claim that Colitis (inflammation of the bowel) and Autism (a behavioural disorder) are linked to the combined MMR vaccine. The media have also been criticised heavily for their support in the sensationalising of this fraudulent paper. The doctor who researched and wrote the paper was subsequently struck off of the Medical Register in 2010 secondary to poor uptake of the MMR and outbreaks of serious childhood illness. I really can’t remember the last time I saw a case of Measles or Rubella. But I do recall seeing a cohort of teenage patients a few years ago who didn’t receive the MMR vaccine in the late 1990s following the MMR controversy whowere admitted to the Paediatric A and E with quite serious cases of the Mumps virus. For boys, in particular, it can render them sterile later in life. I must add that I didn’t receive the MMR vaccine as it postdates my childhood and I had a shocking case of the Mumps aged 3. Subsequently the virus completely destroyed the nerves to my left ear and I am left permanently deaf for the rest of my life. This has had a huge impact on my quality of life and I will never regain that faculty again, despite many appointments in vain with the ENT specialists. I have also met with parents who are quite certain that the MMR vaccine contributed to their child’s Autism despite provision of scientific papers full of evidence to the contrary. Interestingly the behavioural symptoms of Autism often start to become apparent at around the time of the pre-school MMR booster and so we may be looking at a temporal link rather than a causal one. Special mention must be given to the individual vaccines that are only available privately. However the Mumps vaccination is NOT currently available as a single shot and this should be given careful consideration. Glossary of Major Illness Protected by Vaccinating Diptheria – bacterial infection which starts 2-5 days after exposure and causes sore throat, high fever and barking cough. Grey patches often seen to tonsils. Tetanus – a bacterial infection characterised by muscular spasms (lockjaw) which lasts 2-3 mins with a duration of several weeks. Other symptoms include high fever, headache, high blood pressure and difficulty swallowing. Pertussis – the highly contagious ‘Whooping Cough’ which lasts 3 months and causes severe coughing fits often resulting in arrested growth in infants. Polio – a viral infection which causes high fever, vomiting, diarrhoea, stiff neck and muscular weakness. Sometimes results in permanent paralysis. Haemophilus Influenza Type B – an opportunistic bacteria (lives in its host without causing disease until the persons immune system is dampened) that can result in pneumonia, epiglottitis, cellulitis, osteomyelitis and infectious arthritis. Rotavirus – the most common cause of severe diarrhoea in infants and young children. Meningitis C – infection and inflammation of the surfaces covering the brain and spinal cord. May be fatal in some cases. Meningitis B – the more serious of the Meningitis infections which kills 1 in 10 affected and often results in admission to intensive care with long term health consequences. Measles – a viral infection causing a distinctive flat-rash, high fever, runny nose and red eyes. Complications include pneumonia, inflammation of the brain, blindness and diarrhoea. Mumps – viral infection affecting the parotid glands beneath the jaw. Symptoms include painful swelling of one or both parotid glands, high fever, muscle pain, headache and tiredness. Complications include infertility in boys, deafness, inflammation of the brain and pancreatitis. Rubella – also known as ‘German Measles’ and caused by a viral infection characterised by a distinct rash. High fever, inflammation of nerves and testicular swelling are also seen. Can cause miscarriage in pregnancy and complications may involve cataracts, deafness, heart and brain problems. Tuberculosis – this is an infectious disease caused by mycobacteria which affects the lungs and often other parts of the body (gut, spine) and is transmitted via air droplets. Most infections do not have symptoms (known as latent TB) but 1 in 10 latent cases goes on to become active and kills 50% of those infected. Tick Borne Encephalitis -this is tic borne virus (found in rural forests in Sweden) that introduces an infection which affects the coverings of the brain and spinal cord. Hepatitis B -this is a blood-borne virus which affects the liver and causes irreversible changes (cirrhosis and liver cancer). In the UK health care workers (high risk individuals) are required to have this. In the USA it is part of the routine immunisation schedule. Chickenpox – this is a viral infection that has an incubation period of 1-2 weeks and presents with a low-grade fever, followed by widespread pustular (fluid-filled) spots which are both itchy and have the potential to scar the skin. The Routine Immunisation Schedule in the UK – click to download. BCG Administered: At birth for at risk groups (those living in/travelling to highly endemic areas) The BCG vaccine protects again Tuberculosis and is currently recommended for any child born into a high risk area (parts of London where the health authorities have identified a higher prevalence of TB cases) and those families who are likely to travel to endemic regions outside of the UK. The vaccine really needs to be visible and administered to the upper arm as obvious evidence of having had it for future reference. Diptheria, Tetanus, Pertussis (whooping cough), Polio and Haemophilus Influenza type b (Hib) Name: Pediacel or Infanrix Administered: 2, 3 and 4 months. This is also known as the ‘five in one’ vaccine. Note that mothers are now routinely offered the Whooping cough vaccine after 32 weeks pregnancy to protect their newborn babies until they are old enough to receive their first Whooping cough vaccine at 2 months of age. Pneumococcal Disease Name: Prevenar 13 Administered: 2, 4, 13 months. Meningitis C Name: Menjugate or NeisVac Administered: 3, and 13 months (combined with Hib booster – Menitorix). Booster at 13 years old. Rotavirus Name: Rotarix Administered: oral drop at 2 and 3 months. Measles, Mumps and Rubella (MMR) Name: Priorix Administered: 13 months and 40 months (preschool booster) Preschool Boosters Aged 3 years and 4 months (40 months) Children should receive the second MMR shot (mentioned above) and also a booster of Diptheria, Tetanus, Pertussis and Polio. Name: (Priorix) + (Infanrix IPV) Teenage Years Human Papilloma Virus Name: Gardasil Administered: Girls and boys aged 9-26 (*most receive the vaccine at school aged 13). Administered: 3 doses given on nominated day, then at 2 months and 6 months. This vaccine is designed to prevent infection from HPV types 6, 11, 16 and 18 that cause about 70% of cases of cervical cancer. It also protects against vulval and anal cancer caused by HPV warts. Other privately available vaccinations The Meningitis B Vaccine Name: Bexsero Administered: Age < 6 months: 2, 4 and 12 months Age > 6 months: 2 shots, 8 weeks apart Age: 2 months + (licensed) Meningitis B is the leading cause of life-threatening meningitis and septicaemia in the UK for decades. Meningitis B kills 1 in 10 patients affected and leaves a further third with serious long-term damage such as amputations, brain damage and hearing loss. In March 2015 The Health Secretary announced plans to have the meningitis B vaccine available to children on the NHS from September 2015. This is a big step for the health sector and a huge relief to parents lobbying for change to the vaccination schedule. However we await news of whom exactly will qualify for the vaccination and which age groups are included in the pilot. For everyone else the meningitis B vaccine will only be available privately. Given that this is a costly vaccine and you will likely also have to pay the private GP consultation time as well it can start to add up if you have more than one child. So, is this vaccine worth the money? What is the evidence for it? Should I really have my children jabbed for meningitis B this summer? The study on Meningitis B was done looking at 14,000 children in the UK and reports suggest that the vaccine will protect patients from 88% of the strains of Meningitis B in UK vs 78% of Meningitis B strains circulating in Europe. Typically meningococcal disease is most common in children under the age of 5 with age 5 months being the peak age at greatest risk. The second highest group at risk are teenagers. The most common side effect I have seen is a localised skin reaction at the site of the vaccine which usually settles over 24-48 hours. Some children complain that their arm or leg feels slightly numb for a few days afterwards as well. The Chickenpox Vaccine Name: Varilrix Administered: 2 shots, 6 weeks apart Age: 6 months+ The chickenpox virus is a very common childhood illness and has an incubation of 2 weeks before the low grade fever and itchy, fluid-filled pustules begin to appear. It usually lasts around 5-7 days but can be quite severe in some children and even lead to a serious Pneumonia a few weeks later. The virus is spread by infected droplets in the air. This illness is a real nightmare if you are a working parent or with multiple children at home as each child in the family is likely to be exposed and start developing the rash, sometimes staggered several weeks apart. It often means having to organise childcare cover for work and also having the stress of tending to your sick and irritable youngsters for weeks at a time. The Chickenpox Vaccine (Varilrix) is a live vaccine which is administered in 2 doses at least 6 weeks apart. The first dose will confer some protection from the illness, but the booster dose will really give your child the longer lasting protection against this illness. Of note your can still get a very mild form of the chickenpox, even if you have been immunised, but the rash tends to be very short lived and extremely mild (a couple of spots vs a widespread rash). Equally I have seen families where some children are lucky enough to develop antibodies to the virus from first exposure, but never actually develop the rash. This is known as a silent exposure-pathway. Tick Borne Encephalitis Name: Ticovax Administered: 3 doses given on a nominated date, then 1-3 months, and 5-12 months after. Boosters are given at 3 years and then every 5 years. Age: 1+ A lot of my Swedish patients routinely request this vaccine which protects against disease caused by the Tic-Borne Encephalitis Virus. This virus can cause serious infections of the brain or spine and its covering. The virus can be carried by ticks and is passed on by tic bites in parts of Europe and Central Asia. The bite may not always be noticed as the tics are not always spotted on the skin. The protection does not last for life and regular boosters are needed for travellers to endemic regions. Hepatitis B The USA Vaccination schedule has Hep B as part of its routine immunisation programme. Hepatitis B is acquired from infected blood products and so people who work in a healthcare setting in the UK (ie/ doctors and nurses) are required to have this is order to perform their duties. It is given as part of the national immunisation programme in the USA in 3 doses at birth, 2 months and then a booster at 12 months of age. Outbreaks of Preventable Infectious Diseases – World Health Organisation 2000 Meningococcal Disease in UK, USA, France, Oman, Saudi Arabia, Netherlands 22 cases in the UK with 12 deaths 2003 Polio outbreak in Africa – Togo, Burkina Faso and Ghana Diptheria outbreak in Afghanistan 2004 Polio outbreak in Ethiopia, Angola and Somalia 2005 Polio outbreak in Indonesia Meningococcal outbreak in India 2006 Meningococcal outbreak in Africa 2009 Polio outbreak in Nigeria 2010 Polio in Central Asia and Russia Polio in Tajikstan 2011 Measles outbreak in USA, Europe and Africa Polio outbreak in Pakistan 2012 Pertussis (whooping cough) outbreak in UK 2013 Polio outbreak in Syria Polio outbreak in Israel, Gaza strip and West Bank 2015 Meningococcal outbreak in Niger Typhoid outbreak Uganda Measles outbreak in USA The point here is not that you might never travel to these countries in Africa or the Middle East, but rather that immigrant populations are now migrating rapidly into First World countries and are likely to bring infectious disease with them. Many of the Sub-Saharan African countries will not have the resources to put in place even a basic immunisation programme, let alone enforce it or have reliable figures on their population data. There are also poor disease control policies and methods in place to control epidemics once they have started due to financial constraint and the red-tape existing at governmental level. I have recently seen several children from a local school in the Chelsea area of London who have been exposed to TB from a teacher who had travelled to and contracted it in Africa. These children were not born in a ‘high risk’ area and so did not receive the vaccine but are now undergoing frequent blood tests and monitoring to make sure that they have not developed latent (inactive) TB themselves. One of my friends lives in a resort on a beach in Mexico and steadfastly declines to vaccinate her two children or even expose them to simple calpol or children’s ibuprofen. One could argue that perhaps these children are actually highly unlikely to be exposed to the common infectious diseases that a child living in the city, who is exposed to so many other children and immigrant populations, might be. However, should these children ever travel outside of their usual environment what potentially life threatening diseases might they be exposed to and what are the far-reaching consequences if later on in life they should become pregnant themselves and then develop these diseases. And so you see… it really isn’t as black and white or didactic as it first seems. Some parents will opt for certain vaccines and then opt out of others whereas other parents feel completely ill at ease with any vaccinations. I think a degree of common sense is clearly needed and as a Doctor I must try to present the factual, evidence-based data so that parents can reasonably make an informed choice for their children. Attitudes of Different Countries and Cultures to Vaccination Programmes USA In America it is non-negotiable in some states that children must be fully vaccinated before they are given a place at school and the parents have to provide documented evidence of this. The USA also has Hep B and Chickenpox as part of its routine immunisation programme. This removes any element of parental choice which is not necessarily ethical either. There are special exemptions for those with certain religious beliefs or who are medically exempt only (allergies to the vaccine). UK and Europe There is still a degree of choice in the UK regards certain vaccinations Eg/ chickenpox and Meningitis B. I am unaware of any stipulation by schools or educational authorities to demand that parents must have their child fully vaccinated before attending classes in Europe. Africa and the Middle East African and Middle Eastern countries have made great progress in increasing routine immunisation coverage rates but the ambitious Global Immunisation Vision and Strategy has not yet been reached. There are still wild disparities between uptakes of immunisations within and between countries. In 2014 the Pakistani government ruled that the Polio vaccine be mandatory after several devastating endemics in the region. Anyone who refused the vaccine would face imprisonment. Australia and New Zealand The uptake of vaccinations is very high and in 2006 certain benefits (such as family allowance) were not extended to parents who conscientiously objected to and declined vaccinating their children. Similarly to the USA most schools also stipulate that children must have completed their primary course of immunisation in order to attend. Food for Thought: What are your thoughts as a parent and how do you feel about the process of vaccinating your child? Are there things that the Health Professionals could be doing to help explain things to you in a better way? What language do you use to explain the vaccines to your child? Are there any techniques that have worked well with Doctors and Nurses in administering the vaccines to your child? By Dr E Clare Thompson, The Courtfield Private Practice, South Kensington. The Courtfield Private Practice’s head partner is Dr Tim Ladbrooke, the GP in Tatler’s Best Doctor Guide. The practice is expanding and and concentrating its focus on mothers and children.