AskDrSears - The Vaccine Book

HIB Vaccine Shortage Over, but Don’t Rush in to Catch Up

Monday, June 29, 2009

For almost a year now there has been a shortage of HIB vaccine, due to a production snag for one manufacturer last year (Merck, the makers of PedVaxHIB brand). Due to the shortage, doctors have been withholding the final dose of the vaccine (normally given at 15 months of age). HIB vaccine is designed to prevent HIB meningitis, a severe disease that only affects about 25 U.S. infants and young children each year (it used to run rampant back in the 1980s, but has now all but been eliminated).

Sanofi-Pasteur, the maker of ActHIB brand, has been trying to pick up the slack until Merck’s product becomes available again. While it is still unknown when the Merck brand will be ready, the CDC has now determined that there is enough ActHIB brand to go around, so toddlers can begin receiving their 15 month booster. This dose can be given at any time between 15 months and 60 months (5 years) of age. Any child who didn’t get their 15 mo booster can get the dose at any age up until 60 months.

There are two ways to get the 15 month booster: 1. get the ActHIB brand, or 2. Get Pentacel combination vaccine (which contains DTaP, ActHIB, and Polio) at 18 months. These are both made by Sanofi Pasteur. I think it is fine to go with Pentacel combo if your doctor doesn’t carry (or doesn’t have enough) separate ActHIB. Getting Pentacel may give a child an extra polio dose unnecessarily, but I think that’s ok if that’s your only choice. Talk to your doctor about that.

Parents may wonder if they should even bother with catching up on the missing HIB dose. Virtually all cases of HIB occur in children younger than 2 years. A few cases occur in kids 2 to 5 years each year. One 4 year old child died of HIB last year in Minnesota (unvaccinated). So, I think it is worthwhile for any child missing that last dose to go ahead and get it at their next check up, as long as it is before their 5th birthday. This vaccine can be given along with any other vaccines.

Any parent who wants to skip that dose because they feel this risk of HIB is minimal can choose to do so. In general, though, I feel it is important to finish. The 3 infant doses don’t provide lasting protection. Without the 4th dose, an infant is considered not very well protected.

There is ONE situation in which a child would not need a 4th dose, and that is if a baby’s 3rd dose was given at 15 months or later. In those cases, that 3rd dose works well enough that you don’t need a fourth.

One other situation in which only 3 doses are needed is if the Merck brand (PedVaxHIB) was used (prior to its recall in 2008) and 3 doses were given. With that brand, there is no 4th dose. With the ActHIB brand (Sanofi-Pasteur, whether single ActHIB or combo Pentacel), it’s 4 doses.

The CDC is recommending that children NOT rush in to the doctor to get caught up (unless it’s going to be a while until your next checkup – 6 months or more). If everyone rushes in, doctors are going to run out again. The CDC recommends that doctors resume giving any 15 month olds the shot on time, and any toddlers who come in for a check up after that (18 mo, 2 years, etc) should get the shot at that check up.

If your child is already scheduled to get two shots at a check up, I would come in on a separate month for the HIB.

Dr. Bob

Labels: Vaccine News

Government and CDC Finally Agree to do Extensive Research into Vaccine Safety . . . Maybe

Wednesday, June 10, 2009

For over a decade now most doctors, researchers, and government officials have denied that there could be any link between vaccines and autism. They’ve denied it so vehemently that they’ve refused to adequately study the very idea. Until now. The federal government’s vaccine advisory panel (the National Vaccine Advisory Committee or NVAC) just voted to recommend to the US Dept of Health and Human Services that they and the Centers for Disease Control and Prevention conduct large-scale prospective research trials in groups of vaccinated versus unvaccinated children to determine various theoretical risk factors and possible severe reactions to vaccines, including autism.

For those of you who are saying, “Wait – they HAVE researched it extensively and have proven there is NO link between vaccines and autism.” Well, that’s not exactly accurate. To date, no study has “proven” there is no link. Many studies have “failed to demonstrate a causative relationship between vaccines and autism” – in essence, showing there probably is no link, or even there is almost definitely no link. But that is a very far cry from “proving for sure that there is no link.” What they HAVE done so far is use population-based statistical analyses (epidemiological studies) to determine that vaccines probably don’t cause autism. But no large prospective study has yet to be done using unvaccinated children as a large control group to have something to compare the vaccinated children to. This is really the gold standard for coming as close as we can to proving something is safe. And that’s the type of research the government had, up until now, refused to do. And we are not just talking about autism. There are so many other theoretical reactions to vaccines that have never been adequately studied. We’ve just written them off as so rare we won’t worry about them. Finally, after years of public pressure, the government has agreed to do the research.

Maybe.

What they FIRST have to do is do a study to determine if such research is even feasible and figure out how exactly to go about doing it. The government is going to select a neutral third-party research organization (The Institute of Medicine, possibly) to study how to do the study. Such an organization may or may not find such research feasible. If they determine it is feasible, then the research will begin. If not, then we’re back to square . . . whatever square we are on right now, which is “vaccines probably don’t cause problems, but we haven’t really proven it for sure.” This is also going to take time – a couple years to study the feasibility of the study, then a few more years before results start to roll in. But at least the ball is now (probably) rolling. The only thing that could stop it is a roll of red tape. That’s no obstacle at all, right?

Here are a few highlights of what the NVAC recommended the CDC begin doing research on (if it is found to be feasible):

Identifying subsets of our population that may be at higher risk of suffering a severe vaccine reaction, such as those with mitochondrial dysfunction, autoimmune diseases, autoimmune family histories, and genetic predispositions

Accurately determine the statistical incidences of various reported severe reactions like encephalitis, encephalopathy, seizures, autoimmune reactions, demyelinating disorders, and autism

The risks of reactions for babies with a prior reaction or with a family history of reactions in the parents

Study various alternative vaccine schedules, including comparing reactions with multiple vaccinations to fewer vaccinations

Study specific and individual vaccine chemical ingredients, including animal toxicology research (hey, I thought they would have already studied each and every vaccine ingredient in animals before they started giving them to us?)

These issues have always sat in the back of my mind as unanswered questions. And the absence of unvaccinated control groups in vaccine research has probably been the one single factor that has always weighed heavily in my mind regarding vaccines. To date, such control groups have always been infants receiving the current vaccine schedule minus the new vaccine that is being studied. But now there are just way too many vaccines to consider such a group as a placebo control.

FINALLY, the government is paying attention to what parents really want to know regarding vaccines. Let’s just hope they pull through with these plans so we can all feel safer about vaccines.

A more extensive discussion regarding this development can be found here: http://www.huffingtonpost.com/david-kirby/top-us-panel-some-vaccine_b_211843.html , David Kirby’s analysis of the NVAC’s findings. David also provides a link to the NVAC’s 90-page document at the bottom of his blog so you can read the document yourself.

Dr. Bob

Labels: Vaccines and Autism

Do Doctors Have a Financial Incentive to Get Their Patients Fully Vaccinated?

Friday, May 29, 2009

I get a lot of emails from people who wonder if doctors have any sort of financial incentive to get their patients vaccinated. Do we get any sort of bonus from the insurance companies that pay us? I’ve always thought that the answer to this question was no. I recently found out otherwise.

Now, if you count the fact that part of the income for a doctor’s office comes from providing vaccines themselves, and the checkups that go along with the vaccines, you could argue that that’s a financial incentive. Yes, doctors’ offices do make a little money on vaccines. But I don’t really count that as an actual incentive to try to talk any patients into getting vaccines or as a reason to kick a patient out of a practice if they don’t vaccinate. I don’t think any doctor would kick someone out just because the doctor isn’t going to be able to make as much money on an individual patient who doesn’t get vaccines.

But I recently talked with two physicians in different states that told me the HMO plans that they contract with do chart reviews and patient surveys at the end of each year. If their office scores high enough on these reviews, the HMO plan gives them a several thousand dollar bonus. This bonus varies depending on the number of patients the doctor sees. One of the requirements for a patient’s chart to pass the test is that they are fully vaccinated.

Now, I can somewhat understand the logic behind this. The insurance wants to make sure all their clients are fully vaccinated so they don’t catch any particularly severe disease that might result in an expensive hospitalization or disability that would cost the insurance company a lot of money. Oh, and they probably also care about their clients overall health and wellbeing too. So, why not give their doctors a bonus for meeting this goal?

Here’s why. This policy gives any doctor who contracts with such HMO plans an incentive to NOT want any unvaccinating families in their practice. Maybe a few such families wouldn’t make them fail the chart reviews, but if they have too many, there goes their year-end bonus. One colleague here in southern California told me that he happily gives up this bonus because he wants to serve these families. Good for him! But I bet that many doctor across the U.S. refuse care to these families solely because they don’t want to lose this bonus. They make so little from the HMO plan as it is that losing this bonus could make them actually lose money caring for these families. In fact, this bonus isn’t actually a bonus at all. It is actually money that should be paid to the practice anyway month by month, but it is held back until the year-end surveys are done. I don’t know of any PPO plans that do this, fortunately.

I’ve always wondered by so many doctors are so adamantly hardcore about demanding all their patients fully vaccinate, and why they kick patients out of their office who refuse. I’d always just assumed it was because the doctors felt that the vaccine protection was so important that they don’t want any children to be at risk, so they draw a line in the sand for the good of the child (in their minds). BUT some doctors, especially those large groups who rely heavily on large HMO contracts, may actually be doing this because of money. Do they have the right to do so? Of course. But is it right? I don’t know. The American Academy of Pediatrics Committee on Bioethics makes it very clear that the official AAP policy is that doctors NOT kick patients out of their office over this issue. But when money talks, some people don’t listen.

So, knowing this information doesn’t really help parents one way or another. But I thought you’d find it interesting to know why you might be having a hard time finding a vaccine-friendly doctor. If you’ve never checked out my vaccine-friendly doctors list, click here to find one near you (he’ll be the one driving the Honda instead of the Lexus).