Webcast
KMCO Archives
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.
Thank
you for logging on to our webcast production. We're
very interested in your comments and questions regarding
the webcast and we invite you to contact us. Our e-mail
address is kmco@uic.edu. Our telephone number is area
code 312-996-2233 and our fax number is 312-413-0367.
We
hope that you've enjoyed this broadcast and that you'll
also join us for our upcoming broadcasts. They are scheduled
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central time. Please
take note that once we have aired webcasts the first
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you can access them at any time. Our Internet address
is http://www.uic.edu/sph/cade/kidsmco. It features
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Thank
you very much for joining us.
End
of interview.
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