In December, 2009 my sister Liza died of influenza.
She was previously healthy and only 49 years old. She sought medical care early. She was cared for at a good hospital in a major city. She had no other infections. And she was unvaccinated.
To say I was surprised is an understatement. And yet, I’m a pediatric intensive care physician.
As a clinician, it’s easy for me to trace out the clinical course of Liza’s illness. The physiology of organ failure, mechanical ventilation and critical illness are familiar to me in the same way that your daily work is to you. It’s the human side that I still haven’t come to terms with. The part where you watch your sister die over the course of three long weeks while you stand helpless. The part where you listen to a physician tell your family that they are out of options. The part where you know that they are right and you realize that influenza is sometimes too much to handle, even with all our modern medicine.
That part is much harder to process.
Her symptoms started with fever, but progressed to vomiting after a few days. She went to the urgent care clinic twice over the course of a few days before ending up in the emergency department of the local hospital. She had begun to experience difficulty breathing, and the emergency physician noted that the oxygen saturation in her blood was very low. They put her on oxygen, and an x-ray revealed that both her lungs were filled with fluid. A condition that led to her being diagnosed with pneumonia.
You see, your lungs are supposed to have air in them. They should look like sponges. Pneumonia is just the term we physicians use to describe the situation when fluid, infection, and inflammation fill those little air spaces in the sponge.
Pneumonia can come from viruses or bacteria. If your pneumonia is caused by a bacteria, you can get antibiotics to kill the bacteria. However, if your pneumonia is caused by a virus, like influenza, there is not much we can do but ride it out and wait for your own immune system to clear it. The simple fact is that we just don’t have very good medications for viruses. Tamiflu can be prescribed and it might slow down the virus, but it doesn’t kill it or stop it.
So, they did the only thing they really could do, and started her on IV Tamiflu. She was moved to the intensive care unit downtown, and within the next few hours she struggled to breathe and her oxygen saturations continued to fall. She had to be placed on a ventilator, and the hope was that her lungs would recover after a few days. After all, it was ‘just the flu’.
We never did get to speak with her again.
The timing could not have been worse.
It was the holiday season and many family members were traveling great distances to converge on “Mom’s House”. To complicate matters even more, one family member was temporarily living with her mom as a result of being on bed rest for the duration of her high risk pregnancy.
Her mother, who was a fairly active woman in her mid-70 without any health problems, was complaining about back pain. She believed she had strained a muscle but couldn’t seem to get relief. When the rash appeared a few days later, it became clear that she had shingles.
It really shouldn’t have come as much of a surprise.
About one of every three people in the U.S. will get shingles during their lifetime, and the risk increases with age. For immune compromised individuals, the risk of shingles increases by as much as 50 fold. In fact, every year in the U.S. approximately one million people are affected by shingles.
If you’ve ever known someone who has suffered with this disease, you’ll know why you would want to prevent it.
Shingles can cause severe and long-lasting pain. While the shingles rash typically resolves in about a month for most people, the pain is very difficult to treat. Other symptoms include fever, headache, chills, upset stomach, muscle weakness, skin infection, scarring. Shingles can also develop in the eyes and cause vision loss. Additionally, in about 10-18% of cases, patients will suffer with postherpetic neuralgia (PHN) which is a condition best described as a lingering, burning, stabbing, throbbing, or shooting pain that can last weeks, months or even years.
So with one mom down with shingles, her daughter grew concerned over the arrival of her new baby. Would it be possible for her newborn to contract the virus?
Fortunately, people don’t catch shingles from other people. Rather, shingles (also called herpes zoster) is caused by a reawakening of the varicella zoster virus (VZV) that causes chickenpox. After contracting chickenpox, the virus lives in the nervous system for years – even decades – until something causing it to reawaken. Sometimes it’s reawakened by a waking of the immune system from advancing age or immune-suppressive drugs used to treat cancers. But what’s hardest to accept is that most cases of shingles occur among adults who are otherwise healthy. Even having suffered with shingles doesn’t prevent someone from having it again. In fact, a reoccurrence of shingles happens in about 6% of people.
In the case of the mother and pregnant daughter sharing a home, the possibility existed that the newborn baby, too young for varicella vaccine, could potentially be at risk of contracting chickenpox if she were to come into contact with the rash of the infected grandmother. This is why the family was advised by their doctors to be extra diligent in washing hands after touching any of the open sores.
While there are verified cases of shingles in people of all ages – even adolescents – the risk of shingles appears to peak in those age 65 and older (as seen in the chart at left).
So, while scientist have been observing an increase in the incidence of zoster since 1993, they attribute the rise in cases to an aging population as well as a population who is increasingly immune compromised.
To complicate matters further, experts explain that the epidemiology of zoster has been changing and it’s unclear exactly why. The current vaccine, which we know to have poor efficacy in the high risk elderly, also does not provide long-lasting protection. However, it can reduce the risk of shingles by half (51%) and reduces the risk of prolonged pain at the rash site by 67%.
When shingles vaccine was first licensed in 2006, it was approved for use in people age 50 and over. In fact, the research at that time determined that the shingles vaccine had a 70% efficacy among people ages 50-59. However, the efficacy was reduced when administered to older individuals, and protection continued to decline significantly at 5-10 years post vaccination.
So, when the Advisory Committee on Immunization Practices (ACIP) announced their adult vaccine recommendations in 2008, they recommended one dose of shingles vaccine be administered to adults at age 60 and older. Their decision was based on the belief that vaccine administrations should be timed to achieve the greatest reduction in burden of disease and the related complications. Since there was insufficient evidence of long-term protection offered by the zoster vaccine, it was believed that vaccinating persons under 60 years of age may not help protect people when the incidence of herpes zoster and it’s complications were at their highest.
While it appears that there has been a downward trend in childhood cases of shingles since 2005, most likely as a result of increased varicella vaccination among children, current shingles vaccine uptake among adults 60 and over is lower than most other adult recommended vaccines at just 27.9%. If uptake were greater it is suspected that we would be seeing fewer cases.
In looking ahead, we are hopeful that two new shingles vaccines will prove to be more effective.
Every Child By Two’s State of the ImmUnion campaign is honoring National Immunization Awareness Month (#NIAM16) with a Blog Relay highlighting the importance of vaccines across the lifespan and across the nation.
In this guest post, we hear from Heidi Parker, MA, Executive Director of Immunize Nevada. She reminds us that promoting health and preventing disease is not just a cause to recognize during the month of August; instead, it is something we need to do each and every day.
By Heidi Parker, MA, Executive Director of Immunize Nevada
Dr. Donald A. Henderson passed away recently, with little media attention or fanfare. This is alarming, considering “saving millions of lives” was listed as one of his life accomplishments.
In case you’re wondering who he is, Dr. Henderson led the global effort to eradicate smallpox — a disease that, in the 20th century and before it was extinguished, was blamed for at least 300 million deaths. Clearly, his triumph over smallpox proved the power of vaccines.
During National Immunization Awareness Month, we are reminded that promoting health and preventing disease is not just a cause to recognize during the month of August; instead, it is something we need to do each and every day.
We must be relentless, much like Dr. Henderson was. Why? Because our news feeds continue to be filled with stories of vaccine-preventable diseases – a teen dies from meningococcal disease; a summer camp closes due to a whooping cough outbreak; college campuses battle mumps; measles spreads at music festivals; an infant too young to be vaccinated dies from pertussis; the list goes on.
In the United States, vaccines have reduced — and in some cases, eliminated — many of the diseases that killed or severely disabled people just a few generations ago. My great-grandfather died during the 1918 Influenza Flu Pandemic, along with millions of others; but decades later, our family is protected from this deadly virus when we get our annual flu shot. By vaccinating children against rubella (German measles), the risk that pregnant women will pass this virus on to their fetus or newborn has been dramatically decreased, and birth defects associated with that virus are now rarely seen. Countless examples like these demonstrate, day after day, vaccines are one of public health’s greatest achievements.
Unfortunately, tens of thousands of Americans still suffer serious health problems, are hospitalized, and even die from vaccine-preventable diseases. Read more…
Written by Every Child By Two intern, Linn H.
As students of public health, through our courses and fieldwork, we often have the opportunity to travel the globe and work with populations from all walks of life. However, with these great opportunities comes a great responsibility to protect others by protecting ourselves.
I’m not saying we all need to be like Spider-Man here, or that we’re heroes with great power. But I do think that knowing you could have done something to prevent a certain fate is an important lesson.
Take for example the recent case of a Washington Women who died as a consequence of contracting measles at a local medical facility. Since she was on medication that suppressed her immune system, this tragedy illustrates the importance of immunizing those that are healthy in order to provide a high level of community protection to those who are more susceptible to illness.
This case illustrates the fact that many individuals rely on healthy adults like myself to help prevent the spread of dangerous and even deadly diseases. Infants too young to be vaccinated, older adults, and people with weakened immune systems (like those undergoing cancer treatment) are especially vulnerable to infectious disease.
That’s why it’s important for adults to become educated on the recommended adult vaccines. If we fail to get routine vaccinations as an adult, we put those around us and ourselves at risk.
As adults, there is often this misconception that vaccines are just for children, but we never outgrow the need for immunizations.
Vaccines are recommended throughout our lives based on age, lifestyle, occupation, locations of travel, medical conditions and vaccines received in the past.
Even if you were fully vaccinated as a child, the immunity that you received from some of the vaccines you were given can wear off. Vaccines not only prevent against illnesses that we’re susceptible to as adults, but they help protect others we come into contact with such as the very young, the very old, people with weakened immune systems, and those who cannot be vaccinated.
Some of the vaccines recommended for adults are highlighted on a spreadsheet here and include:
- Influenza (flu) vaccine each year to protect against seasonal flu. Flu vaccine reduces your risk of heart attacks or other flu related complications among people with pre-existing health conditions like asthma, diabetes, heart disease and Chronic Obstructive Pulmonary Disease (COPD).
- Tdap booster vaccine to protect against pertussis (whooping cough), tetanus, and diphtheria, at least once every 10 years but more often if you are around young babies. In addition, pregnant women should receive a Tdap vaccine each time they are pregnant, preferably at 27 through 36 weeks.
- Other vaccines – such as shingles, pneumococcal, hepatitis, HPV – are dependent on one’s age, occupation, travel, health status, vaccination history, and other risk factors. For instance, Hepatitis B vaccine reduces your risk of liver cancer and HPV vaccine reduces your risk of cervical, penile, throat, anus and various other HPV-related cancers.