Tuesday, February 25, 2014

Pediatricians can lay out evidence to allay fears over HPV (Cervical Cancer) vaccine

Recent media attention has some adolescents and parents wondering whether the human papillomavirus (HPV) vaccine is safe and effective. The discussions that have prompted all of this chatter are not based on available evidence. Unfortunately, a lack of validity does not prevent rapid transmission of rumors and innuendo, especially on television and the Internet.
Pediatricians can allay fears of patients and families and improve HPV vaccination rates if they are aware of the evidence and respond effectively to patient and parental questions. They also need to be as committed to HPV immunization as they are to all of the other AAP-recommended vaccines.
Following are some talking points that pediatricians can use to answer questions about effectiveness and safety of HPV vaccine.


Clinical trials performed to achieve Food and Drug Administration approval showed the following:
  • HPV 16/18-related cervical intraepithelial neoplasia grade 2/3 or adenocarcinoma in situ were reduced by 100%.
  • Genital warts in females were reduced by 97%.
  • Genital warts in males were reduced by 89% after three doses and 67% after one dose.
Post-marketing surveillance in “real world” settings showed dramatic benefit:
  • 56% reduction in prevalence of HPV strains 6, 11, 16 and 18 in adolescent girls in the United States (National Health and Nutrition Examination Survey) despite the fact that only 33% of girls received three doses.
  • 77% reduction in prevalence of HPV strains 6, 11, 16 and 18 in adolescent girls in Australia within three years of vaccine introduction (three-dose immunization rates of 70%).
  • 75% reduction in low-grade cervical abnormalities in Australian girls younger than 18 years of age within three years of vaccine introduction.
  • 45% reduction in genital warts in girls 16-17 years of age in Denmark.
  • 36% reduction in genital warts in U.S. girls 15-19 years of age despite low HPV immunization rates.
  • 88% reduction in genital warts in Australian females younger than 21 years of age.
  • Data on cervical cancer reduction will take longer to obtain due to the time between HPV infection and development of cancer. But data on prevention of pre-cancerous lesions make it clear that the HPV vaccine is having its desired effect.
While it is important to administer the HPV vaccine prior to sexual debut, there is an additional advantage to providing HPV vaccine at the recommended age of 11 to 12 years. The antibody response is more robust, with higher levels of antibodies achieved when given at 11 to 12 years compared to after age 16 years. Data on persistence of antibody are optimistic, with high antibody levels maintained beyond seven years post-immunization. Continued follow-up is needed to determine how long the antibody persists at “protective” levels. However, it doesn’t appear that a booster will be needed.


  • Nearly 60 million doses of HPV vaccine have been given in the United States through 2013.
  • Post-marketing surveillance has not identified any new safety concerns in female or male HPV vaccine recipients.
  • Injection site discomfort is the most common adverse event.
  • Syncope is the most common safety concern. Adherence to a 15-minute observation period after vaccination should prevent significant adverse consequences due to syncope.
  • Reports to the Vaccine Adverse Event Reporting System have declined dramatically since 2008 with no serious adverse events reported in 2013.
  • Post-marketing surveillance has not shown any increased risk following HPV vaccine for the following conditions: Guillain-BarrĂ© syndrome, seizures, stroke, venous thromboembolism, appendicitis, anaphylaxis or other allergic reactions.
  • While not approved to be given during pregnancy, no safety concerns have been identified in the HPV pregnancy registry, which includes reports of girls who have been immunized with HPV vaccine while pregnant.
  • There is no evidence to suggest that HPV vaccine is responsible for ovarian failure. Genetic, infectious, inflammatory, autoimmune and toxin-related conditions are most likely responsible for ovarian failure in adolescent girls who have received HPV vaccine. (The relationship between ovarian failure and HPV vaccine is temporal but not causal.)
  • As of June 2013, 85 deaths had been reported to the Vaccine Adverse Event Reporting System in individuals who have received HPV vaccine. A majority of these deaths have been reviewed by the Centers for Disease Control and Prevention, which found:
    • There is no diagnosis at death that would suggest the HPV vaccine caused the death.
    • There is no pattern of death occurring with respect to time after vaccination.
    • There is no consistent vaccine dose number or combination of vaccines given and death.
The HPV vaccine has the potential to prevent tens of thousands of cases of cervical cancer. It truly is a cancer vaccine. Initial information strongly suggests efficacy and good safety. Acceptance of HPV vaccination can be enhanced by a strong recommendation from the health care professional.


  • Dr. Brady is chair of the AAP Committee on Infectious Diseases.

Friday, February 21, 2014

Funniest reasons for being NOT ABLE to come to the clinic as per Doctor's appointment :)

Here are some top (or funny) reasons about why patients are unable to make to the doctor's clinic even with prior appointment
> > Got another appointment for the vaccine elsewhere....trip got
> > rescheduled....I read an article by Jenny Mc Carthy.....
> > could not get approval from my hematologist/oncologist/immunologist...

> > my kid is throwing up...
> > I need to make birthday muffins for the first grade class.....got a migraine headache, so I am too sick to leave the house...
> > .just don't feel like getting it today
> > ...squirrel ate through my brake line...rent is due,
> > maxed out my credit card at the casino...
> > .traffic back up on the thruway...I have a meeting at work today, can't miss it....

> > .I am worried that it will exacerbate my raynauds/fatigue/fibromyalgia..........
> > .I have no money, just give ME a big discount, and then charge everyone else a higher fee...
> >  my psychic chiropractor told me that I should never get any vaccines....
> > the town snowplow came by and dumped a pile of snow at the end of my driveway.... won't be able to get to the office till about mid spring... I don't have good snow tires on the car and keep ending up backwards in the ditch.... I tried to leave the house, but was afraid that the  4 foot  icicle would fall on my head...

Monday, February 17, 2014

An important, commonly missed & easily treatable cause of poor school performance in Indian Children

This is a letter from Dr Yamuna, Academic and Behavioral Paediatrician at Vanavani Matriculation Higher Secondary School, IIT, Madras, discussing an important, commonly missed & easily treatable cause of poor school performance in Indian Children

"For the last two months I have been seeing students who are not studying well. 

Though Specific Learning Disability and ADHD have been the significant conditions preventing better performance, I have observed some important medical, physical and Social reasons for poor performance. 

Iron Deficiency:

Iron Deficiency not necessarily anemia, during preschool days is known to cause significant cognitive changes that can hamper comprehension and recollection. Serum Ferritin is the marker for stored iron, keeping in mind that it is also an acute phase reactant. 

I was taken aback to find readings as low as 1, 2 12 etc in children from families belonging to upper middle income. The children eat but do not eat right. Also Literature supports supplementation of Iron during this period of growth to prevent the IRON DEFICIENCY State in the children.Some children had hemoglobin between 11 & 12.g%, which is anemia by definition, but not addressed.

I felt that we as Paediatricians can make a difference to the academic performance of our children by just ensuring IRON SUFFICIENCY state during Preschool years. 

Secondly,  in the presence of Iron Deficiency, an increased level of Zinc Erythrocyte Protoporphyrin is detected and this can be used as a screening tool. 

 On a given day, the number of bottles of Iron containing medicines sold from any pharmacy is much much lesser than Multivitamin containing products. 

Can we start enhancing the storage Iron in our Preschoolers which might help in improving their scholastic ability. 

Thanks for helping me in sharing what I observed,


Comment: I would request all Pediatricians to consider doing a S Ferritin level in addition to Hemoglobin estimation for kids with behavioral & learning problems. Parents may ask their pediatrician for this test, as it is fairly easily available across the country and costs less than a thousand rupees in most places. Make sure that the child is NOT suffering from any acute infections while being tested, since that can raise the Ferritin levels even in children with iron deficiency.

Monday, February 10, 2014

India Vaccine News - Painless DPT running short in India - all brands not available!

After the recent controversy regarding the effectiveness of painless DPT vaccines in India, now there is a shortage of almost all brands of Painless (acellular DtaP) vaccines.
Pentaxim, Tripacel (manufacturer Sanofi Aventis) & Infanrix (manufacturer GSK) are all not available at the present point of time, and this shortage is likely to persist at least till the end of February, 2014. 
If there is no availability private practising pediatricians in India will have to switch to the normal DTwP which is likely to lead to increased fever, pain swelling and crying episodes in children.
One option I can recommend at present is to switch to Boostrix/ Adacel at 5 years age (Tdap), so that we can preserve a few doses of DTaP that can be used for other younger children.

Thursday, February 06, 2014

Parent question : Should I give the polio drops at home during Pulse Polio campaign if my child is already vaccinated?

Question: Should I give the polio drops at home during Pulse Polio campaign if my child is already vaccinated?

Ans. Yes, it is very important from the community perspective that all children in India are given Pulse Polio additional OPV doses as and when the government runs the SIAs (Supplementary Immunization Activty) & NIAs (National Immunization Activity) programs.This is not specifically for your baby's health (they are already protected by the routine vaccinations given by your doctor). However, giving Pulse Polio doses within a few days to all children in a single geographical area (Town. state, country) will help eradicating Polio forever, so that future generations will no longer need the Polio vaccine at all (just like small pox has been eradicated). 
So think of giving Pulse Polio drops as doing a social service, for the society as a whole and for your children's children :)