Integrative Pediatric and Adolescent Health: Educational Web Column

Other Topics in this Series

• April 2009: Eating Disorders
• January 2009: The Cold and Flu Season
• October 2008: Self-Regulation
• September 2008: Herbs and Supplements, Part II
• August 2008: Herbs and Supplements,
  Part I
• July 2008: The Benefits of 'Free Play'
• June 2008: Communicating With Your Provider  

Benefits of Vaccination
Vaccination against influenza is beneficial for us as a population, and for many if not most people individually. Children are particularly good at passing viruses to others- at school and at home. Research data suggest that vaccination of children leads to a significantly reduced burden of disease among the population as a whole, particularly the elderly, those with chronic medical conditions and those not eligible to receive the vaccine.

Over the last few years the recommendations by public health authorities and professional organizations for influenza vaccination for children have shifted. Several years ago, the recommendation was to vaccinate children with certain chronic medical conditions and the very young. As of last year, the recommendation expanded to include all children at least 6 months of age, with or without underlying medical conditions. The reason for this expansion has to do with both protection of children directly as well as protection of the population as a whole. This year, the H1N1 strain (“swine flu” is a misnomer because it is not uniquely related to pigs) poses a range of new challenges with regard to its risks and the development of prevention strategies.

The Unique Factors of H1N1
The H1N1 strain is infecting children and young adults in higher proportion this year than the seasonal flu usually does. Annually in the U.S. approximately 90 children die due to influenza or its complications. Roughly half of these deaths occur in otherwise healthy children. This year to date (as of 10/14/09), a little more than 100 children have died already due to H1N1. An interesting comparison can be made with the 2003-04 flu season when 153 children died due to complications from seasonal influenza. This occurred in part due to a mismatch between the most commonly circulating strain of flu and the ones that were included in the annual shot that year. Interestingly, the elderly have been less affected by H1N1. This seems to be because they were exposed to similar virus strains several decades ago and developed subsequent immunity.

The novel H1N1 strain this year is uniquely different from the strains in 2003-04 and it has been very difficult to predict how virulent it would be. We can estimate somewhat based on the spread of H1N1 in other parts of the world. For example, during Australia’s influenza season a few months ago, the mortality rate due to H1N1 was similar to the seasonal flu. The difference however was that the overall rate of infection and need for hospitalization was much higher than seasonal flu rates. So based on the morbidity and mortality data we have so far, H1N1 does not appear significantly more virulent than seasonal flu strains; rather it is very new to most of us and thus rates of susceptibility and infection are higher – and thus the overall use of medical services, hospitalization and intensive care unit usage are higher.

Risks of Vaccination
What about risk factors for getting the flu shot? First of all, the H1N1 vaccine is made using the same technology, the same procedures, and the same components as the seasonal flu shot. The only difference is the H1N1 antigen. This is analogous to the changes in antigens that occur every year with the seasonal flu shot. While we do not have long-term safety data on the new H1N1 vaccine antigen, the seasonal flu shot has a long record of general safety. Some concern has been raised about the use of adjuvants. These are substances incorporated into vaccines that stimulate the immune response. The currently available seasonal and H1N1 vaccine products in the U.S. do not contain any adjuvants.

There is no such thing as a risk-free vaccination. Depending on whether the nasal spray or injection vaccine is used, variable but small percentages of children will have stuffy nose, low grade fever or other mild symptoms of flu. This is not necessarily a bad thing. It represents the body’s immune response and the development of a defense to fight off the real thing.

On the other hand, there are reasonable questions to ask about how vaccines interact with the immune system. Our immune systems are immensely complex. Our children have higher rates of allergic conditions than a generation ago. Could this be related to increasing numbers of vaccinations? It’s an interesting question, and beyond the discussion here. I believe it has not clearly been answered. But I also believe that there are many other issues about environmental exposures, such as the increased exposure to chemicals that likely have negative effects our immune systems. Overall, the benefits of vaccination far outweigh the risks. But a more open dialog about possible risks is needed.

Another interesting question is: if we are vaccinated every year against the current strains of influenza, what would we be doing to our vulnerability to future strains? Those over 65 are not very susceptible to the H1N1 strain because their immune systems have been in contact with a similar strain in the past and have developed some immunity. What’s the trade-off in native immunity or alteration in the function of the immune system for annual vaccination? My point is not to engender fear, but to raise questions that should be addresses openly even if they cannot be answered (yet).

Given the relatively low rate of complications of flu for otherwise healthy school-aged children, some parents may weigh these risks and decide against vaccinating their children. I understand this choice, but it should be made with a conscious awareness that the decision may have effects beyond their own family.

Bottom line considerations:

1. Good data support vaccination broadly for the protection of us as a population, whether you think of this in saved lives/illness or saved medical/social costs.
2. There are reasonable questions about the long-term implications of annual vaccination against influenza for one’s lifetime. It may be very difficult to get clear answers to these questions. It appears that overall risks are very low.
3. Whether to vaccinate children under the age of 2 remains an open question to me.
4. Ethically, each individual and family should be free to choose whether or not to vaccinate themselves and their children.
5. Even healthy children and adults can have severe illness or die from influenza. This is extremely rare, but possibly preventable through vaccination. 
6. Whether an ideal diet, exercise and lifestyle can prevent consequences of influenza as well as vaccination is unknown. Maintaining such an ideal consistently in our lives is more than one can expect. Vaccination is a way to take advantage of one’s current good health and to boost the body’s ability to withstand challenges.
7. There is no such thing as a risk-free vaccine. All vaccinations carry some risk, however small. The vast majority of children handle vaccination fine without apparent side-effects. Among healthy children there is no way for physicians to predict which children may have a bad reaction.

Additional Resources
Regarding the H1N1 influenza strain, there are several issues to consider with regard to risks for children and potential benefits of vaccination. If you would like to read detailed information about what vaccines are (or will be) available for the seasonal flu and/or H1N1 you can look at the CDC’s webpage for H1N1 and seasonal flu, and Dr. Sears’ webpage. A very good summary of the issues parents face in deciding about vaccines is provided in Dr. Bob Sears’ The Vaccine Book. He keeps a webpage with updates on issues including H1N1 that lists current vaccines available and discusses a number of hot issues related to them. You should be aware that his book has been strongly criticized by a number of pediatricians. A thoughtful response by Dr. Sears is on his webpage. If you have the time and interest, there is a thorough and civil dialog between two people in the comments section as well.

References

The ANZIC Investigators. Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand. NEJM 2009; 361: 1-10.

Intensive-care patients with severe novel influenza A (H1N1) virus infection - Michigan, June 2009. MMWR Morb Mortal Wkly Rep 2009; 58:749-52.

Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5808a1.htm (accessed 10/10/09)

Effectiveness and Cost-effectiveness of Vaccination against Pandemic Influenza (H1N1) 2009: http://www.annals.org/cgi/content/full/0000605-200912150-00157v1 (accessed 10/14/09)

Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Morb Mortal Wkly Rep 2008; 57:1-60.

Jefferson T, Rivetti A, Harnden A, Di Pietrantonj C, Demicheli V. Vaccines for preventing influenza in healthy children. Cochrane Database of Systematic Reviews 2008, Issue 2

About the Column

This column presents an integrative medicine view on a range of topics relevant to children, teens and early adolescents including: nutrition, herbs & supplements, mind-body and self-regulation skills, and general health and wellness.

If you’re new to the concept of integrative medicine, take a few minutes to browse the UCSF Osher Center web site, particularly the page what is integrative medicine? 

Broadly speaking, integrative medicine is practicing good medicine. It is an approach to a child’s health that:

• places illness in the context of the child, rather than the child in the context of illness;
• takes into account family and environmental factors;
• neither rejects conventional medicine nor accepts complementary or alternative medicine (CAM) uncritically.

Integrative pediatric consultations are available at the Osher Center with Kevin Barrows, MD, Rick McKinney, MD, and Priscilla Abercrombie, RN, NP, PhD, AHN-BC. To make an appointment, please call the main clinic line at 415.353.7720.

David Becker, MD, MPH is an Assistant Clinical Professor in the Department of Pediatrics at the University of California, San Francisco, and Affiliate Faculty at the Osher Center for Integrative Medicine at UCSF. He started the Pediatric Integrative Pain Clinic in July 2008. This is a referral-based service for children and adolescents with chronic pain. For questions about referrals, please contact the main Mt. Zion Pediatric number: 415.885.7478.

In addition, we offer two healthy parenting stress reduction classes: Mind in Labor and Mindfulness-Based Childbirth and Parenting.