MMR: MEASLES, MUMPS, RUBELLA Measles, Mumps, and Rubella viral infections are often subclinical, meaning that the child may be fighting the virus but not express any serious symptoms. Antibody titers may show existing natural immunity due to past infection, though the person may not remember ever having the disease.
Common reactions to MMR Vaccination: fever and rash 7-10 days after vaccination (usually due to the measles component).
Measles (Rubeola) The infectious agent associated with measles is the Rubeola virus.
MEASLES is a highly contagious infection spread by respiratory droplets. Measles outbreaks are common in both the immunized and non-immunized communities. Hospital or clinic waiting rooms have been shown to account for up to 45% of known exposures to measles. Measles was considered to be eradicated from the U.S. in 2000. An average of 150 cases are reported in clusters yearly in the U.S. These cases have been related to measles imported from other countries. No deaths were reported in the recent outbreaks.
The incubation period after exposure is 8-12 days, with onset of the rash around 14 days. Patients are contagious for 2 days before the onset of symptoms until 5 days after the appearance of the rash.
Symptoms include a red rash on the face, neck, and abdomen that spreads from the head to the feet, sore throat, enlarged cervical lymph nodes, and an enlarged spleen.
Complications of the disease include dehydration, diarrhea, otitis media, pneumonia, croup, myocarditis, pericarditis, disseminated intravascular coagulation, and encephalitis. Mortality from the disease occurs in 1-2 of every 1000 cases in the U.S. Approximately 1 in 100,000 cases of measles cause a brain inflammation called subacute sclerosing panencephalitis (SSPE), which is fatal. If the mother has experienced natural infection, passive immunity may be conferred to the baby for 6-12 months.
Treatment of measles in the hospital includes vitamin A therapy, fever reduction, fluid replacement, and room humidification to help reduce cough. In general, measles is considered to be a mild disease of childhood.
The measles vaccine is an attenuated live virus variety derived from chick embryo cell culture. Duration of immunity is unknown, although it appears to be limited. A booster is usually suggested when the child is 4- 6 years of age. Natural infection provides lifetime immunity.
A shift in the incidence of measles occurred coincident with mass immunization. Prior to this period, measles was primarily a disease of childhood. Now infants and adults are at greatest risk for contracting a measles infection because the infant?s vaccinated mothers do not pass on natural immunity, and the adult?s vaccination „wears off? and no longer protects them from the disease. Unfortunately, these age groups are also at much greater risk for serious complications from the disease, which accounts for the increased mortality rate.
MUMPS The infectious agent associated with mumps is the mumps virus. Transmission of the disease is by respiratory droplet or direct salivary contact. In most years, there are less than 100 reported cases in the United States. In 2006 an outbreak of an imported virus resulted in 6500 reported cases. There were no deaths. 84% of those reported had previously been vaccinated.
The incubation period after exposure is 12-25 days.
Symptoms include painfully enlarged salivary glands, fever, anorexia, body aches, headache, and difficulty swallowing. Viremia may spread to the gonads, pancreas, and meninges. The disease is most contagious 1-2 days before swelling begins.
Very rare complications include deafness, ocular involvement, sterility, and inflammation of the meninges, brain, ovaries, testes, pancreas, kidneys, thyroid gland, heart muscle, breast tissue, or joints. The meningitis associated with mumps virus is the most frequent complication, but it is usually the benign “aseptic” form.
Treatment in the hospital is generally supportive (fluid replacement, rest, fever reduction, pain reduction, monitoring). The swelling disappears by 1 week, and if testicular pain occurs, it is usually gone by 4-6 days. Testicular atrophy is common, but infertility is rare.
Mumps is typically a mild disease of childhood. Mumps is reported to have a <2% death rate globally. The mumps vaccine is an attenuated live virus variety derived from chick embryo cell culture. As with measles, the immunity provided seems to diminish over time. If the natural infection is contracted, it offers lifetime immunity. Significant numbers of mumps infection occur in those previously vaccinated against the disease.
RUBELLA (German Measles) The infectious agent associated with German Measles is the Rubella virus. Transmission of this disease is by respiratory droplet or direct contact with nasal secretions. Rubella was considered eradicated in the U.S. in 2004 (less than 10 cases per year). Outbreaks in non-vaccinated individuals occurred in 1999 (83 cases) and 2001 (23 cases).
Infection with rubella is contagious 7 days before the rash and 14 days after, but most contagious at the onset of the rash.
Symptoms include a 3-day rash that does not coalesce, begins on the face, then progresses to the truck and extremities, conjunctivitis, arthritis, and lymph node swelling around the neck, ears, and back of the head.
Rare complications include arthritis, encephalitis, bleeding, thrombocytopenia, orchitis, and neuritis. As a childhood infection, the disease is quite mild with very rare complications. This disease puts the unborn fetus at significant risk. This is especially true during the first trimester of pregnancy. If a pregnant woman acquires a rubella infection and passes it on to her baby, the developing fetus is at risk for congenital heart disease, eye and visual defects, deafness, mental retardation, and death. All girls of childbearing age should be screened for adequate anti-rubella antibody levels. If levels are inadequate, they should strongly consider being immunized.
The rubella vaccine is an attenuated live virus variety derived from human tissue cell culture. Unlike the natural infection, which provides lifelong immunity, the protection derived from the vaccine is limited. Those who require absolute protection against infection are women of childbearing years. The full vaccination series is reported to be effective for up to 15 years in 90% of those vaccinated. If a girl receives immunization at a young age, she may not have the desired level of immunity when she needs it most.
POLIO The infectious agent associated with polio is Poliovirus type 1, 2 or 3. It is spread by the fecal-oral route. The disease is now quite rare. On average, 13 cases per year occur in the U.S. with virtually all cases resulting from the oral polio vaccine. Over 90% of polio cases present as minor illnesses. Paralytic cases are extremely rare. There is no allopathic treatment. Two polio vaccines are available. The Sabin oral polio vaccine (OPV) is an attenuated live virus version. It has the advantages of providing intestinal immunity and protecting against natural infection. On the down side, live poliovirus from the OPV can be shed in the stool. Transfer of virus in this manner can result in vaccine-associated paralytic polio in the recipient or in his/her social contacts. The injectable Salk inactivated polio vaccine (IPV) is a killed cell version. It protects against stool transfer of live virus and paralytic disease, but it does not produce intestinal immunity. One vaccination strategy suggests giving the first two doses of polio vaccine in the injectable form and the third dose in oral form.
HEPATITIS B The infection associated with Hepatitis B is a virus. Transmission of the virus to children is through birth to infected mothers, exposure to infectious maternal blood, saliva, stool, urine, or breast milk, or through contaminated blood products. Adult transmission is through unprotected sexual contact and shared needles. Neonates infected with HBV develop a disease pattern of hepatitis that closely resembles adult “chronic persistent hepatitis”. Long term prognosis is not known, though there is evidence of an increased risk of liver disease.
Rare symptoms include acute hepatitis, jaundice, lethargy, failure to thrive, abdominal distention, and pale stools. Severe cases may show signs of hepatomegaly, ascites, and elevated bilirubin, and may be fatal. The most severe cases appear to be born to mothers that are chronic carriers of hepatitis B, not to those with acute hepatitis B.
Treatment depends on symptoms and includes adequate nutrition and monitoring of liver function. Breastfeeding does not appear to increase the risk of postpartum transmission of HBV, especially if vaccination has been given to the infant. Vaccination against HBV can reduce the risk of Hepatitis B infection by 90%. Post-exposure vaccination is recommended for newborn infants of HBsAg-positive mothers. Vaccination is not effective for elimination of existing HBV infection. Pre-exposure vaccination is usually advised for individuals at risk of exposure to HBV (health care personnel, patients using hemodialysis, IV drug users, anyone participating in unprotected sexual contact). New guidelines in many states require that children be vaccinated against Hepatitis B prior to starting school.
VARICELLA The infection associated with Varicella (Chicken Pox) is a form of herpes virus. It is transmitted by respiratory secretions, and usually occurs in childhood. Immunity from natural disease is usually life-long, but re-infection can occur (shingles). Chicken pox is most severe in immuno-compromised individuals, infants over 3 months of age, adolescents, adults, individuals on IV steroid or long-term aspirin therapy, and individuals with pulmonary disorders.
Incubation is 10-21 days after contact, and the disease is contagious 2 days before the onset of the rash until 5 days after lesions stop appearing.
Symptoms include crops of vesicles that appear anywhere on the body every 3 days. Congenital varicella syndrome is caused by maternal infection with varicella during the 1st or 2nd trimesters of pregnancy, and involves limb atrophy, scarring of the extremeties, central nervous system problems and eye problems.
Complications include secondary bacterial infection, pneumonitis, pancreatitis, appendicitis, hepatitis, idiopathic thrombocytopenia, bleeding, nephritis, transverse myelitis, encephalitis, disseminated intravascular coagulation, arthritis, and death. Varicella is the most common vaccine-preventable cause of death.
Adults who have never been exposed to chicken pox are 35 times more likely to die of varicella than healthy children who contract the disease. Treatment includes isolation, acyclovir (antiviral medication), avoidance of salicylates (aspirin), and rest. Vaccination against varicella began in 1995, and involves subcutaneous injection of the vaccine. Duration of immunity has been shown to persist for 10 years, and has been shown to have 84% efficacy. Breakthrough varicella is contracture of the disease despite vaccination, and now represents 25% of all varicella cases. Adults that were vaccinated against varicella have an increased risk of developing shingles.
HUMAN PAPILLOMAVIRUS The Genital Human Papillomavirus (HPV) is the most common sexually transmitted infection. There are over 40 types of HPV virus which can infect the skin and mucus membranes of male and female genitalia. Some types, considered “low risk”, cause genital warts. Others, considered “high risk”, may cause cervical cancer in women. At least half of all sexually active individuals acquire an HPV infection at some time. 90% of HPV infections are cleared by the immune system within 2 years. About 10% of women with “high risk” infections will have changes to the cells of their cervix that may become cervical cancer.
Long-lasting infection may (rarely) progress to vaginal, vulvar, anal, or penile cancers. Regular papanicolau (“pap”) smear screening for cervical changes can monitor women?s risk for developing cervical cancer. Condoms may reduce the risk of transmitting HPV, but they are not fully protective. Vaccination against 2 of the most common “high risk” strains (HPV 16 and 18) and 2 of the most common “low risk” strains (HPV 6 and 11) of HPV has been available since 2006. The vaccine also contains aluminum, yeast protein (caution to those with yeast allergies), and other additives.
In June 2009, the Vaccine Adverse Event Reporting System released statistics that, out of 25 million doses of the vaccine, 14000 adverse events had been reported. (It should be noted that VAERS reporting likely represents approximately 10% of the actual adverse events which occur after vaccination.) Of those reported, 93% were considered “nonserious”, including fainting and seizures. 7% were reported “serious”, including Guillan-Barre Syndrome, blood clots (related to concomitant oral hormonal contraceptive use) and deaths. The CDC has denied that the 43 reported deaths were vaccine-related.
DTaP: DIPHTHERIA, TETANUS, acellular PERTUSSIS
Common Reactions to DTP Vaccination: pain at the injection site, mild – moderate fever (100o-104oF rectally), fussiness, swelling or redness at the injection site, drowsiness, loss of appetite, and vomiting. Less common reactions include anaphylaxis, erythema multiforme, rash, Guillain Barre syndrome (polyneuropathy), and thrombocytopenia.
When To Call The Doctor: If your child exhibits any of the following symptoms within 48 hours of DTP injection, call the doctor?s office. The doctor will report the response to the Monitoring System for Adverse Events Following Immunization at the Centers for Disease Control. It may take up to a week for symptoms of brain inflammation, such as convulsions or altered states of consciousness, so monitor your child carefully.
• High-pitched, persistent crying for more than 3 hours
• Excessive sleepiness (difficult to wake the child)
• Unusual limpness or paleness
• Rectal temperature greater than 104oF (oral temperature 103oF or greater)
DIPHTHERIA The infectious agent associated with Diphtheria is a bacteria. It is spread by either direct contact or by droplets produced from sneezing or coughing. Diphtheria is a rare disease today, with the last reported imported case in 2003. 41 cases were reported between 1980 and 1995, 4 of which were fatal. Once a disease of childhood, most cases now occur in the indigent adult male population.
In infants this disease usually occurs during the first year of life. The overall mortality rate is about 3.5-12% of all cases worldwide. Death may result from a membranous obstruction of the respiratory passages or from infection of the heart or nerves by the diphtheria toxin. If the mother is immune, passive immunity is conferred to the baby and lasts about six months.
Symptoms of diphtheria include nasal discharge, a nasal or pharyngeal membrane, respiratory distress, stridor, cough, hoarseness, paralasis of the palate, neck swelling, cervical lymphadenopathy, conjunctivitis, otitis externa, or (in tropical areas) non-healing skin ulcers with a gray membrane. Rare complications include cardiotoxicity, neurologic toxicity, paralysis of the eyes or diaphragm, peripheral neuropathy, and loss of deep tendon reflexes.
Conventional treatment of diphtheria includes antitoxin and antibiotics. It has also been treated using homeopathy with statistically significant efficacy. Delay of treatment increases mortality. The Diphtheria vaccine is a toxoid, meaning it is a formaldehyde treated diphtheria toxin derived from culture.
Diptheria toxoid is part of the DPT injection. It can also be given alone or in combination with tetanus toxoid. In theory, toxoid type vaccines contain no bacterial components and are considered to be among the safest that are currently available. The vaccine is reported to be effective for up to 10 years.
TETANUS The infectious agent associated with tetanus is a bacteria which produces a potent neurotoxin. The spores of this bacteria are commonly found in the soil. Infection usually occurs when a puncture, cut or abrasion is contaminated with the organism. The spores thrive in unclean wounds that heal at the surface level, leaving an anaerobic environment for the bacterium to produce the neurotoxin. Proper cleaning and healing of wounds is essential for the prevention of tetanus infection.
Symptoms of tetanus include lockjaw (wrinkling of the forehead, distorion of the eyebrows and corners of the mouth), fever (later), tonic contractions of the muscle groups causing painful spasms and difficulty breathing, increased heart rate, flushing, and hypertension.
Complications are related to the severe muscle contractions that can cause vertebral compression fractures, hemorrhages, respiratory failure, and aspiration pneumonia. Tetanus is now rare with an average of 43 cases reported in the U.S. per year. It occurs almost exclusively in the unimmunized or underimmunized. Death occurs in 30-90% of all cases of tetanus. In 2006 there were 290,000 deaths reported worldwide.
Modern high-tech hospital care has significantly reduced the death rate from tetanus infection. It is still, however, a very serious disease. Regardless of underlying health and vigor, a child infected with Tetanus suffers a high risk for lockjaw or death.
Treatment of tetanus is an emergency, and includes hospitalization, heart and respiratory monitoring, possible tracheostomy to prevent fatal laryngospasm, IV nutrition and hydration, antibiotics, sedatives, tetanus immune globulin or antitoxin, and neuromuscular blocking agents to prevent muscle spasms.
The Tetanus vaccine is a toxoid, meaning it is a formaldehyde tetanus toxoid. It is part of the DPT injection. Tetanus toxoid can also be given alone or in combination with diphtheria toxoid. The toxoid type vaccines are considered among the safest currently available. The Tetanus vaccination is nearly 100% effective in producing immunity. It also has the best safety record of any currently used vaccine.
Since the beginnings of tetanus vaccination, the occurrence of the disease has dropped from 40 / 10 million to 2 / 10 million.
PERTUSSIS The infectious agent associated with pertussis is a bacteria. It is spread by the respiratory droplet route and is highly contagious. Pertussis, also known as Whooping Cough, is not a rare disease. Approximately 2000 - 3000 cases are reported in the U.S. every year. The incidence of the disease tends to wax and wane (8000 cases were reported in 2002).
There is a rising incidence of pertussis diagnosis since 1992 despite rising vaccination rates. This may be due to improved testing or previously overlooked cases being tested. Pertussis is considered endemic despite high rates of vaccination, as the effect of the vaccine wanes quickly. Many cases likely go unreported due to mild symptomology. Newborns are susceptible despite maternal immunity.
Symptoms occur in 3 stages. The first stage lasts 1-2 weeks and appears as an upper respiratory infection (runny nose, fever). The second stage lasts 2-4 weeks and is characterized by a paroxysmal, whooping cough that can cause cyanosis and vomiting. The third stage, convalescense, lasts 1-2 weeks but the cough can persist for months.
In children under one year of age pertussis can result in significant complications such as bronchopneumonia, encephalopathy, lung complications, or even death. In most cases the disease is not serious and can be effectively treated with conventional (antibiotics, cough suppressants, observation) and natural therapies.
The pertussis vaccine is part of the DPT injection. It is a killed cell preparation derived from cultures of the Pertussis organism and is the most controversial vaccine of all. The medical and lay literature is filled with documented cases of serious side effects and death from this vaccine. A newer acellular vaccine (DTaP) is preferred and appears to have fewer side effects, but it is too early to know for sure. It is considered 88% effective.
Booster vaccinations are sometimes recommended for adults, not because they are at serious risk of infection but because they risk spreading the infection to young infants. Deaths related to pertussis have been in children too young (<4 months) to receive the full vaccine series.
HEMOPHILUS INFLUENZA TYPE B (Hib) The infection associated with this organism is not the common viral flu. Hib is a bacterium found in some forms of meningitis, epiglottitis and pneumonia and is considered a medical emergency. The peak incidence is between 6 months and one year of age.
Symptoms of bacterial meningitis include stiff neck (in older children, but in younger children with poor muscle tone, this symptom may not be seen), crying that increases when the child is picked up, and flaring of the skin when stroked. Symptoms of epiglottitis include anxiety, preference to sit up or lean forward with the head extended, labored breathing, drooling, inspiratory stridor (noisy inward breaths). If these symptoms occur, no one should attempt to open the mouth or examine the throat.
Some of the consequences of Hib infection can be severe. Complications include seizures, long-term neurological complications, and hearing loss in up to 25%.
Breast feeding longer than 6 months is protective against Hib. Day care outside the home is a major risk factor for contracting the disease. Approximately 500 cases are reported in the United States each year. 3-6% are fatal, 20% result in permanent hearing loss.
The original version of the vaccine was made from polysaccharide components of the bacterial capsule. It produced inadequate immunity in children less than 18 months of age. The newer Hib vaccine is a conjugate of the bacterial capsule and a protein. Diphtheria or tetanus toxoid is commonly used as the conjugate protein, which means that Hib is given with the DTaP vaccine, and carried to the immune system by them. While reports of efficacy remain mixed, the conjugate vaccine is much more effective in the under 18 month old age group who are most at risk from Hib disease. Many studies show a 40-60% reduction in Hib associated disease from vaccination. Other studies show no effect from immunization, and a few studies actually demonstrate an increased susceptibility to Hib disease following immunization. Although the immunization is new, vaccine safety seems to be quite high with few reported side effects.