Acute Flaccid Myelitis – what parents need to know now

Posted November 16, 2018 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2018 Roy Benaroch, MD

You’ve probably seen it on the news – a rare, polio-like illness is causing cases of paralysis in children. Here’s the latest info, based on our best current knowledge from the CDC.

AFM is a sudden illness that causes weakness in one or more extremities – one arm or (less likely) a leg, or any combination of arms and legs. The words in the name express the key features: it’s acute, beginning over hours or sometimes a few days; it’s flaccid, meaning the affected body parts are floppy and weak; and it’s a myelitis, meaning the disease occurs in the spinal cord. The muscles are fine, the brain is fine, but the area of the spinal cord that carries signals to the muscles becomes inflamed and stops working. You can see distinctive changes on an MRI scan of the spine to help confirm the diagnosis.

The first cases of what was later named AFM were reported in California in 2012. The CDC started closely tracking cases of AFM in 2014, when a surge of reports about the illness began to appear in the United States and overseas. Since then, we’ve seen a striking pattern, with most cases occurring in the late summer and early fall, August through October. In the US, we’ve also seen an unexplained pattern where most cases occur in spurts every other year – in 2014, 2016, and now again in 2018. 2015 and 2017 had far fewer cases.

Over 400 cases of AFM have been reported in the US over the last four years, including about 80 in 2018 so far. Most states have reported at least one case, including Georgia. There doesn’t seem to be geographic focus in any area. Overall, the rate is less than one in a million people – AFM is a very rare disease. Almost all cases of AFM have occurred in children, at an average age of 4-6 years.

Several different viral infections have been found in children with AFM, though it’s unclear that these viruses were the cause of the symptoms. The most-commonly associated viruses are from a family called “enteroviruses”, including one that has been implicated in groups of acute severe respiratory disease called enterovirus D68. Other viruses have been investigated including West Nile or Japanese Encephalitis viruses, herpes viruses, and adenoviruses. Most commonly, no specific viral infection is found. The cause of most cases of AFM is unknown.

Still, it seems most likely that a viral infection is the trigger, because of the seasonality of the disease and its propensity to strike children rather than adults. Similar symptoms were once seen with the polio virus, and multiple tests for polio have been performed in  children reported with AFM. But it’s never been found — polio itself is not the cause AFM in the United States or abroad. The CDC is continuing to investigate the possibility of one or more viral triggers, an inflammatory condition triggered after a viral infection, or a possible environmental trigger as causes of AFM.

Children with AFM typically have a preceding illness with fever, runny nose, cough, vomiting, or diarrhea 1-2 weeks prior to the beginning of AFM symptoms. Often these common viral symptoms have resolved by the time AFM begins, with its rapid onset of limb weakness. There may be near-complete paralysis (inability to move the limb), or varying degrees of weakness. Sometimes, symptoms including stuff neck, headache, or pain in the limbs accompanies the weakness. It’s also sometimes possible for AFM to affect the nerves in the upper neck and head, causing a face or eyelid droop, difficulty swallowing or speaking, or a hoarse or weak voice.

Children with AFM need to be hospitalized. Many tests need to be done to narrow down the diagnosis and rule out other causes of weakness (including blood tests, a lumbar puncture, and MRI scans.) Children with AFM can develop weakness of the muscles that help them breathe, and may need to be treated in an ICU. Neurologists, infectious disease specialists, and public health officials will all help guide care.

There isn’t solid evidence that any specific treatment is effective, since good clinical trials of therapy haven’t been performed yet. It’s been difficult to study AFM because it’s so rare, and the disease progresses quickly. In addition to supportive care, many people with AFM have been treated with intravenous immunoglobulin, steroids, and plasmapheresis. Though some children with AFM have recovered quickly, many continue to have lasting paralysis requiring long term care.

So what should parents do about this? First, there’s no need to panic. The press and Facebook like to stir up trouble with blaring headlines and clickbait titles – but remember that AFM is really rare, with about 100 or so cases a year occurring across the entire country. Polio caused about 15,000 cases of paralysis a year in the 1950’s before a vaccine was introduced. We’ve come a long way, and your children are, overall, far safer than children have ever been from infections, environmental illnesses, and trauma.

Some common-sense steps can probably help. Most cases of AFM seem to have a viral trigger, so avoiding infections is a good idea. Teach your children to practice good handwashing, and keep them out of group care when they’re ill. Though we don’t have a vaccine to prevent AFM, vaccines can prevent the neurologic complications of other infections like influenza, measles, and mumps – so be sure to keep your child fully vaccinated. And seek care immediately if your child becomes weak in one or more limbs.

And, please, support your public health community and the scientists who work to keep your children safe. There’s always another new health challenge out there (Ebola, Zika,  SARS, and MERS, to name a few.) We need to keep our public health infrastructure strong to help tackle AFM and whatever the next challenge turns out to be. Go science!

More info from the CDC’s AFM home page, the October 2018 CDC press briefing, and the November 2018 webinar for clinicians

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Allergy Myths – don’t be fooled!

Posted October 18, 2018 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2018 Roy Benaroch, MD

Allergy issues are a big problem – both food and environmental allergies cause quite a bit of misery, and sometimes serious health problems, too. But there are a lot of myths swirling around the world of allergy, too. It’s time for a pop-those-myths listicle!

#1 WRONG: Food allergies are common

Many people think they’re allergic to foods, but rigorous studies using the best, most reliable diagnostic tools find food allergies to be present in about 2-8% of the population. Most of these reactions are mild. True, life-threatening food allergies are quite rare—in the United States, about 150 people die each year from food allergies, which is only a little higher than the number of people struck by lightning.

But: food allergy rates are rising, and we don’t want to be too complacent. When allergies do occur, they can be serious. The best approach is good, science-based prevention, evaluation, and treatment.

 

#2 WRONG: Most reactions to food are allergies

An allergy refers to a specific kind of reaction, most commonly hives or wheezing. Other, more common reactions include lactose intolerance (an inability to digest milk sugar, leading to abdominal cramps and diarrhea) and gastroesophageal reflux related to spicy or acidic foods. The distinction is important because rare, very serious allergic reactions can occur. If the reaction was not allergic in nature, it will not be life-threatening if exposure occurs again.

 

#3 WRONG: Most reactions to medicines are allergies

The most common adverse reaction to a medication is a rash, but these are usually not caused by allergy (the only common truly allergic rash is hives, which are raised, itchy areas that move about the body.) Most people labeled as “allergic” to penicillin are not in fact allergic, and can safely use this medication. Only a careful history and exam can determine this—there is no accurate test to confirm or refute true drug allergies. If you or your child is thought of as drug allergic, review the exact circumstances with your physician to see if it is a good idea to try the medication again (do NOT do this on your own!)

 

#4 WRONG: People who are allergic to a medicine should never take it again

Certainly, if a life-threatening reaction occurred you need to be very careful. And be much, much more wary of medications given as a shot or intravenously (I’m not sure anyone has ever died as a result of an allergic reaction to oral penicillin.) But unless the reaction was a true allergic reaction, usually manifested by hives or wheezing, a medication can usually be given safely in the future (again, do NOT do this on your own!)

 

#5 WRONG: People with egg allergy shouldn’t get a flu or MMR vaccine

Flu vaccines are safe in people with egg allergy – great studies have proven this. People with egg allergies can get routine flu immunizations, and are not at elevated risk of reactions (this is reflected in current guidelines – if anyone tells you differently, they’re not keeping up with the science.)

And egg allergy was never a contraindication to MMR. That was a myth. MMRs can safely be given to anyone with egg allergies.

 

#6 WRONG: Allergy testing can tell you if a child is allergic to something

Hoo boy, doctors misunderstand this one, too. The way to know if a person is allergic is entirely in the history: do symptoms of allergy occur upon exposure? If they do, that’s allergy; if they don’t, that is not allergy. If the history is clear, the diagnosis is nailed, done, confirmed, and set. No tests are needed; in fact, tests are quite likely to confuse the picture.

Allergy tests are for when the history is not clear, to help separate exposures that are “likely” from “less likely”, so that further history can be explored and attempts at avoidance attempted to see what the response is. Allergy testing, either with blood tests or skin testing, is far too inaccurate to be used in any other way.

Be especially wary of web-based labs that promise extensive “sensitivity” testing to investigate vague symptoms like weight gain, abdominal pain, low energy, fatigue, and behavior problems. These symptoms are not caused by allergy, though fraudulent testing will inevitably lead to false positives and incitements to purchase detoxifying supplements. This is expensive quackery. Stay away!

 

#7 WRONG: Hives are usually caused by allergies to foods

In adults, this might be true; but in kids, hives are more often triggered by minor infections than by food exposures. Sure, if there are hives you ought to think about potential new foods, and if there is a correlation you ought to look into that. But in the majority of cases in pediatrics, isolated or even recurrent episodes of hives are not from food allergies.

 

#8 WRONG: Specific allergies run in families

“Don’t give him penicillin! Mom’s allergic!” While the predisposition to allergies, asthma, and hay fever run in families, it isn’t to the same specific trigger. Junior has a mom with shrimp allergies? That means that he might more likely have food allergies of his own, but not more likely to shrimp than to peanut or egg or anything else. Same for medication allergies.

 

#9: WRONG: The best way to avoid food allergies is to avoid or delay giving the food.

This is an old myth that won’t die – but it’s completely wrong. In fact, it’s backwards. One of the best ways to prevent the development of food allergies is to start complementary foods between 4-6 months of life, and to quickly give a wide variety of all foods (avoid honey and anything that’s a choking hazard.)

 

If your physician is telling you myths from the above list, it’s time to ask for a referral to an allergist to get the best information. If it’s an allergist tell you one of these myths, well, I’m stumped.

Adapted from an earlier post

Join the fight – learn how to help prevent suicide

Posted October 15, 2018 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2018 Roy Benaroch, MD

Suicide is among the most common causes of death of teens and young adults, and the rates are rising. Unfortunately, people at the most risk of suicide may not be able to get themselves the help and resources they need.

I’ve written and taped a short, 45 minute lecture series, A Practical Guide to Suicide Prevention, to help family and friends recognize the warning signs of suicide risk, and to help people learn the best steps to take when someone is in danger. It’s part of The Great Courses Plus streaming service, and you can watch or listen to the audio as part of a free trial.

If you do join The Great Courses Plus, please check out my other courses. I have three audio/visual series titled Medical School for Everyone. They’re all presented as medical mystery cases for laymen to figure out. While figuring out the mysteries, you’ll learn about medicine, physiology, therapeutics, and how doctors think through solving diagnostic mysteries yourself. The feedback has been great – I think you’ll enjoy the courses! You can watch them via the free trial on The Great Courses streaming service, or buy them individually (with a no-hassle money back guarantee) from The Great Courses. Links below!

Next year I have a new course coming out called A Skeptic’s Guide to Health, Medicine, and the Media. It’s going to be great – look out for it around February 2019.

My courses:

A Practical Guide to Suicide Prevention – via The Great Courses Plus

Medical School for Everyone: Grand Rounds Cases – medical mysteries for you to solve! From The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Medical School For Everyone: Emergency Medicine – mystery cases from the Emergency Department. From The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Medical School For Everyone: Pediatric Grand Rounds – mystery cases from the world of pediatrics! The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Support for HPV vaccination continues to grow

Posted September 24, 2018 by Dr. Roy
Categories: Guilt Free Parenting, Medical problems

Tags: , , ,

The Pediatric Insider

© 2018 Roy Benaroch, MD

Two new studies have added to the enormous weight of evidence in support of HPV vaccination.

From Pediatrics, September 2018, “Primary Ovarian Insufficiency and Adolescent Vaccination”. This study looked at almost 200,000 young women enrolled in the Kaiser health system from 2006 to 2014, looking at rates of ovarian failure in women who had received vaccines versus women who didn’t. The study was triggered by concerns about ovarian failure related to HPV vaccination – concerns that continue to swirl on Facebook and other social media sites. The study showed that HPV vaccine didn’t trigger ovarian failure, even after an exhaustive search allowing for an association at any time period after vaccination. It just isn’t there. And ovarian failure wasn’t caused by other teen vaccines, either.

And, from Pediatrics August 2018, “Legislation to Increase Uptake of HPV Vaccination and Adolescent Sexual Behaviors”. Another concern that’s been raised is whether encouraging HPV vaccination interferes with “safe sex” or abstinence messaging. By encouraging a vaccine to prevent a sexually transmitted infection, are we giving permission to our children to have sex? This study looked at that question through the lens of how the individual States have approached HPV vaccine legislation. Some states have passed specific laws to encourage HPV vaccines; others have not. It turns out that adolescent sex behaviors, including having sexual relationships and using condoms, isn’t affected by how strongly their states encourage HPV vaccines.

 

Neither of these specific studies is a slam-dunk – and that’s the way science can be. We accumulate more and more evidence as time goes by. But they add up to what we can say with confidence: HPV vaccines are safe, and HPV vaccines can help protect your children from cancer. It’s a compelling story, and something parents ought to feel good about. There is no reason to hesitate – make sure your children are protected and up to date.

 

Key studies on HPV vaccination

A huge, comprehensive review of studies from May, 2018 showed that “There is high-certainty evidence that HPV vaccines protect against cervical precancer in adolescent girls and young women aged 15 to 26.” (Earlier review here) This study from August 2018 documented dropping cancer rates after the vaccine was introduced. The vaccine is working, and it’s saving lives.

A 2010 review of post-licensure studies showing good safety profile, and another large study of 600,000 doses in 2011 didn’t find any important safety concerns. Another 2012 study found no significant problems after almost 200,000 doses. These are big, reassuring studies that all say the same thing: HPV vaccination is safe.

Studies showing HPV vaccines do not cause chronic fatigue, autoimmune diseases, complex regional pain syndrome or postural orthostatic tachycardia syndrome. These and other studies looking for specific diseases or conditions caused or worsened by HPV vaccines have all been reassuring – these vaccines aren’t associated with these or any other worrisome health conditions.

Don’t waste your money on “food sensitivity” tests

Posted September 20, 2018 by Dr. Roy
Categories: Guilt Free Parenting, Pediatric Insider information

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The Pediatric Insider

© 2018 Roy Benaroch, MD

Ah Facebook. Where else could I stumble on a video of a baby hippo taking a bath, or Toto’s Africa performed on solo Harp? But among the shares and silliness and talent, there’s a dark side to Facebook. It’s become a fast way for quacks to push their scams and empty your wallet.

Just today in my feed I received a “promoted” post about a “Food Sensitivity Test”. I’m not going to link directly to the company – feel free to do a Google or Facebook Search, you can find them along with dozens of other companies that push a similar product. What they’re selling, they claim, is an easy, at-home test that will reveal your “food sensitivities”.  They say their test won’t diagnose allergies (which is absolutely true), but it will help you find out which foods might be causing things like “dry and itchy skin, other miscellaneous skin problems, food intolerance, feeling bloated after eating, fatigue, joint pain, migraines, headaches, gastrointestinal (GI) distress, and stomach pain.”

This is absolute nonsense. Their test can’t in any way determine if any of these symptoms are possibly related to food. What they’re testing for in your blood, they say, are IgG antibodies that react to each of 96 different foods in your body. But we know that these IgG antibodies are normal – all of us have some or most of these if we’ve ever eaten the food. IgG antibodies are a measure of exposure, not a measure of something that makes you sick or makes you feel ill. Having a positive IgG blood test for a food means that at some point you ate the food. That’s it. Nothing more.

This isn’t something that we just now discovered. IgG antibodies to food have been a known thing for many years. We know why they’re there and we know what they do. And we know testing them is in no way indicative of whether those foods are making you sick. Recommendations from the American Academy of Allergy Asthma & Immunology, The Asthma and Allergy Foundation of America, the American College of Allergy, Asthma, and Immunology, and the European Academy of Allergy and Clinical Immunology all unequivocally recommend against food IgG testing as a way to evaluate possible food sensitivities. The testing just doesn’t work to reveal if a food is making you sick.

But that doesn’t stop quacks from direct-marketing on Facebook. If you’re offered IgG-based food sensitivity testing, either through the mail, at a physician’s, or at a chiropractor or naturopath, I’ll tell you exactly what it means: Save your money and run the other way. Whoever is pushing the test is either deliberately deceiving you or doesn’t understand basic, medical-school level immunology. It’s a scam.

More details about the (lack of) science behind IgG food testing

Preventing prescription pitfalls – How to save money and hassle at the pharmacy

Posted September 17, 2018 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2018 Roy Benaroch, MD

Doc writes prescription, pharmacist fills prescription, insurance covers prescription. Simple, right? But that’s not the way it works anymore.

Some changes are good. Gone are the cryptic abbreviations and illegible handwriting–replaced by computer printed scripts, or better yet scripts magically transmitted via the ether. But along with fewer errors there’s even less transparency on pricing and coverage. Patients, who haven’t been to pharmacy school and couldn’t possibly decode the pages of exclusions and conditions in their insurance contract, get hosed. And doctors and pharmacists get blamed.

Remember this, if nothing else: it’s all gamed by the payer. Insurance company tricks are there to prevent them from spending money on your health care, while making your doctor and pharmacist look bad. Inscos are often abetted by Pharmacy Benefit Managers (PBMs) – middlemen who skim even more health care dollars off the top, adding another layer of screwage.

But you can fight back. Here are some tips to help you get the medications you need, affordably.

Ask for generics (from your doc and pharmacist). There are often generics available, though these days they’re not always cheaper than the brands. Ask anyway. Remember that newer, brand-only drugs are not more likely to be better or safer. Go with an older, established medication if you can.

Don’t assume your “insurance price” is the best price. You might think your insurance-negotiated rate is better than what you can get without insurance. That’s not necessarily so. Those PBMs mark up everything, and often drive the price of very inexpensive drugs higher for those with insurance. Ask for the retail price to compare. And check out pricing sites, too.

Visit NeedyMeds.org for drug-discount programs and other information. This is a great non-profit, non-commercial site that pulls together just about all of the information you need to save money on prescriptions. There’s a price look-up, lists of industry- and private-sponsored assistance programs, and tons more.

Try out other “pricing sites” to help compare. Two simple ones that work well are Goodrx.com and WellRx.com. They don’t have the depth of info that NeedyMeds offers, but they’re simple to use to find prices in your area. You’ll enter the name of your medication and your zip code, and get back the price (to the penny) available at local chains. This assumes you don’t use your insurance – so keep in mind buying meds this way won’t count against your deductible.

Look into “90 day” supplies of medications. If you’re on a stable dose, your doc may be happy to write for 90 days instead of 30. That often saves $$. But you won’t be able to refill your next supply until that 90 days is almost up, so pay attention to the calendar. If your doc sends the prescription in too soon, the pharmacist will hold it until your insco deems it time for you to be able to refill it. Not doc’s fault, not pharmacist’s fault.

Don’t assume mail-order pharmacies are cheaper than filling locally. This happened to me – the Aetna mail order 90 day supply price was twice what it cost to fill the same medication for 90 days at my local pharmacy. Unexpected. But I’ll take the less-expensive, less-hassle option of a local pharmacy for sure.

Not-in-stock doesn’t mean never-in-stock. If your medication is out of stock at your favorite pharmacy, they can usually order it in just a few days – just ask them, if you’re not in a huge hurry to get the meds. If you are in a hurry, call around to different chains (not just different locations of the same chain, which probably use the same warehouse to resupply them shelves.)

Avoid “prior authorization” medications when possible. A prior auth is a nightmare, designed to prevent you from getting medicine while making it look like your doctor’s fault. “Just tell them to do a prior auth,” you’ll be told – but doing a prior auth typically takes a tremendous amount of time and frustration, and unless you’ve met the “secret criteria” it’s not going to work.

If you do need a prior auth, figure out the “secret rules” first. As with any game, you won’t win if you don’t know the rules. If your insurance insists on a prior authorization, call them and get them to tell you exactly what is needed to happen for the prior auth to be approved. Do you need to try one or more medications first? Which medications? What are the criteria that they use to make their determination of coverage? If you can find that out and tell your doctor, it will save everyone a lot of hassle – and you might just get your meds covered.

Consider OTCs over prescriptions. There’s a mystique to prescription medications, and that makes it seem like they’re more powerful or more-likely to work. That’s just not true. For conditions like allergies and acne, OTC meds or combinations of OTCs and prescriptions are often just as effective, safer, and cheaper than prescriptions.

The deck may seem stacked against you – the insurance company has the resources, and they make the rules. But you’ve got your doctors, nurses, and pharmacists on your side. Work together to get the meds you need at a price you can afford.

When polio was wild

Posted September 12, 2018 by Dr. Roy
Categories: Medical problems

Tags: ,

The Pediatric Insider

© 2018 Roy Benaroch, MD

“Polio. I’ve seen polio.”

Last night, I was speaking with one of the most experienced pediatricians I’ve ever met, Dr. Jack Burstiner. I’ve known him for 50 years. I would have known him even longer if I had been born earlier. He lived in my neighborhood, two doors down. He was my pediatrician.

Jack is almost 90 years old. But he still looks like a pediatrician. He’s got a smile a child could trust, now hidden under a white mustache. His green eyes twinkle when he talks about his patients, the kids he’s seen. There are some things about a pediatrician that never change.

Though he stopped practicing in the 1980’s, Dr. Burstiner worked for 30 years in pediatrics, at a time when pediatricians did everything. Hospitals, emergency departments, newborn deliveries, everything. And in 1955, just starting his training, Dr. Burstiner was a pediatric intern at Kings County Hospital, Brooklyn. It was a busy hospital, sure, but it was especially busy in the summer. Polio season.

“That’s where they’d all come, the kids with polio. They didn’t look right. They’d be dragging a leg, or not moving right. Sometimes an arm wouldn’t move, but usually a leg. And all night, every third night, I admitted all of them. It was just me. I’d do the spinal tap, and I’d look in the microscope, and I’d count the cells. If they had a lot of cells, that was polio. Of course we knew it anyway, but we had to tap all of them to be sure. All night long.”

Polio is caused by specific virus, an enterovirus that circulates especially in the summer and fall. It’s spread by contaminated water, sometimes in swimming pools or from unsafe taps, or from household contamination via stool. Most kids with polio develop a fever and then recover, but many develop paralysis of their skeletal muscles. It doesn’t affect their thinking, or their ability to feel sensations or pain. But it can make it impossible to walk or use other muscle groups, and can sometimes shut down the muscles that keep them breathing.

“It’s funny,” Dr. Burstiner said. “It was a big hospital, and upstairs – up above the emergency department, and the wards, the rooms the patients – upstairs were some of the smartest people in the world. They had dedicated their whole lives to fighting polio, and they knew all about it. But we still couldn’t really do anything to treat it. I was there, this intern, and I could tap them and I’d admit them, and then hopefully they’d keep breathing.”

In 1955 there were about 29,000 cases of polio in the United States. Dr. Burstiner estimates he admitted about 100 of those, ten a night, on the every third overnight he worked at the Brooklyn Hospital for one month during that hot summer.

“100 cases, I think I admitted, just in that one month. And all of those smart people upstairs, what could they do? But you know what happened next? The vaccine came out, and everyone wanted it. And in just a few years, it wasn’t 100 a month in one hospital. There wasn’t any, there was no polio anymore. I saw more polio in that one month than there was in the entire country, just a few years later.”

The first polio vaccine was introduced in 1955. By the mid-sixties, there were fewer than 100 cases of polio per year in the United States. We beat it. There have been zero cases of polio transmitted in the US since 1979; the last imported case to reach our shores from overseas was in 1993. There are still pockets of polio transmission, but it’s very possible the disease will be wiped off the earth entirely in the coming years.

Dr. Burstiner and I talked a while more, trading war stories, talking about cases. I’ve never seen polio, but I have seen children die of pneumococcal meningitis, and I’ve seen complications of chicken pox that put children in the ICU for weeks. Those are some of the diseases I may have the pleasure of never seeing anymore. Maybe someday I’ll tell the next generation of pediatricians about how we knocked out rotavirus diarrhea, and HIB septicemia, and HPV-related cancer. Measles, diphtheria, hepatitis A and B, we’ve got the tools to beat these and other diseases. We just need the will to see the fight to the end.

There’s a lot that hasn’t changed. Parents still worry about their kids, and kids still get sick. But there are many diseases that parents just don’t have to worry about anymore. That’s incredibly good news for you and your family. Protect your children, protect your communities, and help be a part of making the world healthier for the future. Vaccinate.