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.
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.
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.