Measles Memo: VACCINES WORK!

By now you have probably heard about the MEASLES outbreak that originated in Disneyland last month. At this point, over 100 cases (that span at least 14 states) have been documented since the first of this year...and we have only entered February. If you are my age or older (40-something), odds are good you remember HAVING the measles. In my case, I missed the coveted LAST DAY OF SCHOOL in 7th grade...miserably feverish, coughing, aching and covered in itchy red spots, so that particular event is etched in my middle school memories. I lay in bed sobbing in my self-pity for missing all the fun at school that day, as well as the first days of summer. But in truth, I was lucky. The worst part of measles for me was my pre-teenage angst.

Fast forward to medical school, during another measles outbreak in the late 1980's. Our pediatric hospital ward in Houston's medical center was literally filled with very sick kids dealing with complications of measles. Did you know that roughly three out of ten people infected with the measles develops complications? Most of the time, those complications are nonlethal medical "frustrations" like ear infections or diarrhea, but measles also can cause far more serious complications such as pneumonia or encephalitis (brain involvement). Watching a family grieve the loss of a young child from any cause is heartbreaking, but from a preventable disease...words escape me.

In 2000, measles was declared "eliminated" from the United States, meaning that this disease is no longer constantly present here. Measles was not, however, eliminated world-wide. In 2013, the World Health Organization recorded over 400 DEATHS from measles every DAY- primarily in young children under the age of 5. Before routine measles vaccination in the United States (which began in the 1960's), there were over 3 MILLION cases of measles per year, including over 500 annual deaths and nearly 50,000 hospitalizations (each year).  Today, thanks to widespread immunization, we are facing a measles outbreak that is only (so far) in the hundreds of cases.

The good news here is that vaccination WORKS- it saves lives. Worldwide immunization strategies with measles have decreased measles deaths by 75% in the last decade, saving an estimated 15.6 million lives. Who is at the most risk today? Anyone un-immunized, including our precious children too young to be immunized yet (less than one year old).

BOTTOM LINE: The major lesson learned from Measles immunization? VACCINES SAVE LIVES. Check with your doctor to be sure your family is up to date!

'Tis the FLU SEASON

It's that special time of year again...so please give yourself (and your family) the GIFT of a flu vaccine NOW so you are not struck down with this illness at the busiest time of year! Flu shots have been available for a few weeks and seem to be available everywhere.  Clinics, schools, grocery stores, pharmacies and many employers are all offering flu shots these days. Add a flu shot to your grocery list- I'll bet the pharmacy there is stocked and you won't even have to add an extra stop on your weekly errands.

Who should get the flu vaccine?
The Center for Disease Control and Prevention (the CDC) recommends annual flu vaccines for everyone over the age of six months.

What is different this year?
As with last year, we have quadrivalent vaccines (that include protection against four strains- 2 influenza type  A strains, and 2 influenza type B strains) in addition to the usual trivalent vaccines. Pick one or the other, you don't need both. If you have egg allergies, make sure to ask for the trivalent vaccine that is egg-free.

Didn't I hear that the flu vaccine this year doesn't match the strain that is going around? 
Well...unfortunately, yes. We are early in the season, and the CDC is seeing that most of the diagnosed cases are a result of the H3N2 strain (as opposed to the H1N1 that was so devastating several years ago), and although that strain is included in the vaccine this year, there has been a mutation in roughly half of the circulating virus that makes it resistant to the vaccine. The take-home message, however, is that even if the vaccine is LESS effective, it is still the best protection that we have AND it should still reduce the severity of the infection if you happen to contract one of those mutated strains.

But I hate needles...no problem, just ask for the vaccine that is delivered via a nasal spray! The only caveat here is that this is a live vaccine, so there are some restrictions: you must be age 2-49 years, not pregnant, have no major problems with immunity (such as having AIDS or cancer), not take aspirin daily, and not have asthma.

Hate needles and have asthma? There is also a trivalent shot that has a tiny needle which is injected just below your skin, rather than into the muscle.


What is FLU? Influenza is not a simple cold, nor is it a twenty four hour stomach virus. The flu causes fever, chills, cough, runny/stuffy nose, muscle aches, headaches, fatigue, and sometimes involves vomiting and diarrhea (more often in kids). Colds and allergies tend to bother you from the neck up- stuffy, sore throat, headache- but don't knock you down for the count, and coughs are generally less bothersome.

How is the FLU spread? This virus is spread from infected people when the cough, sneeze or talk, via tiny respiratory droplets, and the scary part is that you are contagious a full day BEFORE you develop symptoms (as well as for about a week after you feel sick.)

How can you prevent the FLU? Get vaccinated. Get vaccinated. Get vaccinated! 

Who should NOT get vaccinated? Those with bad reactions to vaccine in the past; infants younger than 6 months; and those people with a history of an uncommon disease called Guillain-Barre. If you are sick with a fever, wait till this illness is over before getting the vaccine.

BOTTOM LINE:  Your best gift for good health this season is the FLU VACCINE!

Gardasil- What's Up Down Under?

The HPV (Human Papilloma Virus) vaccine, Gardasil, was FDA approved in the United States for use in young women in June, 2006, then extended for males in October, 2009. In October of 2011, the Advisory Committee on Immunization Practices (ACIP- the group that creates our national guidelines that you see posted on your doctor's office walls) extended their official recommendations to include ROUTINE VACCINATION of both boys and girls at age 11-12 years, with "catch up" immunizations for those youth  ages 13-21 who had missed getting this vaccine series.

Why are we vaccinating?
We vaccinate primarily for CANCER PREVENTION. Each year in the United States, we have over 33,300 cases of HPV-related cancers (data from CDC, 2012). About 2/3 of these occur in women, primarily with cervical cancers, but also other genital, anal and oral cancers. In men, the majority of HPV related cancers are oral, but they, too, can have genital and anal cancer, though it is less common than in females.
Gardasil also protects against the two strains of HPV that cause 90% of genital warts, and with over one million cases of this malady each year in the US, you can see what an impact prevention can make here!

How well are we doing?
Not as well as we could do...because national immunization surveys have shown that in teenagers 13-17 years old, only 53% of young women had started the series, and only 1/3 of that group had completed the series. A bit more encouraging is an improvement in the very low percentage of teenage males getting the vaccine, which was at 8% in 2011 (the first year it was considered a "routine" universal vaccine) and more than doubled to over 20% in 2012.

How effective is this vaccine? Here is the GREAT news- the HPV vaccine is unbelievably effective when given to young adults not previously exposed to HPV (with no prior sexual intimacy). The CDC's data demonstrates efficacy nearing 100% protection for women in preventing cervical, vulvar & vaginal cancers and genital warts, and 90% efficacy in men for genital wart prevention and 75% efficacy preventing early anal cancers.

What happened down under? 
From 2007-2009, Australia provided the HPV vaccine free of charge to all young women ages 12-26, and had extremely high vaccination rates as they utilized the school system to give out these shots. Follow up studies in 2011 and 2012 showed dramatic results, with 92% decline in genital warts in young women (< 21years old),  72% decline in women ages 21-30, and interestingly...an 81% delicate in young (< 21) heterosexual men and 51% decline in men ages 21-30. This is interesting because the young men saw improvement not because they had been immunized, but simply from the widespread immunization of all the women. Pre-cancerous cervical abnormalities also markedly declined in this short time period, and since cervical cancer typically is very slow growing, we expect to see dramatic falls in cervical cancer rates in the next few years and certainly, in the next decade.

BOTTOM LINE: HPV vaccination SHOULD BE a routine immunization for our sons and daughters- talk to your family physician about it at your next visit*

(In this day and age, I feel compelled to add two things: one, I in no way financially benefit from the makers of the Gardasil vaccine; two, yes, we chose to vaccinate our daughters.)

Flu Season 2012- Ready or Not!

While we are rushing around in December, take a moment to think about whether or not your family has received the flu vaccine this year. The CDC reports show that unfortunately, we are jumping into the season early this year, especially in TEXAS, Alabama, Louisiana, Mississippi, and Tennessee. In fact, this is the earliest in the flu season to reach this level in almost a decade (since 2003-2004). The good news is that the viruses identified with testing DO largely match the strains that are included in this year's vaccine. More good news is that they are susceptible to our antiviral medications, although I am not a huge fan of these drugs in otherwise healthy individuals.
Both types of influenza- A and B- are being documented, with the usual ratio of nearly 3:1 from A:B.

What is FLU? Influenza is not a simple cold, nor is it a twenty four hour stomach virus. The flu causes fever, chills, cough, runny/stuffy nose, muscle aches, headaches, fatigue, and sometimes involves vomiting and diarrhea (more often in kids). Colds and allergies tend to bother you from the neck up- stuffy, sore throat, headache- but don't knock you down for the count, and coughs are generally less bothersome.

How is the FLU spread? This virus is spread from infected people when the cough, sneeze or talk, via tiny respiratory droplets, and the scary part is that you are contagious a full day BEFORE you develop symptoms (as well as for about a week after you feel sick.)

How can you prevent the FLU? Get vaccinated. Get vaccinated. Get vaccinated. It's not too late for this year- get vaccinated. The flu vaccine is indicated for EVERYONE over the age of 6 months, EVERY YEAR.

Who should NOT get vaccinated? Those with severe chicken egg allergies; bad reactions to vaccine in the past; younger than 6 months; history of an uncommon disease called Guillain-Barre. If you are sick with a fever, wait till this illness is over before getting the vaccine.

BOTTOM LINE: It's FLU SEASON again- get vaccinated!

Gardasil- What's IN it?

Continuing the discussion about the HPV (Human Papillomavirus) Vaccine Gardasil...I'd like to step back and talk about exactly what is IN this vaccine. Much of the fear about immunizations surrounds concerns about the makeup of the vaccine, and what peripheral damage could potentially be caused from the content.

First of all, can you "catch" HPV from the vaccine? NO. Absolutely NOT. There are vaccines (like chicken pox or measles) that contain essentially watered-down versions of live virus, and as such, can in the course of an appropriate response cause a mild version of the disease as the body reacts to the vaccine, causing long-term immunity. However, the HPV vaccine does not work this way. There is only a tiny portion of the virus  (a surface protein called L1), that scientists extract, multiply and wad up into a ball. Our immune systems "see" this balled-up material as the whole HPV, and make very effective antibodies to fight it off.

What else is in the vaccine as a by-product? Is there thimerosol? NO. Is there Mercury? NO. Is there a tiny bit of aluminum? Yes. 225 micrograms of alum, to be exact, which is the same tiny amount that is allowed in infant formula (and yes, there is even aluminum in breast milk, though less than formula.) Why is there any aluminum in there at all? Well, aluminum is the most common metal found in nature- present in our water and much of our food. In vaccines, aluminum is an "adjuvant"- something added to improve the immune response.

BOTTOM LINE: The HPV vaccine Gardasil creates very effective immunity against the strains of HPV that cause 90% of genital warts and 70% of cervical cancers, and does NOT contain other byproducts that have raised concern in other immunizations.

PS Full disclosure: I am not on Merck's payroll in any fashion. I am a family physician with a special interest in STDs & I believe this vaccine will help prevent much disease & heartache.

Gardasil & Increased Promiscuity? NOT an Issue

The Gardasil vaccine is back in the news. Gardasil is the vaccine recommended for both boys and girls to protect them against the Human Papillomavirus (HPV), which causes genital warts and cervical cancer) Yesterday, an article published in Pediatrics confirmed that girls who had received this vaccine did not, in fact, have any increased sexual promiscuity compared with their peers who did not receive the vaccine. Why was this study done? One reason for lower vaccination rates with this recommended vaccine (compared to other vaccines recommended in this age group) was parental concern that giving their preteen and teenage daughters this shot would appear to be giving "permission" to be more sexually active since they would be protected.

This study looked back at roughly 1400 girls over three and a half years. Almost one third of these girls received the Gardasil vaccine, while the other 2/3 did not. After the immunization, medical issues that can result from increased sexual activity- pregnancy and sexually transmitted diseases- were measured and compared between groups. Results? No significant difference in the two groups.

The results are not surprising, but I am happy to have this data to help reassure any parents who may have this concern. I have not yet found a teen who believes that the Gardasil vaccine somehow makes them bullet-proof in the sexual arena, although I have seen many who falsely believe condoms will do so- but that is a different discussion. If teens are aware of Gardasil, they know it is "for cancer". Only the rare teen (and parent, frankly) seems to realize that this vaccine also protects against genital warts- a disease that affects over a MILLION sexually active people each year in the United States; a disease that often destroys the self-image of young people just as they are trying to make critical life decisions. Genital warts make people feel "dirty" and "gross", and although we can treat warts to make new outbreaks resolve more quickly, we do not have a cure. And if you've ever had a wart frozen off your knee or finger, you know it hurts, so add painful plus embarrassing when that wart is in the genital area.

BOTTOM LINE: Gardasil is recommended as part of our routine vaccinations for both girls and boys to protect them from HPV-related cancers and genital warts. If your child is not yet vaccinated, talk with his or her doctor at the next visit.

Shingles Vaccine- Starts Now at Age 50

Shingles, also known as Zoster, or Varicella Zoster, is a delayed eruption from the Chicken Pox virus. The chicken pox virus is in the herpes family of viruses, all of which stay in your body after the initial infection, and then show up later along a nerve pathway. In the case of shingles, the secondary eruption typically only happens once (versus herpes simplex that can cause many recurrences for years.) Roughly 10-20% of the population will develop shingles at some point in their lifetime.

What does it look like? Shingles is a very localized rash that occurs in a band pattern that wraps around one side of your body, most often the face, back or chest. The rash is made of clusters of red bumps that turn into blisters, then scab over. There is often tingling, stinging or burning pain in the affected area, starting before the rash even appears. The pain can range from mild to severe, and unfortunately, the pain can persist long after the rash has resolved in roughly 15% of patients- this is called Post-Herpetic Neuralgia (PHN.) The good news is that early initiation of anti-viral medication can not only shorten the duration and severity of infection but also decreases your chance of developing PHN.

Additionally, we have a shingles vaccine available, and the FDA has lowered the age of recipients from 60 to 50. A study of 22,000 patients between the ages of 50-59 showed that receiving the vaccine reduced their chance of having shingles by 70%. Although the FDA has APPROVED it for use starting at 50, I should note that our current guidelines from the ACIP (Advisory Committee on Immunization Practices) still recommends the vaccine be given starting at age 60, so please discuss this with your family doctor.

BOTTOM LINE: Consider adding a Shingles Vaccine to your your health prevention list when you turn 50!

FLU News: 2011 Season

Flu season can be a scary, challenging time for all of us, especially the last two years, thanks to H1N1 (formerly known as the Swine Flu). The BAD news this year is that we're already seeing some cases of the flu, but the GOOD news is that we already have this year's flu vaccine available, and it will provide immunity to several strains of the flu, including the 2009 H1N1. In fact, each year the flu vaccine has three parts, including an influenza A (H1N1) virus, an influenza A (H3N2) virus, and an influenza B virus.

There are two types of vaccines offered- a live vaccine, which is a weakened version of the virus (this is the nasal spray vaccine) and a "killed" vaccine, the traditional injection. I often hear patients say they "got the flu" from the vaccine, but that is impossible from the injection because those viral particles are NOT ALIVE- they can NOT cause disease. It takes about two weeks for your body's immunity to kick in after the shot, so plan ahead, especially if you are traveling.

In the 2010-2011 flu season, which peaked in early February 2011, was less severe than the pandemic flu season the year before, but still had very significant impact on our population. While most people infected have a miserable several days to a week of symptoms, there were over 300 deaths confirmed to be from influenza, including over 100 pediatric deaths (average age around 6 years.) This is not a disease to be ignored.

WHO should get the flu vaccine this year? The CDC recommends that "EVERYONE 6 months of age and older should get a flu vaccine as soon as the 2011-2012 vaccines are available." And that is NOW! Don't worry about the effects wearing off before the end of flu season, by the way, because the effects last throughout the whole season.

When is flu season? Though typically we say October to January, it really starts with September and most likely extend beyond February this year. Let's be proactive and line up early to receive a vaccination, and then follow up with consistent hand-washing and STAYING HOME if we get sick! I LOVE that all our grocery stores, and many other public places now have the anti-bacterial cleansers positioned right as you enter their store- USE IT!

BOTTOM LINE: Don't wait- head to your doctor's office or your pharmacy for a FLU VACCINE now!

How Safe is Gardasil?

Parents are appropriately concerned about vaccines, but I get frustrated with the enormous amounts of negative popular press that immunizations are receiving these days. Vaccines are not only saving lives, but they are improving the quality of our lives dramatically with every decade. Today I'd like to discuss the statistics with Gardasil, a vaccine that protects against four strains of the human papilloma virus which cause genital warts and cervical cancer.

Gardasil was FDA approved and recommended in June of 2006. Since that time, over 32 million doses of the vaccine have been administered. There have been over 17,000 "adverse events" reported, including roughly 1000 "serious" events. The mild to moderate events (over 90%) include transient local swelling or pain, mild and moderate fevers, and nausea or fainting.

So what about the serious events, including 56 deaths? The serious events included primarily Guillian-Barre syndrome (a severe neurologic disorder) and blood clots. The numbers of GBS are no higher than expected in the age group receiving the vaccine, and the girls with blood clots typically had other risk factors for clotting, such as taking the birth control pill. Though deaths in young people are tragic REGARDLESS of the cause, there has been no identifiable pattern in these deaths to suggest that the vaccine caused them. If you look at any age population of 10 million people (32 million doses divided by the 3 shots in a series), sadly, you will see certain lethal cancers, neurological diseases, and other rare ailments.

It is important to understand that in order to figure out side effects from vaccines, any and ALL events that happen within a month (or up to a year) after receiving an immunization can and should be reported- even if it looks like they are completely coincidental. For example, if you get a flu shot today, and are diagnosed with advanced leukemia tomorrow, it gets reported as an "adverse event" of the flu shot- even though it obviously was going on before your shot. Why do this? Because we want to be SURE that there is NOT a relationship between any serious diseases and vaccines, and the only way to know is to collect all the data.

BOTTOM LINE: For Gardasil, look at these numbers and remember there are 1 million new cases of genital warts per year, 12,000 cases of cervical cancer and 4000 deaths from cervical cancer. You do the math. We are choosing to immunize our daughters.

Dodge This Bullet...HPV

Yesterday I mentioned that the New England Journal of Medicine recently published a study regarding HPV vaccine efficacy in boys. Today I'd like to explain the study. The title is "Efficacy of Quadrivalent HPV Vaccine against HPV Infection and Disease in Males". "Quadrivalent" refers to the fact that the vaccine targets four strains of the Human Papilloma Virus: strains 6 & 11, that cause 90% of genital warts, and strains 16 & 18, which cause the majority of cervical cancers (roughly 70%).
I'll start by saying that yes, the study was partially funded by Merck, the manufacturer of the vaccine. That being said, I do not feel it negates the study, although obviously it introduces some bias. They took over 4000 boys/young men age 16-26, from 18 countries, and gave half a placebo vaccine series, and half real. The study was double blind (no one knew what they were giving or getting), and randomized (which raises the quality of the study.) Some of the participants were fully screened initially to determine if they already HAD any HPV strains, and others were not. Note that in "real life medicine", we have no way to test people ahead of time to see if they have already contracted HPV.

In the young men with unknown prior HPV status, the vaccine had an efficacy of 60%. In those known to be HPV negative initially, the efficacy was 90%. It is not surprising that the vaccine would appear to work better in those that did not already have some strain of HPV, and this supports the reasons to vaccinate youth BEFORE they are sexually active. I thought it was interesting that they ended up with 1% of the placebo subjects developing genital warts- the same as in the general population. I am encouraged that the incidence in those vaccinated dropped to 0.1%.

The devil is always in the details, and how people pull out statistics. I could note, for example, that 3 patients in the placebo group received gun shot wounds, while only one in the vaccine group did- but obviously the vaccine did not prevent gun shot wounds! The good news here is that true adverse events were minimal and of uncertain relationship to the vaccine.

BOTTOM LINE: HPV vaccination can significantly reduce the incidence of genital warts in young men as well as young ladies, with minimal side effects.

Flu Vaccine- It's Time AGAIN!

Last year's flu season was a scary, challenging time for all of us, thanks to H1N1 (formerly known as the Swine Flu). The BAD news this year is that we're already seeing some cases of the flu, but the GOOD news is that we already have this year's flu vaccine available, and it will provide immunity to several strains of the flu, including the 2009 H1N1.

When is flu season? Though typically we say October to January, we'll need to start with September and most likely extend beyond February this year. Let's be proactive and line up early to receive a vaccination, and then follow up with consistent hand-washing and STAYING HOME if we get sick! I LOVE that all our grocery stores, and many other public places now have the anti-bacterial cleansers positioned right as you enter their store- USE IT!

WHO should get the flu vaccine this year? The CDC (Center for Disease Control) has recommended that EVERYONE over the age of 6 months receive it this year, so we can avoid the near pandemic we faced last year. It is especially important for people at high risk of serious complications: pregnant women, kids <5 years old, adults > 50 years old, anyone with chronic illness (asthma, diabetes, cancers, etc.) and health care workers. I would add TEACHERS to that list, as well.

BOTTOM LINE: Don't wait- head to your doctor's office or your pharmacy for a FLU VACCINE now!
(PS If you are a West Lake Family Practice patient, we are expecting our vaccine shipment to arrive next week.)