Should Parents Continue to Give Their Infants the Pneumococcal Vaccine (Prevnar) in Light of Current Controversies Over it?
Wednesday, October 22, 2008
The NY Times published a very interesting article summarizing the challenges with the PC vaccine. http://www.nytimes.com/2008/10/14/health/14vacc.html?_r=1&em&oref=slogin
Since the vaccine came out in 2000/2001, the number of total cases of severe PC disease has declined dramatically (from about 100 cases for every 100,000 children under 5 years of age down to about 20 per 100,000). This occurred because the PC vaccine protected infants and children against the 7 most common PC strains. While these strains are still circulating among the general population, they are no longer causing many severe infections in young children since kids are now protected. Plus, kids aren’t spreading these strains to the elderly, another at-risk age group for severe PC disease. Almost everyone has a variety of strains of the PC bacteria living within their nose and throat. For the most part, the germs are harmless. But occasionally they invade into the body and cause severe internal infections like meningitis, pneumonia, bloodstream infections, and severe ear infections. This vaccine prevents those 7 strains from doing this anymore.
However, there are dozens of OTHER strains of PC bacteria that are not covered by the vaccine, and one particularly nasty strain is now jumping in and replacing some of the vanishing strains. It is called strain 19A. Since the PC vaccine’s use began, 19A has increased from about 3 cases per 100,000 children under 5 to about 11 cases per 100,000. Plus, some areas of the country are reporting that this strain in their area is resistant to most antibiotics (New York and Texas, for example). But in most areas, the strain is likely still susceptible to most antibiotics. Overall, the number of total cases of severe PC disease from all strains combined is much lower than it used to be.
The logical next step would be to update the current PC vaccine to include 19A and other emerging strains, and that’s exactly what vaccine makers Wyeth and Glaxo Smith Kline are doing. However, these vaccines are about 1 to 2 years away. Wyeth has developed one, but safety and efficacy approval testing is a long process. Wyeth hopes to apply to the FDA for review and approval some time next year. I don’t know how far along the GSK company is with their version.
There are now two main questions parents are asking: Should parents stop giving their kids the current PC vaccine since those strains aren’t causing as much severe disease? NO. My opinion is that since those strains ARE still around, living in older kids and adults, any unvaccinated child could catch it and come down with a severe case. I recommend that parents continue with the vaccine for now.
The other question is this: Does getting the current PC vaccine (and therefore preventing those 7 strains from living within that child) make that child more likely to have other strains of PC (namely the 19A strain) set up shop in their nose and throat and possibly cause a severe internal infection that may be antibiotic resistant? I don’t think so. Or rather, I hope not. We just don’t know yet. Someone will have to do the following research: compare the rates of severe PC disease in vaccinated versus unvaccinated kids (I think they’ll find it lower in vaxed kids). But IF the rates are higher in vaxed kids (which I don’t think they’ll find), what strains are they finding and are they antibiotic resistant? If they find that vaxed kids are catching more severe and antibiotic resistant PC diseases compared to unvaxed kids, then the current vaccine would NOT be a good idea. But I just don’t think that they will find that to be true in a research study.
I feel the benefits of the current PC vaccine are still valid and parents should continue to vaccinate with it until an updated version of the vaccine becomes available. Should parents skip the current one and wait for the new one? No – it is at least one, maybe two, years away.
Dr. Bob
Since the vaccine came out in 2000/2001, the number of total cases of severe PC disease has declined dramatically (from about 100 cases for every 100,000 children under 5 years of age down to about 20 per 100,000). This occurred because the PC vaccine protected infants and children against the 7 most common PC strains. While these strains are still circulating among the general population, they are no longer causing many severe infections in young children since kids are now protected. Plus, kids aren’t spreading these strains to the elderly, another at-risk age group for severe PC disease. Almost everyone has a variety of strains of the PC bacteria living within their nose and throat. For the most part, the germs are harmless. But occasionally they invade into the body and cause severe internal infections like meningitis, pneumonia, bloodstream infections, and severe ear infections. This vaccine prevents those 7 strains from doing this anymore.
However, there are dozens of OTHER strains of PC bacteria that are not covered by the vaccine, and one particularly nasty strain is now jumping in and replacing some of the vanishing strains. It is called strain 19A. Since the PC vaccine’s use began, 19A has increased from about 3 cases per 100,000 children under 5 to about 11 cases per 100,000. Plus, some areas of the country are reporting that this strain in their area is resistant to most antibiotics (New York and Texas, for example). But in most areas, the strain is likely still susceptible to most antibiotics. Overall, the number of total cases of severe PC disease from all strains combined is much lower than it used to be.
The logical next step would be to update the current PC vaccine to include 19A and other emerging strains, and that’s exactly what vaccine makers Wyeth and Glaxo Smith Kline are doing. However, these vaccines are about 1 to 2 years away. Wyeth has developed one, but safety and efficacy approval testing is a long process. Wyeth hopes to apply to the FDA for review and approval some time next year. I don’t know how far along the GSK company is with their version.
There are now two main questions parents are asking: Should parents stop giving their kids the current PC vaccine since those strains aren’t causing as much severe disease? NO. My opinion is that since those strains ARE still around, living in older kids and adults, any unvaccinated child could catch it and come down with a severe case. I recommend that parents continue with the vaccine for now.
The other question is this: Does getting the current PC vaccine (and therefore preventing those 7 strains from living within that child) make that child more likely to have other strains of PC (namely the 19A strain) set up shop in their nose and throat and possibly cause a severe internal infection that may be antibiotic resistant? I don’t think so. Or rather, I hope not. We just don’t know yet. Someone will have to do the following research: compare the rates of severe PC disease in vaccinated versus unvaccinated kids (I think they’ll find it lower in vaxed kids). But IF the rates are higher in vaxed kids (which I don’t think they’ll find), what strains are they finding and are they antibiotic resistant? If they find that vaxed kids are catching more severe and antibiotic resistant PC diseases compared to unvaxed kids, then the current vaccine would NOT be a good idea. But I just don’t think that they will find that to be true in a research study.
I feel the benefits of the current PC vaccine are still valid and parents should continue to vaccinate with it until an updated version of the vaccine becomes available. Should parents skip the current one and wait for the new one? No – it is at least one, maybe two, years away.
Dr. Bob
Labels: Vaccines and their diseases
posted by Dr. Bob Sears @ 9:09 AM
15 Comments:
At October 22, 2008 6:08 PM ,
MJ said...
One of the items that I have read recently about the pneumococcal vaccine is that it is not as effective as thought and could be linked to an increased incidence of asthma. A document that references this was published recently by the WHO
http://www.who.int/bulletin/volumes/86/08-054692.pdf
I am not positive that this is referring to the save vaccine but it seems to be. Would you be able to comment on this report?
At October 23, 2008 10:36 PM ,
Dr. Bob said...
I would need to look more closely at the studies cited in this article, which I can't do right now. BUT it seems to me to say that the vaccine does cut down on the pneumonia caused by the vaccine strains, as well as the severity of the disease, BUT not overall pneumonia from all causes. I will need more time to investigate this.
At October 29, 2008 4:28 AM ,
Permission to Mother said...
This is off topic for this post...
It was nice to meet you at the Florida LLL Conference.
I posted a photo from brunch on my blog.
http://permissiontomother.blogspot.com/2008/10/meeting-dr-bob.html
I do appreciate the attention you have put into vaccines and educating parents and providers alike.
I looked over your Florida list to see if I recognized any of the names. The IBCLC who did introductions at brunch works in Sunshine Pediatrics. That is the only provider name I recognized.
At October 30, 2008 8:06 AM ,
Anonymous said...
I have an infant with a probable milk/soy allergy. (Starting at 4 weeks baby had very small amounts of blood in stool. I eliminated dairy first but bleeding continued. I then went on an Elimination Diet and the bleeding has ceased.). I read in your book that the Prevnar vaccine is prepared using a soy peptone broth. My son's doctor is very pro-vaccine and says that he strongly advises that he be vaccinated with Prevnar. I have serious concerns about vaccinating but understand that at least with respect to this vaccine, it protects against potentially fatal conditions. Dr. Sears, do you have an opinion on the Prevnar vaccine under these circumstances? I should also add that my family has a strong history of autoimmune disorders. Baby is breastfed and stays at home but has an older sibling. Thank you so much for your time and insight.
At October 30, 2008 10:08 AM ,
Dr. Bob said...
I would be concerned about this shot in a baby with confirmed soy allergy. You could try going on soy again and see how your baby does, since you don't know that it was going off soy that helped in the first place. If he does well, then maybe proceed with the shot.
At November 3, 2008 4:04 PM ,
Zinberry said...
Dr. Sears,
I was reading an article about vaccines in SJ (Southern New Jersey) Magazine-Sept. 2008. The article interviewed a former CHOP (Children's Hospital of Philadelphia) ER doc, Dr. Adam Richards, who said that prior to the Prevnar vaccine, if a child came in with a high fever, he assumed the worst and would run invasive blood work as well as a course of antibiotics until the blood cultures came back. Now, because of the Prevnar vaccine, he knows that the vast majority of children with fevers have viruses -- he no longer assumes the worst and does not have to do the blood culture.
With PC strain 19A infections rising, could ER docs be back in the same scenario as before the Prevnar vaccine? Could 19A infections, in fact, become more serious because of the less invasive treatments that were predicated by the Prevnar vaccine?
The vaccine book and this blog are a tremendous resource for concerned parents.
Thank you,
Frank Zintl
At November 4, 2008 10:34 AM ,
Dr. Bob said...
19 A is rising, BUT not enough to make doctors worry as much as they used to. I think it's ok for a doctor not to be as aggressive with the testing now, but each case has to be decided individually. We'll know more over the next few years about what's happening with PC. To answer your questions: No, not yet, and not for a while. And the second question - they wouldn't become more serious, it's just that infections could be missed and then become more serious if a doctor doesn't suspect it and test for it.
At November 4, 2008 12:09 PM ,
TEST said...
what about attacking the 19A strain with pro-biotic??
At November 10, 2008 3:47 PM ,
Dr. Bob said...
test. Yes, that may help. Never been studied though.
At November 14, 2008 6:28 PM ,
Anonymous said...
I am concerned with the higher than normal seizure rate with this vaccine as well as the serotype replacement issue. I worry that I may be putting her at risk for uncessesary side effects for something that she could still get anyway,especially since most of the hospitilizations from a few children's hospitals are from strain 19A (please correct me if I"m wrong...I'm new in my research on this)...I'm also concerned with the studies that I have read that have shown that they are more likely to have a antibiotic resistant (staph) ear infection if vaccinated and I am having a really hard time deciding about Prevnar. I want her to be protected but I don't want the vaccine to do more harm than good. This vaccine is relatively new and I"m very concerned about the effects of it that we just don't know yet. I am delaying all vaccines but have been going back and forth on this one vaccine.I have been considering this one before she's 2...She is 7 months old now I am going to breastfeed for 2 years and she is not in daycare and I feel comfortable delaying the other ones until 2. I'm really conflicted about what to do on this vax. I'd love to know a little more. Your vaccine book has been really helpful!
At November 15, 2008 5:38 AM ,
Anonymous said...
i forgot to add...I'm also very concerned with the aluminum in the Prevnar vaccine as well!
At December 7, 2008 9:37 AM ,
Jenna said...
Dr Sears,
Thank you for your helpful book and website!
My 11 month old son's grandfather (89 years old) has had pneumonia 4 times in the last three years. We see him several times a year. The side effects and the number of strains in the PC vaccine make me hesitate in giving it to my son, but I am wondering if his exposure is increased because of his grandfather and if I should be more concerned about giving him the PC vaccine as a result?
Our son is breastfed and cared for at home.
Thank you!
Jenna
At December 30, 2008 2:54 PM ,
Pensive said...
This post has been removed by the author.
At December 30, 2008 2:55 PM ,
Pensive said...
Dear Dr Sears,
Interesting review of Dr Offit's article, which was myopic and biased, as normal.
However, I would like to make a constructive criticism of your reply.
Please remove any use of "merely" or "simply". State what you state, because those two words make your reply sound like a reactive cowed obescience. :)
I'm sure it won't be his last swing at you, no matter what you have to say.
At December 31, 2008 12:40 AM ,
Ariel Balter said...
My wife and I had a very hard time deciding whether or not to vaccinate. As you have hoped, your measured, reasoned analysis in your book cut through the fear on both sides. We adopted one of your slower vaccine plans rather than opting out entirely.
A great example of the complexity of the vaccination issue is captured in this recent episode of This American Life (in which you were interviewed):
After a measles outbreak started by one non-vaccinating family, both pro- and anti-vaccination families felt vindicated. On the one hand, the virulence and severity of measles was exposed confirming the need for vaccines. On the one hand, the children that contracted measles survived unharmed, so why are we so scared of it?
This exemplifies the difficulty of finding solid common ground. Both proponents and opponents of standard vaccination are deeply concerned about health and safety. But each express it differently.
Sadly, both sides often base their convictions on fear: Don't vaccinate and horrible diseases will spread like wild fire; Vaccinate and you run the risk of unknown short term and long term side effects that might be worse than the disease itself.
As you again demonstrate in your response to Dr. Offit's article in Pediatrics, you have the ability to walk the line. You maintain a dialogue that acknowledges unknowns and valid concerns regarding vaccines and vaccine science and carefully weigh this against the clear benefits--both to the individual and to society--of reducing infection rates of dangerous diseases.
Thanks for maintaining your poise, and please continue your work and advocacy in this area!
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