Be Healthy - Immunizations

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VOL. 6 • NO. 12

© August 2012

MMUNIZATIONS For the most part, adults are more casual about vaccinations than their younger counterparts. Those who travel abroad or work in the health care industry are the exception rather than the rule.

While most immunization rates for children in this country hover around 90 percent, the rate for adults is woefully low and ranges from under 1 percent for shingles to a high of 69 percent for influenza.

The cost of this oversight is high. According to the Centers for Disease Control and Prevention (CDC), approximately 45,000 adults die each year from vaccine-preventable diseases. Most of these deaths are due to influenza and pneumonia, but the human papillomavirus (HPV) strains that cause the majority of cervical cancers, accounted for more than 4,000 deaths in 2011.

There are several reasons for this disparity.

Most common is that many adults don’t know that they’re supposed to get a number of preventive shots. They think vaccinations are just for kids.

That’s understandable. Several older people are naturally immunized against a variety of infectious diseases — all without the benefit of shots or doses of medicine. Long before vaccinations existed for the measles, mumps and chickenpox, kids suffered the rashes, muscle aches and blisters associated with these communicable viruses.

These aches and pains, however, provided a long-term benefit. When certain germs invade the body, the immune system generates

an army of fighters called antibodies to kill the intruders. These antibodies cannot prevent the initial attack of the disease, but can help make you well.

They also remember.

If those germs try to re-infect you, the immune system recognizes them and rallies a force to prevent them from entering.

By the 1970s, the need for natural immunity became obsolete as a result of the

emergence of several new vaccines. Children are now protected against the measles, mumps, German measles (rubella), diphtheria, tetanus, whooping cough (pertussis), chickenpox and polio.

Adults — regardless of age — who have not had these illnesses or been immunized against them, are advised to get catch-up shots. In addition, three doses of HPV vaccine are recommended for men and women up to the age of 26. The vaccine reduces the risk of genital warts in males and cervical cancer in women.

Because of the lower incidence of several communicable diseases in this country, there is a misperception that they are no longer a threat, thereby obviating the need for continued surveillance. The recent outbreaks of measles and whooping cough in several states prove the contrary. The fact is that many communicable diseases are alive and well and still scouting for unsuspecting victims.

Yet, one of the 10 great public health achievements in this country is the reduction of vaccine-preventable diseases. The last case of diphtheria was diagnosed in 2003, as reported by the CDC. Polio is almost a distant memory.

According to the World Health Organization, smallpox was eradicated worldwide in 1979.

Inoculation against this once dreaded disease has been discontinued.

For the most part, one shot or a series of shots can do the trick. The flu, however, is a different story altogether. And sometimes Adults, continued to page 4

Vaccines boost senior health Baby boomers might think that the days of vaccinations are way behind them.

Not so fast, according to Dr. Myechia Minter-Jordan, the chief medical officer of the Dimock Center. “You have to check the titers,” she explained.

A titer is a blood test that measures how effectively one’s immune system is fending off a virus or other germ. It determines the amount of antibodies — disease-fighting proteins — available to prevent a resurgence of measles, polio or other infectious intruders.

Adults mistakenly assume that they are permanently protected against an array of illnesses. For the most part, that is true.

Many have endured the discomfort and inconvenience of several infectious diseases, while others — typically born in the 1970s or later — have been inoculated against these invaders.

Minter-Jordan pointed out that protection from these diseases, whether natural or provided through a needle, is not necessarily permanent. Only the titers will tell.

The elderly — those 65 and above — are of great concern. They have a higher incidence of many chronic diseases, such as heart and kidney disease, diabetes and several cancers, which make them more vulnerable to certain infections and their complications.

There are four vaccinations people 60 and older must have, said Minter-Jordan.

The first is a yearly flu shot. People tend to dismiss the flu as just a more serious common cold that will go away with rest and plenty of fluids.

In most cases, this is true, but in too many cases it is not. Influenza and pneumonia are the eighth leading cause of death for all ages in this country. The

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elderly are among the hardest hit. Pneumonia alone is the fifth largest killer of older adults, especially during the winter months. Seniors with chronic diseas-

es are even greater targets.

That’s why the second vaccine recommended for this age group is to protect Seniors, continued to page 4

Getting the right dose over time, booster shots may be recommended at later ages, too.

Odds are good that you are familiar with certain vaccines, such as those that protect against polio or measles. You might scratch your head about others like the pneumococcal vaccine (it helps block bacteria that can cause pneumonia and infections in the blood, brain and spinal cord), or the rotavirus vaccine (it helps prevent infection with a contagious virus that is the leading cause of severe diarrhea in children, prompting dehydration and sometimes hospitalizations). If you have questions, talk to your health care provider. Or learn more about vaccines through the Blue Cross Blue Shield of Massachusetts website, www.ahealthyme.com.

The first day of school seems very far away when the hunt is on for a slice of shade to cool down from summer’s heat.

Yet every parent knows that day is coming.

Along with new clothes and calculators, one essential for kids heading back to school is vaccinations to help them stay healthy.

That’s also true for babies and younger children who won’t be cracking the books.

Why should I vaccinate my child?

“Vaccines protect all of our children against dangerous diseases like polio, diphtheria, whooping cough and measles,” said Jan Cook, medical director of Blue Cross Blue Shield of Massachusetts. “Many younger people have never known anyone who has had these diseases because the vaccines work very well. They’re especially important in the early years of a child’s life before the immune defenses that fight off bacteria and viruses are well-developed.”

When you vaccinate your child you protect others, too. Babies, young children, elderly people and anyone with an immune system compromised by illness may become very sick, or even die, if exposed to certain diseases vaccines help prevent. For pregnant women, such exposure might harm a growing fetus.

No vaccine is 100 percent effective, but the Centers for Disease Control and Prevention (CDC) notes that most of the recommended childhood vaccines are 85 to 95 percent effective.

Which vaccines does my child need?

Discuss the right vaccines for your child with your pediatrician. Recommendations change as new information flows in and new vaccines become available. Your child’s age, health issues and other factors affect which

What about side effects?

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vaccines your doctor recommends. Additional vaccines or particular formulations may be suggested for children considered at high risk due to certain illnesses, such as sickle cell disease. If your child has missed some vaccines or skipped doses, your doctor can choose the best catch-up schedule.

The CDC recommends several vaccines for most children and teens between birth and age 18. Many vaccines require a few doses given weeks, months or years apart to help develop strong immunity. So even if your child had a specific vaccine before age 2, he or she may need another shot between ages 4-6 or 11-12 to get full benefits. Because immunity can wear off

All medicines, including vaccines, may have side effects. These vary depending on the vaccine and not every child will experience them. Common examples are a low fever, rash or soreness at the spot where a shot was given.

Serious reactions like seizures, severe allergic responses or brain swelling are rare, generally occurring once per thousands to millions of doses, according to the CDC. Vaccines have been successful enough that many people have never experienced the dangers of certain diseases. Comparing risks to benefits may help ease fears about side effects. Diphtheria, for example, coats the back of the throat with a thick covering that can prompt breathing problems, paralysis and heart failure. Tetanus (lockjaw) can painfully tighten muscles all over the body and thus may prevent opening the mouth or swallowing.

Pertussis (whooping cough) is a highly contagious respiratory tract infection that causes violent coughing fits and difficulty breathing. Deaths stemming from actual cases of diphtheria (1 in 20), tetanus (1 in 10) and pertussis (1 in 1,500) far outstrip deaths from the DTaP vaccine (none proven) that protects against these diseases.

Some parents worry that vaccinations could trigger conditions like sudden infant death syndrome, autism or diabetes weeks or even years afterward. However, a 2011 report from the U.S. Institute of Medicine investigating these claims found no evidence to support these concerns.

A SCHOOL PASS States typically mandate specific immunizations students must have before starting a school year. The Massachusetts requirements for grades one through 12 for school year 2012-2013 are as follows: Diphtheria, tetanus, and pertussis (DTaP) Tdap (age 11 and older)

4 doses

1 dose

Hepatitis B

3 doses

Polio

3 doses

Measles, mumps, rubella

2 doses

Chickenpox (varicella)

2 doses

Source: Massachusetts Department of Public Health Immunization Program 2012

Although not required for school attendance, additional vaccines are recommended for older children and young teens.

Human papillomavirus Influenza

3 doses Yearly

Hepatitis A

High risk*

Pneumococcal (PPSV)

High risk*

*Recommended for kids with certain chronic health problems

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QUESTIONS & ANSWERS Since so many people in this country get immunized, is it okay for some to forgo vaccinations?

When an entire population of people receives vaccinations, then we all achieve what is called protective herd immunity.

This allows the population to be safe from vaccine preventable communicable diseases. It is only effective when each member/majority of the community Bela Bashar, M.D. participates in a vaccination Internal Medicine campaign. When a few people The Dimock Center forgo vaccinations, then there is a break in herd immunity and this allows for localized epidemics that can spread more broadly. Immunizations are an individual as well as a public health responsibility.

If a person has not been immunized against or infected with an infectious disease such as chickenpox, is it necessary to receive a vaccination as an adult?

Although we think of certain illnesses as occurring in childhood like chickenpox, they have a strong potential for infecting adults and causing great harm. In fact, chickenpox is more damaging if contracted as an adult. Our routine screening involves checking to see if individuals lack immunity against diseases like chickenpox and if they are lacking we actually vaccinate adults to prevent illness.

August is National Immunization Awareness Month

A human firewall In general there are two types of immunity In natural immunity germs invade the body, causing an infection that results in an illness. The immune system develops proteins called antibodies that destroy the germs.

These antibodies remain in the bloodstream and they remember. If the same germs try to infect you again, the antibodies know how to fight and destroy them before they can make you sick again.

GET SICK

REPEAT EXPOSURE TO THE DISEASE

YOU DON’T GET SICK

In acquired, or artificial immunity, vaccines contain weakened or killed germs. When injected, they cause the immune system to make antibodies against them. The difference is that you don’t get sick. As in natural immunity, the antibodies protect you if you are exposed to the disease at a later date.

Since the last case of polio in this country occurred several years ago, does that mean the disease has been eradicated?

Despite worldwide efforts at eradiation attempts of polio, the incidence of polio globally is not zero so, it has not been eradicated on an international level. The success of the vaccine, however, has decreased the incidence levels dramatically and there is great hope that polio will be successfully eradicated just like smallpox.

GAIN IMMUNITY

VACCINATION

GAIN IMMUNITY

EXPOSURE TO THE DISEASE

YOU DON’T GET SICK

In many cases the immunity is permanent. However, some vaccinations lose their protection with time or the immune system may lose its ability to fend off diseases.

Which adults should be vaccinated against hepatitis B? Hepatitis B is a virus that mainly infects and causes damage to the liver. It is spread through contact with blood and other body fluids from an infected person. Adults that should be vaccinated are as follows: people with chronic diseases like liver, kidney diseases, diabetes and HIV; sex partners and household contacts of infected individuals; people who share drug paraphernalia for injection of street drugs; people with high-risk occupations that might expose them to blood or body fluids; travelers to endemic countries; residents in institutionalized settings and frankly anyone else who wants to be protected against hepatitis B infection.

Can an immunization cause the illness it is designed to prevent?

Immunization cannot cause the targeted illness in any way. Vaccines are usually a less potent form of the causative agent or a portion of it so the vaccine by itself is unable to cause the disease.

Vaccines in contrast stimulate the immune system to produce antibodies (memory response) that are ready to prevent any attack from targeted microorganisms.

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Are immunizations 100 percent effective?

No vaccine is 100 percent effective. Most routine childhood vaccines are effective for 85 to 95 percent of recipients. For reasons related to the individual’s immune system, some people will not develop an adequate response and remain vulnerable.

Why do some vaccines require boosters?

It is not completely clear why the length of protection varies with different vaccines. Some have lifelong immunity with only one dose, while others require boosters in order to maintain immunity. Recently, researchers have suggested that the perseverance of immunity against a particular disease may depend on the speed with which that disease typically progresses through the body. For example, if a disease progresses very rapidly (like tetanus), the immune system’s memory response (those antibodies generated after an immunization) may not be able to respond quickly enough to prevent infection. They have to be reminded about the disease fairly regularly and be vigilant for it. Boosters serve as these reminders to your immune system.

Given the epidemic of whooping cough in this country, is it necessary for a person who has had whooping cough to be vaccinated?

According to the Center for Disease Control and Prevention (CDC), during the first half of 2012, more than 17,000 cases of pertussis (whooping cough) were reported through July 12, 2012. The best way to protect yourself is to get vaccinated, even those who have had the disease. The CDC recently changed its vaccine guidelines to reflect this epidemic by recommending the booster Tdap (tetanus, diphtheria, acellular pertussis) vaccine for all adults under 65 years who have never received a Tdap. Adults including women who may become pregnant and adults older than 65 years who expect to have contact with an infant younger than 12 months should also receive Tdap to reduce the risk of the infant contracting pertussis. All healthcare workers with direct patient contact should receive the booster as well.

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The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician.

We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.

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Seniors, continued from page 1 borns and pregnant women. against the most common type of pneuOnly one inoculation of Zoster is recmonia (pneumococcal). Unlike flu shots, ommended at this time – even for those only one inoculation is required. who have suffered a bout of shingles.

The third vaccine recommended One other vaccine is recommended for seniors is the herpes zoster vaccine for older adults. “Older people — even (Zostavax) that was approved by the those older than 65 — should get a Food and Drug Administration (FDA) Tdap if around young children,” adin 2007. The shot is recommended only vised Minter-Jordan. for seniors who have had chickenpox.

Tdap is a booster for tetanus, diphHerpes zoster, better known as theria and accelular pertussis (whoopshingles, is a ing cough). It has painful, blisterbeen found that the ing skin rash due protection against to the virus that these illnesses wanes causes chickenwith time. Grandpox. The immune parents that care for system cannot their grandchildren completely oblitand those who work erate this virus. in day care centers Instead, it damps should be vaccinated. down its impact, “Others who but the virus rearen’t around young mains dormant children can get the in certain nerves Tdap or Td booster,” in the body’s nershe explained. The vous system.

Td booster is recShingles can ommended every 10 Myechia Minter-Jordan, M.D., M.B.A. occur if the viyears for everyone to Chief Medical Officer rus becomes acguard against tetanus The Dimock Center tive again in these and diphtheria. nerves years later.

RecommendaThe reason for this sudden resurgence tions are one thing, but compliance is is not clear. Often only one attack oc- another. The Massachusetts Behavcurs, but that’s more than enough for ioral Risk Factor Surveillance Survey most people. The pain can be quite ex- (BRFSS) found that in 2011, 17 percruciating and last for several weeks. cent of those 60 and older had ever had This inoculation cannot prevent a Zoster shot, and only 19 percent of chickenpox. Nor can it treat shingles, adults 18 and older received the recombut it can significantly reduce the re- mended Tdap.

More disturbing is the disparity currence of an outbreak. The Centers for Disease Control and Prevention in those who benefit from these vacrecommend the shot for those 60 and cines. The BRFSS found that while the older although the FDA in March 2011 overall rate of seniors who received a approved it for people as young as 50. flu shot in 2011 was low, it was lowest The shingles vaccine protects not among blacks — 45 percent as comonly the recipient, but others as well. If pared to 70 percent of whites and 58 an adult or child has direct contact with percent for Hispanics. Forty-four perthe shingles rash on an afflicted person cent of blacks were immunized against and has not had chickenpox as a child pneumonia versus 75 percent whites or a chickenpox vaccine, that person and 59 percent Hispanics. can develop chickenpox, not shingles.

Though baby boomers might Those with active cases should think that the days of vaccinations are avoid physical contact with anyone way behind them, it’s clear that is not who has a weak immune system, new- the case.

Vaccinations aren’t just for kids anymore. New vaccines for adults, like Zoster, have become available. Also, the protection afforded by shots or from having had the illness can diminish with time. Below are general recommendations for adults, but can vary because of lifestyle, health status or occupation. Check with your doctor to determine the best schedule for you.

65+

× Yearly flu shot × Zoster1 – 1 dose if not already received × Pneumococcus2 – 1 dose × Tdap3 – 1 dose if around young children and if not already received × Td4 every 10 years after 1 dose of Tdap

50-64

× Yearly flu shot × Zoster1 – 1 dose* × Tdap3 – 1 dose if not already received × Td4 every 10 years after 1 dose of Tdap

27-49

19-26 Vaccines: 1 Shingles 2 Pneumonia

× Yearly flu shot × Tdap3 – 1 dose if not already received × Td4 every 10 years after 1 dose of Tdap × HPV5 – 3 doses if not already received

3 Tetanus/Diptheria/Pertussis 4 Tetanus/Diptheria

5 Human papillomavirus

*Although the Food and Drug Administration approved the Zoster vaccine for people 50 and older, the Centers for Disease Control and Prevention recommend it for those 60 and older.

Those who have missed vaccines typically given when younger, such as chickenpox or measles, are advised to get catch-up vaccinations. People of high risk — those with chronic illnesses or risky sexual behavior — may require additional protection from hepatitis A and B and meningitis.

Source: Advisory Committee on Immunization Practices

Adults, continued from page 1

it’s a hard sell, said Dr. Myechia MinterJordan, the chief medical officer at the Dimock Center. “Many people say ‘I had one last year,’ ” she said, “but the vaccine is tweaked a bit each year.”

The strain of flu changes, requiring development of a new vaccine for each new mutation.

In addition, protection from some vaccines can wear off over the years. For instance, epidemiologists have found that the vaccination for diphtheria, tetanus and acellular pertussis, commonly known as whooping cough, is almost 90 percent effective, but that protection eventually fades.

The researchers discovered that roughly five years after the last dose, the long-term effectiveness had fallen to roughly 71 percent.

For that reason, booster shots called Tdap are recommended for children, adolescents and adults.

Another possible reason behind the loss of protection is longevity.

“We’re living a lot longer,” said Minter-Jordan.

The memory of the immune system begins to age.

The recommendations on the type, dosage and frequency of vaccines as well as the age to be administered are dictated by the Advisory Committee on Immunization Practices (ACIP), a panel of 15 experts in fields associated with immunization.

While some vaccinations, such as the flu, are required for all adults, a small subset is geared toward those of high risk. For instance, those with chronic illnesses and those who practice risky sexual behavior require additional vaccines.

People who have multiple sex partners, men who have sex with men and drug users who share needles are urged to be vaccinated against hepatitis B, a sexually transmitted virus that can result in liver damage.

People with diabetes, asthma and other chronic illnesses are advised to protect themselves against pneumonia and meningitis.

Their immune systems are already in overdrive trying to keep their illnesses at bay and are less able to ward off these infections and their complications.

Although national and state public health agencies advocate strongly for immunizations for adults, not everyone is getting the message.

Results from the 2011 Massachusetts Behavioral Risk Factor Surveillance System, a survey of the CDC, found that only 45 percent of adults interviewed said that they had received a flu shot in the past year, and 54 percent of high risk residents 18 years and older had been vaccinated against hepatitis B. Only 55 percent of diabetics and a mere 40 percent of those with asthma aged 18 to 64 were protected against pneumonia.

These illnesses do not necessarily increase the risk of getting pneumonia, but sufferers can have worse outcomes.

The American Diabetes Association noted in a study that people who had diabetes were more likely to die within one year of getting pneumonia mainly because of underlying conditions, such as kidney and heart disease.

Some people should forgo vaccinations, according to Minter-Jordan. For instance, pregnant women should not be vaccinated against measles, mumps and rubella (MMR) because live viruses are used. It is possible that it could harm the fetus. They should be inoculated after child birth, however, to reduce the risk of infecting their newborn.

People with allergies to components of vaccines and others with weakened immune systems are often exempt.

The bottom line is protection, said Minter-Jordan. If you won’t do it for yourself, do it for others.

According to the CDC, approximately 45,000 adults die each year from vaccinepreventable diseases.

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Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.