Vaccinations: or, is it too good to be true??

On a trip to South America several years ago I was in a remote village with missionaries and we passed a nice looking van pulled up by the side of the road. I asked “what is that doing out since we  are in the middle of nowhere???” I was told “Oh, that is the vaccination van”- the county health dept gets a lot of vaccinations they need to use up by the end of the month so they send out the van to the villages to give the shots. There were no records of vaccinations being given or taken--the kids just lined up and got whatever shot was being given at the time- never mind that they may have gotten the same shot one month ago or whenever the last time the van was in town.

Although this is not China, this was a vivid illustration for me about the difficulties of knowing whether those shots your child got were really given and were they correct.

There is some sleuthing that can be done by  to get a sense of whether the vaccination record is correct--sort of like determining what the dog did in the nighttime or achieving six impossible things before breakfast. "Watson, the game's afoot!" Here we go:

Several practical questions that come up about vaccinations:

First did the child actually get any of the vaccines that the records said he did?

In 2002 some studies were done on a group of international vaccination records by Schultz (in the Journal Pediatrics 2002) which found that the records were valid in 93% of kids. That being said there are some tip offs that the records may be incorrect. 

First remember in the rest of the world (other than the USA) months and dates are written reversed so 12/1 (Dec 1^st) here is written 1/12 there.

Does the child record show they were immunized before they were born? Yes, believe it or not,  it has been seen.

Are the immunizations in the proper intervals for the series? For example every two months apart rather than one?

Are all the records in the same handwriting and too neat? It is true that some orphanages may have a clinic where the same nurse does all the immunizations but most don't. (on the other hand, can you tell when they are written in Chinese??)

           

If my child got the shots, was she healthy enough to respond to them and get the protection they need? The immune system doesn’t develop good memory if it is malnourished and let's face it, most of these babies are malnourished. If your baby is in the bottom 10% of weight (malnourished kids lose weight first then height and finally head size) then this is a real possibility (but make sure you are looking at the Chinese growth chart, not the US).



How soon do I need to get this evaluation for shots done? Since most kids here in the States have had shots, the chance of your child picking up one of these diseases from another child is low in the short term so a visit within a month of coming home is reasonable unless your child is  around a lot of other children like daycare (the cesspool of pediatrics but oh so good for business) or the church nursery (ditto!)



When we got with  China 1, she was from a small orphanage with bare walls, and bungee elastics holding her diaper on, and even more suspect records; so when we got home and went over the records with our family doctor, he suggested blood tests to confirm whether she had immunity, rather than re-vaccinating  her for the entire lot. I was the lucky parent to pin her down for the blood draw and I wished I had ear plugs. Despite our concerns, her immunizations were confirmed by the blood work and she didn't need any additional shots other than the ones indicated by her current age.



When we got China 2 last month, she was from Beijing Children's Welfare Institute, a large well-funded orphanage with toys, therapy rooms and play rooms that would rival any at a daycare here Stateside, so we were more believing of the records. Even with ,she was due for 5 shots to catch her up to the recommended immunizations for a child of her age, and rather than hitting her immune system with that much excitement (and hitting her and us with that much grumpiness!) we had her get two shots, and will give her a second round after she has forgotten the first. I will admit I am going to draw some bloodwork to verify she got some of the shots they said she did- particularly for diseases that have a high chance of being deadly such as measles, rubella, and HIB. I also recommend having your doctor check for anemia and lead and parasites.

A recent review of this topic provides some help with: the article is Vaccines for Travel and International Adoption by Paul J Lee in The Pediatric Infectious Disease Journal vol 27 (4): April 2008. It yawns to make me even think about reading infectious disease but this was well written, clear, concise and may be worth letting your doctor know about. Out of courtesy to your doctor do not expect the office to be able to decide which and how many immunization your child needs at the time of the visit. Give your physician a copy of the record in advance to look over before you get there or let him get back to you with what needs to be done as these are too complex to figure out in a short visit. 


How to hold a child down for shots or blood work: never a pleasant experience. Our social worker suggests that at this point parents should play a variation of Good Cop Bad Cop: the parent the child has bonded to the best should not be the parent to pin her down for the blood draw or shots. There is an anesthetic cream EMLA available which can be applied an hour before blood is drawn which will help with pain but often just the sight of a needle is enough to send the child over the edge. Explaining what is going to be done may help in older kids but not always. Don't tell a child it won't hurt she is  not stupid! I have seen adults cry like babies about getting blood drawn and 4 year olds hold still for shots (particularly the Amish). As one who has sewn up a lot of lacerations on kids, I have seen a couple of techniques over the years that work well. For shots, the nurses will have their own favorite technique. The key to all of these is to hold tightly-- that is tighter than you are comfortable with. I have learned the trick of applying tremendous pressure with what looks like a gentle hand on the head or arm.

The first is the Bear hug - if the child is older whomever is strongest takes the child in his arms chest to chest with the both arms pinned under the arms--a free arm is going to move to wherever it hurts and usually hit someone. The other technique is to lie the child down on a firm table and literally lie over top of his abdomen with the arms pinned (but beware this won't work unless you really put some weight on him that will prevent movement). The third method, often used for blood work, is the Papoose which is a Velcro board which the child lies down on and is strappen in by velcro into it. It is currently less in favor because it appears to be "mean:" but a flailing child isn't kind either particularly if it results in multiple attempts to draw blood. My favorite for the older kid is the "Superman Cape" with the child standing -you put a pillow case (or wrap a bedsheet around him) on his back with his arms (one arm in the case of blood work) in the pillow case. Once you have him down on the bed, have someone hold the free arm tightly. I always recommend taking the child out for ice cream or some treat afterward a painful experience such as shots or bloodwork.

So here is the summary by vaccine (lab test needed in parenthesis) the whole issue of how many shots we’re giving kids and whether it is good for them is another topic too hot for me to handle. The following is a bit deep and confusing if you aren't  medically trained but your doctor or nurse would understand it if you want to copy, paste and print this list.

Diphtheria/tetanus – if the baby is at least 6 months old check blood work because over-immunization can cause local reactions (diphtheria antitoxoid Ab, Tetanus antitoxoid Ab)

Pertussis- do not check levels because blood levels are often inaccurate. If the tetanus and diphtheria levels were normal you can assume they have immunity to this

Polio- check (Polio  neutralizing AB ( types 1,2,3) if more than 6 months old

Measles/Mumps,Rubella- if the child has records of having had it check titers and reimmunize if not immune to all  (Measles IgG Ab, Mumps IgG AB, rubella IgG AG)

Varicella (Chickenpox) check titers if 12-15 months (Varicella-zoster IgG Ab)

Hepatitis A- check titers if >6 months (Hepatitis A total Ab)

Hepatitis B- Always check to access Hep B chronic infection, carrier state and immunity (Hepatitis BsAg, HB Core Ab, HBsAb) – Hepatitis B is endemic and widely spread in China all children should be checked

Meningococcal- age appropriate vaccination (no titers available)- your baby may have “epidemic cerebrospinal meningitis" on her records – this is for group A and C and is either a tetravalent or bivalent vaccine.

The next two are suggested as no testing just immunize since they are not usually given at young ages but with more and more kids being older many of them did have them listed in their Chinese shot records so I would consider testing if they were listed as having received them

H. Influenza- no testing recommended just immunize if age appropriate or accept records-(H. Influenza type B IgG) – although our baby had this listed as a vaccine so I think they are now giving it.

Pneumococcal- testing not recommended just immunize if age appropriate

Others: if there is a vaccine missing the doctor should use the catch up schedule.

JEV- Japanese encephalitis vaccine may also be given but isn’t usually needed here in the US.

BCG will be covered in a future post- too complex and confusing for this one.

Always note any adverse reactions and report them to your doctor. So there you have it the final word on the alphabet soup of immunizations. Ouch!!!