Editor's note: An earlier version of this story included information about deaths during the measles outbreak in Ohio which was incorrect. We regret the error.

By Heather Duge

During the recent measles outbreak in Ohio, the majority of children under 5 years old who were infected did not receive the measles, mumps and rubella (MMR) vaccine. Of the 85 children infected with measles, 25 of those children were hospitalized and several were treated in intensive care. Mary Suzanne Whitworth, M.D., Medical Director of Pediatric Infectious Diseases at Cook Children’s, said the under 5 age group is more at risk for severe cases of measles.

Not only that, but even children who recover from measles, especially those younger than 2 years old, are still at risk for developing SSPE – delayed brain inflammation – seven to 10 years later.

“Delaying the vaccines only leaves children vulnerable for longer than necessary,” said Dr. Whitworth, who never questioned vaccinating her children. “I could not sleep until my children were vaccinated.”

The Centers for Disease Control and Prevention recommends that all children receive two doses of the MMR vaccine – one at 12 to 15 months old and another at 4 to 6 years old. One dose is 95% effective against measles and two doses are 97% effective.

Some areas in the U.S. are more at risk for outbreaks – particularly communities with anti-vaccine sentiment. Age makes a big difference – being exposed in early infancy can be devastating which is why herd immunity is crucial to protect the vulnerable ones.

Herd immunity means enough people are immune through having the disease or vaccination so the disease does not have an easy place to land and cannot spread. If a person with measles coughs in a room with 10 people and everyone has been immunized, it will not spread. But if four of those people are not vaccinated, it will begin to spread.

Devastating Effects of Measles

Measles infections typically begin with high fever, congestion, cough and watery eyes. Three to five days later a rash may appear with flat red spots starting at the head/neck area and working its way down the body along with spots in the back of the throat. For some children, the infection worsens to measles pneumonia.

“One out of 1,000 children have brain inflammation and one to three children out of every 1,000 will die from respiratory or neurological complications,” Dr. Whitworth said. “These potentially tragic effects of measles are completely preventable.”

View CDC facts about measles.

By Jean Yaeger

National Infant Immunization Week amplifies a key point: Vaccines safely and effectively protect babies against various diseases.  

This campaign of awareness, which runs April 24-30, emphasizes the proven track record of shots that fight vaccine-preventable diseases such as polio, Hepatitis B and measles. Who benefits when an infant is immunized? The child, their family and the wider community.

Parents should know that vaccines work to stop the spread of infectious diseases at home, in daycare and school settings, and in the general population. Certain shots are needed before kids enter kindergarten, seventh grade and college. But babies and toddlers need shots too before they can be enrolled in a child care center or pre-kindergarten program.

In order to start or stay in daycare in Texas, state law requires proof of up-to-date records for eight vaccines, including periodic booster shots. Regular visits to the pediatrician’s office can help children and teens stay on track for their vaccines – or get caught up if they’re behind. 

The Texas Department of State Health Services (DSHS) ensures compliance during licensing visits by checking the immunization records that the daycare centers keep for each child. Records should include the child’s name, the date the vaccine was received (month, day and year), the provider’s initials or stamp to validate, and clinic contact information.

A conscientious exemption affidavit should be submitted if a child is following an alternative vaccine schedule. According to DSHS rules, a current record or exemption must be on file; otherwise, the child in daycare is considered “vaccine delinquent.”

The DSHS website lists the 2022-2023 minimum vaccine requirements in a chart, in English and Spanish. The chart covers:

• DTaP (Diphtheria, tetanus, and pertussis) – doses by 3 months, 5 months, 7 months and 19 months
• Polio – doses by 3 months, 5 months and 19 months
• HepB (Hepatitis B) – doses by 3 months, 5 months and 19 months
• Hib (Haemophilus influenzae type b) – doses by 3 months, 5 months and 16 months
• PCV (Pneumococcal conjugate) – doses by 3 months, 5 months, 7 months and 16 months
• MMR (Measles, mumps and rubella) – one dose by 16 months 
• Varicella (Chickenpox) – one dose by 16 months
• HepA (Hepatitis A) – doses by 25 months and 43 months

Flu and rotavirus vaccines are not required but may be recommended by the child’s health care provider.

Christina Sherrod, M.D. and the staff at Cook Children’s Pediatrics Southlake will make copies of the patient’s vaccine record and also fill out a health statement form for the daycare if requested. Dr. Sherrod said the vaccine requirements serve as a safety net to help families know when to bring in their babies and toddlers for shots. “That’s the practical side of it,” she said.

For instance … Kids' Place, located across the street from Cook Children's Medical Center in Fort Worth, sends reminder notifications to parents whenever a child is due for their next vaccines.

But the ultimate goal is preventing an outbreak of disease. “If you have a daycare full of 400 kids, and fewer than 95% are vaccinated against measles, that could easily lead to an outbreak in the daycare and in the community,” Dr. Sherrod said.

At Cook Children’s neighborhood clinics across Fort Worth and nearby cities, the medical teams also promote immunizations as recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. 

“Adhering to this vaccine schedule is the best way to protect children and keep them healthy,” said Sharhonda Ansley, M.D. at Cook Children’s Neighborhood Clinic Northside. “By keeping up with their child’s regular checkup visits, parents will help ensure they are prepared for daycare and kindergarten. And the healthier we will all be!”

Dr. Ansley and Dr. Sherrod both pointed out that the symptoms of some diseases can be mild for some patients but serious or even fatal for babies. 

Your Questions Answered

How do vaccines work? Dr. Sherrod puts it this way: “A vaccine injects a protein or molecule into your body that tricks the immune system to make your body think you're getting that disease. It makes your immune system ramp up and build antibodies and memory T cells to prevent getting ill in case you're exposed to the real disease later on.”

What's it like to immunize an infant? Some vaccines are given orally. If it’s an injection, the needle goes into the thigh, and a Band-Aid is applied. The baby usually cries. “You can't warn a baby that the shot is coming, and you can't explain to them why,” Dr. Sherrod said. “The truth is they do really well and they usually calm down very quickly.”

What are some tips to help with discomfort afterward? Breastfeeding or a bottle can be soothing. Don’t give Tylenol right away. “Usually if the baby needs Tylenol, it's that evening or maybe even the next day. I tell parents to go home and see how their baby does. A lot of babies get kind of sleepy the day after their shots. If they have a fever and they're fussy, go ahead and give them Tylenol. But a lot of babies never need it. They just go home, maybe sleep a little bit more, and are fine.”

Anything else? The bacteria that might cause an ear infection or sinus infection in an older child can cause brain damage or even death to a 2-month-old, whose immune system is more immature.  Vaccines benefit the babies who receive them as well as the bigger picture of public health in our country. “It's a privilege that we have these vaccines,” Dr. Sherrod said. “As a nation, we really don't know how bad it can be without these vaccines. I just hope enough people keep getting them that we can continue to see that disease prevention.”

Children and teens need up-to-date shot records to start the new school year, and the doctors at Cook Children’s are eager to help get students caught up on their routine immunizations.

Alice Phillips, M.D. at Cook Children’s Pediatrics Cityview said vaccines can prevent contagious diseases such as hepatitis, measles and mumps from spreading through the classroom and to family members at home.

“We can look back at history and see stories about polio and whooping cough and the toll that that took on our kids and on our society. We do not want to go back to that,” Dr. Phillips said. “Vaccines are safe. They work. And they are tried and true and proven over many decades.”

But the latest annual immunization report by the Texas Department of State Health Services identified a drop in overall vaccination coverage among kindergarteners during the 2021-2022 school year. The report also cited a high number of seventh-graders behind on shots for meningitis and Tdap (tetanus, diphtheria and pertussis).

In the report, the COVID-19 pandemic was listed as the main reason more children missed out on their required vaccines last year. Additional barriers to immunization include lack of transportation, missed opportunities, lengthy wait, and lack of culturally appropriate educational materials, according to the state health department.

Dr. Phillips pointed out that only 85% of Fort Worth Independent School District kindergarten students were current with their measles shots last school year. To reach herd immunity, and limit transmission, the rate should be 90-95%, she said.

Many families were afraid to come to the pediatrician for their child’s annual checkup during the early months of the pandemic in 2020, Dr. Phillips said. Most of her patients have since received any overdue vaccines.  

Heather Miller, M.D. at Cook Children’s Neighborhood Clinic Northside also saw a trend of families not making appointments -- or canceling, or not showing up -- for well-child visits because of COVID-19 concerns during the past two years. To make up for the shots they missed, some 6-year-olds are now coming in for vaccines normally given at age 4.  

Dr. Miller has good news for children and teens who fell behind: There are combination vaccines that can be given in most cases, meaning “fewer pokes,” as she puts it.

Most of the patients that Dr. Miller and her colleagues see at the Neighborhood Clinic Northside are on Medicaid or the Children’s Health Insurance Program (CHIP), which is available to those who can’t afford private health coverage. She wants parents to know that the Texas Vaccines for Children Program provides vaccines to eligible children from birth through age 18.

Dr. Miller says getting back-to-school vaccinations will help protect children from potentially serious complications from those diseases. “That’s why we’re here,” she said, “to help keep children healthy.”

Cook Children’s families can go to the MyCookChildren’s patient portal to schedule an appointment or access the immunization records needed for school registration. Dr. Miller said the staff at the neighborhood clinics can help their families navigate the portal or print out a copy of immunization records. 

In addition to the delays the pandemic caused, Dr. Phillips believes vaccine hesitancy also played a role in the 2021-2022 drop in the immunization rate.  She invites parents to ask questions and talk to the doctor about any concerns.  

“Let me discuss with you what I know – the science, the data – to tell you why these vaccines are safe for your child and why they are effective at preventing illness for not only your child but all of their friends and the community,” said Dr. Phillips, who describes a team partnership of trust between the physician and patient families working together to keep kids healthy.

“I truly believe after 25 years of doing this, that what’s absolutely best for their child is to be fully immunized and protected, because these diseases are still out there,” Dr. Phillips said.

Vaccines Checklist

Because many vaccines are typically given in the first 12-18 months of life, an incoming kindergartner might not have received a vaccine since her first birthday. Between the ages of 4-6, these additional vaccines are due:

• MMR (measles, mumps and rubella)
• DTaP (diphtheria, tetanus and pertussis)
•  IPV (inactivated poliovirus)
•  Varicella (chickenpox)

And an incoming seventh-grader might not have received a vaccine since he was a preschooler. Between the ages of 11-12 years, these additional vaccines are due:

• MCV4 (meningitis)
• Tdap (tetanus, diphtheria and pertussis)
• HPV (human papillomavirus)

A booster of the meningitis vaccine is also recommended at age 16.

Cook Children’s follows the vaccine schedule adopted by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

____________________________________________________________________________________________________________________________________

For 10 key facts about immunizations, including why it’s important to follow a vaccination schedule, go to Vaccine and Immunization (cookchildrens.org)

To view the recommended ages for shots from birth through the teen years, go to cook-childrens-vaccinefacts2.pdf (cookchildrens.org)

Meet Heather Miller, M.D.

Dr. Miller’s desire to become a doctor took root as she grew up in the Piney Woods of East Texas. She earned a Bachelor of Arts in Biology from the University of Texas at Austin, then attended the University of Texas Medical Branch for medical school and residency. Along the way she proudly served in the U.S. Air Force for three years as a General Medical Officer at Lackland Air Force Base in San Antonio. After fulfilling her military commitment and completing pediatric residency training, she started her career at Cook Children’s Northside Clinic in 2002. Then came a 10-year journey following other career opportunities in San Antonio, Mississippi and New Mexico.

With a happy heart, this native Texan returned to Fort Worth and rejoined the Northside Neighborhood Clinic. Reconnecting with Cook Children’s has been a wonderful homecoming. She feels blessed to have this opportunity to provide care for the children and families of North Texas once again. Her special interests in pediatric care include safety and prevention as well as behavior and development

With her husband Steven and son Andrew, Dr. Miller enjoys exploring the world and taking trips by train.

Learn more about Dr. Miller here.

Parents may be wondering if they should get their children vaccinated. Vaccines are the best way to prevent serious illness in people of all ages, including children. 

Based on available data, our health care providers and pediatricians at Cook Children’s strongly recommend that parents get children vaccinated as soon as they are eligible.

“It is important to keep our children safe now and in the future," said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s. "This is one way to safely protect your children AND protect people who they might expose from catching SARS-CoV-2."

We asked Dr. Whitworth to answer some of the big questions and shed a little light on the subject.

Why should my child get the COVID vaccine? 

Children are at risk to get sick from COVID-19 disease, requiring hospitalization, and in rare cases, dying from the infection.  More commonly they will get a mild infection and recover quickly. But while they are contagious they can spread this to others such as vulnerable grandparents.

How do we know it’s safe for children 5 and under?  

The children who participated in the vaccine research had no serious adverse events and we know that the FDA is extremely cautious and will review the data quite carefully before approving this.

Should parents get their children vaccinated, even if their child recently had COVID?  

Yes. Those who have been infected with this virus can get infected again. This second infection may be the same, milder, or more severe – and they are able to transmit SARS-CoV-2 to those who are more vulnerable.

What about if I live in an area with a low number of cases?  

SARS-CoV-2 will not be eradicated.  We will have this infection with us for years to come, just like influenza.  Low numbers now are something to enjoy, but we will all be exposed at some point in the future. 

What should parents do if they have more questions?

Talk to your pediatrician. They have your child’s medical history and are the best source of information for this topic. They have the latest information available and want to help you make an informed decision. 

If your child is eligible for the COVID-19 vaccine, please contact your local pediatrician's office to schedule an appointment.

RELATED: BioNTech Asks the Food and Drug Administration to Authorize COVID-19 Vaccine for Children Under 5

Now that schools have opened, who needs COVID-19 testing?

Rapid testing for COVID-19 can be helpful to promote isolation for positive cases, and to prevent prolonged unnecessary isolation for those children exposed to COVID-19 or with questionable symptoms. The symptoms that most likely warrant testing are combinations of the following: fever and headache, vomiting, diarrhea, congestion, loss of taste or smell, cough, muscle soreness, extreme fatigue and shortness of breath. Children with diabetes may see unexplained difficulties with sugar control. Any combination of these symptoms should be taken more seriously if there has been a known contact with a COVID-19 case.

Does a child who has had COVID-19 need a negative test to return to school?

While we have seen some schools and athletic programs requiring a negative test in order to return, this is based on outdated guidance. Testing may remain positive for weeks after symptoms have passed but does not mean that the child remains contagious. The current guidance is that students may return when their symptoms have resolved for 24 hours AND they are 10 days since the start of symptoms. In practicalities, most of these students will be waiting until the 10 days pass. If a child was hospitalized, it is recommend that they wait 20 days from the start of symptoms.

If a child is exposed to COVID-19, can we end their quarantine early with a negative test?

Testing is reasonable if symptoms develop to make a diagnosis, but quarantine should continue for 14 days from the end of the last contact. A negative test should not provide false reassurance as symptoms could continue to develop throughout the 14 day period despite a negative test.

Many parents are concerned about whether their child is at more risk for COVID-19. Which patients are at risk for more severe disease?

Risk factors for severe disease at any age include: cancer; COPD; immunosuppressed state due to organ transplant; obesity (BMI >30); serious heart disease such as heart failure, coronary artery disease, and cardiomyopathies; sickle cell disease; and type II diabetes.

Individuals with the following conditions MAY be at increased risk for severe diseases: asthma; stroke; cystic fibrosis; hypertension; immunocompromised state due blood or bone marrow transplant, steroids, or immunosuppressing medications; neurologic conditions; HIV; liver disease; pregnancy; pulmonary fibrosis; smoking; thalassemia; and type I diabetes.

Children who are medically complex, who have serious genetic, neurologic, metabolic disorders, or congenital heart disease might be at increased risk for severe illness from COVID-19, as well as children with obesity, diabetes, asthma and chronic lung disease, or immunosuppression.

What do you do when a child has a family member who is at risk for severe disease? Does the child’s age matter?

In this situation, distance learning might remain the best option for this family. Because the disease can be contracted at any age, this should not factor into the decision. While child to adult spread may not happen as easily as adult to child, there are studies that show it does occur.

Do children who are planning to do virtual learning need to have their vaccines updated?

According to the Texas Department of State Health Services (TDSHS), vaccine rules are still in effect regardless of whether a student is participating in on-campus or virtual learning.

Read more about Cook Children's recommendations for safely returning to school on our website.

*This post includes information provided by Marc Mazade, M.D., medical director of Infection Control and Prevention at Cook Children’s and Justin Smith, M.D., pediatrician at Cook Children’s Pediatric Trophy Club.

To identify the hot spots, researchers from the University of Texas at Austin and Johns Hopkins University looked at each area’s volume of international travel from foreign countries with large measles outbreaks and the prevalence of nonmedical exemptions from childhood vaccinations.

The same researchers previously predicted outbreaks in Washington, Oregon and New York which are all experiencing an influx of measles cases.

“For measles, most experts believe that there will be one to two deaths per 1,000 cases, most likely infants. We are set to see over 1,000 cases in the U.S. in 2019. So, for the first time since the 1980s, we may expect infant deaths from measles in the U.S.,” said the study’s lead author, Sahotra Sarkar, a philosophy and integrative biology professor at UT Austin and an expert on public health, in UT news. “We have long known that vaccine avoidance is a critical public health issue in the U.S. and Europe. Our results show how travel from regions elsewhere compounds this risk.”

The Texas Department of Public Safety has confirmed 15 measles cases in Texas this year, including one in each: Tarrant, Dallas and Denton counties and two in Collin County. Comparatively, Texas had nine measles cases in 2018 and only one in 2017.

Already this year, more than 760 cases of measles have been confirmed in the United States, the highest number in decades.

Physicians at Cook Children’s call this news frustrating because measles is a disease once thought to be all but gone from the planet. Texas has one of the highest rates of unvaccinated children in the U.S., partly due to a 2003 state law allowing parents to opt out of getting their children immunized for reasons of conscience.

“It’s not a coincidence that as we have seen more people hesitant to receive the vaccine, we have seen the number of measles cases increase nationwide,” said Justin Smith, M.D., a pediatrician at Cook Children’s. “The numbers are very concerning.”

Measles is a highly contagious respiratory illness spread by contact with an infected person through coughing and sneezing. Measles is so contagious that if someone has it, 90 percent of the people around that person who are not immune will become infected.

The Centers for Disease Control and Prevention (CDC) recommends children who are older than 12 months get two doses of MMR vaccine, starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age. Teens and adults should also be up to date on their MMR vaccination.

Two doses of the MMR vaccine are about 97% effective at preventing measles; one dose is about 93% effective.

"Populations who choose to not follow the recommended vaccine schedule are actually setting up the perfect conditions for the diseases they are unvaccinated for to erupt into an outbreak. It is really not a question of whether these outbreaks will occur but when," said Jason Terk, M.D., a Cook Children's pediatrician.

Other Texas counties to make the Top 25 were Harris at No. 9 and Travis at No. 22.

To learn more about where you can receive vaccines in the Tarrant County area, visit the Immunization Collaboration of Tarrant County website.

For More on This Topic:

• 25 U.S. Counties Identified as Most at Risk for Measles Outbreaks
• Vaccines and Immunizations
• Immunization Collaboration of Tarrant County
• Common Questions About Immunizations
• Why Children Like Olivia Need You to Immunize
• From Vaccine Hesitant to Pro Vaccines. Why This Mom Changed Her Mind.
• Pediatricians Remember Experiences with Measles
• What The First Measles Case in Tarrant County Means for Your Child
• 'Vaccines Are Safe and Effective'
• When It Comes to Your Kids It's Never Just a Virus
• Measles Outbreaks Increase as Vaccination Rates Decrease
• Measles In the Classroom
• MMR/thimerosal/mercury: What you should know

You probably did, but hopefully that didn't prevent you from getting your child's flu vaccine.

New data from the CDC suggest that the vaccine was 50 percent effective for pediatric illness, which is actually a fair year. We’ve had better. We’ve had worse. But it's definitely way better than the 10-30 percent estimates that were being thrown around earlier this year.

In previous years, data have shown that nearly two-thirds of pediatric deaths have occurred in children who were not vaccinated. This data is even more significant as three-fourths of pediatric deaths have occurred in children who were not completely immunized (either no vaccines or only one vaccine in a baby who needs 2 for full protection).

Only 54 percent of children who died of flu had a condition that characterized them as high risk. This means that they were older, healthy kids who got the flu and died.

Is the flu shot perfect? No. Do I wish it were better? Yes.

But do any of these reasons for not getting one hold up?

"It doesn't sound like it's going to work very well this year anyway.""My kid's healthy, so I don't think they really need one.""We stay really careful to avoid others who are sick so we'll be good."

Nope. Nope. And, unless you live in a bunker from October to March: Nope!

It's actually still not too late. You can get protection from this year that will help and there is mounting evidence in adults that getting flu vaccines year over year may provide more protection than just for that season. We're still waiting on that evidence in kids, but logic says it could still apply.

Only time will tell for sure, but a new article published in The New England Journal of Medicine makes the case for a potentially severe influenza season.

The article explains that clinical experts have been watching the Southern Hemisphere, which recently went through its “flu season,” for signs of what might be in store for us in the north.

Australia saw record-high amounts of flu cases. The number of notifications reached 215,280 by mid-October, easily beating the mark of 59,022 cases during the 2009 H1N1 influenza pandemic.

Of special concern to the experts is the type of flu seen in Australia - Influenza A (H3N2). H3N2 is a more dominant strain of the flu and can cause more severe illness.

What makes this news worse is that the vaccine used in Australia, the same one used in the United States, was only 10 percent effective in preventing H3N2.

Last week, 33 kids tested positive for the flu at Cook Children’s and 28 of those cases were Flu A.

The article asks whether our current vaccines can be improved, but also stresses that immunization is still our best defense against the flu right now.

“However imperfect, though, current influenza vaccines remain a valuable public health tool, and it is always better to get vaccinated than not to get vaccinated,” the authors of the articles write.

The Centers for Disease Control and Prevention (CDC) estimates that influenza vaccination averted 40,000 deaths in the United States between the 2005–2006 and 2013–2014 seasons.

Still, the vaccine has a rate of between 50 to 70 percent effectiveness against other strains of the flu and people who are vaccinated generally get a milder and less dangerous form of the illness.

“The vaccine strains are chosen about nine months before flu season, based on circulating strains around the world by epidemiologists who are geniuses and do this for a living,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases . “They are not perfect, but they are very good.”

Even when the vaccine is a perfect match to the influenza virus that a person is exposed to, there are other factors in play. The child or adult who receives the vaccine has to be a “good host” and their immune system has to respond to the vaccine and develop protection.

“This does not always happen if the vaccine recipient has a weak immune system or is on medications that inhibit their ability to respond to the vaccine, or other things we don’t understand yet scientifically,” Dr. Whitworth said. “We do know that thousands of deaths nationally are prevented every year by vaccination against the flu. It is important to note that although the vaccine has known side effects that are similar to all vaccines given, side effects are mild and uncommon. Serious side effects are very rare.”

Even more importantly, Dr. Whitworth stresses a person cannot get the flu from the flu shot. They may feel achy for a day or two but that is very different from being in bed with high fever for a week with true influenza infection.

“The flu season has definitely arrived in the Fort Worth area and the time to get vaccinated is now,” Dr. Whitworth said. “I am vaccinated every year by choice and my adult children choose to be vaccinated yearly also.”

Jason Terk, M.D., a pediatrician at Cook Children’s, has received national attention for calling HPV vaccination rates an “epic fail.” Now, he’s steering a plan to improve HPV vaccination rates for pediatricians in each of Cook Children’s 27 primary care practices.

Using the reporting capability of the electronic medical record at Cook, Dr. Terk will calculate the HPV vaccination rate of each primary care pediatrician’s and practice’s 12-14 year old patients. Then, half of those pediatricians and practices will be given an educational session showing how they can improve their vaccination rates while the other half will serve as a control group.

The goal is to get more patients between the ages of 12 and 14 vaccinated against HPV.

“We will help lay out an action plan for the practices and set a goal of increasing vaccination rates by 10 percent over six months,” Dr. Terk said.

The physicians will then be given a progress report after 3 months.

“We will compare the vaccination rates between the group who received the educational sessions and those that did not both at 3 months and 6 months to measure the effectiveness of the educational sessions and action plan,” Dr. Terk said. “If the process improves vaccination rates, we will spread the education throughout the system with the goal of providing the best care for all of our patients.”

Vaccination rates for HPV are comparatively lower than other adolescent vaccines primarily because parents don’t perceive that their teens' physicians strongly recommend it. And, physicians may not provide an unequivocally affirmative endorsement of the HPV vaccine because they erroneously believe they will meet resistance from the parents of their teen patients.

Across the country, the number of children who receive the HPV vaccine is very low compared to other vaccines they are scheduled to receive at the same time. This is despite the fact that meningitis and pertussis are much less common than HPV.

HPV is so common, in fact, that the journal JAMA Oncology reported in January that nearly half of American men may have an HPV infection known to cause cancer. This is based on a study of 1,868 men, ages 18 to 59. Among the group, only 10.7 percent were vaccinated against HPV while 45 percent reported having genital HPV.

The study shows that work still needs to be done to raise awareness about the dangers of HPV and how to prevent an infection with the highly effective HPV vaccine.

“One of the major problems with HPV is that it may be 20 or 30 years before a person develops cancer due to an infection that happens in the teen years,” Dr. Terk said. “Unfortunately, waiting until HPV is contracted is not an option. We have to make every effort to provide our patients the HPV vaccine so we can put an end to the thousands of teens who move through Cook Children’s without ever gaining this indispensable protection.”

The AAP (American Academy of Pediatrics) and the Centers for Disease Control’s ACIP (Advisory Committee on Immunization Practices) stated, “Health care providers should not use live attenuated influenza vaccine (LAIV) in the upcoming 2016-2017 season due to poor effectiveness.”

The first thought that went through my head was this: my kids have to get the injectable flu vaccine next year AND I have to convince them that it’s a good thing. (I may be a pediatrician, but I’m still a dad.)

The committee looked at data from the last three flu seasons showing that the nasal vaccine had limited to no effectiveness for preventing flu.

Here are 4 facts you need to know:

1. Even in bad years, the flu vaccine continues to provide the best layer of protection against this deadly disease. Last year’s injectable flu vaccine was 50 percent effective in preventing disease which means thousands of people were protected.
2. Assuming there’s no new information or guidance, your pediatrician should not offer your child the nasal flu vaccine. Even if we hear something new, I would choose to do the injectable vaccine and I will do so for my kids.
3. The committee is hopeful that this early decision will help prevent any issue with the vaccine supply. However, there are flu vaccine supply issues nearly every year so I recommend getting in to get your shot early.
4. There’s a committee out there who is looking at this data and making the best recommendations possible based on the latest information. Is it frustrating that we were giving a vaccine that didn’t work? Of course. Am I glad that I won’t do it for another year? Definitely.

Stay tuned for more information about flu and flu vaccines as we get closer to September when flu vaccine supplies start arriving at your Cook Children’s pediatrician’s offices.

About the author

Justin Smith is a pediatrician and the Medical Advisor for Digital Health for Cook Children's in Ft. Worth, Texas. He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. His interest in communications started when he realized that his parents were relying more on the internet for medical information. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” is set to open in Trophy Club in the fall of 2016.

Last week, a Plano CPS agent responded to a different type of call after a Facebook post inviting parents to bring their children over to be exposed to chickenpox was reported

What is a pox party?

Pox parties were more common prior to the introduction of the chickenpox vaccine in 1995. The general feeling was that, if your child was going to get chickenpox at some point anyway, you might as well get it out of the way. It seemed like a rite of passage that everyone should go through. Because most people survived chickenpox with a few days of itchy annoying rash, there are some that ask me if the vaccine is necessary. “Wouldn’t it be better for us to just get the disease?”

Why do we vaccinate for chickenpox?

Most children with chickenpox develop fever, sore throat and loss of appetite which is followed by the classic rash. I was taught that the rash was like “dew drops on a rose petal” because of the clear, fluid-filled bumps that form on a red base. The rash would then crust over with the crusts lasting one or two weeks before falling off.

It was a memorable disease but not dangerous for most. I happen to remember riding around in the floorboard of my dad’s gas truck (it was a different time for lots of reasons) while I was recuperating, not able to go to school because our local farmer’s couldn’t wait for my rash to heal to have gas for their tractors.

Unfortunately, not all children with chickenpox have a simple course. Here is a list of possible complications that can arise from chickenpox:

1. Skin infections-These could be simple and treated with antibiotics but also can be deeper and involve muscle or other tissues. This would be more dangerous now that we see more antibiotic resistant bacteria.

2. Neurologic complications-Infection of the tissue around the brain could lead to confusion and infection of a particular part of the brain lead to a loss of coordination, both complications lead to hospitalization.

3. Less frequent complications-Pneumonia and hepatitis (liver infection) can also occur but do so less commonly.

Prior to the vaccination, there were 11,000 hospitalizations and 100 deaths from varicella yearly. About three children out of 1000 infected required hospitalization. Since 1996, hospitalizations and deaths have fallen significantly (70 and 88 percent).

Is there anything wrong with having a pox party?

As best as I can tell (I am not a lawyer), there is nothing illegal about throwing a pox party. One thing is clear, sending lollipops through the mail (even pox parties want to be the next Uber) to infect others is. There is also a picture that has been shared around the internet which reportedly quotes the mom from the Plano area pox party as saying, “I had to open my husband’s shingles blister and swab their mouths.” I have a feeling most of those out there who would throw or go to a pox party would consider this a little much.

Should CPS have been called?

I have to say when I first read this story; I thought that the call to CPS was a little overboard. CPS is busy as it is. Investigating pox parties is probably not the best use of their time. I have served on local CPS boards and the things that we talked about needed the full attention of a staff that was already stretched thin.

Secondly, the likelihood of serious harm resulting from contracting chickenpox is overall pretty low. Should CPS be called for every parenting infraction that minutely increases the risk of harm to children? No. That would mean I should report every family that turns their child’s car seat around at 21 months or that allows their baby to sleep on their stomachs. While I disagree with those decisions, I choose to educate as best as I can but don’t log on and report them to CPS.

My only pause in this case came from what I admit is a slippery slope argument but stick with me for just a second. What if one of these children ended up seriously harmed as a result of contracting chickenpox at this party?

Seeing children suffer from vaccine preventable diseases (pertussis is the most common which admittedly occurs in both vaccinated and unvaccinated babies) is hard. If I saw a child suffering from a complication of chickenpox only to discover that the child had contracted chickenpox intentionally at a pox party, this would be even harder.

How can we prevent against chickenpox?

The most effective and best way is through vaccination. Vaccination at age 1 and 4 years protects against 90 percent of chickenpox disease and 99 percent against severe disease. Rarely, children can get chickenpox after they have been vaccinated but the cases seem to be milder.

“Vaccinations are still the best answer to preventing the flu and protecting your children from the upcoming season,” Dr. Whitworth said.

The flu shot is recommended for children ages 6 months and older. However, the Centers for Disease Control says only 47 percent of the nation’s eligible population received a flu shot. The only age group that met the CDC’s coverage goal of at least 70 percent was children 6 months to 23 months of age with 75 percent getting their shot.

It’s important for babies to get their shots beginning at 6 months of age. Flu shots are not approved for younger infants,” Dr. Whitworth said. “Because these younger babies cannot be protected by getting flu shots, their caregivers and household contacts must get theirs. If those individuals who are around the baby don’t get infected with influenza, the baby is much less likely to be exposed. It’s especially important for pregnant women to get their vaccines in order to protect their newborns.”

Last year, a lot of talk focused on how ineffective the flu vaccine was, with the CDC saying it was less than 23 percent effective against the dominant strain. The CDC says the vaccine will be more effective this year based on data from early detected cases.

Dr. Whitworth says it’s too soon to predict what the flu season will bring as far as severity and it’s difficult to say how effective the vaccine will be because different strains circulate each year. But vaccines are still the most effective way to fight against the flu.

During the 2014-2015 flu season, 145 children died in the United States from influenza-related illness and the American Academy of Pediatrics says many of those children had no underlying medical condition. The AAP states that an estimated 90 percent of pediatric deaths have occurred in unvaccinated children.

Two types of influenza vaccines are available for children this year, according to the AAP:

• The inactivated influenza vaccine (IIV) is given by injection and is approved for children 6 months of age and older. It is available in two types, one which protects against three strains and one which protects against four strains of influenza.
• Also available is the live attenuated influenza vaccine (LAIV), which is given by intranasal spray. It is approved for healthy patients 2 through 49 years of age and protects against four strains of influenza.

 The AAP also recommends:

• Everyone who is 6 months of age and older should receive annual influenza vaccine.
• Children ages 6 months through 8 years need two doses this flu season, if they have had less than 2 doses of flu vaccine before July 2015.
• Special efforts should be made to vaccinate household contacts and out-of-home caregivers of children with high-risk conditions, and all children under the age of 5.
• Parents should not delay immunization in order to receive a specific vaccine formulation. It is more important to be vaccinated at the earliest opportunity.
• Pregnant women, who are at high risk of influenza complications, can safely receive influenza vaccine at any time during pregnancy. This also provides protection for their infants during their first 6 months of life.
• Mandatory influenza immunization programs for all health care personnel should be implemented nationwide.

About the source

Mary Suzanne Whitworth, M.D. is the medical director of Infectious Diseases at Cook Children’s, which offers care for children and teens with diseases caused by bacteria, parasites, fungi or viruses. Our team provides a broad range of services including diagnosis, inpatient and outpatient consultations, immune deficiency evaluations and treatment of recurring infections.

Articles and news reports about infectious diseases and their impact on our children keep me up at night. Tonight, it’s not an article about an outbreak of disease that has me up typing away at 11:30 on the night before I come home from vacation.

Tonight, at least in the United States, there’s no large ongoing outbreak.

Tonight, my concern isn’t so much about those parents who choose not to vaccinate. I’ve been down that road before.

Tonight, I’m concerned about parents who are choosing to vaccinate their child, but then also choose (often unknowingly) to send them to a school where the low vaccination rates put even their fully vaccinated child at risk.

We know that families who choose not to vaccinate tend to cluster in geographic regions because studies have shown this. I have proposed the theory before that perhaps clusters of unvaccinated children in our area might be more based on ideology (faith-based or otherwise).

Why does this matter?

Herd immunity.

Keeping vaccination rates relatively high (somewhere around 90 percent) actually helps protect all children (vaccinated or not) from diseases. In addition, when outbreaks occur (which is much more likely when herd immunity breaks down), even children who are vaccinated become at risk for contracting disease due to the number of possible exposures. (If you are about to say, “If your child is vaccinated, why do you care if mine is?” read the post above.)

NBC 5 Investigates released a really enlightening (frightening) report this week on vaccination rates in local school districts. They highlighted the growing number of vaccine exemptions in three public school districts (Frisco, Plano and Lewisville).

At first glance it may not seem that concerning. If you look at an individual school or district, the percentage of vaccinated children in those districts is still really high.

My bigger concern, and what keeps me up at night, is in the schools where unvaccinated children, for some reason, are clustered together.

Take a look at what’s happening in our area:

• 30 schools in the DFW area have vaccination rates below 96 percent.
• 5 schools in the DFW area have vaccination rates below 90 percent.
• The highest unvaccinated rate in our area is around 13 percent. The highest in the state is near 50 percent.

Why does it matter?

If you read the names of the schools that fall into the categories above, you’ll see a trend. They are private schools. They are schools that have a high likelihood of having people go overseas for mission trips or other opportunities.

Traveling to countries where diseases are more common increases the likelihood of bringing a disease back to school. Waiting at school are their unvaccinated friends and their vaccinated friends who could even be at risk as the number of cases rise. Outbreaks are possible.

Do you think this is far-fetched?

The Tarrant County measles outbreak from 2013 basically had all the characteristics that I am describing. A large group of unvaccinated people, grouped together based on their faith that contracted measles from a visitor who brought measles into the United States after traveling overseas.

What can you do?

• Get the best start to protection by vaccinating your child.
• Be aware of the vaccination percentages of your child’s school, your church and your social community.
• Be especially cautious when your child’s unvaccinated contacts return from overseas travel. If they are sick, stay away.

Human papilloma virus is a cause of warts that affect the genital areas of males and females. They can also cause infection of the mouth and throat.

HPV is the most common sexually transmitted disease in the United States.

HPV does not show symptoms for many people who are infected but it can lead to cancer of the cervix or penis. Every year approximately 17,500 women and 9,300 men will be affected by cancers that are caused by HPV.

HPV Vaccination

Fortunately, we now have a vaccine that prevents HPV. It was licensed for use in 2006 and targets four strains of the virus: 6, 11, 16 and 18. Types 6 and 11 account for 90 percent of genital warts and types 16 and 18 lead to cervical cancer.

Any time something is “new,” rumors abound. I was privy to an online discussion about HPV on Facebook this week ... because it’s not the best venue for having these discussions I had to hold my fingers (tongue).

But, here are some of the myths I saw that I felt needed to be addressed, beginning with the HPV vaccine has been proven ineffective.This myth takes on a few different forms. I’ll address each one.

HPV Vaccine Myths

1. Myth: The HPV vaccine does not decrease the amount of HPV disease.

Truth: In the United States, the percentage of cases of HPV caused by those strains in the vaccine dropped by 56 percent after the introduction of the vaccine. Other studies in the UK and Australia showed decreases in the number of HPV cases after introduction of the vaccine. The vaccine prevents HPV disease.

2. Myth: The effectiveness of the vaccine wears off over time.

Truth: This study in Pediatrics showed that, at the end of eight years of surveillance, those who received the vaccine continued to have antibodies to the virus. There is no indication that will decrease over time but studies continue. Even if we found a fall-off, a booster could be used to prolong coverage and if we could get protection for any period of time it would decrease the rates of HPV and cervical cancer.

3. Myth: Even if it prevents HPV, the vaccination has never been shown to prevent cancer so why get it?

Truth: Despite the logical conclusion that decreasing HPV infection rates should decrease the rate of cervical cancer, some challenge the HPV vaccine by saying that it has never been shown to decrease the rate of cervical cancer. This study in Denmark showed a 40 percent decrease in atypical cells found on Pap smears (a precursor to cervical cancer). I believe that more studies like this will show even more proof that it is preventing cancer.

4. Myth: The HPV vaccine is not safe.

Truth: This is perhaps the most pervasive of all the different myths about HPV vaccine. News reports and anecdotal stories of teenagers who have received the vaccine and then experience weird, otherwise unexplainable symptoms can be quite compelling. The problem with relying on those stories is that, even before the HPV vaccine, teenagers had events or health outcomes that were unexplainable. Even those who choose not to be vaccinated today have some of the same symptoms. Wouldn’t it be nice if we had some way to determine if these events were caused by the vaccine or were merely coincidental?

Fortunately, we do. If we look at a large population of teenagers who received the vaccine and compare them to another population who did not, we can see if the vaccine increased the risk for bad outcomes or if there were events that would have occurred anyway.

Multiple studies have done this. One of my favorites is one that included almost 200,000 girls who received one or more doses of HPV vaccine. It showed a slight increase in passing out after the shot (we ask girls to sit for a while after receiving it) and skin infection, but no other increase health risks. Another included almost 1 million and showed no increase in autoimmune, neurologic or blood clotting disorders.

I am not concerned about the safety of these vaccines. I understand that, with anything new, parents are going to have concerns but as more and more data come in, the safety of HPV vaccine is confirmed. My kids will get it when they are the right age.

5. Myth: The HPV vaccine allows or causes teenagers to be promiscuous. (Related: We shouldn’t vaccinate because it protects promiscuous kids.)

Truth: This is the most infuriating myth for me regarding the HPV vaccination debate. It angers me because it preys upon the fear of some parents that their child might take sexual risk as a result of something the parents have done. If that is a concern, it might be justifiable if it were true ... BUT it’s not.

Studies have shown that girls who receive the vaccine are no more likely to engage in risky sexual behavior or to have more sexually transmitted diseases. Using that myth to scare other parents is inappropriate, just stop.

6. Myth: Because I’ve raised my child “right,” they won’t be at risk for HPV.

Truth: What? This line of thinking has so many holes.

First of all, you won’t always know about your child’s activities. Trust me, you won’t always know. You may think you know, but I’ve diagnosed a pregnancy in more than one girl who “never had sex.” Stuff happens.

Protect your child even if you’re sure they’d never have sex or won’t until they meet “the one.” Why? You can’t predict you child’s future partner’s sexual behavior. Maybe your children will grow up, meet the partner of their dreams and only have sex with that person for their whole life. But, maybe their partner’s history isn’t the same. Their partner could carry HPV, could give it to your child and leave them at risk for cervical or penile cancer. Why risk it? By withholding the shot, you are only putting your child at risk.

These are some of the common myths I’ve heard about HPV. I’m sure there are many more out there. But I urge you to go in with an open mind and talk with your doctor about your questions or concerns. We’d be happy to help!

In the year 2000, measles were declared eliminated from the United States. This occurred because there was a 12-month period where no measles cases were contracted here, making the disease no longer native to the United States.

I hear this question often in my office and its logical based on the fact that measles was eliminated:

“We haven’t seen outbreaks of these diseases for years. Do we really need to continue vaccinating for them?”

The answer is yes and it's exactly because of what we've seen in the past two weeks. Measles are only a plane ride away. We live in a society with global mobility. People fly in and out of countries where measles continue to be a huge problem and then fly back to the United States. Measles are highly contagious via droplets from coughs and sneezes. In addition, people are contagious before they start to show symptoms. (Contrast that with another infectious disease we dealt with recently (Ebola) that requires blood or body fluid contact and is not contagious until there are significant symptoms.)

Continued vaccination programs protect our citizens when they travel abroad. It protects our citizens when travelers return to the United States. It helps to control outbreaks when they do occur.

Another common questions centers around the severity of these diseases.

I pulled this quote from an interview with The Today Show in Australia and Dr. Sherri Tenpenny:

“I don’t believe that measles, mumps, rubella or chicken pox are routinely fatal illnesses. If you ask any person over the age of 50…they had all those illnesses when they were children and growing up.”

There are so many false assumptions mixed in with this statement:

1. You cannot ask a person in their 50s that died from one of these diseases how serious it is.

2. Even if not fatal, the complications associated with these diseases can be very serious.

3. This completely discredits the suffering of any family member of someone who experienced complications from these diseases.

Just look at the stats. In the United States, prior to the introduction of measles vaccine in 1963:

• 3-4 million people had measles each year
• 400-500 died
• 48,000 were hospitalized
• 4000 developed encephalitis (brain swelling)

These complications don’t happen as much in the United States, but do continue to occur in areas where vaccination rates are not as high. There were 145,700 measles deaths worldwide last year. This is a 75-percent drop since 2000 due to efforts to make vaccinations available to children all over the world.

Continuing to vaccinate for measles is important because measles are serious and only a flight away ... and lately, even in our own backyard. 

This is part 2 of Dr. Smith’s series on measles. For more information about measles vaccination and herd immunity, click here.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

Get to know Justin Smith, M.D.

Justin Smith, M.D., is a pediatrician in Trophy Club  and the Medical Advisor for Digital Health for Cook Children's in Fort Worth, Texas. Dr. Smith is an experienced keynote speaker for a variety of topics including pediatric/parenting topics, healthcare social media and physician leadership. If you are interested in having Dr. Smith present to your conference or meeting, please contact him at thedocsmitty@cookchildrens.org.

He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” open now. Click to learn more. To make an appointment, call 817-347-8100.

Breaking news concerning the weirdest week in celebrity-infectious disease history:

Peyton Manning helped lead the Broncos to victory despite suffering from a flu-like illness.

Sidney Crosby and multiple other National Hockey League stars have been diagnosed with mumps.

Angelina Jolie missed press events for the release of Unbroken, a movie which she directed, because she was diagnosed with chicken pox.

Maybe it is not breaking news. In fact, I’m pretty confident that they will all recover without any issues. Most people with any of these three diseases do.

We so rarely see mumps and chicken pox that we often forget how people used to suffer severe consequences from these diseases.

Here’s a quick reminder of some of the problems people can have as a result of these infections:

Flu

We have talked a lot about flu and flu vaccination in the past few weeks. Most children with the flu will have fever, cough, congestion and body aches,but will recover without incident in three to five days.

What do we need to watch for?

The most common problems with flu are dehydration and wheezing or difficulty breathing (especially in children with asthma).

A couple of more rare complications:

Pneumonia - Children can have viral pneumonia or a “secondary” bacterial pneumonia after the flu. (Secondary means that it comes after and as a result of having the flu. Think of it like the flu made the lungs weaker and more likely to get a different kind of infection.)

Nervous system involvement - These are rare but can involve confusion (caused by encephalitis-which is inflammation of the lining of the brain) and weakness (Guillain-Barré syndrome).

Mumps

Most children with mumps have low grade fever, fatigue, headache and muscle soreness. These symptoms are followed quickly by the most characteristic sign of mumps which is swelling of a gland in the cheek, called the parotid gland. The infection is typically more severe in adults than children.

What do we need to watch for?

Orchitis - This is a mumps infection involving the testicles. It is the most common complication in adolescent and adult males and can lead to sterility. A similar infection can occur in girls in the ovaries but is less common.

Nervous system involvement-Infected persons can have meningitis which causes fever, headache and neck pain. In addition, prior to vaccination mumps was one of the most common causes of deafness in children.

Chicken Pox

Because most of us had chicken pox and only suffered fever and the characteristic red, itchy rash, it is sometimes difficult to understand why we are vaccinating against the virus. Fortunately, that is the case for most children who contract the disease.

What do we need to watch for?

Skin infections - Because staph skin infections are so common now (and often resistant to some antibiotics), I am glad that we have a vaccine to prevent chicken pox. Any open sore, especially one that children are scratching is prone to infection.

Best advice is to stay away from athletes and celebrities this holiday season.

Ultimately, just remember that these diseases can be serious even though these celebrities should be just fine.

Measles is highly contagious and can easily spread by simply breathing, coughing, sneezing or coming in close contact with an infected person. If you or anyone you know develops symptoms of this disease, please contact your health care provider immediately.

Measles begins as a mild infection with fever, congestion, cough and some oral lesions. It then worsens to a severe respiratory infection, with very red eyes, lots of coughing and a rash all over the body with red, slightly raised, round spots. Measles can have complications such as pneumonia, dehydration and in rare occasions swelling of the brain (encephalitis). Measles is especially dangerous for people with weak immune systems.

Donald Murphey, M.D., medical director of Infectious Disease at Cook Children’s, and TCPH remind people that measles is a vaccine-preventable disease. Adults who have received a measles vaccine series are considered immune. Those who have not been immunized against measles, or have never had measles, should contact their health care provider to get vaccinated.

“If you think you, or your child, may have measles or have been exposed, call your doctor immediately and try not to come in contact with others,” Dr. Murphey said. “The measles, mumps and rubella (MMR) vaccine is safe and very effective at preventing measles.  If you are travelling with children, they can be immunized against measles to protect them as early as 6 months old. Children normally start the MMR vaccine at 1 year old. If you or your child has not had the vaccination, please call your doctor to arrange this ASAP.”

The Centers for Disease Control and Prevention recommends two doses of the vaccine. The first dose should be given at 12 months of age and the second between the ages of 4 to 6 years. But children can get the second dose at any age, as long as it is at least 28 days after the first dose.

You can find more information about Measles by clicking HERE.

The last recorded cases of Measles in Tarrant County were in 2013.

Click here to find a Cook Children's pediatrician in your area to get your child vaccinated.