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The ins and outs of immunization

The American Academy of Pediatrics, the American Academy of Family Physicians and the Center for Disease Control's Advisory Committee on Immunization Practices recently released their updated immunization schedule for 2000. There are three major changes and one addition.

Administration of rotavirus vaccine at 2, 4 and 6 months of age is no longer recommended.

Inactivated poliovirus vaccine is now recommended for all four doses of vaccine. Oral polio vaccine (OPV) is no longer approved for routine use. This is an attempt to eliminate the risk of vaccine-associated paralytic polio, which is associated only with OPV.

Acellular pertussis vaccine combined with diphtheria and tetanus toxoids (DTaP) are now recommended for pertussis vaccine in the United States. The whole-cell pertussis vaccine (DTP) is no longer advised.

The only addition to the schedule was hepatitis A vaccine, but it is recommended only in areas with a high incidence of hepatitis A infections. Physicians and parents should consult their local health department to determine whether this vaccine is needed.

Hepatitis B: In April 1992, physicians caring for children began immunizing infants against the dreaded hepatitis B virus. About 200,000 to 300,000 hepatitis B infections occur every year, causing 5,000 deaths from chronic liver damage and liver cancer.

Hepatitis B is passed through blood or body secretions exchanged during sexual relations, or from the sharing of hypodermic needles or razors. In about 27 percent of children who contract the disease, none of the previously mentioned risk factors are present. Since the number of hepatitis B cases is rising in adolescents, it is required that all children complete the series by the time they start seventh grade. The hepatitis B virus, incidentally, is 20 times more contagious than the AIDS virus.

Children born before April 1992 who have not started (or completed) their three dosages of the hepatitis B vaccine series should see their physician. The vaccine is safe, and side effects are rare. Infants should receive the first dose of hepatitis B (HepB) vaccine by 2 months of age. The second should be given at least one month after the first, and the third at least four months after the first.

Measles mumps rubella (MMR): The MMR vaccine protects children against measles, mumps and rubella (or German measles). For many years, it was given between 12 and 15 months, and no booster was necessary. Recent measles outbreaks in young adults prompted medical authorities to require a second MMR vaccination on entry into kindergarten. This change took place in 1993, which means that many adolescents may not have had a second MMR vaccine. Parents who do not think their older child is current should contact the youngster's physician. Like the hepatitis B vaccine, few adverse reactions have been noted following a MMR booster. Though most children recover completely from measles, serious complications can occur, including pneumonia and encephalitis (brain infection).

Tetanus-diphtheria pertussis (whooping cough): Diphtheria and whooping cough used to be two of the most feared childhood illnesses, before the vaccine. Though both diseases are rare today, they are deadly and difficult to diagnose. All three diseases can have severe consequences. Tetanus, also called "lockjaw," can produce severe muscle spasms in the jaw muscles, neck and face, causing death in one out of three affected children. The respiratory form of diphtheria causes a thick, gray membrane in the back of the throat, leading to airway obstruction. In addition, a poison can enter the bloodstream, causing inflammation of the heart muscles. (Incidentally, adults should receive a tetanus-diphtheria booster every 10 years.) Whooping cough causes uncontrollable coughing attacks, leading to pneumonia and brain damage from inadequate oxygen. Before the vaccine, it killed thousands of babies a year. Only the acellular form of the vaccine is now recommended, in combination with diphtheria and tetanus (DTaP) given at 2, 4 and 6 months of age, with boosters between 15 and 18 months of age and between 4 and 6 years of age.

Varicella (chicken pox) vaccine: Although chicken pox usually is a mild illness, it can result n serious complications, including pneumonia and encephalitis. The disease can also lead to death in children with immune deficiency. The chicken pox vaccine (varivax) can be administered to children any time after 12 months of age. Unimmunized children ages 13 years or older should receive two doses, given at least four weeks apart.

Polio vaccine: Before the vaccine was made available in 1955, polio was common and often resulted in child paralysis. Today, the number of infections has dropped to only a few cases a year. The inactivated polio vaccine (IPV) is now recommended and is not linked to cases of actual polio, as was the oral vaccine (OPV). The vaccine is usually administered at 2, 4, and 15 to 18 months and before the child enters school, or between 4 and 6 years.

Hepatitis A: Hepatitis A is a liver disease caused by the hepatitis A virus. Many children with this infection will not show symptoms. If symptoms are present, they usually occur abruptly and may include fever, tiredness, loss of appetite, nausea, abdominal discomfort, dark urine and jaundice (yellowing of the skin and eyes). Symptoms usually last less than two months; a few patients are ill for as long as six months. Hepatitis A virus is spread from person to person by putting something in the mouth that has been contaminated with the stool of a person with hepatitis A. This type of transmission is called "fecal-oral." For this reason, the virus is more easily spread in areas where sanitation is poor or good personal hygiene is not observed. Most infections result from contact with a household member or sex partner who has hepatitis A. Casual contact does not spread the virus. Hepatitis A vaccine is recommended (before exposure to hepatitis A virus) for children who are at risk of hepatitis A infection or are more likely to become seriously ill if they do get hepatitis A. Parents should consult their local health department to see if hepatitis A is prevalent in their communities.

Over time, children's immunizations have proved so effective at preventing disease that they are now a vital part of a youngster's health care.

If vaccinating a child against life-threatening, preventable illnesses is so easy and safe, why do so many of our youngsters fail to become protected? The major reason seems to be missed opportunities. Parents may mistakenly assume that their child should not be given a vaccine because of a co-existing minor illness. Too often, other concerns or unnecessary precautions lead parents to postpone or cancel scheduled immunizations, leaving their children vulnerable to a serious illness and unable to attend school because of immunization requirements.

The changes in immunization routines are based on medical knowledge, the availability of newer vaccines and judgments by public health officials and medical experts. Thanks to modern vaccines, today's parents will never know about the serious childhood diseases from which their youngsters are protected. This year, additional vaccines are expected to be approved, including new combination vaccines to reduce the number of injections a child receives at each checkup.

Bruce A. Epstein practiced pediatrics in St. Petersburg for 26 years. He edits the Web site