Serious side effects of vaccines are rare. What does that mean?

Posted October 23, 2014 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

“Serious side effects of vaccines are rare.”

Vaccines are not 100% safe. Like any medical intervention, there’s some risk (honestly, like anything at all, anything we do, there’s some risk. But let’s not get sidetracked here.) Side effects, including serious side effects, can happen after vaccines. What are these reactions, really? How often do they occur?

Here, I’m only talking about genuine, established side effects. Things are genuinely, scientifically, reliably linked to vaccines. Some things that had once been thought be a potential side effect of vaccines are now known to have been caused by other conditions (like seizures and encephalopathy after DTP, now known to be most-often caused by a rare genetic condition called Dravet Syndrome, that would have occurred whether the child was immunized or not.) There are also side effects reported that are clearly unrelated, like choking on a bean in the trachea or turning into the Incredible Hulk. We’ll ignore those, and concentrate on the real, serious, potentially deadly side effects that have been documented to be caused by vaccines. I’m going to list all of them, for every vaccine. If I missed any, please add in the comments.

Any vaccine – Serious allergic reactions can occur. These do happen, though the rate of serious reactions depends on the vaccine. For most immunizations, the rate is less than 1 in 1 million; however, some very-rarely used vaccines can have a higher rate. The yellow fever vaccine, for instance, causes severe allergic reactions in about 1 in 55,000 people; anthrax vaccine is estimated to cause severe reactions in 1 in 100,000. Almost all severe allergic reactions occur within minutes of vaccination, and health care facilities who give vaccines should have people trained to treat rare reactions like these.

Influenza – The Pandemrix brand of influenza vaccine, which was never licensed or used in the United States, has been linked as a cause of narcolepsy in about 1 in 55,000 vaccine recipients in several countries in Europe. This product was only used during the 2009-2010 season. The CDC is currently sponsoring an international study to try to better understand this, and why that one formulation seemed to be a unique trigger for this rare condition.

In 1976, a different specific Swine Flu vaccine was linked to about 450 cases of Guillian-Barre Syndrome (GBS), a neurologic disorder that was estimated to occur in about 1 in 100,000 people who got that specific vaccine that year. The baseline rate of GBS is probably 1-2 per 100,000, so when 45 million doses of vaccine were given in 1976, some cases were going to occur coincidentally. Substantial studies have shown that other flu vaccines from more-recent years do not cause GBS. Ironically, influenza disease itself causes more GBS than even the 1976 Swine Flu vaccine is purported to have caused, and even if that association were true influenza vaccination would prevent far more GBS than it would trigger.

Japanese encephalitis – Rarely used in the United States, the Japanese Encephalitis vaccine has been linked to prolonged arm and shoulder pain among vaccine recipients. I could not find an exact rate, but this appears to be an uncommon reaction.

MMR – About 1 in 30,000 people given a dose of MMR will have a drop in their platelet count, which can predispose to bleeding. The rate of low platelets is much higher in real measles than after the vaccine, so, again, ironically MMR probably prevents more cases of low platelets than causes it. This condition is temporary and almost always requires no treatment at all.

Polio – The oral polio vaccine, no longer used in the United States, could trigger genuine, full-blown polio in some people—probably about 8 per year in the entire US, back when we used the oral version. We’ve been using only the injected polio since the mid-1990s, which carries zero risk of causing polio.

Rotavirus – Rotavirus vaccines carry a small risk of causing an intestinal blockage called “intussusception.” This condition is treatable, though it often requires a brief hospitalization. The risk was highest after the first doses of the original brand of vaccine, Rotashield, which was withdrawn from the market; the risk after current brands is probably in the range of 1-3 in 100,000. However, rotavirus itself, the real infection, is also a cause of intussusception. To put this in perspective: using the high end of the risk estimates, about 40-120 vaccinated infants may develop intussusception each year in the USA, compared to 65,000 infants who had been hospitalized for rotavirus illness each year prior to the vaccine becoming available.

Smallpox – Routine smallpox vaccinations stopped by 1970 in the US, but a smallpox vaccine is available for high-risk researchers and military people and others thought to be at risk of exposure. The vaccine can cause heart problems in 1 in 175 people, and there is a risk that the vaccine virus can spread on the skin of a vaccinated person or contacts, especially when the skin is damaged or there are immune problems.

Yellow fever – Used only in certain travelers, some kinds of typhoid vaccine can causes severe neurologic problems (about 1 in 125,000) or death, especially in elderly people (1 in 500,000).

That’s it—that’s the list. All of the serious, lasting, you-need-to-worry about side effects. You’ll notice that almost all of the really serious side effects occur only with vaccines that aren’t likely to be recommended for your children. Most of the routine childhood vaccines (DTaP, HIB, pneumococcal conjugate, hepatitis B, hepatitis A, chicken pox, meningococcal conjugate, human papilloma virus) only carry a very rare risk of allergic reactions, and even those are entirely treatable and temporary. In other words, science has failed to find any evidence for any real, lasting, serious vaccine reactions among any of the vaccines currently recommended for routine use in children in the United States.

When we say “serious side effects are rare,” we mean “serious side effects are very very very rare, and really only happen with vaccines that we don’t even use.”

What parents need to worry about are diseases, not vaccines. Don’t let the scaremongers and internet rumors sway you. The risk of a serious, lasting side effect from any routine childhood vaccine is just about zero. Make sure your children are safe and protected. Vaccinate!

Defeating Ebola: Nigeria did it, so can we

Posted October 21, 2014 by Dr. Roy
Categories: In the news

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The Pediatric Insider

© 2014 Roy Benaroch, MD

In June, a man became very ill during a flight into Lagos, Nigeria. On the plane, he developed vomiting and diarrhea, and he collapsed in the very busy airport. Contacts on the plane and on the ground had no idea that he had Ebola—initially, he was treated for malaria—and many healthcare workers and bystanders on the plane and in the airport were exposed to his infectious body fluids. One of his close contacts, while ill, flew across the country to consult with a private physician.

A nightmare? Well, it wasn’t good. But health officials in Nigeria stepped up to the plate and dealt with it. Following protocols (yes, protocols) recommended by the WHO and CDC, and relying on a fairly meager public health infrastructure built to track polio cases, workers carefully tracked every single contact, and kept tabs on all potential cases. People who became sick were then isolated. In total, Nigeria experienced 19 cases of Ebola (including 7 deaths), all traceable to the single imported case.

Nigeria has not had any new diagnoses of Ebola disease in 42 days, twice the maximum incubation period of 21 days. The WHO has declared Nigeria Ebola-free.

No special medicines, no vaccine, no high-tech anything. Nigeria is Africa’s largest country, and the case was imported through a planeload of about 50 people, all potentially exposed to infectious material. All of these people then traveled through the country’s largest airport in its largest city. Yet there was no widespread illness—the outbreak was contained through the boring, tedious, essential work of screening and following. And it worked.

The media are in an absolute frenzy over Ebola in the US, pointing fingers and practically frothing at the mouth. I realize that in the noisy world of the internet, one has to shout to sell, and shout to be heard; I also realize that there’s an election coming up in just a few weeks, so anything that makes someone else look bad is going to be a tool that just has to be used. Politicians are doing what politicians do (grandstanding), and journalists and those-pretending-to-be-journalists aren’t far behind.

One example: everyone seems to clamoring for us to shut down flights from countries affected by the epidemic (Liberia, Sierra Leone, and Guinea). Politicians from both sides and pundits on the TV news are blasting the administration and public health authorities:

 “Of course we should ban all nonessential travel…” – Bret Stephens, Wall Street Journal

“…we should not be allowing these folks in. Period.” – Rep Fred Upton (Republican, MI)

“It starts with a travel ban for non-citizens coming to the US from affected areas…” – Sen. Mark Pryor (Democrat, AR)

But a widespread travel ban will do more harm than good. There already are no direct flights from any affected countries into the USA—anyone getting here will actually be coming from somewhere else. If a travel ban is in place, people who are potentially exposed will do what humans do: they’ll lie. And they’ll get here anyway, from Morocco or France or wherever. (The Liberian man who flew into Dallas, starting our only outbreak here, flew from Belgium). A travel ban will create a panic and a logistical nightmare. We won’t be able to know who is actually coming from where, and people who need to be tracked (maybe including people already sick with disease) may end up hiding from authorities. What happens then?

There are other reasons why a travel ban is a bad idea. It will prevent aid from getting where it’s needed (and the longer the epidemic brews in Africa, the longer we are at risk.) It will further destabilize struggling governments in the heart of the crisis. We should not take steps that will prolong the primary source of cases in West Africa. In fact, the most effective way to end this mess is to end it in Africa. We need to be there, helping with the fight.

None of that seems to matter—it’s all about the symbolism and messaging. Politicians want to look like they’re taking a Tough Stand to Protect America, and journalists want to sell their stories and newspapers. Shut the border! Meanwhile: there have been no further cases of Ebola from the small Texas outbreak. Though infection-control procedures needed to be tighter at first, it looks like health authorities have quickly adjusted their response to contain the spread, and it worked.

There will be more cases of Ebola appearing in the USA. We’re a big country, and we cannot practically just stop travel from an entire side of a continent. Despite what’s being screamed in the media, the CDC has done a good job at responding to this crisis. Future cases will be identified, and spread will almost certainly be limited to a handful of people genuinely at risk (not you, and not your kids.) There’s no need for panic. If Nigeria can do it, so can we.

Previously:

USA Ebola cases double. Media goes nuts, and still misses the point

Ebola and you

USA Ebola cases double. Media goes nuts, and still misses the point

Posted October 13, 2014 by Dr. Roy
Categories: In the news, The Media Blows It Again

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Technically, it’s true: the prevalence of Ebola infection just doubled in the USA, as news spread that a nurse in contact with the first case in Texas has come down with the disease. Technically, that’s not true. The first man died, which dropped the prevalence of Ebola to zero, then it went back up to one. But let’s not split hairs. The total cases just went from 1 to 2, which is a DOUBLING! Clearly, it is time for panic.

No, it is not. Ebola remains difficult to catch, requiring direct contact of either broken skin or mucus membranes (eyes, nose, mouth) with infectious fluid from a victim. And victims don’t become contagious until they’re sick, which explains why the planeload of passengers who accompanied Mr. Duncan from Liberia remain healthy. The people at the most risk aren’t you, or your children—unless they’re healthcare workers, and, really, unless they’re working in West Africa.

That’s where the tragedy is, and that’s where the international community needs to concentrate its resources. Until the epidemic is stopped in Sierra Leone, Guinea, and Liberia, a few cases are going to trickle out and potentially spread to a handful of people wherever they end up. The next case could be in Baltimore or Santiago or Moscow—but, as long as there’s a reasonable health infrastructure, cases can be identified and contained. It takes legwork and money and a grinding, relentless attention to detail, but it can be done. I doubt fancy-pants new vaccines or medicines are going to make much of a difference, here. This one’s got to be surrounded and defeated by old fashioned record keeping and case tracking and isolation by people right there where the action is.

Back to the unfortunate nurse in Texas: The CDC has blamed the spread on a “breach of protocol”. That’s an awkward, weird phrase—and it strikes me as odd that the director of the CDC, Dr. Tom Frieden, would so blithely blame the staff there. Dr. Frieden himself is an internist and infectious disease specialist, and he is no dummy. Any smart doctor knows you never toss your nurse under a bus. It may just be the jet lag talking, but I think there is more to this story, and more to this “breach”.

Stay tuned, though if you’re smart you’ll disregard the media blowhards. Ebola is a huge problem, and a huge human tragedy, but it’s still not something to panic about.

Infection Report 5: What you really should be worried about

Posted October 10, 2014 by Dr. Roy
Categories: Medical problems, The Media Blows It Again

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The Pediatric Insider

© 2014 Roy Benaroch, MD

This week’s posts have all been about infections, new and old—infections newly found, and infections sneaking back. On the one hand, the media is agog with news of Ebola and the mysterious paralysis virus; on the other hand, threats that are far more likely to kill us are being largely ignored.

One infection is on the verge of sneaking back, which is a shame. We had it beaten, and now we’re allowing it to gain a foothold. We’ve got a great way to eradicate measles, but fear and misinformation have led to pro-disease, anti-vaccine sentiment, especially among those white, elite, and wealthy. As we’ve seen, we’re all in this together—so those anti-vaccine enclaves are going to affect all of us.

Measles, itself, is just about the most contagious disease out there. You don’t need to have infected fluid splashed on you (Ebola), and you don’t need to actually even touch a contaminated surface (influenza). All it takes to catch measles is to breathe the same air as someone with the disease. The measles case doesn’t even still have to be in the same room—particles of infectious measles can float around long after the patient has left. Measles can also be transmitted from contaminated surfaces (and even if person A who touches the surface is immune, he can spread it later on to person B.) Measles is so transmissible that 90% of non-immune people who come near someone with measles will themselves get it. To make matters worse: a person with measles starts spreading virus 4 days before they get sick (compare that to Ebola, which has no transmission until symptoms appear.)

And it’s serious, too. Measles is far more than spots. In the USA, about 1 in 20 people with measles require hospitalization for pneumonia; about 1 in 1000 get brain swelling, which can lead to permanent disability. Measles still kills close to 200,000 people, worldwide, every year (about 1 in 4 people with measles die in the developing world.)

While no vaccine is 100% effective, the measles vaccine is pretty darn close. About 95%-100% of people develop lifelong protective antibodies after the two-dose series. Unfortunately, not everyone can be vaccinated—the vaccine isn’t routinely used less than 12 months, and some people with certain health conditions and immune problems can’t safely be vaccinated. Still, when vaccine uptake rates were strong throughout the developed world in the 1990s, there was very little transmission of measles in the United States, just a handful of cases each year.

And now, it’s back. 2014 is going to have by far the most measles cases in 20 years. Though overall rates of vaccination remain strong, some neighborhoods have immunization rates poorer than third-world countries. And cases that begin or are imported into those areas become outbreaks that public health officials struggle to contain.

Think about this: in west Africa, thousands of people are dying of Ebola, for the lack of rubber gloves and other ways to isolate cases. Here, we do have a safe and effective vaccine against a disease that’s far more transmissible—and some people choose not to get it. There, they battle a lack of basic health resources. Here, our enemy is fear and misinformation. That’s what American families really need to worry about.

This week’s posts about infections new and old were meant to contrast the kinds of challenges faced here, versus the challenges faced in most of the rest of the world. We’re so safe and rich that we can afford to be afraid of things that really shouldn’t scare us (vaccines), while the media becomes preoccupied with things that aren’t likely to become a threat here (Ebola.) We don’t get our flu vaccines because “I heard the flu vaccine can give you the flu” – an utter falsehood that is probably contributing to thousands of deaths. At the same time, we guzzle unnecessary antibiotics for viral infections that do us far more harm than good.

Preventing infections is always the best strategy. Wash your hands, stay away from sick people, keep your kids home when they’re ill, and listen to what every legitimate health authority on the planet says: get yourself and your kids vaccinated. As long as we get them, vaccines are one thing you do not have to worry about.

This week’s posts: The Infection Report

Why are infections such a problem again?

Ebola and you

The single biggest infectious health risk is preventable

Two newcomers and the importance of paying attention

What you really should be worried about

Infection Report 4: Two newcomers and the importance of paying attention

Posted October 9, 2014 by Dr. Roy
Categories: Medical problems, The Media Blows It Again

Tags: , , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

While Ebola makes the headlines and influenza prepares its yearly visit, two other “new” infections have been brewing this summer. We’re still got a lot to learn about “the new respiratory virus,” AKA enterovirus D68, and whatever seems to be causing cases of paralysis in 9 kids in Colorado. It’s even possible that these two infections are the same. These infections are coming to light because hospitals and public health officials stay on the lookout for new patterns of disease and infections. It’s not complicated, and it’s really not rocket science. It’s all about paying attention.

Earlier this year, hospitals first in Illinois and Missouri reported an unusual spike in ER visits and hospitalizations for respiratory symptoms, including cough, wheezing, and difficulty breathing. Often, children with this infection became very sick very rapidly, requiring hospital or ICU-level care very shortly after the onset of symptoms. Most, but not all, affected individuals had pre-existing lung problems, mostly asthma. Though routine testing for a specific agent still isn’t widely available, laboratories were able to identify a specific viral cause, an “enterovirus” named D68. That virus has been around since at least 1962, but until this year hadn’t caused widespread infections. It’s probably spread throughout the United States, and continues to contribute to many hospitalizations.

Many children (and adults) with this infection probably have mild symptoms, indistinguishable for any other viral “cold”, but some go one to become seriously ill. By the way, that’s true for almost all ordinary cold viruses—though most people sail through those infections just fine, every once in a while an ordinary cold virus makes someone very, very ill. This new enterovirus isn’t really that different from many other respiratory viruses, but it’s newly widespread and seems to have a disproportionately high rate of complications.

Or maybe it is kind of different, after all. We’re also hearing reports out of Colorado of a new kind of illness, one that looks like an infection, that’s caused flaccid paralysis in at least 9 children (actually the CDC is investigating about 23 reports, though it’s not yet clear if all of these are the same condition.) Many of those children seem to have had a respiratory illness about 2 weeks prior to the onset of the paralysis. MRI scanning is showing changes in the part of the spinal cord that controls motor functioning, and in some ways the clinical presentation and MRI findings look similar to an old infection, poliomyelitis. But specific tests for polio virus have been negative.

Here’s an theory: this respiratory virus D68 and polio virus are related—they’re both from a large, diverse family of viruses called “enterovirus.” These viruses typically cause summer infections, and different kinds of enterovirus can cause disease of the gut, lungs, liver, nerves, skin—all sorts of things.  About half of the Colorado 9 children have tested positive for D68. That’s not definitive—that doesn’t mean D68 is causing the paralysis—but it’s certainly suggestive and interesting. It is possible that these two new things, the respiratory virus and the paralysis, are actually being caused by the same infection.

We’ll be learning more about these infections in the coming months. For now, the best steps available to protect your family are common sense things: wash hands, stay away from sick people, don’t touch your face, and beware of signs of bad respiratory disease. Though there are no vaccines for these new infections yet, you can prevent the return of polio and the widespread sickness of influenza with current, safe, effective immunizations. Hospitals, doctors, and staff at hospitals in the midwest did a great job in identifying these new problems and alerting public health officials to begin their investigation. Our health depends on all of us, together, paying attention to and confronting health threats like these.

Next: What you really need to worry about

Infection Report 3: The single biggest infectious health risk is preventable

Posted October 8, 2014 by Dr. Roy
Categories: Medical problems, The Media Blows It Again

Tags: , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

Here’s what people are dying of in the United States, in order: heart disease, cancer, chronic lung disease (mostly COPD, usually among smokers), stroke, accidents, Alzheimer disease, diabetes. And at number 8, the first infectious cause of death on the list: influenza and pneumonia, about 54,000 deaths a year.

(By the way, at least some cancers are infectious diseases, and two of those we can prevent with vaccinations. But let’s focus on influenza and pneumonia here.)

The most common fatal complication of influenza is pneumonia, so it can be difficult to tease out how many of those 54,000 “pneumonia and influenza” deaths were caused by influenza. Influenza also contributes to death by many of the other causes (it is the final straw in many patients with COPD or other health problems.) It’s likely that influenza viral infections are the proximal cause of about 36,000 deaths a year in the United States.

Unlike Ebola, influenza spreads rapidly in a community. Influenza virus can be spread by sneezing or coughing, or even better by mucus left on surfaces and doorknobs. Also, unlike Ebola, people with influenza become infectious a day or so before they’re obviously sick.

There are simple steps you can take to prevent contracting and spreading influenza. Most importantly, people with influenza symptoms shouldn’t go to school or work. Keep your mucus to yourself, as much as you can, by sneezing into tissues and using hand sanitizer to clean your hands. Remember, influenza virus gets from place to place on hands—once deposited somewhere, it doesn’t jump up and fly around. You have to touch it, then touch your own face, to get sick from influenza virus.

One more step that we all need to take: make sure you and your family get influenza vaccinations! The vaccine is terrifically safe, and it works well most of the time to  reduce the transmission, rate, and severity of influenza. Taken as part of an overall influenza prevention scheme, vaccination is an essential step.

The CDC recommends influenza vaccinations for all of us, everyone over six months of age. That’s because the more people get the vaccine, the more all of us are protected. It doesn’t work 100% of the time, and young babies and people with some health conditions can’t be vaccinated—so it’s up to the rest of us to keep vaccination rates high, to protect everyone. One lesson is clear from the current media hysteria over Ebola, Enterovirus D68, and other new infections: we’re all in this together. Influenza is one infection that we’ve got the tools to beat.

Tomorrow: more new infections that are making the headlines.

More info:

Flu myths

CDC comprehensive flu info

Infection Report 2: Ebola and you

Posted October 7, 2014 by Dr. Roy
Categories: Medical problems, The Media Blows It Again

Tags: , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

Ebola isn’t actually a new infection, but it’s pretty close: the first cases were reported in the 1970’s, in central Africa. Since then there have been several, relatively small outbreaks, typically beginning in communities with close contact with animals, sometimes with infections appearing in chimps or other primates before appearing in people. The infection itself rapidly causes severe disease, and has been associated with a fatality rate in the 50-70% range.

Symptoms begin 2-21 days after exposure, and typically include high fevers, aches and pains, diarrhea, and vomiting. More severe cases develop “hemorrhagic fever,” with bleeding under the skin and in the gut, followed by shock, cardiovascular collapse, and death. This infection is fast, and it is bad news.

But here’s the thing: unlike horrible epidemics portrayed in movies and novels, Ebola is not actually that easy to catch. A person with Ebola cannot spread the virus before symptoms appear—there is no “silent carriage.” You can ride in a planeload of people who have contracted Ebola, but until one of them actually has symptoms, they’re not contagious, and you’re not at risk. And since the symptoms themselves are not subtle, it is unlikely that someone with Ebola is quietly sitting next to you on a bus. Those people are going to head to the hospital, pronto.

And, even if that person is sitting next to you on the bus is sick with Ebola, you cannot catch Ebola unless you come in direct contact with body fluids: blood, bloody diarrhea, or vomit. Staying away from blood, bloody diarrhea, and vomit is a good idea, whether or not there’s any Ebola around.

Though there’s media panic brewing, containing Ebola in the United States is something we’re equipped to do. We’ve got a good public health infrastructure in place, and we’ve got hospitals equipped to handle infectious material from sick people. What we need to do most, here, is to stay aware of the possibility of Ebola in people who’ve recently been in west Africa, where Ebola cases have truly become epidemic (mostly Sierra Leone, Liberia, and Guinea.) If people who’ve lived or traveled to those areas become ill with fevers and other Ebola symptoms, they need to be treated, isolated, and tracked.

The problem, honestly, isn’t here. The problem is in west Africa, where there is no public health infrastructure, and no hospitals, and no way to protect families and communities from contact with Ebola. When someone gets sick, they stay home with their families, and they are spreading infectious fluids. It’s nearly impossible to clean up those homes or protect people. No gloves, no disposable sheets, no autoclaves, not even enough plastic body bags. It is truly a health disaster, and we need world governments to step up to help the people there—or this is going to spread throughout the developing world. And, of course, the more cases there, the more the risk here, as it becomes more difficult to identify people exposed to cases that might spread to an ever-widening area. Helping the people of west Africa overcome this epidemic is both a moral and public health imperative.

Unlike Ebola, which can’t spread in the air and is only being contracted by people in a limited area, there are far-more-common infections right here, right now, and one of those will end up sickening far more of us in the United States. Yet many of us won’t even bother to take one simple, safe step to prevent it. Want to do something that can really help keep your family safe this winter? Tune in tomorrow!

More about Ebola from the CDC, and my Ebola podcast from The Great Courses.

Next: an infection that kills thousands in the USA… and can be prevented.


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