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Friday, October 30, 2009
One of the most challenging and controversial parts of the alternative vaccine schedule is splitting up the MMR into three separate shots, spread out over a few years. The reasoning behind this idea is to expose a child to only one live viral vaccine at a time to allow the child’s immune system to better handle each vaccine and possibly experience fewer side effects. Although there is no medical evidence that this precaution is necessary or even useful, some parents, long before my book came out, have been skipping the MMR over fear of side effects. Some of these parents are more open to getting the separated vaccines. I presented this option as a way to allow such families to vaccinate for these diseases. I didn’t claim that it is the best way to go. I simply acknowledged it as an option.
Now, however, it seems that this option has been taken away from these families. The official word on Merck’s website is that these vaccines are not available for order. I’ve called Merck to ask if they are planning to start making more, but I can’t get anyone from the company to call me back. I have heard from numerous people and some news reports that Merck isn’t currently making the vaccine. I haven’t heard that they’ve decided to stop permanently, just that they aren’t producing any at this time. So, it’s pretty clear that, at least for the time being, there is no more to be had. It is probably safe to say that there won’t be any more for at least 6 months to 1 year. It is also possible that they won’t ever make the separate vaccines again.
This puts many parents in a difficult position. Some children have already received part of the series and are now left without a way to finish it without getting the entire MMR (and thus accepting extra doses of some components). Part of me wonders if Merck has stopped production as a way to force parents into an all-or-nothing decision. The AAP and CDC continue to insist on a “one size fits all” approach to vaccinating, without offering any suggested alternatives. Is this their way of forcing parents into the full MMR? I don’t know. The official word from Merck is that they need to devote all of the manufacturing capabilities to the full MMR and Chickenpox. They also state that the demand for the separate vaccines is so low that it doesn’t justify its production. One news story stated that the separate components only make up about 2% of the total MMR demand. Well, with 5 million babies being born each year in the U.S., that could be as many as 100,000 families searching for the separate vaccines each year. That would be a lot of unvaccinated children if these parents refused the full MMR.
One issue that I don’t understand is that the separate rubella vaccine is routinely used for adult women after they have a baby. Any new mom who doesn’t have rubella immunity is given the vaccine. If Merck stops making it, such women will have to get the full MMR, even if they still have good measles and mumps immunity.
The separate mumps vaccine also has its usefulness. During the outbreak of 2005/2006, many teens and adults needed a mumps booster to help contain the disease. If separate mumps vaccine isn’t made available for such events, the full MMR will have to be used. The same would be true if a measles epidemic occurs.
So, what can parents do? Parents hate to give their children an extra dose of a vaccine if it isn’t needed. You’ve gone to all the trouble to try to split it up, and now you are faced with having to give it all together anyway. I know it’s frustrating. One note of encouragement is that there is no known harm in getting an extra dose, other than the fact that you are taking the small risk of a side effect an extra time and the frustration of knowing the separate shot you gave earlier was all for naught. If a child already has some immunity to one of the diseases from a previous vaccine, I’ve never seen any research that shows a child is any more likely to react to a second dose compared to anyone just getting their first dose. I’ve seen no evidence that getting an extra dose is dangerous. I know it’s very small consolation, but I just mention this so that parents aren’t afraid to get any extra components of the MMR if they decide to.
Part of me wants to rally the nation’s parents in a campaign to insist that Merck begin making the shots again. Write your Senators, email Merck (politely!), refuse to get the full MMR! But that just isn’t responsible. Skipping the shots altogether leaves children at risk, the riskiest disease being measles. Of course, parents do have the option to skip the vaccine altogether. Even in states with mandatory vaccines laws, parents can still exercise a religious exemption (except for West Virginia and Mississippi).
But for those of you (which is most of you) who do want MMR protection, I will offer you some choices. There isn’t one right choice here. When it comes to MMR there is so much controversy that I don’t believe there is one clear option. So, I will lay out all the choices so you can think it through. Most people who are very pro-vaccine feel my MMR recommendations should more closely reflect the standard American vaccine schedule. Now that the separate M-M-R vaccines are no longer available, most such vaccine advocates are hoping that I will now begin recommending the MMR at the standard ages of 1 and 5 years. To these people I would like to point out that I don’t make absolute recommendations. I present options. That’s what I’m going to do here.
Here are all the options, depending on whether or not your child has received some of the separate components:
CHILDREN WHO HAVE NEVER HAD ANY MMR COMPONENTS
- Parents who feel confident in the safety of the MMR vaccine should go ahead and vaccinate at the recommended age of 1 and 5 years.
- Parents who were planning to do it separately because they have some worry about side effects should wait until a later age to get the full MMR. I suggest waiting until a child is either 4 years of age or enters school, whichever comes first. The reason for the 4-year recommendation is two-fold: 1) Many kids don’t enter school until age 4, so their risk of catching measles, mumps, or rubella is very low, and the risk that they would expose other kids if they got sick is very low, and 2) Most states only require one dose of mumps and rubella if that one dose is given at age 4 or older, because the vaccine works much better for older kids like this. Some states do require a second dose of measles, however. See the State Requirements section below.
- Parents who don’t feel comfortable leaving their children susceptible to these three diseases until age four, but want to delay it for at least a little while, can get the MMR at whatever age you feel most comfortable. If your toddler or young child is entering early preschool at age 2 or 3, you may want him to have the disease protection. If you get the MMR before age 4, your child would need a second dose around age 5 according to the regular vaccine schedule. This second dose is given because a small percentage of kids lose their immunity from the first dose and need a booster. From a health care cost perspective, it isn’t economical to test every child’s blood at age 5 to see which kids need a booster, then only give those kids a booster. So, the routine practice is to just give the two doses to everybody. If you don’t want to simply follow this routine 2-dose schedule, and instead want to try to get by with just one dose, you can do the one dose at any age, then get a blood test around age 5 to check immunity, then repeat the MMR if needed.
- When you do get the MMR, I would suggest getting it alone, without any other shots. You can pick any time in the vaccine schedule to do it. There is no exact time that I would place it into my Alternative Vaccine Schedule. It’s an individual choice for each parent. If you get the shot at 1, 2, or 3 years of age, you can then either get the booster at 5, or do blood testing to confirm immunity and skip the booster if your child is still immune to all 3 diseases. There is also the possibility that in a few years we will have separate M, M, R component vaccines again, and you can give a booster shot for only those diseases your child needs a booster for, based on the blood immunity results. If the separate shots are not available, and 1 or 2 parts of the first shot (but not all three) have worn off, it’s okay to get the full MMR again. Or, you could just leave your child susceptible to a disease. The choice is yours.
The risk of skipping or delaying the MMR
Although these diseases are rare, outbreaks can occur. I encourage you to re-read the MMR chapter to refresh your memory on these diseases. The riskiest disease is probably measles. While most kids weather the disease without problems, occasional complications do occur. The risk of suffering a fatality from measles is about 1 in 1000 to 1 in 3000 cases. The risk of suffering a non-fatal complication that requires hospitalization (such as pneumonia, dehydration, and a variety of others) is unclear, but is probably 1 in 100 to 1 in 300 cases. Many years have gone by in the U.S. without a measles fatality. I pray it stays that way.
CHILDREN WHO HAVE ALREADY HAD ONE DOSE OF ALL THREE MMR COMPONENTS EITHER SEPARATELY OR TOGETHER
This decision is easy. Either get the 5 year booster of MMR, or do a blood test around age 5 to check immunity and don’t get any more MMR if immune to all three diseases. If your child is only immune to 1 or 2 diseases, but not all, it’s OK to get a full MMR. Or you can wait for the separate vaccines to come out again.
CHILDREN WHO HAVE ALREADY HAD 1 OR 2 COMPONENTS OF THE SEPARATED MMR VACCINES
Those of you who have already begun the process of separated MMR vaccines, you probably did so with two things in mind: You at least had some concern about MMR safety, and you felt comfortable to some degree with leaving your child susceptible to some of these diseases during the early years until all three doses were given. But now what do you do?
- If your child has already received 1 dose of rubella (but no mumps or measles yet), you either have to get the full MMR now or wait until 4 years of age and get it then. It all depends on how comfortable you are with leaving your child susceptible to mumps and measles. You can review the book information on mumps and measles to refresh your memory. Leaving a child open to measles is probably the riskiest of the three diseases. If you get the MMR at 4, you can verify mumps and measles immunity with a blood test about 6 to 12 months later if your state requires it, since your child only received one dose. If your state doesn’t require it, I wouldn’t bother with an immunity check since most kids get full immunity after just one dose given this late. See State Requirements below.
- If your child has already received 1 dose of mumps (but no rubella or measles), the same information applies as the previous paragraph. Rubella is extremely rare, and harmless to young children. Review the disease information in the book to remind yourself of the risk to pregnant women.
- If your child has received 1 dose of measles, but not mumps or rubella, then I suggest you wait until age 4 to do the full MMR. That will give your child the required 1 dose of mumps and rubella, and 2 doses of measles. I wouldn’t bother checking blood immunity levels in this instance – you are pretty well covered. Since rubella is harmless to young children, and mumps is virtually always harmless, it is generally safe to remain susceptible to these until 4, especially if not in school yet. However, you should fully inform yourself about the personal and public health risks of delaying these shots by reviewing those pages in the book.
- If your child has received 2 out of the 3 components already, it is not worth getting a full MMR prior to age four just to get protection from the third disease now, only to have to get another booster dose at age 5. Just wait until age 4 or 5 to get the full MMR, as long as you feel comfortable with the disease risk for a couple years for whichever vaccine hasn’t been given yet. See State Requirements below if you worry that your state laws may require you to get the shot sooner. If the third disease that you haven’t gotten the shot for yet is measles, I would just wait until 4 to get the full MMR dose.
- Technically you can get the full MMR as close as only 1 month after any doses of the separate vaccines. However, as a precaution I would suggest putting at least a few months between them if you move on to the full MMR
MEETING STATE REQUIREMENTS
If you live in one of the 20 free states (these are listed on page 218 of the book) that allows parents to skip a vaccine for personal beliefs, and you chose to skip the MMR during infancy, I would suggest getting the MMR around age 4 or 5 when your child is going to have more exposure to other children and the general public. I wouldn’t bother with immunity blood testing – this one shot works very well in virtually all kids who get it late. If you want to skip the shot until the pre-teen years, it may be useful to check blood immunity around age 10 prior to the shot, since by that time your child will have been around many kids for many years and might have acquired some natural immunity. If your child does not have immunity to one or more diseases, you can either get the full MMR or separate components if they are available at that time.
If you live in one of the 30 states that have mandatory vaccine laws, and you don’t want to claim religious exemption, realize that this doesn’t mean you absolutely have to get the MMR at age 1 and 5 years. You only have to meet the state requirements by the time a daycare, preschool, or kindergarten is going to enforce it. So, this means that if you are worried about the MMR, you can delay it for a year or two (or more) until your child enters school. Most states only require one dose of mumps and rubella if given at age 4 or older (since getting the shot at this later age works much better). Most states, however, will require either 2 measles vaccines, or a blood test to verify immunity from just the one dose. I suggest getting a blood test 6 to 12 months after the shot to prove this immunity. If not immune to measles, a second dose may be required by your state. This may mean another full MMR if the separate shots aren’t being made yet. If you do need (or want) to get the full MMR at an earlier age (between age 1 and 3 years), I suggest you do it alone, without any other shots.
In the vaccine book I clearly state that vaccines are important, and that I believe the benefits outweigh the risks. Each vaccine can have a serious side effect, but in most cases this is rare. The MMR, however, is unique in that it is a triple live virus vaccine, and therefore has a more extensive list of possible reactions. These reactions mimic what the actual disease complications can be. Some of these reactions are very serious. Yes, the serious reactions are extremely rare, but it is a risk nonetheless. However, vaccinating for the MMR diseases is also a very important individual and public health concern. Measles will continue to increase if parents don’t vaccinate. Rubella may come back. The more people that don’t vaccinate, the more likely this is to happen.
I have presented the options here. It’s not based on what the right or wrong decision is. It all comes down to what you as a parent and individual believe about the safety of the MMR and the risks of the three diseases. Remember, my alternative vaccine schedule isn’t a reflection of what I believe all parents should do. It is a suggestion for parents who are more worried about vaccines than the average person, and want to vaccinate their child more carefully. Splitting the MMR was part of that approach, but now it’s not an option for the foreseeable future. If I was to have written my alternative vaccine schedule without the separate vaccines, it would probably look something like this: MMR at age one and five, with an asterisk that says if you are worried about a reaction to the MMR, wait until age 4 to get the first (and only) dose, or get it sooner if your child will be entering early preschool (and possibly need a booster dose around age 5 or 6).
LOOKING INTO THE FUTURE – WILL WE HAVE SEPARATED DOSES AGAIN?
I think that one of two things are going to happen:
1. Many angry parents are going to delay or skip the MMR vaccine (either out of protest against Merck or out of worry over side effects), and once the government notices this (as measles increases or reports on non-compliance grow) they will ask Merck to begin producing the separate doses again. Post-partum moms who need a Rubella shot, but refuse the full MMR, may add to this campaign. When outbreaks of measles and mumps do occur (and they will!), and the parents of any unvaccinated children refuse the full MMR (but make it known they would happily accept the single component vaccines), the government might take notice.
2. Only a small minority will skip the full MMR. Most parents who wanted the separate shots will go ahead with the MMR at the recommended age of 1 year, and enough children will be vaccinated so we don’t see any appreciable rise in measles, mumps and rubella. Merck won’t begin making the separate shots again.
Labels: Vaccine News