Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, June 30, 2008

4-5 Shots at a Time; Not Just for Babies Anymore

The science of immunization continues apace. New vaccines are developed and new recommendations for old ones are elaborated. Back when I started my practice, the most shots an infant usually got at once was no more than three. Nowadays it can be easily be five. Still, once you got past the first year, which included the so-called primary series', toddlers rarely got more than one or two boosters per visit and adolescents hardly ever more than one at a time.

Times change.

Nowadays infants can routinely get up to five shots at a time: DaPT, Hib, Prevnar (PCV), polio (IPV), and Hepatitis B. There are all kinds of combination vaccines available, but with my relatively small pediatric population it's not economically viable to stock them all; hence, more needles per visit. Toddler visits can also generate up to four shots at once: MMR, Varivax (chickenpox) and Hepatitis A (brand new recommendation) along with some combination of DaPT, Hib, Polio and Prevnar boosters. I do my best to limit it to no more than 2-3 needles per visit, given that I get a shot at them (if you'll pardon the pun) at 12, 15 and 18 months.

This isn't really all that big a deal. Little kids are much more easily restrained, and they really don't remember the trauma of shots from one visit to the next. Even so, they generally forget about it by the time they've reached school age. I like to reassure the parents that it's really much more traumatic for them than it is for their child.

Times keep on changing, though.

First came the change in the recommendation for chickenpox vaccination: instead of a single dose at age 12 months, now everyone needs a booster at age 4. This means that for everyone over 4 who's only had one Varivax, they're "due" for their booster.

Next came the shift in the recommended age for the meningococcus vaccine. Previously recommended at entrance to college (and dorm life), it's now recommended at age 11.

Then came the new and improved dTap. It was known that immunity to whooping cough (pertussis) waned rapidly after vaccination, but it wasn't thought to be that common a disease. This was wrong. Upon the realization that adults and older kids really did still get whooping cough, an "adult" (over age 7) formulation of dTap was developed. dT boosters were always recommended at 10 year intervals, though if a patient sustained an open wound or burn AND it was more than 5 years since the last dT shot, a booster was due. With the last childhood dose due at age 4, once a kid turned 9 he was in the 5-10 year "window" when he didn't really "need" a booster right then, but if he got hurt he would. I used to offer the shot to kids as an option then; now, with the new dTap it's a good idea to get them the dose as soon as possible, to enhance their pertussis protection. Hence, eveyone over 9 really ought to get their dTap. That's 3 shots, in case anyone lost count.

Finally, the makers of Hepatitis A vaccine American Council on Immunization Practices decided that Hepatitis A was now dangerous enough to recommend that all children be immunized against it at age 12 months. This means that everyone over 12 months of age now needs the two-shot series.

What all this means is that a perfectly healthy 11-year-old, previously up-to-date on all his immunizations as of his last checkup, now "needs" 4 shots. If it's a girl, there's also HPV vaccination (Gardasil) which I now discuss at length with my patients even though I have made the business decision not to provide it in my office. Hypothetically, that makes 5 shots.

One of the principles of vaccination is to jab 'em while you have 'em. That is, you're supposed to give all vaccines for which a patient is eligible at once; that day; without delaying.

You try explaining that to a frightened fifth grader, who's now big enough to run and hide; or at least make your life very difficult if he chooses not to cooperate. He's really too big for a parent to physically hold him down, so if he doesn't want shots, there's no realistic way you're going to be able to force him. Suffice it to say, it's much more traumatic than it was when he was four months old, with nice, plump, juicy thunder thighs you could jab in a moment and then let mom give him a great big hug.

I do my best to split the difference, and limit the kids to two shots this year and wait until next year. I feel the meningitis and dTap are important enough not to wait on. Meningitis is rare but catastrophic; I'm looking forward to the inevitable point when the age is shifted downward yet again and it gets added to the infant series, thus cutting down on the last major cause of bacterial meningitis. Pertussis is annoying enough -- and hard enough to diagnose -- that I think the dTap is also a good idea. The chickenpox booster is meant to theoretically cover the 10% of kids with suboptimal response to their first dose. I'm willing to take the 90% chance in order to limit the trauma of my interaction with them by putting off the Varivax booster until the next visit. Ditto Hepatitis A. Of course you never know where and when the next Hepatitis outbreak is going to be, but in my humble opinion they're still rare enough in this country to allow me to put off universal immunization; at least until it means the poor kid doesn't need 5 shots at once.

I'm well aware that my opinion is not shared by many pediatricians, who prefer to follow the letter of the recommendations and just perforate the kids at will. More power to them. For what it's worth, I prefer to be a kinder and gentler dinosaur that I hope my patients appreciate.

(By the way, for purposes of commenting, anti-vaxxers: go to hell.)


At Tue Jul 01, 06:18:00 AM, Blogger Evil Transport Lady said...

It may help the kiddies on the "ouch" level, but I worry that's too many at one time.

P.S. I did have my kids vaccinated;)

At Tue Jul 01, 08:15:00 AM, Anonymous Anonymous said...

I'd love to hear more about the decision with Gardasil. I work (now, I used to be an RN) for a social network for moms and it's a hot topic.

At Tue Jul 01, 09:03:00 AM, Blogger jen said...

I was *so* happy when my office building's nursing station had a one-off event offering dT and dTap vaccinations (something like $25). I hadn't known there was an adult pertussis vaccination (and given my tendency to cough up a lung or two every time I get a cold or allergy, I don't want to take even a slight risk of worse).

They were quite busy - I think the level of participation surprised them. (You were supposed to make an appointment, but they seemed to have a lot of walk-ins.)

At Tue Jul 01, 10:30:00 AM, Anonymous Anonymous said...

Oh, Heavens Dino.
I agree, meningococcus is devastating. Chickenpox, I HAD at age 21, tyvm, and I would have been perfectly happy not to have had it, that one could slide. the 10% suboptimal response, that's just butt-covering.

But the hepatitis A-you got to look at the consequences of NOT vaccinating. Hep A doesn't lead to carcinoma, nor chronic active hepatitis, it's just a pain. I'm fully down with Hep B and I hope they develop a C vaccine.

But, none of my patients need vaccinating anyway.

William the Coroner

At Tue Jul 01, 01:38:00 PM, Blogger Midwife with a Knife said...

I have to agree about Hepatitis A. In an otherwise healthy person, it's annoying, but not deadly, and it's uncommon in the developed world. I was vaccinated for hepatitis A because I'm headed out on a trip to South America and I'd rather not ruin my trip with it if it can be avoided, but I don't think it needs to be a mandatory vaccination.

We probably should try to limit mandatory vaccinations to things that can be life threatening (like H. influenza or even chicken pox in adults).

At Tue Jul 01, 02:15:00 PM, Blogger CrankyProf said...

I can tell you, from recent experience, that the Goddamned dTap makes your arm ache for a couple of days. But I'm a wuss when it comes to needles.

No wonder babies are crabby for a few days after shots.

And THANK you for not commenting on MY vaccinatable thunder thighs.


At Tue Jul 01, 04:02:00 PM, Anonymous Anonymous said...

Thank you Crankyprof, for making me feel better. My arm hurt for several days after the dTap and all my friends laughed at me (of course they havn't had that vaccine yet).
In general I think vaccines are one of the modern world's miracles, right up there with airplanes and chocolate.

At Tue Jul 01, 04:24:00 PM, Anonymous Anonymous said...

I think it's either the tetanus or the diptheria portion of the dTap that hurts. Because I had a tetanus booster after getting cut on a rusty shedding blade at a barn when I was 16 (so before the new adult dTap) and it hurt for days....

Another painful one is the rabies vaccine. Made my arm hot and sore for a week. Then again two weeks later, then two weeks after that. Stupid boosters.

At Tue Jul 01, 11:27:00 PM, Blogger Manda said...

One of the family doctors here won't give more than one shot per leg, per visit. Whooping cough outbreaks were common in Fairbanks, AK last year. I've spread out some of my kids shots - but I'm up to date on all of them. I believe in vaccinations strongly, but I won't do five in a day. I agree with your reasoning about the Hepatitis A vaccine. However, with possibly unclean drinking water in the villages and all the shell fish along the coast up here (Alaska), it's necessary. We spend a lot of time at the beach, and my son tends to stick things in his mouth. He went through a car licking phase last winter too. Glad that one's over.

At Wed Jul 02, 03:20:00 AM, Blogger LicensedToILL said...

It's funny that you write about this topic, a blogger cowinkidink if you will.

My boy has just turned one. More immunizations.

I just took the NCLEX last Monday (nursing boards) and got immunization questions up the wazoo.

Read yet another fear provoking article in Newsweek about the connection between autism and multpiple immunizations. (not sure the date of the NewWEAK, within the year) Of course the article drew no reasonable conclusions about the safety of immunizations, it just made me fear my kid is gonna be catastrophically autistic no matter what I do.

My wife just got diagnosed on Thursday with pertussis (of course without C&S just on the basis of day glo green sputum and is now on Le Z-pack) but everything is cool cuz little one had the DTaP...right?

My long winded point is that from my basic basic understanding it seems like an awful lot of crap to load onto an infant who in all reality is likely to come into contact with some of these diseases exactly when in the first year of life?
Not saying immunizations are bad but I thank my lucky stars that my pediatrician didn't poop himself when I said Hep B wasn't on the top of my prioirity immunization list for my son's first year of life.
What do strains of pertussis dream of when they sleep? Is my son in them?

At Wed Jul 02, 09:26:00 AM, Blogger Can'tSpell, DVM said...

I seem to have a somewhat uncommon rxn to tetnus- my arm swells up like a basketball and I run a fever for two days.

Ironically enough, the rabies vaccs (yes, all three) didn't hurt me a bit. Others in my classs, though, were fun to watch while in the fever loonies.

At Wed Jul 02, 10:06:00 AM, Anonymous Anonymous said...

Okay, I'm confused! I thought my kids' vaccines were up to date, needing only tetanus at this point (or the 10-year-old one, whatever it may be)...but the "rules" have changed and now they need MORE boosters? Am I understanding correctly? That should be a fun doctor visit.

Maybe you can talk a bit about your opinions on Gardasil. I think I'm going to hold off on that one because it's still so new, but would like to make sure my daughter gets it at some point...after I'm comfortable it's been around long enough and safe. :)

What do us old fogeys need? Last shot I got was tetanus, and so long as I'm not leaving the country, I thought I was pretty much immunized as much as needed for the time being.

At Wed Jul 02, 12:04:00 PM, Blogger Crucis said...

Interesting. I'm 61 and visited my Doc yesterday for my 6 months visit to the clinic vampire (chloesterol, blood sugar, etc.). During the visit, my Doc suggested that next time we do a complete physical and immunizations!.

Is there now a series for older adults? My last series of shots was during Basic Training some 40 years ago.

At Wed Jul 02, 01:20:00 PM, Anonymous Anonymous said...

TM, you should have been getting a tetanus booster at least once every ten years, my last one was 3 years ago. That is nothing new.

There are also annual flu shots.

The newest thing is that they have added the pertussis part to the adult DT shot, making it the Tdap.

Another new think is a zoster booster to help prevent shingles.

You are probably not at a risk for HepB... and while HepA does not turn chronic for older folks, it will knock you down for a few weeks. It may also depend on what part of the country you live in.

Our county was among the first to recommend HepA vaccines since there were often monthly or weekly announcements that if a person ate at a certain restaurant that they had been exposed to hepatitis, and to go to their doctor for an immuno-globulin shot. The office bay I worked next door to had hepatitis A spread through a popcorn bowl... one young lady was out for a month, and the rest of the group who shared the popcorn had to get the shots.

Since the HepA vaccine came out, there are fewer of those incidents.

If you plan to travel (like my in-laws since their retirement), you may want the HepA, plus a few other things, like Yellow Fever... though it depends on where you go, but there is a page to help you figure that out:

At Wed Jul 02, 09:10:00 PM, Blogger undergrad RN said...

Heya dino, I too would like to hear your take on Gardasil.

I turned it down because Merck offends me with their money grubbing corporate greed, and I'm low risk for HPV anyway so it didn't bother me...

But would I be doing ladies everywhere a huge disservice by sharing that opinion?

At Thu Jul 03, 02:46:00 AM, Anonymous Anonymous said...

Dino said "If it's a girl, there's also HPV vaccination (Gardasil) which I now discuss at length with my patients even though I have made the business decision not to provide it in my office."

I assume that Dr. Dino is not really that much a fan of it. Though it is obviously something a young lady can decide on for herself, just like you have.

I did decide for my 14 year old daughter. She received the three shots... but it was not that big a hassle, and she none the worse for it. Also, I do trust her... it seems that boys are more afraid of her! She tends to dress in black with skulls as a decorative motif. Her hair color ranges from bright blond to blue, or green to bright magenta.

She is also in Honors math and plans on becoming an astronomer, along with being a big time fan of Doctor Who. She does not understand why her friends worry over boyfriends, girlfriends or whatever --- she thinks that it is more important to get through school with good grades and worry about that stuff when one is gainfully employed.

Punky nerd? Scary girl?

Who knows? But I am playing the odds in keeping her protected (she got the Tdap last year,

At Tue Jul 08, 12:34:00 AM, Blogger Vitum Medicinus said...

"if it's a girl, there's also HPV vaccination (Gardasil)"

I wonder how long until they convince the populace that men should be taking Gardasil too?

At Mon Jul 21, 05:27:00 AM, Anonymous Anonymous said...

That is one hell of a long list of vaccinations you do wherever you are (I'm assuming US?)

Here in the Netherlands, we do a much smaller program: tetanus boosters only when you have an open wound, no chickenpox vaccination (we all just go through chickenpox at age 3, when it's not such a hassle as it is in adults), hepA only for travellers, hepB only for risk groups... etcetera.

However, we are generally happy about gardasil, that is to say, the family practice where I was doing my GP-internship was vaccinating girls weekly. I'm thinking about getting it myself, except it's not insured for girls older than 10 or so, so I have to go find the 375 euros somewhere first.

At Thu Aug 21, 01:53:00 PM, Anonymous Anonymous said...

I'd have to say that, as far as the "vaccines cause/increase the odds of your kid becoming autistic" debate goes, I tend to be sceptical of any claims that little Suzie became autistic because of the vaccines.

"How many vaccinations did she get at one time," I tend to ask. "Which vaccines was she given?" I feel that, while there probably -are- kids who's autism was triggered by vaccines, they're also most likely anecdotal cases.
However, I do also feel that it's more likely to happen if the kid is being given a lot of vaccines at one time ("a lot," in this case, being defined as more than the four or five at one time that Dr. Dino's described - I think the most I've ever heard of is 14 in one go. I'm not sure what-all they were injecting that kid with, to be honest.)

But as someone who plans to be a mom once Fiance and I are in the right spot to start trying (out of uni, and have at least a semi-permanent home of our own, and the money needed to support kids), I am wondering about the vaccines - so I do have to ask: what's the point of vaccinating the kid for chicken pox? I believe you (or possibly someone else) have mentioned that chicken pox immunity lasts well into adulthood, if caught as a child - but tends to wear off somewhere in the teens or earlier, if received via a vaccine. So, asides from the kids where they're at risk of suffering more than the average, mild "itchy hives, and low fever" that chicken pox gives in childhood, what's the benefit of giving kids this vaccine?

At Fri Sep 26, 12:55:00 PM, Anonymous Anonymous said...

The main benefit of giving chicken pox to kids is that they won't get shingles when they are elderly. Also if you get chicken pox as an adult is is a very serious condition.


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