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.

Friday, July 04, 2008

Immunization Primer

It's a slow time for blogging between holidays, vacations and needing to devote time to (PAID!!!) writing, yet I wanted to respond to some of the commenters on my previous post who asked about what immunizations are recommended for "perfectly healthy adults." Here's the thing about official vaccine recommendations. They are:
  1. Easily accessible
  2. Changing at an accelerated pace, and
  3. Developed with applicability to populations as opposed to individuals.
This last point is often lost in the translation of "recommendations" to actual patient care. I have a confession: much as I respect the work of the Advisory Committee on Immunization Practices, I find some of their more recent recommendations harder to sell to patients -- on medical, epidemiologic and financial grounds -- than many of their previous ones. I take care of one patient at a time, so I need to be able to explain to a patient (or parent) what the specific advantages of a given recommendation are to them specifically.

Given that the original triumph of vaccination was the vanquishing of vaccine-preventable childhood diseases, any immunization recommendation regarding diseases that are specifically a hazard to infants and young children are easy to sell. Likewise, the prevention of catastrophic diseases -- even if rare (meningococcal disease) -- are accepted more easily than preventing illnesses that may be uncomfortable and inconvenient but do not have lasting sequelae (hepatitis A.) Questioning the ACIP is difficult for me, like discovering the views of a cherished professor shifting away from what I can comfortably agree with; but I do find myself coming to different conclusions than they when faced with individual patients instead of patient populations.

All that as a disclaimer that the following applies specifically to healthy adults with no special medical issues, no chronic diseases, no specific travel or occupational issues; people not under medical care, living in the United States with reasonable standards of sanitation and hygiene; not in intimate contact with large groups of people (ie, not living in dorms, military barracks, etc.) Also taken into account are my personal opinions based on my clinical knowledge of the applicable vaccine-preventable diseases involved. (Note: explicitly reviewing each of those diseases would render this post ridiculously unwieldy. That information is easily and quickly found at the CDC website linked above.)

Every year: Flu shot

Should be obvious.

Every 10 years: Tdap (tetanus, diphtheria, pertussis)

At the moment, the official recommendation is only one lifetime Tdap dose with plain Td given every 10 years, but given the waning of pertussis immunity, I'd bet that before the decade is up, plain Td will be history.

At age 60: Zostavax (shingles)

Often devastatingly painful disease, with the pain being permanent up to 10% of the time. The shot is still extremely expensive, therefore difficult for us dinosaurs to stock, and a PITA to obtain at a pharmacy and bring to the office for injection, since it has to remain frozen, but overall probably a good idea.

At age 65: Pneumovax (pneumococcal disease, the #1 cause of pneumonia in the elderly)

Once per lifetime; previous recommendations for boosters have been rescinded.

For those few adults who have had neither chickenpox disease nor vaccination: Varivax, two doses 4-8 weeks apart

Chickenpox is no big deal in kids, despite the ACIP scare tactics of including immunosuppressed kids undergoing cancer chemotherapy or suffering from HIV in their morbidity and mortality statistics, but vaccination has become such a juggernaut I can't really do anything about it anymore. Still, adults are more likely to suffer complications from chickenpox; and varicella pneumonia carries a 10% mortality. Nothing to sneeze at.

That's basically it. Don't get me started on the Hep A and Hep B (covered in the disclaimer by the travel, sanitation and occupational clauses) or the HPV vaccine Gardasil. As I've said previously, I've softened my virulent stance against it somewhat, but that's a post for another day.


At Fri Jul 04, 01:20:00 PM, Anonymous Anonymous said...

I had chickenpox in my early 30s. I didn't have dangerous complications, but it was an incredibly miserable experience because nothing relieved the itching. I've heard that having chickenpox as an adult makes shingles more likely, so I am planning to get the shingles vaccine as soon as my pharmacy gets in back in stock, even though it will cost me $300 out of pocket because I am under 60 (I'm 53). The doctor gave me a prescription and the pharmacy will give me the shot--check around for pharmacies that offer that service.

At Fri Jul 04, 01:54:00 PM, Blogger CrankyProf said...

Uhm. Never had the pox -- chicken or otherwise.

You're going chase me around the office with a needle, to give me a shot when I see you again, aren't you?

At Fri Jul 04, 02:18:00 PM, Blogger #1 Dinosaur said...

No, Cranky, but the next time we check your cholesterol I'll tick off the box to see if you actually did have them without knowing it. Otherwise...[get ready for it]...A Pox on you!

At Sat Jul 05, 09:49:00 AM, Anonymous Anonymous said...

You know, the only reason I choose to vaccinate my son for chickenpox was that I was concerned that I wouldn't be able to find an infected kid anywhere to get him a natural case. I think I may be right - in the two years he's been at his daycare facility, there hasn't been even ONE case.

I do worry about long term immunity and possibility of shingles in the future... I also worry about the non-vaccers children growing up and getting chickenpox as adults. Foolishness can affect one for decades.

At Sat Jul 05, 03:42:00 PM, Blogger Swedoz said...

Virulent stance against Gardasil? Sounds interesting. I can appreciate that it isn't the be all and end all, especially in places with a good cervical cancer screening program in place, unlike in poorer places around the world where it will save many, many lives if it ever gets there, but virulent opposition seems a bit excessive...

At Sat Jul 05, 03:44:00 PM, Blogger Swedoz said...

I forgot to add that over here in the socialist paradise somehow the makers of the hep B vaccine have got permission to advertise on TV. So we now have lovely adds describing the risk of catching hep B from someone else in a bloody car accident. Strange but true!

At Fri Jul 11, 10:54:00 PM, Blogger SHELLY said...

I'd love to hear your stand on Hep A, Hep B, and Gardasil. Perhaps a post sometime soon?


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