What I Tell Parents About Vaccines

My Biography

I was born and raised in a small town in Arkansas. When I was young my family was poor. Things were better by the time I got to high school and I skipped my senior year to go on to college in 1975. My wife, Stacy, and I married in my junior college year, which was the best collegiate academic year. I majored in Chemistry and was among three of two dozen applicants accepted to the University of Arkansas at Little Rock at the age of 21.

In 1983 I began a Pediatric residency at Oklahoma University Tulsa Medical College, my second match choice. The program was fairly large and we covered our own clinic, three very large hospitals, and an NICU called the Eastern Oklahoma Perinatal Center.

In those days there were no Pediatric intensivists in Tulsa. All of the residents managed the sickest of children with there attending some which were Pediatric Cardiologists or Neurologists who made rounds with us morning and night.

I remember successfully managing the fluids and electrolytes of a hypernatremic child with a sodium of 175. Over three days I very carefully reduced her sodium, and though she did once seize, and we suspected partial herniation, she survived without any sequelae. Her mom hunted me down later in private practice to once again thank me.

The EOPC was a 45-bed NICU. There was no lung surfactant available yet, and the mortality rate was 30%. We took referrals from Arkansas and Missouri as well and were staffed with some of the best neonatologists and other specialized caretakers available.

My stipend was only about $16,000 when I started, and the EOPC was the only place to moonlight. I became extremely interested in neonatology and infectious disease and considered pursuing one of these. I decided though that the need was greatest for Primary Pediatricians and thought that was where I could do the most good.

I started solo practice in a small to medium town in south Arkansas. Because it was several hours away from any other referral NICUs, the Pediatricians there did a fair amount of neonatology. For me that was great. I did Level III NICU as part of general solo Pediatric practice for almost seven years.

During that time I became part of the last year of Exosurf artificial studies. The results we were seeing was extraordinary. I accumulated a panel of almost 70 premie neonates during those years, the smallest of which was a 1 pound 13 ounces (822 gms). That child went home after three months and suffered very minimal deficits long term.

A geek to the bone, I wrote and deployed my EMR in 2000 and we used it to see and network three clinics seeing some 35,000 patient visits a year I continue to manage the medicine and that EMR for myself.

The majority of my thirty four years of Pediatrics have been solo. While I do sometimes get tired. But I enjoy teaching parents and residents a lot. After a request from one my parents, I published a lengthy account of what I tell all my parents about vaccines on Facebook. That garnered mostly praise but at least some anger from those against vaccination.

And it seems to have gotten me an invitation to speak to you today! I’m going to tell you what I teach my patients about vaccines. I have also self-published a free Apple ebook entitled “The Pediatric Guide for Parents” which discussed much of this as well.

Now I am nothing special, and I mentioned all that stuff about me for one reason. I want to put a hunger in you residents for general Pediatrics. I want you to strive to be the best physicians you can. The relationships you will have with your parents will provide you with a uniquely fantastic  opportunity to give them the best information about vaccines.

Edward Jenner, circa 1796, coined the terms “vaccine” and “vaccination” which are derived from Variolae vaccinae or smallpox of the cow. He was the first to inoculate healthy individuals with the lesions of cowpox scabs. He was successful in preventing smallpox because the two viruses share certain proteins.

In 1980, smallpox was declared eradicated almost 200 years after Jenner’s discovery. Today smallpox exists only in the Centers for Disease Control and Prevention in Atlanta, Georgia, and the State Research Center of Virology and Biotechnology (VECTOR Institute) in Koltsovo, Russia where they are supervised by the World Health Organization:

Facts to just to have handy. In late 1975, Rahima Banu, a three-year-old girl from Bangladesh, was the last person in the world to have naturally acquired variola major and the last person in Asia to have active smallpox. She was isolated at home with house guards posted 24 hours a day until she was no longer infectious. A house-to-house vaccination campaign within a 1.5 mile radius of her home began immediately, and every house, public meeting area, school, and healer within 5 miles was visited by a member of the Smallpox Eradication Program team to ensure the illness did not spread. A reward was also offered to anyone for reporting a smallpox case.

Ali Maow Maalin was the last person to have naturally acquired smallpox caused by variola minor. Maalin was a hospital cook in Merca, Somalia. On October 12, 1977, he accompanied two smallpox patients in a vehicle from the hospital to the local smallpox office. On October 22, he developed a fever. At first he was diagnosed with malaria, and then chickenpox. He was correctly diagnosed with smallpox by the smallpox eradication staff on October 30. Maalin was isolated and made a full recovery. Maalin died of malaria on July 22, 2013 while working in the polio eradication campaign.

Janet Parker was the last person to die of smallpox. It was 1978, and Parker was a medical photographer at the Birmingham University Medical School in England and worked one floor above the Medical Microbiology Department where smallpox research was being conducted. She became ill on August 11 and developed a rash on August 15 but was not diagnosed with smallpox until 9 days later. She died on September 11, 1978. Her mother, who was providing care for her, developed smallpox on September 7, despite having been vaccinated on August 24. An investigation performed afterward suggested that Janet Parker had been infected either via an airborne route through the medical school building’s duct system or by direct contact while visiting the microbiology corridor one floor above.

Smallpox is the poster child of vaccination success and eradication. But why should this be any more beyond medical history?

In 2014, employees at the National Institutes of Health found six sample smallpox vials, at least two of which contained viable virus. As long as this virus is still present especially in these two labs there is risk and we need to be prepared.

http://www.dailykos.com/story/2014/7/11/1313409/–It-s-Alive-Smallpox-vials-misplaced-in-1972-are-still-alive-NIH-promises-to-look-around-for-more

Has anyone here been vaccinated for smallpox as a child?

Diphtheria is a bacterial illness caused by corynebacterium diphtheriae. In contrast to smallpox, diphtheria is still very much an infectious concern in the world. In 2013 is was down to under 5000 cases from 1980 when there were almost 100,000 cases.

I’ve never seen diphtheria. It is very pertinent here because there is the very real possibility any of you here might just discover a case. That is not because the vaccines is not effective, but because we are fighting a trend to not vaccinate. You are faced with the possibility that if you are not vigilant you are going to miss it.

The effectiveness of the diphtheria vaccine has been enormous and the disease with its toxin is terrible. In the winter of 1924 to 1925, there was a physician named Welch in Nome, Alaska, a town of less than 2,000. The port had already closed and the last ship departed for the winter when he discovered his vaccine supply was expired.

An outbreak of what he initially thought was pharyngitis was found to be diphtheria. Four children died shortly thereafter and Welch was facing a epidemic winter with no vaccine. More children began to get sick. Expired vaccine was ineffective and there were more deaths.

With the 1917 flu epidemic that killed between 25 and 50 million fresh on Welch’s mind, they radioed for help. The weather was unplayable by plane and so antitoxin had to be brought in by dogsled across the Iditarod using relays of teams.

Do you think you will never see a case of diphtheria? Will you even have the presence of mind to consider it just because you haven’t?

In 1983 as a first year resident I was taking care of a young boy with factor 8 deficiency. We were giving him concentrated factor 8 which was a pooled product from some 30,000 donors. I was the one that told that boys parents that he had contracted HIV. He was the first child diagnosed in Tulsa as far as I know. HIV had just burst on the scene.

Since then we’ve seen the likes of newcomers like hantavirus, ebola, zika and surges of oldies like dengue, yellow fever, chikungunya, and of course malaria. Our task today as physicians is to be very vigilant. I can promise you that frontline general Pediatricians will get the first shot at seeing old and new infectious disease.

We are also the ones that must be the educators. I spend a great deal of time teaching patients especially since the Lancet, in 2010, repudiated Andrew Wakefield’s origin 1998 study as a fraudulent. He was kicked out of Britain and practiced in Austin, Texas for about a year before getting out of medicine altogether.

But the damage was done. Now everyone from hairdressers to manicurists weigh in as qualified to have an opinion. We better remember Welch. The only way out of this problem is to sway people with good teaching.

Parents need to understand that a healthy immune system thrives on exposure to common viruses and bacteria…to a great degree. A recent study of three-year-old children who ate dirt (that’s called pica) showed their immune systems to be healthier that children who did not. They need to stop reaching for the antibacterial soap and give their child’s immune system the ammunition that it needs.

Recently it was shown that delaying a child’s exposure to foods to very late in the first year rather than at three to four months results is a significant increase in food allergies. Food allergies are immunological analogous to the immunologic reactions to viruses and bacteria. Why wouldn’t we suspect that delaying vaccines has some analogous effect?

Exposure used to be viewed differently. I remember before the chickenpox vaccine that parents would have chickenpox “parties” to expose their healthy children to a child with active lesions. The idea was for them to go ahead and get chickenpox and get it over with.

That logic is very similar to Edward Jenner, except that children got the actual chickenpox. The difference is the serious cases of chickenpox were extremely minuscule compared to smallpox. The longterm consequences of shingles however take a toll as each infectious agent has its own twists and turns.

All vaccines are measured by a “take rate.” That is the percentage of individuals who develop immunity through the production of antibodies against the the bacteria or virus that the vaccine targets. A poor take rate of 85% is a bare minimum while an excellent rate is 95%.

The MMR vaccine has a take rate of 75% at 6 months of age, 84% at 8 months, 95% at 12 months, and 100% at 15 months. Current vaccine recommendations are to give the MMR at 12 months then a booster at about 4 years which protects that 5% which didn’t develop immunity.

Take rates of 95% effectively halt the speed of disease because it effectively isolates that other 5% so that they don’t get exposed to MMR. The booster then helps catch that 5% and also prevent  lasting immunity in the 95% from waning.

I wish we gave the MMR at 6 months and 12 months. If we can start verifying that mom’s have MMR immunity, then their babies will carry maternal antibodies for the first 3 to 4 months. Vaccinating at 6 months means that there is a much shorter window of infectious opportunity.

It is these windows of opportunity that we need to educate parents. I can’t tell you how many times have I heard from a mother that she wanted to delay vaccines until close to the first year. We give the 2, 4, and 6 month diphtheria, pertussis, tetanus, Hib, and pneumococcus when we do because it laps that window of opportunity entirely.

Understanding grouping is important for parents. They need to know why we do what we do. A recent study demonstrated that when you give vaccines grouped, though not in the same syringe, that the take rate improves for individual components. There is one study that suggests that fever left untreated in the first twenty-four hours also improves the take rate while treatment or pretreatment with antipyretics is counterproductive.

Vaccine safety has improved dramatically. In 1986 when I first started solo practice I used to see 4 to 6 cases of fever a month primarily because the Pertussis vaccine was a whole cell type with cell proteins that had no benefit except to cause fever. That changed with the advent of processes which isolated the specific and best protein targets. Now I might see 4 to 6 cases of reactionary fever every two or more years.

The Redbook defined a vaccine reaction as one where the fever reached and maintained 102.5°F or there was inconsolable crying for two to three hours or so both within the first twenty four hours. That is still pretty much the standard.

The improved manufacture of Pertussis led to more dramatic results with Hemophilus influenza type b. The vaccine first was required in Georgia in 2000 which is about when I moved here. Between 1986 and 2000 I used to see around 2 kids a year with a positive spinal tap in my office. I’ve seen not one case of H. flu type B meningitis since. I tell my parents what my experience is because it wins the argument. I think I see many parents who are fence-sitters just waiting for me to give them a good reason to give the vaccines. Personal experience here goes a long way.

Sometime you need overwhelming numbers. Some of you probably heard about that recent metanalysis study of 1.2 million kids where the incidence of autism was LESS if they got their MMR. Though one shouldn’t submit that the MMR is protective against autism, this is a stunning number. It gives parents a reason to believe us over Dr. Google. I gave up fighting agains Dr. Google a long time ago…he’s here to stay folks, so we have to have better information.

HPV is another battleground vaccine. My wife had breast cancer in 2000 and my argument and the information I relay centers around them understanding that I think this vaccine can help prevent cervical cancer. When I’m the real person in front of them like this, or I explain that my children get their vaccines according to our schedule, they put a human face on the one doing the explaining. You capture their confidence by being real.

Since Dr. Jaime Davis has joined me, we’ve had several talked about how that the frequency of ear infections seems to have decreased markedly since the pneumococcus vaccine was require in 2007. This is a real decrease in my three decades. I mean I remember when otitis was the bread and butter of Pediatrics. Now I see things like CH50 deficiency, hepatitis C, MRSA, and optic toxoplasmosis. These are signs that the vaccinations improvements are really working I think.

In 1986 I had only two other vaccines besides MMR in my arsenal of preventative medicine; DPT (diphtheria-pertussis-tetanus) and oral polio. Probably the most famous polio sufferer was President Roosevelt. I have never seen a case of paralytic polio nor diphtheria myself. Those vaccines have had astronomical impact such that like me you have to research the history to understand how much suffering and death were prevented by them.

Adults need more vaccines too. We have long been recommending that both parents of newborns get the Tdap to cover for Pertussis. Remember it’s called the Hundred Days Cough for very good reason and for long after the bacteria has been eradicated.

Adults whose immunity has waned are the current source of continued whooping cough in this country. An adult has up a 21% of have a Pertussis infection if the cough has been present for two or three weeks. Children’s caretakers need to be a surrounding palisade of protection.

The flu vaccine always has those who wax reticent. This is the hardest vaccine about which to educate. The strain of flu that popped up a handful of years ago hasn’t been seen since I was a kid and had it. It’s the same strain that killed between 25 and 50 million people in 1917. It is important to teach parents that the vaccine doesn’t cause the flu. The manufacturing process begins about thirteen months before the batch that is currently being given.

The long manufacturing process makes for a quick antigen mutation in the viral signature as happened a couple years ago. That year the protection rate was about 50% because the flu virus changed a month before millions of doses were already manufactured. This is not the fault of the vaccine makers but the nature of that flu manufacturing process. Parents don’t know that though.

Preservatives in vaccines is another issue about which more than occasionally comes up. Vaccines that are provided in multi-dose vials require a preservative. Most vaccines are now in unit dose vials and are fine without them.

The preservative is thimersol, also known as thimerosal. This substance is presence in very small amounts, and it contains just over 49% mercury by weight all of which is metabolized to ethyl mercury and thiosalicylate. The actual amount of mercury in a multi-dose vial is very, very small.

Mercury is neurotoxic, especially to children. Japan’s Minimata Bay was a constant source of that population’s regular diet. It became contaminated with local industrial mercury waste. The result was Minimata’s Disease a sometimes devastating illness seen in both children and adults. It was the ills of mercury contaminations like this that propelled strong argument against vaccination containing thimersol.

Mercury in industrial waste is methyl mercury while the thimerosal is metabolized to ethyl mercury. Ethyl mercury has a half-life of only a few days in humans, while methyl mercury has a half-life of 49 days. In constant to the steady intake of long-lived methyl mercury intake contaminated fish, ethyl mercury exposure if preserved vaccines is very, very limited and extremely short-lived so much so that mercury in vaccines is a non-issue.

Aluminum is sometimes touted as a concern in vaccines. The problem here is that aluminum is the most common mineral we are exposed to everywhere…the vaccine exposure is minuscule in comparison. There just really isn’t a good way to evaluate any possible effective without removing us from earth where we are exposed all the time.

Conclusion

I still remember in residency a Pediatric practice in north Tulsa that decided they wouldn’t take any babies that weren’t breastfed. Trying to force your opinion about vaccines on parents is like that practice trying to force their way or the highway too.

I talk extensively and sometimes daily about these aspects of vaccination. You will not win the vaccine argument if you are holding parents with one arm behind their back. You must win them with good information and sound reasoning. That means you have to develop a strong Pediatrician parent relationship…and we Pediatricians have to do that well. You can do it well.

Why Vaccine Mandates Won’t Stop Measles In The US

The recent outbreaks of measles have caused a great divide within the ranks of parents with young children over vaccinations. There is an alarming trend in Pediatric offices toward strong-arming parents into vaccinating their children. Some offices are even giving parents who don’t vaccinate their marching orders to find a new Pediatrician. Those who know me will tell you that I’m a strong proponent of vaccinations, and I believe that vaccines are safe and effective. As a world medical traveler, I’ve had all of mine and then some, including the smallpox vaccine I got as a child.

However, I refuse to try and dictate to parents what they will or won’t do with vaccines. A pinch of caring and compassion I think will go further than a pound of forced “persuasion.” I will try to persuade parents through a good patient-physician relationship where they can trust that the vaccine information I present to them is sound and reasonable. I must, and will, however, put this decision in their hands as the parents of children that they love deeply.

No doubt much of the current rancor from vaccine-reluctant parents stemmed from the article published some thirteen or so years ago by Andrew Wakefield in the journal Lancet. His article stated that his research showed a direct relationship between the MMR vaccine and autism. Though the Lancet did recently refute these findings and retract his article, it took them more than a dozen years. The damage that the Lancet sought to correct had already been long done, and the MMR vaccine will probably forever be tainted by that article. As a result of his repudiated research, Andrew Wakefield now resides in the U.S. and no longer practices medicine at all.

The storm of anti-vaccine sentiments however continues. Those with children who are under a year or who cannot receive the MMR for health reasons are calling for ‘non-vaxxers’ to be forced to do so under the guise of public interest and safety. Those who refuse to vaccinate are holding to the rights they see as citizens to choose not to vaccinate. Underlying motives are difficult sometimes to ascertain on both sides. One thing I can say about mandates is that you only have to go so far as the current health care mandate mess to know what can happen. Once a mandate is in place, it is very hard to step back from it. A vaccination mandate would only add to more bad mandate decisions.

There are three groups of children that I think we need to consider here. The children in the first group are those who are ill and cannot receive the MMR vaccination because even an attenuated live virus vaccine poses a serious risk. Their parents want them to be able to attend school or daycare and try to live as normal a life as possible, free from the risk of infection with viruses like measles and such, wherever they go. The children in the second group are those whose parents are wary, even fearful, of the vaccines harming their children, and elect to refuse some or all of the vaccines, or opt for a different vaccine schedule than the current recommendations. The children in the third group are those whose parents are already planning to vaccinate per published recommendations, but the children have not yet been vaccinated for MMR.

Children in the first group who can’t receive vaccinations because of a medical condition are at risk everywhere in society unfortunately. As much as I would like, we cannot protect them everywhere they go. All large public venues are a danger to these medically immuno-incompetent children. I suspect that some 50,000 people a day may pass through many of WalMart’s 24-hour facilities. I tell my parents that I generally consider everything in such large, well-travelled places to be contaminated. I counsel the parents of my immunocompromised patients to be very careful about where they take their children.

Children in the second group, who may receive only a few or no vaccines, are at risk of getting the infections when they are exposed to others who bring in the infections across our borders, or when they travel beyond our borders. Unlike Yellow Fever, where visitors to endemic countries must be vaccinated prior to travel, and who must also present a Yellow Fever vaccination certificate before regaining entry back into the United States, we have no such screening for any other contagious infections. Even Ebola screenings, where death rates are upwards of 70 percent or more, are not properly done before a person reenters from an endemic Ebola area. Simply measuring a temple temperature is not good enough to make any clinical decisions by non-medically qualified airport personnel. I don’t trust these types of devices to make sound medical decisions in my office, and I’m an experienced physician. It has been shown, even among highly intelligent physicians and other healthcare professionals, that self-quarantine does not work either. Physicians and nurses are no better than anyone else who would try to circumvent heath prevention measures at our border. They act as though these barriers are good for everyone else, but do not apply to them.

Children in the third group are those who are in the process of being vaccinated according to schedule but are not yet immunocompetent. With respect to the MMR vaccination and measles, these children, however, are at risk for a period of up to the first year, where they have limited or no immunity. The MMR is not routinely given until on or after the first birthday. This is because the seroconversion rate, which is the measure of vaccine effectiveness, after the one year measles vaccination is around 95 percent or better.

While the solution for the first group lies in exposure prevention on a day to day basis, and for the second group in convincing parents to vaccinate, there is something more I think we can do to help the third group. It may also help to limit the exposure of immuncompromised children more effectively than trying to simply mandate that all children receive the present schedule of vaccines. Children can get the MMR vaccine before their first birthday. They will still be required to get vaccinated according to the regular two-dose schedule at and beyond age one year. It has been demonstrated that 74 percent of children who get MMR vaccine at 6 months do seroconvert and become immune to measles. Over 89 percent of those vaccinated at 8 months have been shown to acquire measles immunity. At 15 months the conversion rate is reportedly 100 percent.

It is already recommended that unvaccinated children as young as 6 months get the MMR prior to travel to endemic areas of the world or during local outbreaks of measles. I am now recommending to parents of my patients that they consider giving their children their first MMR at age 6 months. Currently, here in Georgia, these children will still have to have two more MMRs at or beyond their first birthday for daycares, schools and such that require a completed Georgia form 3231 vaccine certificate for attendance. This will, I think, significantly reduce the susceptible population of young children. It will also indirectly reduce some of the risks to the first group of children who are immunocompromised.

What about immunity to measles in the first 6 months of life then? Because the largest antibody transfer from mother to child occurs at some point prior to delivery, I’m recommending that all women who have low measles, mumps, or rubella titers, have their measles titers measured. If their titers are low, then they should be vaccinated prior to pregnancy. Prenatal transfer of the maternal measles antibody from seropositive mothers to their newborn children can give immunity that may last perhaps up to 4 months of age. Breast feeding does also transfer some maternal antibodies, but I don’t think that the quantitative effect is really known, and it probably cannot be relied upon to provide the protection we want.

Pregnant women or those planning to soon get pregnant within 28 days should first discuss MMR vaccination with their obstetrician. The CDC recommendations against live virus MMR vaccination during pregnancy are also based, according to the AAP Redbook, on theoretical risks of infection to the unborn baby. Women have been unknowingly vaccinated during pregnancy without negative effects to the fetus. Women thinking about becoming pregnant or who are pregnant need to discuss MMR titers and the indications for vaccination with their obstetrician. Determining pre-pregnancy measles titers are a very good idea.

This policy should help to significantly narrow the susceptibility of a significant number of healthy vaccinated children down to about two months. It will indirectly help reduce the risk to immunocompromised children. I will continue to encourage and educate my parents who refuse or want to delay vaccines why I recommend the current vaccine schedule for all children. The problem with forcing these parents to vaccinate seems politically driven rather than well-reasoned. Mandatory vaccination will certainly not stop the entry of measles into our country across the border which seems to be how the virus is getting here. Until we demand verification of an approved MMR vaccination by all citizens and non-citizens coming through customs, and until we fully control illegal entry at our borders, we will continue to be at risk for measles. Mandatory vaccination will gain nothing but the control of one group of people over another. It will further limit the shrinking freedoms for which we as Americans have fought and died.

Those interested in MMR vaccination before the first birthday should call their health care professional’s office and discuss all the particulars of insurance coverage, risks, etc. More information about the current MMR recommendations and the supporting sources for my information are found at PubMed.govthe CDC’s Morbidity and Mortality Weekly Reportthe CDC’s Measles, Mumps, and Rubella (MMR) Vaccine Safety Studiesand the CDC’s Vaccines and Immunizations page on the measles vaccination. I have written a free iTunes ebook for my parents called “The Pediatric Guide for Parents” which has extensive information on the various diseases vaccines protect against and lots of pictures. It may be helpful to parents who remain unconvinced.

Our New MMR Vaccination Policy

As some have seen in the news, there is an alarming trend in Pediatric offices toward strong-arming parents into vaccinating their children and giving them their marching orders to find a new Pediatrician. Those who know me will tell you that I’m a strong proponent of vaccinations. I believe that vaccines are safe and effective. As a world medical traveler, I’ve had all mine and then some, including the smallpox vaccine as a child.

However, I refuse to try and dictate to parents what they will or won’t do with vaccines. A pinch of caring and compasion I think will go further than a pound of forceful ‘persuasion.’ I will try to persuade parents through a good patient-physician relationship where they can trust that the vaccine information I present to them is sound and reasonable. I must and will, however, put this decision in their hands as the parents of children that they love deeply.

There are three groups of children that I think we need to consider here. The children in the first group are those who are ill and cannot receive vaccinations as a result. Their parents want them to be able to attend school and try to live as normal a life as possible free from the risk of infection with viruses like measles and such wherever they go. The children in the second group are those whose parents are wary, even fearful, of the vaccines harming their children, and elect to refuse some or all of the vaccines, or opt for a different vaccine schedule than the current recommendations. The children in the third group are those whose parents are already planning to vaccinate per published recommendations.

Children in the first group who can’t receive vaccinations are at risk everywhere in society unfortunately. Much as I would like, I cannot protect them wherever they are. I sometimes wonder if the same parents who demand that all other children be vaccinated to protect their children, are also careful about taking them out to large venues. For example, I suspect that some 50,000 people a day may pass through WalMart’s 24-hour facilities. I am suspicious that everything that a child could touches in these places puts them at risk of infection. I have no studies to back this up, but that is my suspicion, nonetheless. I care for children with significant immune deficiencies myself, and their parents and I always have the discussion about these risk factors, and I am very aware of the needs of these children.

Children in the second group who may receive only few or no vaccines are at risk of getting the infections when they are exposed to others who bring in the infections across our borders. Unlike Yellow Fever, where visitors to endemic countries must be vaccinated prior to travel, and who must also present a Yellow Fever certificate before regaining entry back into the United States, we have no such screening for any other contagious infections. Even Ebola screenings where death rates are upwards of 70% or more, is not properly done before a person reenters from an endemic Ebola area by simply measuring a temple temperature.

Children in the third group are those who are being vaccinated according to schedule. With respect to the MMR vaccination and measles, these children however are at risk for a period of up to the first year where they have limited or no immunity. The MMR is not routinely given until on or after the first birthday. This is because the seroconversion rate, which is the measure of vaccine effectiveness, after the one year measles vaccination is around 95%.

While the solution for the first group lies in exposure prevention on a day to day basis, and for the second group in convincing parents to vaccinate, there is something more I can do to help the third group, and perhaps very significantly. It may also help to limit the exposure of immuncompromised children more effectively than trying mandate that all children receive the present schedule of vaccines.

Children can get the MMR vaccine before their first birthday. However they will still be required to get vaccinated according to the regular two-dose schedule at and beyond age one year. It has been demonstrated that 74% of children who get MMR at 6 months do seroconvert and become immune to measles. Over 89% of those vaccinated at 8 months have been shown to acquire measles immunity.

It is already recommended that unvaccinated children as young as 6 months get the MMR prior to travel to endemic areas of the world or during local outbreaks of measles. I am now officially recommending that parents of my patients consider giving their children their first MMR at age 6 months. Currently here in Georgia they will still have to have two more MMRs at or beyond their first birthday for entities that require the official form 3231 for attendance. This will, I think, significantly reduce the susceptible population of young children, and indirectly reduce some of the risks to the first group of children, whose parents are particular concerned about exposure.

What about immnity to measles in the first 6 months of life then? Because the largest antibody transfer from mother to child occurs at some point prior to delivery, I’m recommending that all women who have low measles, mumps, or rubella titers, be vaccinated prior to pregnancy. Pregnant women or those planning to soon get pregnant within 28 days should first discuss MMR vaccination with their obstetrician.

The CDC recommendations against live viruse MMR vaccination during pregnancy are also based, according to the AAP Redbook, on theoretical risks of infection to the unborn baby. Women have been unknowingly vaccinated during pregnancy without negative effects. Many physicians caring for expectant mothers are starting to check for the presence of measles antibodies. Women thinking about becoming pregnant or who are pregnant need to discuss MMR vaccination with their obstetrician.

Prenatal transfer a measure of their measles antibdoy to the children of mothers who are measles seropositive, which can last up until perhaps 4 months of age. Breast feeding does transfer some antibodies but I don’t think that the quantitative effect is really known there, and it cannot be relied on in lieu of prenatal seropositivity.

This policy should help significantly to narrow the susceptibility of healthy children who are being vaccinated. The problem with forcing the current vaccination schedule on all children seems politically driven rather than well-reasoned, though I understand the fear behind it. It will certainly not stop the entry of measles into our country across the border which is how the virus is getting here. Until we demand verifcation of an approved MMR vaccination by all citizens and non-citizens coming through customs, and until we fully control illegal entry at our borders, we will continue to be at risk for measles. Mandatory vaccination will gain nothing but the control of one group of people over another, and it will further limit the shrinking freedoms we as Americans have traditional enjoyed and fought and died for.

Those who are interested in MMR vaccination before the first birthday should call our office and discuss all the particulars of insurance coverage, risks, etc. More information about the current MMR recommendations are found at these web sites below to support the data that I have presented.

http://www.ncbi.nlm.nih.gov/pubmed/24837773

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6334a1.htm

http://www.cdc.gov/vaccinesafety/Vaccines/MMR/MMR.html

http://www.cdc.gov/vaccines/vpd-vac/measles/vacc-in-short.htm

Ron Smith, MD, Pediatrics

ronsmithmd.com

Sensibility About Measles Vaccination

History of Vaccines

The first vaccine was aimed at Polio, a virus which can render children and young adults permanently crippled or wheelchair bound or even ventilator dependent. Our experience in America is rife with the images of iron lungs, and even growing up in a small town of 10,000 I knew of an adult who was wheelchair bound from it.

Today, there are only pictures of that terrible past for us. In other countries, such as India, the disease ravages on. Access to the vaccine is the obstacle.

Whooping cough, known to me as a Pediatrician as Pertussis, used to be a rampant childhood illness also. Few of today’s Pediatricians have ever confirmed a case they have treated. It is hard, because the best test still requires a thin metal swab be inserted into the nose all the way to the very back of the nasal cavity. Very carefully the swab is rotated to sweep off some of the cuboidal epithelial cells of the mucous membrane there. Mucous and blood will not do and may cause the test to be falsely negative. Picture trying to do this in a 4 month old baby.

Now the swab has to be carefully rolled on the surface of a fresh, clean glass slide, so that the epithelial cells become adherent to it. The number of cells you get onto the slide is critical to the diagnosis of Pertussis. The bacteria adheres to these cells and the more you get the better. You see the slide must then be air dried and packed in a special cardboard transport package and sent off for testing. At the lab, the slide is treated with a special fluorescent antibody stain which sticks to the bacteria on the epithelial cells. If there are not enough bacteria or the epithelial cells that were collected didn’t have the bacteria attached to them, then there is no fluorescence. Thus a negative fluorescent antibody test for Pertussis, could mean that the test was truly negative, or falsely negative. There are few other tests that offer better results even today.

Measles is a viral infection which produces a rash and high fever. The tell-tale signs of the Koplik spots in the inside of the cheeks is very short lived. In addition to this, there are relatively few cases in the US because the vaccine is so effective. Because there are so many other viruses that causes rashes, what medical professionals call exanthems, most physicians have never seen a true case. I haven’t seen a bonafide case in my thirty-three years of Pediatrics, and if I ever considered the diagnosis, the clinical impression must be confirmed with serologic testing.

Herd Immunity

In the discussions about population immunity, what is referred to as herd immunity, the theory is that at some point if you get enough individuals vaccinated that you can eliminate the existence and spread of the disease. Those individuals who aren’t immune to the disease are then so spread apart by the individuals who are that all become protected. In cases of the original oral Polio vaccine, when you immunized a child, they shed that attenuated virus in their stool, and as a result other chidren and individuals who because infected with it, also could develop immunity.

Not all individuals who are vaccinated become immune to the targeted infectious agent. Developing an immunologic response to an infection is critical here. Vaccines are rated by their effectiveness at producing an immunologic response. I like to see vaccine responder rates of 90% to 92%. Rates of 95% are excellent.

Threats To Effective Herd Immunity And Infection Barriers

I see three threats with varying levels of concern toward the protection of population from diseases for which we vaccinate. Understanding these is very important especially when everyone is throwing in their two cents on how to deal with serious threats of infectious spread at the population level.

If the number of vaccinated individuals in the population drops to some certain level, then you will have more and more non-vaccinated individuals contacting other non-vaccinated individuals. Non-vaccinated individuals would include both those who were too young to produce a reliably adequate immunologic response, such as with measles and children under a year of age, and those individuals who have compromised immune health issues that precludes their vaccination.

It also includes those individuals who could have have gotten an immune response, but didn’t get the vaccine. The recent focus on American citizens who refuse the vaccines for their children however, have overlooked the more significant threat, which is individuals coming to our country unvaccinated. They pose a much bigger threat because by virtue of being outside our society, we have no way to monitor or encourage vaccination, nor do we know that the vaccines they received are ones that are effective, since vaccine manufacturers in other countries are not held to the higher standard generally required here in the United States.

Additionally, there is this thought that once you are vaccinated, that you’re good to go. That is not true however, as anyone sustaining a pentrating wound with a rusty nail would understand after they got a tetanus booster. This is particularly true of Pertussis which I mentioned already.

Not many medical studies really impact what Pediatricians actually recommend in the exam room. About a half dozen years or so ago, however a study came out which really caused me to tack in how I dealt with coughs in children. It turns out that an adult who has a cough that lasts two to three weeks has a 21% chance of actually having Pertussis. This is the prime reason we have to still be so vigilant even with a vaccination effort that has been effective but unable to mostly eradicate this disease. The repository of the bacteria is in the adult population whose childhood immunity has waned. As adults they don’t get as sick as infants, and most actually don’t go to a physician and get treated with the proper antibiotic. The usual antibiotics are all but ineffective agains Pertussis.

This adult repository is the reason that I recommend all parents of newborns that I see to get a Tdap, which is a tetanus vaccine that includes the Pertussis. Many hospitals are now starting to give the vaccine as well to the parents of newborns before they go home. I laud this, but the one problem in ERs and urgent cares is that many of them still give the Td tetanus vaccine which does not contain the Pertussis vaccine component.

Where Pertussis, which is called the Hundred Days Cough for good reason, can easily hide in the adult population by simply being a prolonged cough, Measles symptoms are not so easily undetected. High fever, coryza, and rash usually prompt an exam. Serious sequelae of measles is relatively higher than Pertussis. In the dozen or so cases of whooping cough that I’ve diagnosed in all my years have all responded well and none died. Measles can debilitate and kill.

To bring this all then back to three threats to preventing the spread of these infectious diseases in our country we have to pay close attention. The largest threat to our unvaccinated population of citizens comes from non-citizens who visit here or come illegally. Large amusement parks like Disneyland will promote the mix of those foreign individuals with our population. Similarly large warehouse-sized retail outlets are highly likely to be points of transmission of infectious disease. Personally I caution parents with newborns that Walmart and other large high-traffic stores are possibly a risk. Though I am guessing, I would suspect that many of the retailers might see 10,000 up to mabye even 50,000 people a day vist them. Contagion doesn’t have to be personal contact. I consider all the surfaces in those stores to be infection risk myself.

Clearly the biggest threat is the way our population mixes in normal life now compared with thirty years ago when superstores and large amusement were an rarity.

The second largest threat is from the waning immunity of our population. We are not vigilant enough as individuals toward vaccination as a lifelong thing. We associate vaccination with children.

Now we come the third threat I see from those individuals who are not vaccinated. While our citizens must be vigilant about Pertussis, these individuals can be vectors for disease. Unvaccinated popultions can include citizens of our country who can’t, or choose not to, be vaccinated. Those ‘antivaccine’ individuals actually make up a very small part of this. The problem is the non-citizens who are not vaccinated who visit or come and stay here illegally. The number of these individuals is so very much greater than citizens who choose not to vaccinate, yet I see this mostly ignored in discussions about forcing all citizens in this country to be vaccinated.

When a non-citizen comes to this country they do not have to show immunity to these diseases. Yellow fever is perhaps the exception. If you as a citizen visit certain areas of the world, you will be required to show proof that have been vaccinated upon reentry. This yellow fever certificate is as valuable as your passport. We don’t do this for measles. We don’t do it for Pertussis.

While presently there is a raging anger at those citizens who choose not to vaccinate, there is nothing said about foreign visitors who come to this country, and the conversation is even shunned when we discussed illegal visitors because of the current political correctness that is choking society.

What Should Be Our Priorities

If we are to eliminate the threat of such serious diseases like measles, then we must stop unvaccinated individuals at the border. We already do this for Yellow Fever so this is not novel. We must start admitting that illegal immigration carries more than political and ecomonmic implications. The health implications are the ones that will bring home the serious illness to our children.

We must stop being angry at those citizens who choose not to vaccinate their children. As a Pediatrician I think they should vaccinate and that the vaccines are safe. As a free citizen, however, I cherish the freedom that our country was founded and built on. It is no different than free speech. It is not only the ones who lose their freedom to choose, that lose their freedom. We all lose.

Many years ago in the new wake of the popularity of breastfeeding, I heard of a clinic in the Tulsa area where I trained, that stopped taking new infants whose mothers didn’t breast feed. Is that nonsense any different that medical practices who refuse to take children who aren’t vaccinated?

The most important way to prevent contagion in a medical office is to use appointment scheduling and stay on target with the exam schedule during the day. This prevents the mix of patients in the waiting rooms. Walk-in clinics are notoriously effective at transmitting infectious agents from one patient to another. Urgent cares and ERs are often very crowded, yet we see an alarming percentage of children who get almost routine healthcare there instead of establishing a regular physician relationship to private practitioners.

We stopped using paper on our exam tables long ago. The typical practice is in most practices to simply pull a fresh piece of paper over the exam table rather than actually clean the surfaces with an appropriate disinfectant.

Our policy is that we will try to take care of things that don’t need to be seen without a visit to our office. This makes not only good economic sense for parents, but good contagion prevention for the children we see.

I strive to develop good relationships with all my parents, even those who don’t want to vaccinate. Trying to force them goes against my grain, and will not be effective anyway. Developing a strong physician bond and trust can give parents a reason to decide to vaccinate. It is not that I’m trying to accommodate their decision, but rather give them access to my knowledge so they won’t be led astray by Dr. Google and all his non-medical cohorts. In a nation used to its freedom, there is marked push back when one group focuses on another over traditionally free-choice areas in our lives as though they are the bad guys

Its Just Chickenpox, Right?

I’m always very careful not to lambast parents who choose not to vaccinate. The reason is that I want to persuade rather than force. This is supposed to be a free country and even if I think otherwise about vaccines, I do think we ought to respect the right to choose not to vaccinate.

Be that as it may, this post itself is to give parents who choose not to vaccinate an informed appreciation for the darker side of that choice.

In an article posted here on ABC News’ web site, there is a sad story of a six year old girl who contracted chickenpox, i.e., varicella, and then subsequently developed pneumonia. The storm of both infections was more than she could repel. She passed on in her mother’s arms.

Her mother was reportedly talked out of childhood vaccines that have proven efficacy against those infections by the child’s physician. He apparently told her he was suspicious of the vaccines and that the child should be exposed to the illnesses and develop immunity naturally.

At autopsy, Abby was found to not have a spleen, which predisposed her to fatal infection by encapsulated bacteria in particular. Her asplenia is what happens to children with Sickle Cell Disease where the malformed red cells destroy the spleen over time. We vaccinate those children to Pneumococcus to prevent those fatal kinds of infection.

So often anti vaccine proponents tend to point blame at reactions to vaccines. But the dark side is that not giving vaccines is not the same thing as doing no harm.

Let me repeat that I staunchly support a parents right to refuse medical care, including vaccines, (except of course in the case of child abuse), but it is vitally important to clearly understand that not vaccinating does not equate to no consequences.

If you have further questions about vaccines, come in for an appointment and I’ll be glad to tell you what I know. We will treat you with respect and courtesy and answer your questions honestly.

Warmest regards,

Ron Smith, MD

A Mere Christian

A Mere Christian

What Christians Need To Know About Christianity

Just last week I published a work that some of you might be interested in. I teach Sunday school at my church and have been teaching Mere Christianity by C. S. Lewis. My book is called A Mere Christian and is the culmination of things I’ve learned and taught about what Christians should know about Christianity. If you are a Christian then this book is for you. The website is http://www.amerechristian.com for the book where you can read excerpts and learn more. It is available currently as an ebook on Amazon, Barnes & Noble, and iTunes for iBooks. I hope soon to have an on-demand print copy in Amazon as well.

School Letters Policy

Because of stricter guidelines for attendance at schools, parents are required to provide school notes for any days of school that will be considered “excused”. Most schools will allow parents to write notes for minor illnesses, but have a limited number of “non-excused” absences. For this reason, we are asked to supply school notes for various reasons. Therefore, we have put in place the following policies for school notes that we will write.

  1. Absence due to illnesses: We will provide an excuse for any patient who is seen in our office that is sick. If you child is running a fever the date of his office visit, he may not return to school until he is fever-free for 24 hours. If the student tests positive for illnesses such as strep or mono, we will adjust the days of excused absences accordingly. If you choose to keep your child at home additional days, then you may attach a parent’s letter to our office letter for the school office.
  2. If your child was seen in the ER or after-hours care, or by a specialist’s office, even if referred by our office, you must request a school note from that doctor or office. We cannot write school excuses for other providers.
  3. Some schools and daycares have begun asking parents to get “special request” letters from their doctor’s office. These letters include special diet requests, reduced activity requirements, special bathroom privileges, etc. These requests will be written for patients seen in the last 12 months and only if deemed medically necessary by the provider and documented in your child’s chart. For instance, if your child has a known food allergy, etc, that requires a special diet plan, that allergy must be noted in your child’s medical chart in our office in order for us to write a school note.
  4. If your child participates in sports at school, sports physicals can be done in conjunction with your child’s annual physical (well check). The sports participation forms required by schools can be provided at the end of the physical. These are good for only one calendar year. We can fax the forms, but please be aware that the forms have a page that must be completed by the parent.

Thank you for your understanding and help with this matter.

After-hours Care Recommendations

We strive to always see patients in our office for medical care. It is not only cheaper, but much more efficient. Sometimes however, your child may need treatment when my office is not open. We often are asked our recommendations and so we have put together a list of the best sources of after-hours care in our opinion. This is not to say that in an emergency you should ignore other places to get treatment. Sometimes situations demand other choices. These recommendations are intended to be a helpful list. Please note, all urgent care providers’ hours of operation may change during any holiday.

After-hours pediatric urgent care

CorrectMed
4861 Bill Gardner Parkway
Locust Grove, GA
770-626-5740

  • Hours: Mon-Fri, 8 am-8 pm, last appt @ 7 pm. Sat-Sun, 9 am-6 pm, last @ 6 pm.
  • Does not accept Medicaid or HMO plans
  • Has x-ray capability
  • Will see children 3 months and older

Primary Pediatrics
110 Regency Park Drive
McDonough, GA
770-288-2285

  • Hours: Mon-Fri, 5 pm-10 pm; Sat-Sun, 10 am-9 pm
  • Accepts most insurance plans
  • No x-ray capability

Kids Time Pediatrics
125 Eagles Walk
Stockbridge, GA
678-289-4483

  • Hours: Mon-Fri, 6 pm-9 pm; Sat-Sun, 10 am-5 pm
  • Accepts most insurance plans
  • Not an emergency care facility

Pediatric Emergency Care Facilities

Scottish Rite Children’s Hospital
Atlanta, GA.

Osha Blood Borne Pathogen Occupational Exposure Policy

Section A. Occupational Exposure Policy

1. The purpose of this policy is to prevent the occupational exposures of the staff to the following potentially infections materials: blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, plural fluid, amniotic fluid, pericardial fluid, peritoneal fluid, saliva in dental procedures, and human tissue.

2. Occupational exposure means contact with skin, eyes, mucus membrane, or parenteral exposure by the potentially infectious materials.

3. Information and training: all employees involved in work that would involve occupational exposure must participate in a training program which must be provided at no cost to the employee, during working hours. The training shall be provided at the initial time of assignment and at least annually thereafter. Any new standards of or techniques shall be taught at the time of their inclusion into the program. The training program shall include:

  • a general explanation of the epidemiology and symptoms of blood borne diseases and their modes of transmission;
  • an explanation of the employer’s control plan and a copy of the control plan;
  • and explanation of which activities involve exposure to potentially infectious materials and the methods which will prevent or reduce exposure to them;
  • the proper handling and disposal of potentially infectious materials and protective equipment;
  • all necessary information on the hepatitis vaccination
  • information on what action is to be taken in case an emergency occurs, or an exposure incident occurs; and
  • information on post-exposure follow-up.

4. Training session records shall include: the date of the session; a summary of the session; the names and titles of all persons attending the session. These records shall be kept for at least three years from the time of the session and shall be made available to the appropriate person(s) if requested. These records shall be available for transfer as required by the Director (the Director, Department of Labor, Occupational Safety and Health Administration). If the business ceases and there is no one to transfer the records to them the Director shall be notified and he shall receive the records; if he so desires.

5. The employer shall establish and maintain an accurate record for each employee with occupational exposure which shall include:

  • the name and social security number of the employee;
  • a copy of their hepatitis B vaccination status; a copy of all results of medical exams and testing;
  • a copy of the health care professional’s written opinion of the situation; and
  • a copy of information provided to the health care professional.

The employee’s medical record shall be kept confidential and not divulged except with the written consent of the employee. These records shall be kept for the duration of the employee’s employment plus 30 years.

6. Definitions of contamination and decontamination: If something is contaminated it has the presence of a potentially infectious material on it. Examples of potentially contaminated items include laundry and sharpes (sharpes are any objects that can penetrate the skin). To decontaminate something means by the use of physical or chemical means to inactivate or to destroy infectious materials on the item to the point where they can’t transmit disease.

7. Personal protection equipment (which shall be impermeable to all potentially infectious materials) will be worn when there is a risk of occupational exposure to potentially infectious materials. This equipment included the following: gloves, gowns protective equipment shall be available at the work site whenever there is risk of occupational exposure. When the employee leaves the work area, the equipment shall be removed and stored, cleaned, or disposed of by the employer. If a protective garment is penetrated by a potentially infectious material it shall be removed as soon as feasible. If gloves are penetrated they shall be replaced as soon as feasible. Disposable gloves shall not be reused. If an employee declines to use protective equipment this event has to be documented and a wavier has to be signed by the employee. Masks and goggles shall be used whenever there is danger of contamination of the face or eyes by potentially infections materials.

8. Handwashing facilities shall be available in every work site. If these are not readily available an appropriate antiseptic hand cleaner in conjunction with appropriate clean clothe or paper towels shall be available. Employees shall wash their hands as soon as feasible after removing protective equipment. If they come in contact with potentially infectious material they shall wash their skin with soap and water and flush mucous membranes with water. The work site shall be maintained in a clean and sanitary condition. All equipment and working surfaces shall be cleaned and decontaminated after contact with potentially infectious materials as soon as feasible. Such equipment includes bins and pails. Broken glassware which may be contaminated shall not be directly picked up with you hands. Housekeepers need to use gloves and other appropriate equipment when cleaning a work site. Use appropriate antiseptics. Bleach at 1:10 or metri spray-cetylcide or autoclave for instruments.

9. Eating, drinking, and applying cosmetics are prohibited in work areas where contamination is possible. Food and drinks shall not be kept in these hazardous areas. All procedures involving potentially infectious materials shall be done as carefully as possible to minimize splashing, spraying, spattering, and droplets of these materials. Mouth pipetting is prohibited.

10. Contaminated needles shall not be recapped but carefully placed in the appropriate container. These containers shall be OSHA approved. All potentially infectious materials shall be disposed of in the appropriate OSHA approved containers. The containers shall be closed prior to removal from the work area and prior to shipment to the appropriate facility for disposal. Disposal containers shall be available in each work area. Contaminated laundry shall be transported in the appropriate bags which can be closed and are leak proof for all potentially infectious materials. The bags shall then be transported to the appropriate facility for disposer. Protective gloves shall be worn when handling such materials if there is risk to the face.

11. Hepatitis B vaccination shall be offered to all employees who are at risk of exposure. This shall be offered to them within ten working days of employment. The schedule for vaccinations is as given by the state health department recommendations for Hepatitis B.

12. Post-exposure evaluation and follow-up: following a report of an exposure incident, the employer shall make available to the employee a confidential medical evaluation and follow-up including the following documents:

  • documentation of the route of exposure and the circumstances under which the incident occurred; and
  • identification and documentation of the source individual if feasible.

The source individual’s blood shall be tested as soon as feasible for HBV and HIV infectivity if consent is obtained (unless consent is not needed) from the individual. Results of the source individual’s testing shall be made available to the exposed employee. If consent is obtained the exposed employee’s blood shall be tested as soon as feasible. All of the above are to be documented (as well as results of medical exams and blood testing) Within fifteen days of the completion of the evaluation the employee shall be given a written opinion of the evaluation.

13. Dates: this plan is currently effective in all aspects for all office locations.

14. Hepatitis B vaccination schedule: per current health department recommendations. Post-exposure management policy is included in the training also.

15. Gowns- at least 12, masks- at least 12, goggles- at least 4 per office.

Section B. Application Of The Occupational Exposure Policy

1. A Staff Exposure Assessment List will be kept on the premises and will include:

  • A list of all staff and those who are at risk
  • Indication of those who have reviewed the occupational exposure policy and discussed it
  • Indication of those who have been offered the Hepatitis B vaccine
  • Indication of those who were given the opportunity to sign any necessary waivers concerning vaccinations and protective equipment
  • Indication of those who have had occupational exposure incidents

2. Regular inspection and replacement of any defective equipment shall be on a monthly basis and more often as needed.

3. Sharpes containers shall be replaced when full and picked up by a licensed disposal company. They shall be sealed while waiting to be picked up. Needles can be removed from syringes and deposited in sharpes containers and the syringes disposed of in the regular garbage if no blood was drawn into syringe. If blood was drawn into the syringe the syringe and the needle are to be disposed of in a sharpes container. The needle is to be removed from the syringe with a hemostat or other appropriate device. Do not bend, shear or break contaminated needle. Needles are never to be recapped. Broken glass is to be cleaned up with a dust pan and brush. Capillary tubes need to be put into sharpes containers.

4. Any containers that may be contaminated or leak must be placed in a second container: containers must be maintained in an upright position during transport..

5. The work areas that are contaminated will be cleaned as soon as feasible after a procedure and then daily by the cleaning crew. Appropriate antiseptic will be used.

6. Contaminated laundry is to be bagged in labeled containers using gloves (and gowns if necessary). It is then to be transported to the laundry facility where it is again handled with gloves. It is then washed and brought back to the office where it is autoclaved before additional surgical use.

7. The following categories associate tasks with the required protective equipment.

Job Category Nature Of Task Personal Protective Equipment
Available Worn
I Direct contact with blood or other body fluids to which universal precautions apply Yes Yes
II Activity performed without blood exposure but exposure may occur in emergency Yes No
III Task/activity does not entail predictable or unpredictable exposure to blood No No

8. Urine slide covers will be disposed of in sharpes containers, and slides will be cleaned and soaked in antiseptic and reused. Cotton swabs and tongue depressors will be disposed of in the regular garbage. Used gloves, masks, and gowns will be disposed of in the regular garbage.

9. Throat cultures and urine cultures will be disposed of in red bags marked as hazardous waste.

10. Documentation for the following will be maintained:

  • Vaccination forms
  • Training forms
  • Incident forms and follow-up
  • Inspection (monthly) forms
  • Annual training forms

Section C. Hepatitis B Vaccination Policy

1. Hepatitis B vaccination will be made available to all employees who are at risk for occupational exposure to bloodborne pathogens. The vaccine will be offered in accordance with existing employee health protocols:

  • within 10 working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete Hepatitis B vaccine series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.
    • A prescreening program is not a prerequisite for receiving the Hepatitis B vaccination.
    • If the employee initially declines Hepatitis B vaccination but at a later date decides to accept the vaccination while still employed and still at risk for occupational exposure to bloodborne pathogens, the Hepatitis B vaccination will still be available.
    • The employees who decline to accept Hepatitis B vaccination offering will sign a statement of refusal.
    • Routine booster doses of Hepatitis B vaccine which are recommended by the US Public Health Service at some later date will be made available to employees free of charge.
  • and after the employee has received the required training, including information on Hepatitis B vaccine safety, efficacy, method of administration, vaccine benefits, and its provision to the employee free of charge.

2. Hepatitis B vaccine will be administered in accordance with existing employee health protocols for administration of the vaccine..

3. Our office has administrative responsibility for overall compliance with this protocol.

4. Hepatitis B Vaccine. Please read the following carefully. Employees will have the opportunity to ask questions and have them answered to their satisfaction before making a decision about receiving the Hepatitis B vaccine.

  • Hepatitis B is an inflammation of the liver caused by the Hepatitis B virus. You may not be very ill with the virus or you may have severe symptoms that require hospitalization.
  • The symptoms of Hepatitis B include loss of appetite, fatigue abdominal discomfort or pain, an enlarged liver, jaundice (yellow skin tone) and abnormal liver function tests (blood tests).
  • People who have Hepatitis B can develop long term consequences that include chronic active Hepatitis, cirrhosis, and liver cancer.
  • Health care workers are 20 times more likely to contract the virus than the general public.
  • Everyone who has contact with blood or body fluids is a risk. Your job description signifies whether you are at risk.
  • The Hepatitis B virus can survive for seven days in dried blood. Every contact with the Hepatitis B virus is capable of causing infection.
  • You have as high as a 30% chance of contracting Hepatitis B from a single contaminated needlestick.
  • Shot-term consequences of Hepatitis B include an average of seven weeks lost from work, and the risk of permanent liver damage.
  • Long-term consequences include chronic active hepatitis and cirrhosis of the liver, as well as a 12-300 times greater risk of developing liver cancer.
  • Every week 4 to 5 health care workers die of Hepatitis B or its complications.
  • The vaccine, Engerex-B, is a noninfectious synthetic vaccine, containing no blood or blood products.
  • Three doses of the vaccine administered appropriately (IM in the deltoid_ over a six month period will provide protection to over 90% of recipients. Immunity is thought to be for life.
  • Local reactions may include soreness, redness, and swelling at the injection site.
  • Contraindications to receiving the vaccine include; sensitivity to yeast, sensitivity to thimerosal (vaccine prior to the middle of 2000), pregnancy, breastfeeding, cortisone therapy.
  • The vaccine will only protect you from Hepatitis B.
  • You may donate blood if you receive the vaccine.
  • The Hepatitis B vaccine is offered free of charge to all employee who are at risk for occupational exposure to blood and/or body fluids.

Section D. Bloodborne Pathogens Exposure & Post-exposure Policy

1. Exposure Incident will be defined as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.

  • Blood will be defined as human blood, human blood components, and products made from human blood.
  • Bloodborne pathogens will be defined as pathogens microorganisms that are present in human blood an can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).
  • Potentially infectious materials will be defined as the following human body fluids:
    • semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;
    • any unfixed tissue or organ (other than intact skin) from a human (living or dead);
    • HIV-containing cell or tissue cultures, organ cultures, and HIV or HIV-containing culture medium or other solutions.

2. Medical evaluation, procedures, and follow-up will be:

  • Made available at no cost to the employee through the practice
  • Made available to the employee at a reasonable time and place.
  • Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional.
  • Provided according to recommendations of the US public health service current at the time these evaluations and procedures take place. The doctor will review and update post-exposure management guidelines as new directives are issued, but at least annually.
  • All lab tests will be conducted by an accredited laboratory at no cost to the employee.

3. Post-exposure evaluation and follow-up will include at least the following elements:

  • Documentation of the route(s) or exposure, and the circumstances under which the exposure incident occurred
  • Identification and documentation of the source individual, unless identification is infeasible
    • The source individual’s blood will be tested as soon as feasible for HBV; and as soon as consent is obtained, for HIV infectivity. Individuals who will not consent can be tested in accordance with policy.
    • When the source individual is already know to be infected with HBV or HIV, tested for the source individual’s known HBV or HIV status need not be repeated.
    • Results of the source individual’s blood, if available, will be made available to the exposed employee, and the employee will be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.
  • Collection and testing of blood or HBV and HIV serological status of the employee:
    • The exposed employee’s blood will be collected as soon as feasible and tested after consent is obtained.
    • If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.
  • Post-exposure prophylaxis, when medically indicated, will be as recommended by the US public health services, to include counseling and evaluation of reported illnesses.

4. Information provided to the healthcare professional responsible for the employees Hepatitis B vaccination and/or the employees evaluation after an exposure incident will include at least the following:

  • A copy of the OSHA regulation 29cfr part 11910.1030 Occupational Exposure To Bloodborne Pathogens; Final Rule
  • A description of the exposed employee’s duties as they relate to the exposure incident
  • Documentation of the route(s) of exposure and circumstances under which exposure occurred
  • Results of the source individual’s blood testing, if available
  • All medical records relevant to the appropriate treatment of the employee including vaccination status

5. The healthcare professional’s written opinion will be obtained and provided to the employee within 15 days of the completion of the evaluation.

  • The healthcare professional’s written opinion for post-exposure evaluation and follow-up will be limited to the following information:
    • Whether Hepatitis B vaccination is indicated for the employee has received such vaccination
    • That the employee has been informed of the results of the evaluation
    • That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.
  • All other findings or diagnoses will remain confidential and will not be included in the written report.

6. Medical recordkeeping: the office of Ron Smith MD will establish and maintain an accurate record for each employee with occupational exposure to include:

  • The name and social security number of the employee
  • A copy of he employee’s Hepatitis B vaccination status including the dates of all the Hepatitis B vaccinations and any medical records relative to the employee’s ability to receive vaccination
  • A copy of all results of examinations, medical testing, and follow-up procedures
  • The employer’s copy of the healthcare professionals’ written opinion
  • A copy of the information provided to the healthcare professional
  • All medical records will be kept confidential and will not be disclosed or reported without the employee’s express written consent to any person within or outside the workplace expect as required be law, and will be maintained for at least the duration of employment plus 30 years.

Section E. Post Test

This section requires registration and an invitation code. Please use the code ‘RSMD’ when you register.

You need to be registered and logged in to take this quiz. Log in

This Time

Online For Life has an amazing video created in partnership with John Elefante. I think this tells the argument for life with amazing visual clarity. Thanks to Online For Life for graciously permitting me to link to the music video here. If you think that your situation is too hard, then I would suggest you read our Laura’s ebook story, Forever And A Day For Laura Michelle, available free on iTunes. May I also suggest full screen viewing.