Immunization Update
December 27, 2000
Hello and welcome to our webcast from the Quality Community Managed Care Project from the University of Illinois at Chicago School of Public Health.
I'm Faye Eldar, your moderator. I'm the family coordinator of the Quality Community Managed Care Project and I'm happy to be with you today.
This is another webcast in our ongoing series in the Special Kids and Managed Care web site. Today's webcast is about immunizations and children with special health care needs.
We're very fortunate to have two experts in this field with us today. Dr. Miriam Kalichman who is a developmental pediatrician and director of the Children's Habilitation Center at the University of Illinois at Chicago Hospital, affiliated with the Title VI Children With Special Health Care Needs Program in Illinois, and Dr. Norman Jacobs who is a specialist in pediatric infectious disease at Cook County Children's Hospital also in Chicago, Illinois.
Q. We're going to start off with Dr. Jacobs, and our first question is, could you explain to us exactly what is an immunization?
A. Sure. There are lots of infectious organisms that we are exposed to. Some of them have over the years been involved with outbreaks, epidemics and that has always worried physicians and we've over the years attempted to do various things about it. It was observed a long time ago, first with the smallpox vaccine, oh maybe, actually Jenner did it 200 years ago, but even before that there were things that were done. An attempt to prevent these outbreaks, these epidemics. It was observed that once you had the disease, you no longer got it again, meaning children would get the disease and they would grow up and they would have an uneventful life with respect to that disease subsequently. So something about having the infection, your body reacts to it and subsequently what we would call immune, meaning that you don't get it again.
Immunization is a way that we have to administer something. It's not necessarily the organism. Sometimes it's the organism that's been killed or the organism that's been altered or a portion of the organism to--it can be children or adults, and it will simulate it will reproduce this whatever the body's mechanism is to handle infection and react to it establish some kind of--the word that we use is immunity--but prevention of this disease occurring. It may not completely prevent it really. It may only modify at least the outward reaction of the disease, but having been exposed to the disease or some portion of the organism, frequently we can go ahead and lead a life without acquiring the disease at least in a severe form.
So, immunization is a way that we're administering a portion of the organism or a modified form of the organism so that when you are then confronted with the organism, you will not develop the disease at least in its full-blown state.
Q. Okay, so what you're saying is for example for a polio immunization this is a little bit of the polio disease or the flu immunization is a little bit of the influenza disease?
A. Well, okay the organism. You know actually with, well, certainly with polio there are two forms of the vaccine. The first one--remember Salk came out? But what that is is just the organism, the virus, the polio and actually there are three of them. They were killed. They were subjected to formula. So the organism is dead and we react to the dead organism. Whereas, Sabin created or developed an organism that was mild. It was still alive. It was attenuated and we react differently to them, it's interesting. But both of them are efective when they're administered to children in preventing disease from occurring.
Q. Now another question-you talked about some diseases that were very dread diseases and epidemics in the past such as smallpox or polio. I remember a polio epidemic from my own childhood, but isn't it true nowadays that very few children get these diseases so then do people still need all of these immunizations?
A. Well, yes. Take for example, we could take polio. Polio has been pretty much gone in the United States for a number of years. Must be about ten years ago. There have populations within the United States that didn't receive the vaccine. There are some religious groups, for example, that feel that they should not take vaccines, and they would be in clusters of people. Clusters, you know, little communities. A child I think came from Holland originally to Canada who had polio and introduced the organism into one of the communities there, and then somebody from that community came to the United States and they had quite a bit of an outbreak among this community with polio.
So, that in this world these organisms even though we may not have them right here in the United States at the present time, we are very susceptible to having these introduced all the times in some place. So, that an unimmunized population is like sitting, like dry grass waiting for a match to be lit. If the organism is eliminated from the world, something like that is possible and happened once, which is the smallpox vaccine and that took a great effort of the WHO [World Health Organization]. Smallpox has been eliminated from the world. There is nobody who has smallpox.
Q. What is the WHO? The World Health Organization. Okay so that's a United Nations organization interested in health worldwide, but so many nations became involved in this but it was sponsored by WHO and other groups besides.
Q. Okay. So you're saying nowadays nobody needs to get the smallpox vaccination anymore?
Right, and we haven't for a number of years because there is no smallpox and therefore, there is no risk. That's not true with polio. There's still polio going on. There is a big effort of polio elimination in this world, you know eradication. And some countries are great efforts are going into this and it's possible.
They had hoped that they would have this by the year 2000, but still there are areas where polio does exist and there are reasons.
I think it is a plan of certainly in our country if polio really does become non-existent or the likelihood of introduction becomes so unlikely, then we will discontinue the vaccine.
We still see it here in this country let alone other countries. Diphtheria and tetanus--I don't think the vaccines are going to eliminate the diseases. Measles, there's a big effort and that's starting to go and maybe within a generation we may have that eliminated. Okay? But these diseases still exist.
Q. I understand what you're talking about, so nowadays we have more people traveling all around the world. We have more people immigrating from different countries and different places and so it seems like there might be a chance for some of these diseases to be spread.
A. Right, and an unimmunized population is a susceptible population.
Q. Okay. Now we all know that babies need to get their shots. But do school age or teenagers still need to get shots, and if they do, which ones do they need?
A It turns out even adults need to get shots.
Q. Oh no.
A. Yes,
unfortunately right? Yes. A number of these diseases occur in young children.
So, it's best to immunize these children when they're very young ,to protect
them while they are very young. Some diseases really do not occur until you're
older, and therefore you need not be immunized until you're older.
Under the immunizations, these vaccines that are being given don't last, oh but, maybe a number of years so that over time your immunity, your ability to fight off the infection is less so that as you become older, you do need what are called boosters. In other words, something to reboost your immunity to this. So there are several things that are given to children at various ages all through childhood and into adulthood.
Q. How do you advise parents to keep track of their child's immunizations?
A. I'll tell you how my Mother did it. My Mother had a book. I don't remember what the book was. She had all her children in there and she just wrote them down. I bet it was a lot easier than, one is there weren't so many vaccines and there wasn't a lot of information that went along with it. But I think it's better to have these immunization cards that physicians or health care centers will fill out and try to keep it though that's very difficult I realize.
Q. What should parents do if they lose the immunization card that they got at, say, the health department?
A. The easiest thing to do is to go back to the health department and say could you look up my child and make me another card? It doesn't always work, especially if it's a good number of years later. There's no guarantee that the same health clinic that you're going to or that the doctor hasn't retired or that the hospital or what have you has misplaced the records so they can't find it. It gets complicated sometimes.
Q. Dr. Jacobs, I've been hearing people talk lately about vaccine registries. What is that and how can it help families?
A. Well, it's an idea that they would like to do nationally. I think they're going by states. There's a push nationally is to put on the computer everybody, and when they are immunized, they will have this information put on to a computer and therefore, if a child goes to another health site within the state and hopefully within other states, you know passing on from one state to another. All they have to do is look into the computer. I would think it would be feasible even for the school systems to be able to pull out this data and say if there's they would no longer have to say bring in the records. They could just pull it up from a computer. So it would be a wonderful way to keep information and make it available, but you know there's a down side too which is why some people are fighting it is, there's information about you that other people can get and that seems to worry some people.
Q. Now, another question is does health insurance usually pay for the children's immunizations?
A. For the ones that are recommended, yes. In other words, there are several organizations--there's a public health service, the pediatrics, there's a family practice--that make recommendations and they are usually the same. Those vaccines that are recommended are presently paid for I think at least in Illinois by the state government. I don't exactly know the details of it but yes, they can get the vaccines free. Not the administration. That costs money, so it's being given to physicians or clinics, and then whatever it costs that group to administer, I think they will try to recover.
Q. And if people have insurance from their job, does that kind of insurance pay for the immunizations?
A. Probably even more so. I mean they would probably even pay for the visit and for the administration of it.
Q. What should families do if their insurance doesn't cover immunizations for the children?
A. I think they can go to health clinics. Certainly like our hospital, Cook County Hospital, there's no charge for the vaccines, and people just come in because they need them just before school starts so they have the big rush. But I think that would be true of most doctors' offices. So even if the insurance doesn't pay, I think the state pays for the vaccines, at least the recommended ones.
Q. Okay, and we will be having some resources about this in the resource section on our web site and we will also have links, so people can find out where to get health department information for their own state and find out where to go to get shots. And one more questions for you. Do people still need to get shots if they travel outside the United States?
A. They probably even need more. There are probably more infectious, you see what we immunize against are the diseases that have occurred in this country or people are likely to encounter in their daily lives if we didn't have vaccines. Outside the United States, and even within the United States in small pockets, there's some unusual diseases for which there are effective vaccines. And outside the United States there are several diseases that we don't encounter in this country. So, probably they would even need more.
Q. Okay, so you're recommending that parents talk to the child's doctor before getting ready for a trip about any immunizations they need?
A. Right. Not all physicians are going to be knowledgeable of what happens in other countries. Hopefully their doctor if he doesn't know can certainly find out and they probably have a better source of finding out the information than individuals do. But this kind of information is available from places like the Centers for Disease Control (CDC). I think they have a number if you're going to a given country what vaccines would be required.
Q. We'll have their contact information as well in our resource lists so people can access them.
Q. Thank you for explaining all of this to us now Dr. Kalichman, I have some questions for you about children with special health care needs. Do they also have some special needs that are related to their immunization?
A. I think they do. The problem that we run into with children with special health care needs and of course that's a big broad description and it's not specific to any one child, is that in general, they have a lot more exposures than average children because they tend to be in school or in therapy younger than other children, and because if they get sick, particularly if it's a child and his seizures are made worse by fever, if it's a child who has breathing problems because he doesn't handle his secretions or if it's a child who has difficulty eating and gaining weight, even the usual kinds of colds and ear infections that of course we can't prevent with immunizations really knock these kids out for a long time. So that when an average child has let's say an ear infection and they don't eat well and they're out of school for a couple of days, really within a couple of days, they are all the way back to being better. If you've got a child who can barely gain weight anyway and he loses weight or he becomes dehydrated quickly with a fever, it may be a month before you get back to where you were.
So, I feel very strongly that we want to be preventing as many illnesses as we can, even if they're not likely to leave lasting damage, just to keep the kids healthy.
So, in my practice, we really try to push the chicken pox vaccine even if the parents are hesitant about it for their healthy children to try to prevent an eight to ten day illness which is usually minor but can cause a child like a child who is having seizures to be ill for quite a while. We usually recommend influenza vaccine for our children who have difficulty with secretions because influenza will be ten days of coughing and choking and gagging in the healthy child. It will be worse in a child who can't cough well in a child who has seizures because again ten days of fever may really exacerbate or worsen seizures and in children who have difficulty gaining weight because ten days of fever is usually going to be a problem for a child who is that weak. So, for children in that group, we do use and really push influenza vaccine and we have been using the pneumonia vaccine the old one until the new one recently became available.
It's also, I think, historically important to realize that the hepatitis B vaccine, which is now a universal vaccine in young children, was first looked at in children who are mentally retarded because they had an extremely high incident of getting hepatitis B, and part of that is that kids who cannot handle their secretions well, children who drool, children who are not able to be careful with their personal hygiene, can be much more contagious than a child who can wipe his own nose and wash his own hands, and doesn't need to be cleaned up and helped and washed by someone else. So kids that have difficulty with their secretions in some ways more risk to others if they become ill but are also very likely to get to get sick with those things more than average developing children who are physically healthy.
Q. Okay, now should the children who have special health care needs get their shots on the same schedule as other children?
A. I feel very strongly that they should. The reason that we're using the shots is to keep the children from getting sick. And it's important to realize that for most of the baby vaccines the ones that are given in the first year and a half, they've been major advances in preventing disability. So you know whooping cough, as Dr. Jacobs says we still see, causes death, causes seizures, causes brain damage, we can prevent that if we vaccinate children. Polio obviously we vaccinate because it was a major scourge that caused life-long weakness or paralysis in people who recovered from it.
The big change in my 20 year professional life has been the Haemophilus influenzae or Hib vaccine. When I was in training, youknow we had a child a week with this disease and five percent of them died and 40 percent of them had life-long disabilities and another 10 or 15 percent became deaf. We can prevent that. Most of the residents in training now have never seen a child with that disease.
But children who are not yet known to have developmental disabilities for instance children who at a year or 18 months it'll be clear have cerebral palsy are often rather sickly, rather weak, having feeding difficulties, having coughing difficulties even as young kids, and if we wait and wait and wait because the baby always has a cold, we wind up with a completely unimmunized child and that's bad.
Q. And then you were saying it's much harder for them to fight it off.
A. Yes, a child who can't eat well is going to get dehydrated faster when he has a fever, is going to not be able to clear the phlegm from his throat and is more likely then to get pneumonia as a complication of any of these illnesses and a child who has a propensity for seizures, the biggest trigger for seizures in a child who's taking his medicine is fever and illness. So, we would like to prevent all of those things from happening.
Q. And I know we talked about this before as we were getting ready for the show, that my daughter has been your patient now for almost 18 years, and that she did have the haemophilus influenzae before that vaccine was available and she was a very sick little girl, and I remember your advising us to have the pneumonia vaccination when that came out and also get a flu shot every year. And I think her health status has really improved a lot.
A. I’d like to take credit for that. I think a lot of the credit is Maya's because she's gotten stronger and she can cough and she can clear her secretions now much better than she did when she was a baby. I think Dr. Jacobs will probably agree with me that the influenza shot prevents influenza. It doesn't prevent every kind of cough and cold and fever in the winter.
Q. Oh, I know that. I mean I can say as a parent she could still get the flu but it would not be as bad and it would not be such a risk of having to go into the hospital.
A. Right and not so much time off school and not so much time trying to get her strength back as it use to be when she was little.
Q. And what would be the best way for parents of children with special needs to find out about which immunizations they need, or if they need to get some of the extra ones the families of other children would not be getting?
A. I think you start with your primary pediatrician or your family practitioner. Many children who have special health care needs, there are special needs, particularly if they have cerebral palsy, tend to be managed by surgical specialists, such as orthopedicsurgeons who are you know very skilled and competent people, but not expert in these areas and I think if the pediatrician is feeling that he's needing or she's needing consultation in developmental disabilities, or people who specialize in immunizations and infectious diseases are good backups for for that kind of problem.
Q. You know as I've been researching for this show, I've been looking around in web sites in literature for parents and I'm not finding very much in print about guidance for immunizations related to families who have kids with special needs. So, if you have some good resources, I would really appreciate if you could share them with us.
A. I don't and you're right. The package insert for the influenza vaccines, you know, list chronically ill people of any age. But that's not, a lot of people whose children for instance have cerebral palsy don't think of them as chronically ill. They tent to think of disability and chronic illness in two separate boxes.
Q. And what would you recommend people in the public health field do about this?
A. Well, let me sidestep that for a second and say there is a lot of discussion now about whether or not to immunize healthy children against influenza because even healthy children miss a lot of school because of this, and they are huge contacts for bringing influenza into homes of elderly people and just their healthy adult care givers. I think that it would be wonderful if the public health community worked more with the disability community and I am hopeful that as we get more certification in the field of developmental disabilities, that this becomes something that we have more legitimacy to our voice in suggesting that.
Q. Okay, and that sounds like a good idea. We will be looking for some resources to put up on our web site about that. I also know recently I'd heard about some new vaccinations. Vaccinations for ear infections, vaccinations for chicken pox, vaccinations for RSV. Could either of you tell me some more about them and how a physician decides whether or not a child needs one of these vaccinations?
A. Well, there are, it use to be easy for physicians let alone for parents. When I first started, there were a number of vaccines that were given, maybe the number on your hand and it was pretty much consistent. I mean from year to year to year, we didn't really change very much. So a physician could learn what immunizations needed to be given and that was it. Over the years, newer and I would say better vaccines have become available and they've been introduced slowly at first. But now they're really coming pretty fast. I mean that's a problem not only for the parents but for most physicians that these new vaccines are being introduced, licensed and available and they have to relearn things too. So it makes it difficult for everybody.
Some of the vaccines that you mentioned are already-- meaning there's a lot of work on a lot of diseases that people would like to see controlled better by immunizations and the list is quite long. Some of these then become available and they will become licensed by the FDA, the federal drug, is that how they say it?
Q. Food and Drug Administration.
A. Food and Drug Administration. Once they are licensed, then people can make recommendation for its routine use or not routine use. So it goes through that. One of the vaccines certainly chicken pox has been licensed and is recommended by the American Academy, the United States Public Health Service, etc. But you're calling the ear infection vaccine--there is a pneumococcal vaccine.
Pneumococcus certainly contributes a lot of bacterial otitis media. It also leads to other diseases. So there are a number of diseases that pneumococcus will cause. So when they tested the vaccine, they could show that the systemic--the disseminated disease--is controlled by the vaccine. And there is a significant difference if they receive the vaccine. Otitis media is not very impressively different. It probably is going to decrease itself, but not a lot. So, I wouldn't really call it an otitis media vaccine and anticipate that parents are going to see a lot less otitis media. They may see some less, and certainly I think it leads to a worse type of otitis than other infectious agents.
Respiratory virus. There is no real active immunization, no vaccine that's available. There was one that was tested a number of years ago and there were problems. There is a globulin. There is a--a globulin is a way of supplying immunity that's acquired in somebody else. It's removing something from somebody else's blood that will modify infection, and they use this in immuno-compromised people.
We were talking about are vaccines necessary for special people? You mentioned one group, but a larger group which you will see more information on, are children that are unable to deal with infections normally because their normal immunity doesn't work right. And for that group of children, they either give extra vaccines or sometimes even not give them vaccines that you would normally give them.
Q. So you're saying perhaps a child who is being treated for cancer or a child who has HIV disease or something like that?
A. Exactly. Those are two very good ones. Right. But even somebody like well even some asthmatics get very high-dose steroids and they would be immuno-compromised. So that's even a more common reason, and some are born with some diseases that impair their immune response. So, they would have some variations in their immunization schedules.
Q. For children who have those kinds of medical problems, would the special immunizations be handled by the medical specialists who are treating them?
A. Usually. Like you were talking about respiratory syncytial virus. As this immune globulin which is a serum that's given once a month to produce antibodies in these children, we only use it in the very small premature infants and it's the neonatologists that take care of that right now.
Q. Do you have any brochures or literature for parents that explain about these types of vaccinations?
A. There is a lot of information about each vaccine that's available. Certainly the public health service has it. There's a group, I think it's in Minnesota, okay, it's a coalition, how can I put it? It's a group that's interested in immunizations. I think they became interested because of hepatitis. And they put out a lot of information and I can get you that number where they have a large number of brochures about each of the vaccines.
Q. That would be wonderful if you could forward that to me. I know I get a newsletter called Needle Tips.
A. That's the one I'm talking about.
Q. Okay. They have good information and we will put that on our web site.
A. Okay.
Q. Now talking about issues that parents have, a couple questions I have is first one, how as doctors, how can you help kids deal with the pain of getting a shot and being afraid of needles?
A. Well they certainly do hurt, okay ,and I don't know. You had talked when we were talking before that you would have liked to have happened to you and what you would like to do with your children.
Q. Well, I said what I did with my daughter,. and I said also you know you have to figure out how to explain to a child what an immunization is. This is when they're older, not when they are at the developmental level of a baby. I would tell her she had to get a hurt and it was a shot and you know I learned the sign for shot in sign language and I had to show her exactly where it would be.
And then she would be okay. Because I remember as a child always being told that it wouldn't hurt a bit but it really hurt a lot and I still have visions of being chased around the pediatrician's office and he had a needle in his hand, and when I told my daughter it's going to hurt, I told her the truth and she isn't afraid. But I know that many children are afraid and sometimes I think with parents you know we're at great risk of passing on our own fears to our children.
A. When you're talking to somebody who had to be dragged out from under a doctor's desk by three people when I was 14 years old and that was my pediatrician and he refused to ever see me again. So I have some insight into this. I think honesty is part of it. I think that when the parent insists on leaving the room because they can't stand it that that is not helpful to the child. I understand closing your eyes, but I don't understand not holding your child's hand. We try to do things like singing and counting to try to get the child to focus on something else. Some people have used ice cubes on the skin, sometimes you can spray with something like a chloride which feels like a freezing on the skin. But the other problem is that what hurts about the shot is not just the needle. It's the stinging as the stuff is injected and we can't really numb that up and to some extent, if you've got a child who's really pretty panicky, holding them to where you're going to put a needle just prolongs the experience. So my sense is you go fast. You really try to hold the child and you really try to distract them and praise them for the fact that they tolerated something that hurts.
A. I think those are good ideas that you're saying. You know I think a lot of it is the parent's fear. And we have a doctor here who refused to get immunized because she's afraid to get a shot. So I think there's a lot of still fear in adults. Truly injections don't in themselves hurt very much. The material may sting and sometimes after the vaccine goes in, you'll have a lot more pain because of what's going in. That's true of other injections that go too. So you could have pain tomorrow more than the actual injection. There is this fear, but if the parent appears to be relaxed and comfortable, and holds the child for example, I think they feel so much better. You know they have that security blanket.
Q. I can also say as a parent, there are not very many people out there who help us as parents understand what's going on and help us learn what to say to our kids and deal with it. You know fortunately we do meet some doctors and some nurses who are very helpful and supportive in this area, but you know some people just remember like lining up in the basement of the school with 200 other kids and everybody is scared and everybody cries and they had a bad experience. And so it's hard to help your child with that.
A. My children go to a dentist that has an open operatory. So they have five dental chairs in the same room and the theory is the children will be ashamed to cry in front of the other kids. I have not seen that that's actually true, but that is one theory and I don't buy it.
A. I'm not so I don't think that crying is a bad thing. You know if we do something and then the child cries, you say it's okay to cry. I mean I would cry too but try to keep your arm still because it will only hurt more. I mean when they're older you can explain that to them.
When I was very young, I saw a movie. I must have been like in the first grade of school. It was during, we had a war going on at that time and the movie was about immunization and they tried to show us its relationship to what goes on with soldiers. And I saw the movie and I felt very patriotic when I next went for my immunization. But I mean it is I mean the movie, it was a cartoon. I tried to find it years later and I've never been able to find it. It was a child coming into a doctor's office and the doctor explaining to the child about what the vaccine is and the way they explained it is that that these infectious organisms are there and they're like an army a foreign army that's going to invade you and do damage to you. And what immunization is is the introduction of a few of the soldiers only so that your army is aware that they're out there and mobilizes and becomes what would that be, alert to the existence of this foreign army so that when that foreign army does come, that they're able to control it.
A. I know that there's also concern about how many needles a child gets at one time. You know, I don't like watching it either. As a mother, I would rather be able to say to my child, we're going to do it all in one day than to come back tomorrow and get another one and come back the day after and get another one. Really it doesn't hurt that much more. It's more the fear than anything else.
Q. For my daughter, I know she responds a lot to the authority of the doctors that she's known for most of her life, in that they have said that she needs to have the shot. and it will prevent her from being sick in the future. And that seems to satisfy her and she can deal with that now.
A. Until she gets sick in the future.
Q. Well, this is why you get your flu shot. It will prevent you from being sick in the future.
A. Yeah, exactly.
Q. I can tell her that Dr. Kalichman said she needs to have it once a year before the wintertime, so she's okay with that. I know that every child is different, and we have to think about ways to help get our own children cope with it, and I close my eyes, and she's braver than I am.
Q. Now I had another question about immunization. Something that has been very controversial and is in the minds of lots of families nowadays. Some people are having the feeling that perhaps immunizations may cause some developmental disabilities such as autism. I understand recently there was a television program about that. I'd like you both to explain about this to us. What does it mean and what does scientific literature say about this issue?
A. You go first.
A. Thanks. If I step on an infectious disease toe, we'll see. One of the problems with linking immunizations to developmental disabilities is that the ages at which kids typically are first perceived to not be developing normally or where they're diagnosed is also typically in early childhood. And it's very hard particularly with the youngest children a two-month old, to really see the difference between a child who's developing normally and somebody who isn't. And one of the problems then is just because something happens after something doesn't mean that it was caused by something. The best example of that, of course, is in the controversy about drug use. Is it almost every heroin addict in the entire world drank milk as a child. Does milk cause heroin addiction? I don't think so and nobody in their right mind thinks so. But you can't go back and say that's a common exposure and this guy turned out bad like that so that happened. So that's one problem.
Another problem is that when you're doing historical look-backs, as you're taking a history from any one particular parent, people who have concerns about their children or whose children are obviously ill or disabled, tend to have really gone over their pregnancy, their family, every single illness and injury that their child had with a fine tooth comb looking for something that they might have done, that somebody else might have done that causes this. So they tend to have a better and sometimes exaggerated recall of how you know of illnesses the child had so if you, for instance, prospectively looking at the future ask a number of pregnant women to write down during every week of their pregnancy how they felt every day, you get you know virtually everybody has a cold during pregnancy. Virtually everybody has some kind of stomach upset or something like that during a pregnancy because you can't go nine months without having a minor illness. But the only people who really remember those things are the women whose children wind up being disabled in some way. So, it's very hard to get historical control.
When you're looking at does this really cause problems, there's a few kind of tenants of medicine and maybe Dr. Jacobs can answer this a little bit. One is there either historical control before we did this vaccine was there a difference in the incidence of this disease, which is apparently not related to the vaccine like autism and the MMR. And in British studies, the answer is no. And certainly in American studies, what seems to be an increase in autism in the past ten years, well the MMR's been around a lot longer than ten years. So if it were there, we should have seen it. These are not things that any one doctor can do from his or her own experience. They really have to be looked at by the thousands and thousands and thousands of cases, and so that information is necessary.
Another is does it make sense from what we understand about the biology of the disease, does it make sense that an immunization or an infection could cause this problem, and I guess I don't see it as biologically plausible for MMR and autism.
And the third is a general issue. There are--if we think about developmental disabilities and things that are clearly in your brain--there are problems that seem to be in-born there from maybe the moment of conception that we don't see until a person is at a certain stage of development. Okay, one example of this is something that we almost never see in childhood. It's Huntington's disease, which is a severe degenerative disease. People lose their ability to move and they become demented, typically in adulthood, sometimes in older adulthood, and occasionally in childhood. Now that disease is from a defective gene and that gene was there at the moment of conception. But, that person looked normal for most of his life. So he always had it, but you didn't see it until later and if that person had had let's say a car accident or had fallen and hurt his head it would be tempting to say that that had caused the problem but in fact, it hadn't.
And autism seems to be that way. We don't have a gene identified. But it seems to kind of unfold itself at a particular point in development. We were expecting to see communicative language use and it seems like it must have been there before. But there's another kind of brain problem in which we have an injury, a child as well, something happens, the brain is not working well right immediately like a near drowning, like a head injury, like some cases of hypoxia at birth. The child is not alert. The child may be in a coma. The child may be having seizures. Something tells you in a very obvious way this is not okay now and later on that injury does not fully recover and that child has permanent impairment, or to use a lay term, brain damage.
When you're looking at linking an immunization to that kind of problem, you would really like to say okay what did that child look like that day? Was this child fine that day, and you know within hours after the immunization was extremely ill and then never got better, that's more plausible than, you know, the child seemed fine at the doctor's office and seemed fine when he went to bed that night, and seemed fine the next day and three weeks later he had his first seizure. That is less plausible because to reiterate what I said first, the age of onset of the most serious kind of seizure disorder that children have is typically four months, infantile spasms. And that's right after most kids have gotten the DPT. The most common age for crib death is about four months. That's right after most kids have had their second set of immunizations. The most common time for people to begin to be concerned about autism is 15 to 18 months, until a couple of years ago the most common time for a child to get an MMR. So it's very understandable that a parent wants to find out what made their child be like that. But there's not really good evidence for it.
Q. Dr. Jacobs, what would you say to a parent who's you know bringing in their child to be immunized and they would ask you should I really do this? Could my child develop autism from this shot? What do you tell parents?
A. People that are involved in this are truly sincere in what they are doing. What's being brought up is it's difficult to prove, cause and affect. And this is a pretty rare event, relative to the number of immunizations and it's not really consistent with what we know about the disease or the agent that causes the disease. So, what you would call the regular medical channels are skeptical that there is this relationship. And personally, I do not believe it. I think that there are certainly things that I don't know and we may find more, and I think that this group is bringing up information to us that somebody has to look at.
What I would tell the individual parent is the disease, these incidents that are occurring are occurring very rarely. If we were not immunizing children against let's say measles, the problems that would be occurring would be occurring so much more and the complications would be so much more than these rare events if they are even related to the vaccine are occurring. So it's not worth the risk. I wouldn't discontinue immunization because of this possibility and I'm not convinced that this is a real thing, but even if it were, it's too rare to risk all these children not immunizing them and exposing them.
Q. Thank you both for clarifying this because I know this is something that is quite controversial among many families. Now it's almost time for us to end the webcast but I do have enough questions about two other groups of children who may have some special medical needs related to their immunizations. One is children who are born outside of the United States and the other one is children who are in foster care and if you have some advice for families of children in one of these groups.
A. When you're saying that they're born outside of the United States, meaning wherever they're born, they should be immunized. The schedule that is recommended I think is best for most children unless there are some special needs that they have.
Q. Are the same immunization schedules used all over the world?
A. No. There are different diseases in different parts of the world and people have different access to vaccines. Many places are not as wealthy as we are in this country and cannot afford many of the vaccines. So WHO, for example, has recommendations of about, oh, a half dozen vaccines. that's all that is worldwide recommended. If we get a number more than that, we must get place as many different vaccines than they are using elsewhere.
But there are other issues as well for instance you know if you're looking at children who've been in orphanages and are internationally adopted or children who come from places where hepatitis B in mothers is extremely common, some of those children are already infected before they've come here at all, and sometimes you get no record and you really you're faced with either having to just do everything or to try to prove immunity with blood tests or you know looking all over the child's body for chicken pox scars. And those are complicated issues.
Q. Is there a good resource for information for families on these topics?
A. I would think that a general pediatrician would have access to it I mean there is a the American Academy of Pediatrics puts out a book from the committee on infectious diseases that pediatricians all should have that goes into this, what to do with children adopted from other countries. But I don't know that this is on a web site accessible piece of information.
Q. Well, I will check that out and make sure that there are resources available.
A. And the foster care issue is, a lot of these children have had very inadequate health care generally and their records may not be findable. The parent may not remember or be willing to tell the worker who removed the child where that child's had any medical care and sometimes you just have no record. Maybe that child had no immunizations. Maybe he did. And sometimes you do wind up starting all over again.
You had earlier said Faye how do you keep records? If the child's been in school, the school health form will have had the record that was submitted at the time of that child's shot to a health examination and usually the school will share it. It might not be up to date, but it's a start for people.
Q. Okay. As we're getting ready to close, I'd like each one of you to share some important advice and information that you feel families need to have about immunizations and their children with special health care needs.
A. Wel,l I'll go first because these are the groups of children who are my patients. I think it's crucial that when we are working with children where we can't make better everything we would like to make better that we make better what we can make better. And that means preventing illnesses and it means treating acute illnesses aggressively, sometimes more so than it seems we need to do in well children, and to always remember that all the vaccines are preventing diseases that use to be devastating, cause death, cause permanent disability. I saw yesterday a child who became deaf a month ago from meningitis that's now preventable. It wasn't. We now have the Prevnar the new pneumococcal vaccine. Had this baby been born now instead of 18 months ago, he wouldn't have had this almost certainly.
Measles use to cause deafness one percent of the, I mean one in a thousand, and encephalitis and permanent brain damage that often and death that often. that's gone and, nobody knows that anymore. And that's another reason to immunize is it is one of the few ways besides not drinking during pregnancy and using seat belts and car seats that can really prevent disability.
Q. Thank you, and Dr. Jacobs?
A. Well, I concur with what she said. Immunizations just in my lifetime have changed this country so much in terms of what diseases are prevalent. What terrible things that were in the past no longer are. Vaccines are not perfect and problems do occur with them, but the risks are miniscule compared to the benefits that we have seen with it. So I certainly wholeheartedly think that vaccines have done so much. And people are truly interested in trying to find more and I think that they are successful and you will see that more and more vaccines will become available.
I think that there are so many injections is certainly a drawback, but people are working out how they can combine vaccines without interfering with each other you know that the different immunizing agents don't interfere with each other so they get adequate immunity, so this is going on too. So we have a lot going on and I think things are getting better and better.
Q. Well, I want to thank you both very much for sharing your expertise and your extensive experience with us and making the topic of immunization for children with special health care needs more understandable to our listeners. It's a pleasure to work with both of you.
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End of interview.