Prevention and Immunization
Why are vaccinations recommended
or – in certain countries – prescribed by law ?
1. Because people feel threatened by epidemic-like infectious diseases.
2. Because the individual person is to be protected against the risk from specific infectious diseases.
3. In order to eradicate certain diseases altogether as far as possible, including infantile paralysis (polio) and measles. Smallpox has been eradicated.
It is recommended – or is obligatory – almost everywhere in the world today that all children be vaccinated against tetanus, diphtheria, whooping cough, poliomyelitis, Hib, Hepatitis B, pneumococci, measles, mumps, rubella, chickenpox and meningococci during the first two years of life. In some countries there is the additional protective vaccination against tuberculosis. Although there is no general statutory mandatory vaccination requirement in Germany, there are the recommendations of the Standing Vaccination Commission at the Robert Koch Institute, STIKO. Hence it is not always easy to consider the subject of vaccination in a factual way and be involved in making decisions on one’s own responsibility. But the benefits and risks of the currently recommended vaccinations must be openly discussed – particularly also with regard to possible indirect effects on the development of immunity. Parents and doctors should be allowed to decide jointly without pressure whether the child should be vaccinated and what vaccinations he or she should be given.
We wish to support the reader in coming to a decision and provide him or her with a foundation on which to make a judgement with regard to these far-reaching questions. Anyone who has read the section about the meaning of (childhood) diseases (p. 175f.) and the ethical aspects (p. 182f.) will not be surprised to find vaccination dealt with differently here from the way that is otherwise typical of the advisory literature. We hope that decisions are made as a result which do justice to the individual situation of the child and his or her health ; but also, in the long term, society. We do, however, expect that parents who are cautious with regard to vaccination also grant their children the necessary rest, treatment and recuperation in any illness which may occur as a result. That includes, for example, not travelling during an illness and to give a sufficient period for recuperation. We refer to the specialist literature for additional information, particularly by Martin Hirte and Wolfgang Goebel (p. 251f.) and the Arbeitsgemeinschaft der Ärzte für individuelle Impfentscheidung : www.individual-impfentscheidung.de
Recommended reading
Hirte, Martin : Impfen Pro & Contra. Munich 2011.
The current recommendations can be looked up on the website of the Robert Koch Institute (RKI) under the keyword “Infektionsschutz”, (rki.de) or on the following websites :
Ärzte für individuelle Impfentscheidung : www.individuelle-impfentscheidung.de or www.impf-info.de
What happens in vaccination ?
The aim of vaccination is to prevent certain infectious diseases. Injecting or swallowing vaccines stimulates the organism to develop protective agents. These are similar to or the same as those which are formed as so-called antibodies by the organism in the course of an infectious disease. In this way vaccination generates more or less strong protection against the disease for a period which is unknown in each individual case. It is thus a process of artificial active immunisation.
Vaccines made from pathogens which can proliferate but have been weakened are described as “live vaccines”, those resulting from cleavage or metabolic products of the pathogen as “dead vaccines”. Then there is the administration of antibodies and other components of the blood serum which protect against disease, also described as serum treatment or passive vaccination. Here the protective agents from other humans or animals are injected into the person at risk of disease. (In this book we will call both methods vaccination for short.) These foreign protective agents are soon broken down in the organism so that there is protection worthy of the name for two months at most. With active vaccination, the protection should, in contrast, last for years.
Most vaccination recommendations apply to the first year of life, thus falling into the period of the greatest development of the immune system – but also of the nervous system.
The influence of vaccination on the immune system with regard to the development of allergies or autoimmune diseases is difficult to prove or disprove and can certainly not be identified within the framework of the obligatory clinical trials. One example of such a debatable influence is the still unknown cause for the increase in diabetes mellitus in children in the industrialised countries.
As allergies and autoimmune diseases only occur very much later, and studies are rarely set up for a period longer than three years, there are few meaningful results on the subject. But all studies which have so far explicitly investigated the connection between vaccination and allergies have tended to find that the number of allergic problems rises (e.g. the work of K. Dharmage SC et al. : Is childhood immunization associated with atopic disease from age 7 to 32 years? in : Thorax 2007, 62(3): 270-5 and the PARSIFAL Study 22a).
Thus the question about a possible overload of the immune system through the ever growing number of components in a mixed vaccine is an issue which should be taken seriously and is not invalidated by the statement that these vaccinations are safe and effective.
Below we set out the most important aspects regarding the production and composition of and the accessory agents in the most common vaccines.
Tetanus and diphtheria vaccines contain the respective pathogenic bacterial toxins in detoxified form as toxoids with the aim of stimulating the human organism to form antibodies.
With the first vaccination injection such stimulation is still considered to be weak, in the second it should be stronger. The ability rapidly to develop new antibodies is, as a rule, achieved with the third vaccination or through contact with a pathogen some weeks after the second vaccination. This effect is called a “booster”. If the vaccinated person encounters the pathogens after the second or third vaccination, and if they penetrate the organism, their toxins are mostly rendered harmless by the antibodies which already exist or are immediately formed in great quantities.
For pertussis vaccines , acellular vaccines (aP or ap for short) are currently used in central Europe in combination with two to five other vaccination factors. The whole-cell vaccine (P or wP = whole Pert) had too many side effects. According to the technical information, however, side effects such as “hypotonic-hyporesponsive episodes” also arise from the acellular vaccinations.
The active substances in the above vaccinations (including the ones against Haemophilus influenzae B, see p. 236) are attached to aluminium hydroxide or aluminium phosphate because they stimulate immunity better that way. The aluminium dose per ampoule is between approx. 0.1 and 0.7 mg aluminium. Although intensive work is being undertaken to reduce these accessory agents, it has not been possible so far to find more suitable substances.
The injectable measles, mumps and rubella vaccines (MMR) consist of weakened proliferating viruses. They are cultured in cell cultures of monkey kidneys, chicken embryos or human tissue. Apart from traces of antibiotics (from the treated tissue and cell cultures), they contain as minor compounds hydrolysed gelatine, some human albumin (non-allergenic human protein) and traces of various other substances.
There is a complete list of rare and doubtful, also possibly serious side effects such as shrill screaming, seizures or other neurological complications in the package insert included with the vaccine by the manufacturer. Parents may as a rule assume that their doctor has not yet experienced any serious side effects with the vaccinations he or she has carried out himself or herself and therefore cannot say more on the subject than is contained in the package insert. It is recommended in all cases that the vaccination should be delayed if there is an incipient or acute infection. The vaccination interval, combinations and contraindications are best discussed with the doctor carrying out the vaccination.
There are no mandatory vaccinations in Germany. They can only be ordered for the persons at risk if the disease takes a serious course and there is a threat of it spreading. There is no obligation to vaccinate even if, for example, hepatitis A or B occurs in a school. With measles, it is likely that the health authorities will in the near future order mandatory vaccination before children without assured measles immunity are allowed back into school or kindergarten.
Vaccines made from pathogens which can proliferate but have been weakened are described as “live vaccines”, those resulting from cleavage or metabolic products of the pathogen as “dead vaccines”. Then there is the administration of antibodies and other components of the blood serum which protect against disease, also described as serum treatment or passive vaccination. Here the protective agents from other humans or animals are injected into the person at risk of disease. (In this book we will call both methods vaccination for short.) These foreign protective agents are soon broken down in the organism so that there is protection worthy of the name for two months at most. With active vaccination, the protection should, in contrast, last for years.
Most vaccination recommendations apply to the first year of life, thus falling into the period of the greatest development of the immune system – but also of the nervous system.
The influence of vaccination on the immune system with regard to the development of allergies or autoimmune diseases is difficult to prove or disprove and can certainly not be identified within the framework of the obligatory clinical trials. One example of such a debatable influence is the still unknown cause for the increase in diabetes mellitus in children in the industrialised countries.
As allergies and autoimmune diseases only occur very much later, and studies are rarely set up for a period longer than three years, there are few meaningful results on the subject. But all studies which have so far explicitly investigated the connection between vaccination and allergies have tended to find that the number of allergic problems rises (e.g. the work of K. Dharmage SC et al. : Is childhood immunization associated with atopic disease from age 7 to 32 years? in : Thorax 2007, 62(3): 270-5 and the PARSIFAL Study 22a).
Thus the question about a possible overload of the immune system through the ever growing number of components in a mixed vaccine is an issue which should be taken seriously and is not invalidated by the statement that these vaccinations are safe and effective.
Below we set out the most important aspects regarding the production and composition of and the accessory agents in the most common vaccines.
Tetanus and diphtheria vaccines contain the respective pathogenic bacterial toxins in detoxified form as toxoids with the aim of stimulating the human organism to form antibodies.
With the first vaccination injection such stimulation is still considered to be weak, in the second it should be stronger. The ability rapidly to develop new antibodies is, as a rule, achieved with the third vaccination or through contact with a pathogen some weeks after the second vaccination. This effect is called a “booster”. If the vaccinated person encounters the pathogens after the second or third vaccination, and if they penetrate the organism, their toxins are mostly rendered harmless by the antibodies which already exist or are immediately formed in great quantities.
For pertussis vaccines , acellular vaccines (aP or ap for short) are currently used in central Europe in combination with two to five other vaccination factors. The whole-cell vaccine (P or wP = whole Pert) had too many side effects. According to the technical information, however, side effects such as “hypotonic-hyporesponsive episodes” also arise from the acellular vaccinations.
The active substances in the above vaccinations (including the ones against Haemophilus influenzae B, see p. 236) are attached to aluminium hydroxide or aluminium phosphate because they stimulate immunity better that way. The aluminium dose per ampoule is between approx. 0.1 and 0.7 mg aluminium. Although intensive work is being undertaken to reduce these accessory agents, it has not been possible so far to find more suitable substances.
The injectable measles, mumps and rubella vaccines (MMR) consist of weakened proliferating viruses. They are cultured in cell cultures of monkey kidneys, chicken embryos or human tissue. Apart from traces of antibiotics (from the treated tissue and cell cultures), they contain as minor compounds hydrolysed gelatine, some human albumin (non-allergenic human protein) and traces of various other substances.
There is a complete list of rare and doubtful, also possibly serious side effects such as shrill screaming, seizures or other neurological complications in the package insert included with the vaccine by the manufacturer. Parents may as a rule assume that their doctor has not yet experienced any serious side effects with the vaccinations he or she has carried out himself or herself and therefore cannot say more on the subject than is contained in the package insert. It is recommended in all cases that the vaccination should be delayed if there is an incipient or acute infection. The vaccination interval, combinations and contraindications are best discussed with the doctor carrying out the vaccination.
There are no mandatory vaccinations in Germany. They can only be ordered for the persons at risk if the disease takes a serious course and there is a threat of it spreading. There is no obligation to vaccinate even if, for example, hepatitis A or B occurs in a school. With measles, it is likely that the health authorities will in the near future order mandatory vaccination before children without assured measles immunity are allowed back into school or kindergarten.
Tetanus vaccination
Tetanus is rare in the wealthy countries but it is one of the most serious diseases we know. When infected, 30% to 50% of sick adults die. Many newborns succumb to the disease in the tropics if their mothers have not been vaccinated.
If dirt has contaminated an injury, patients who have not yet been actively vaccinated are given preventive passive immunisation. In other words, an antigen concentrate is injected which has been obtained from highly immune human donors.
More suitable for prevention is active immunisation in which the organism is stimulated to form its own antibodies. Two injections at an interval of about one month and a third one after six months to one year are sufficient for vaccination protection of about ten years; then further boosters at intervals of ten years (on antibody creation, see p. 232).
In the event of injuries occurring some years after the last vaccination, an earlier “refresher” will be given, particularly if the wound has become very dirty or the patient is seriously injured (see table). These additional boosters serve the purpose of providing assurance; whether they are necessary is unclear. But more frequent revaccination can lead to complications. This vaccination is, however, considered to be one of the ones which is better tolerated.
Tetanus immunoprophylaxis for injuries
Previous history of tetanus immunisation (number of vaccinations)
Clean, minor wounds
All other wounds
tetanus / diphtheria / whooping cough
TIG1
Tetanus / diphtheria / whooping cough
TIG1
unknown
yes
no
yes
yes
0 to 1
yes
no
yes
yes
2
yes
no
yes
no2
3 or more
no3
no
no4
no
1 TIG = tetanus immunoglobulin / 2 Yes, if the injury is older than 24 hours / 3 Yes (1 dose), if more than ten years have passed since the last vaccination / 4 Yes (1 dose), if more than five years have passed since the last vaccination.
Source : Epidemiologisches Bulletin No. 30/2011, p. 292, Robert Koch Institute.
Since tetanus is a rare disease in the wealthy countries, a great number of people would have to be vaccinated to prevent a single tetanus case with statistical probability. Curiously, suffering tetanus does not leave any immunity. In central Europe, the risk of falling ill with tetanus is exceptionally low. Woman who are immune against tetanus transfer antibodies during pregnancy which give the infant protection for several months. For this reason we recommend vaccination only at one year, starting with the sixth preventive medical checkup (in Germany there are six standardised paediatric examinations in the first year) and not, as otherwise customary, in the third month. We do that because children are significantly more stable in their bodies at one year. Furthermore, a reaction to vaccination is more difficult to identify in babies.
If dirt has contaminated an injury, patients who have not yet been actively vaccinated are given preventive passive immunisation. In other words, an antigen concentrate is injected which has been obtained from highly immune human donors.
More suitable for prevention is active immunisation in which the organism is stimulated to form its own antibodies. Two injections at an interval of about one month and a third one after six months to one year are sufficient for vaccination protection of about ten years; then further boosters at intervals of ten years (on antibody creation, see p. 232).
In the event of injuries occurring some years after the last vaccination, an earlier “refresher” will be given, particularly if the wound has become very dirty or the patient is seriously injured (see table). These additional boosters serve the purpose of providing assurance; whether they are necessary is unclear. But more frequent revaccination can lead to complications. This vaccination is, however, considered to be one of the ones which is better tolerated.
Tetanus immunoprophylaxis for injuries
Previous history of tetanus immunisation (number of vaccinations)
Clean, minor wounds
All other wounds
tetanus / diphtheria / whooping cough
TIG1
Tetanus / diphtheria / whooping cough
TIG1
unknown
yes
no
yes
yes
0 to 1
yes
no
yes
yes
2
yes
no
yes
no2
3 or more
no3
no
no4
no
1 TIG = tetanus immunoglobulin / 2 Yes, if the injury is older than 24 hours / 3 Yes (1 dose), if more than ten years have passed since the last vaccination / 4 Yes (1 dose), if more than five years have passed since the last vaccination.
Source : Epidemiologisches Bulletin No. 30/2011, p. 292, Robert Koch Institute.
Since tetanus is a rare disease in the wealthy countries, a great number of people would have to be vaccinated to prevent a single tetanus case with statistical probability. Curiously, suffering tetanus does not leave any immunity. In central Europe, the risk of falling ill with tetanus is exceptionally low. Woman who are immune against tetanus transfer antibodies during pregnancy which give the infant protection for several months. For this reason we recommend vaccination only at one year, starting with the sixth preventive medical checkup (in Germany there are six standardised paediatric examinations in the first year) and not, as otherwise customary, in the third month. We do that because children are significantly more stable in their bodies at one year. Furthermore, a reaction to vaccination is more difficult to identify in babies.
Diphtheria vaccination
It was possible to overcome the diphtheria epidemic in the countries of the former Soviet Union which reportedly affected 80% of adults. In Germany, the number of reported diphtheria cases has to all intents and purposes not risen. But it is clear that only a few adults here have measurable diphtheria protection.
This vaccination, like the one for tetanus, consists of two injections at an interval of one to two (to four) months and a booster six months to one year later. In connection with the recommendation to start vaccination in infancy with the hexavalent and heptavalent vaccines, three vaccination dates in the first year of life and a further one in the second were introduced. Fever often occurs after the second and third vaccination and there can be an inflammatory swelling at the vaccination spot, particularly if a little of the vaccine flows back under the skin from the muscle. Complications rarely occur. The protection from the vaccine is considered to be satisfactory for about five years. Then there is a refresher consisting of a single injection and later, on travel to epidemic areas, at an interval of ten years. Austria provides for the vaccination of infants at two, four and eleven months. There should be boosters at the age of between six and eight and at the age of 18 ; thereafter at ten-year intervals. From the age of six the vaccination dose is reduced to approx. 1/10 of the infant dose due to reduced tolerance.
For the same reasons that apply to tetanus vaccination, we recommend in non-epidemic periods that parents who want to vaccinate their children against diphtheria do not do so until the age of one.
This vaccination, like the one for tetanus, consists of two injections at an interval of one to two (to four) months and a booster six months to one year later. In connection with the recommendation to start vaccination in infancy with the hexavalent and heptavalent vaccines, three vaccination dates in the first year of life and a further one in the second were introduced. Fever often occurs after the second and third vaccination and there can be an inflammatory swelling at the vaccination spot, particularly if a little of the vaccine flows back under the skin from the muscle. Complications rarely occur. The protection from the vaccine is considered to be satisfactory for about five years. Then there is a refresher consisting of a single injection and later, on travel to epidemic areas, at an interval of ten years. Austria provides for the vaccination of infants at two, four and eleven months. There should be boosters at the age of between six and eight and at the age of 18 ; thereafter at ten-year intervals. From the age of six the vaccination dose is reduced to approx. 1/10 of the infant dose due to reduced tolerance.
For the same reasons that apply to tetanus vaccination, we recommend in non-epidemic periods that parents who want to vaccinate their children against diphtheria do not do so until the age of one.
Vaccination against Haemophilus influenzae type b bacteria.
Haemophilus influenzae type b bacteria (Hib) are involved in the very perilous acute epiglottitis (see p. 90), often also in purulent meningitis, and not infrequently in childhood otitis media. These bacteria can also be found in about 5% of healthy children. Before this vaccination was introduced, about every five hundredth infant went through a serious Hib-related illness once. That is to say, the other children were immunised unseen. Apparently about 10 to 30 children died in the whole of Germany each year from one of the serious forms of this disease before the vaccination was introduced and the same number again suffered permanent damage. The risk is judged to be greater among lower socio-economic groups and highest in children with congenital immunodeficiency or immunodeficiency caused by serious illness.
Contrary to some information, the Hib vaccination does not protect against meningitis but only against one of several meningitis pathogens. The disease incidence has fallen greatly since the introduction of the vaccination and with it the occasional vaccine failures still observed at the beginning as well as the cases of illness among those who were not vaccinated. This means that the circulation of the bacterium was slowed down by the vaccination campaign.
As children under 18 months are deemed to be most at risk, only early vaccination actually makes sense. Today this form of hexavalent vaccination (Hib, whooping cough, polio, diphtheria, tetanus and hepatitis B) is recommended in the third, fourth and fifth month as well as a booster in the eleventh to fourteenth month. There is the approved single vaccine Act-HIB. It has to be refreshed twice – only once if vaccination started after the sixth month of life – at an interval of one to two months and a final time in the second year of life. If vaccination is started after the first birthday, a single vaccination with the single vaccine is sufficient.
Contrary to some information, the Hib vaccination does not protect against meningitis but only against one of several meningitis pathogens. The disease incidence has fallen greatly since the introduction of the vaccination and with it the occasional vaccine failures still observed at the beginning as well as the cases of illness among those who were not vaccinated. This means that the circulation of the bacterium was slowed down by the vaccination campaign.
As children under 18 months are deemed to be most at risk, only early vaccination actually makes sense. Today this form of hexavalent vaccination (Hib, whooping cough, polio, diphtheria, tetanus and hepatitis B) is recommended in the third, fourth and fifth month as well as a booster in the eleventh to fourteenth month. There is the approved single vaccine Act-HIB. It has to be refreshed twice – only once if vaccination started after the sixth month of life – at an interval of one to two months and a final time in the second year of life. If vaccination is started after the first birthday, a single vaccination with the single vaccine is sufficient.
Whooping cough vaccination
Today’s “acellular” vaccines contain two to four antigens of the germ. There is no longer a single vaccine but only the combination with other vaccines.
In infancy, three injections should be given from the third month at intervals of four to six weeks. The fourth injection after six months to one year should then produce the so-called booster dose offering many years of protection. But there are plenty of examples of children who have been vaccinated three or four times going through regular whooping cough at the age of five.48
The group which actually needs protecting is premature babies and infants up to the age of three to five months. As already explained, they cannot be reached with vaccination in the first months. The recommended strategy tends towards reducing the opportunities for spreading an infection through older siblings. In fact whooping cough in childhood is significantly falling in populations with pervasive vaccination cover. But the strategy has holes because – as already shown – whooping cough cannot be eradicated in that way.
The more people are vaccinated, the more adults turn into a risk as a source of infection for small infants. Mostly they only have an annoying cough which lasts for several week and pass on the infection without being aware that it is whooping cough.
For an overall judgement, the following comparison continues to be illuminating. In Great Britain, it was decided to withdraw the vaccination after several years because of concerns about harmful side effects after most of the population had been vaccinated and the circulation of whooping cough stopped. A few years later a great epidemic occurred with many serious cases. In Germany, the vaccination cover was never as high and the rise of the disease after the vaccination recommendation was withdrawn was not as clear-cut and did not lead to a greater rise in mortality than in previous years (almost always less than ten percent per year in the old West Germany). The much higher mortality from whooping cough in the 1930s and its fall after the Second World War therefore had reasons other than the lack of or inconsistently implemented vaccination.
In our experience the presence of the mother plays a decisively positive role particularly among those children who are affected at an early age. Her presence is the best remedy to reduce the fear of choking as a key magnifier of an attack.
Vaccination may make sense in the case of certain pulmonary and heart diseases – or for social reasons in crèches and in situations where many children live in close proximity (on the risk of whooping cough in infancy, see p. 169).
In infancy, three injections should be given from the third month at intervals of four to six weeks. The fourth injection after six months to one year should then produce the so-called booster dose offering many years of protection. But there are plenty of examples of children who have been vaccinated three or four times going through regular whooping cough at the age of five.48
The group which actually needs protecting is premature babies and infants up to the age of three to five months. As already explained, they cannot be reached with vaccination in the first months. The recommended strategy tends towards reducing the opportunities for spreading an infection through older siblings. In fact whooping cough in childhood is significantly falling in populations with pervasive vaccination cover. But the strategy has holes because – as already shown – whooping cough cannot be eradicated in that way.
The more people are vaccinated, the more adults turn into a risk as a source of infection for small infants. Mostly they only have an annoying cough which lasts for several week and pass on the infection without being aware that it is whooping cough.
For an overall judgement, the following comparison continues to be illuminating. In Great Britain, it was decided to withdraw the vaccination after several years because of concerns about harmful side effects after most of the population had been vaccinated and the circulation of whooping cough stopped. A few years later a great epidemic occurred with many serious cases. In Germany, the vaccination cover was never as high and the rise of the disease after the vaccination recommendation was withdrawn was not as clear-cut and did not lead to a greater rise in mortality than in previous years (almost always less than ten percent per year in the old West Germany). The much higher mortality from whooping cough in the 1930s and its fall after the Second World War therefore had reasons other than the lack of or inconsistently implemented vaccination.
In our experience the presence of the mother plays a decisively positive role particularly among those children who are affected at an early age. Her presence is the best remedy to reduce the fear of choking as a key magnifier of an attack.
Vaccination may make sense in the case of certain pulmonary and heart diseases – or for social reasons in crèches and in situations where many children live in close proximity (on the risk of whooping cough in infancy, see p. 169).
Poliomyelitis (infantile paralysis) vaccination
Epidemic infantile paralysis has to all intents and purposes been eradicated in the developed countries as a result of the vaccination which was introduced between 1955 and 1960.
As a disease of civilisation and with increasing hygiene the epidemics grew larger and more dangerous, e.g. because children no longer received occult immunisation in infancy. In the USA, for example, more than 25,000 cases of paralysis were to be expected in the epidemic years. The surreptitious nature of this disease with its sudden paralysis and sometimes life-threatening course was the reason for the development of the vaccines.
The recommendation of the vaccination commission STIKO no longer to use anything but the injectable dead vaccine (IPV Salk vaccine) has applied in Germany since 1998. It is included in almost all common multivalent vaccines and as per schedule is given three times (twice as a single vaccine) and then once more between 11 and 14 months. Booster vaccinations are recommended from the age of ten and then every ten years.
Europe has been free of wild polio infections for some years but worldwide there are still several hundred cases each year. This means that the risk for the individual has become low and the goal of the WHO to eradicate polio worldwide within a few years appeared reasonable. But more recent experiences with the circulation of reverse mutating viruses from the oral vaccine are curtailing this hope. A booster is only recommended for young people and adults if they plan to travel to countries where there is a polio risk.
As a disease of civilisation and with increasing hygiene the epidemics grew larger and more dangerous, e.g. because children no longer received occult immunisation in infancy. In the USA, for example, more than 25,000 cases of paralysis were to be expected in the epidemic years. The surreptitious nature of this disease with its sudden paralysis and sometimes life-threatening course was the reason for the development of the vaccines.
The recommendation of the vaccination commission STIKO no longer to use anything but the injectable dead vaccine (IPV Salk vaccine) has applied in Germany since 1998. It is included in almost all common multivalent vaccines and as per schedule is given three times (twice as a single vaccine) and then once more between 11 and 14 months. Booster vaccinations are recommended from the age of ten and then every ten years.
Europe has been free of wild polio infections for some years but worldwide there are still several hundred cases each year. This means that the risk for the individual has become low and the goal of the WHO to eradicate polio worldwide within a few years appeared reasonable. But more recent experiences with the circulation of reverse mutating viruses from the oral vaccine are curtailing this hope. A booster is only recommended for young people and adults if they plan to travel to countries where there is a polio risk.
Chickenpox vaccination
There has been an official general chickenpox (= varicella) vaccination recommendation from the German vaccination commission STIKO since the autumn of 2004 (further information at www.rki.de). Previously it had only applied to patients with certain immunodeficiencies or a serious tendency to develop eczema. The vaccine is now offered at the same time as the measles-mumps-rubella vaccination (MMR) (see the following pages).
Criticism of the specialist medical bodies is growing alongside the recommendation of this vaccination as the complications of chickenpox are more than doubtful as a reason for vaccination. It is therefore interesting that the STIKO most recently also put forward economic arguments : if all children were vaccinated, mothers would work one extra day per year on average. We are keeping to the risk indication as before (see above). Furthermore, the disease is deferred into adulthood with incomplete immunity. The vaccination of all children also increases the risk of adults catching shingles as they no longer have any opportunity for a booster.
Criticism of the specialist medical bodies is growing alongside the recommendation of this vaccination as the complications of chickenpox are more than doubtful as a reason for vaccination. It is therefore interesting that the STIKO most recently also put forward economic arguments : if all children were vaccinated, mothers would work one extra day per year on average. We are keeping to the risk indication as before (see above). Furthermore, the disease is deferred into adulthood with incomplete immunity. The vaccination of all children also increases the risk of adults catching shingles as they no longer have any opportunity for a booster.
Rubella vaccination
An injectable live vaccine against rubella has been officially recommended since 1973. It is exclusively intended to immunise girls in view of a future pregnancy so that their children cannot be harmed if they fall ill with rubella in the first months of pregnancy. It represents a great psychological burden for pregnant women if they are infected with rubella and learn that they do not possess any antibodies. The risk of an embryopathy is up to 90% with rubella in the first eleven weeks of pregnancy. After the sixteenth week of pregnancy a defect can still be expected in a maximum of 5% of children, particularly of the inner ear. Possible long-term consequences are diabetes and the development of autism.
The vaccination is recommended from the twelfth month of life with a repetition at the sixteenth month of life. The vaccinations are mostly given in combination with the measles, mumps and chickenpox vaccination. The previously recommended renewed vaccination for girls at the age of ten to fifteen following the two previous vaccinations is currently the subject of debate.
These recommendations are not optimal. From an epidemiological perspective the vaccination should only be given to girls in puberty so that the natural spread of the infection is not disrupted. It is meanwhile known that, as a result of the current mass vaccination, the vaccinated women of child-bearing age on average have a lower antibody titre than those who have not been vaccinated, provided that latter had the opportunity to be infected and are now protected through such contact with the wild virus. The vaccinated group also has a much greater tendency to be reinfected in pregnancy than the second group (whereby the risk of foetal damage is evidently low). The second group is better protected even with a low antibody titre than the vaccinated first group. A repeat vaccination is also of less benefit than infection with the wild virus. With regard to the argument that the number of children born with defects caused by the virus has fallen considerably through mass vaccination, it must be pointed out that an unknown number of children were aborted on suspicion of having a defect. Both the rubella vaccination and rubella itself can occasionally affect the joints rheumatically – mostly temporarily – and more frequently so in adulthood and with repeat vaccination than in children.
The vaccination is recommended from the twelfth month of life with a repetition at the sixteenth month of life. The vaccinations are mostly given in combination with the measles, mumps and chickenpox vaccination. The previously recommended renewed vaccination for girls at the age of ten to fifteen following the two previous vaccinations is currently the subject of debate.
These recommendations are not optimal. From an epidemiological perspective the vaccination should only be given to girls in puberty so that the natural spread of the infection is not disrupted. It is meanwhile known that, as a result of the current mass vaccination, the vaccinated women of child-bearing age on average have a lower antibody titre than those who have not been vaccinated, provided that latter had the opportunity to be infected and are now protected through such contact with the wild virus. The vaccinated group also has a much greater tendency to be reinfected in pregnancy than the second group (whereby the risk of foetal damage is evidently low). The second group is better protected even with a low antibody titre than the vaccinated first group. A repeat vaccination is also of less benefit than infection with the wild virus. With regard to the argument that the number of children born with defects caused by the virus has fallen considerably through mass vaccination, it must be pointed out that an unknown number of children were aborted on suspicion of having a defect. Both the rubella vaccination and rubella itself can occasionally affect the joints rheumatically – mostly temporarily – and more frequently so in adulthood and with repeat vaccination than in children.
Mumps vaccination
The mumps vaccination is only possible in combination with measles and rubella. It is recommended from the twelfth month of life. The meningitis which occurs with mumps cannot be presented as a leading argument for vaccination, given the current course of the disease, as it heals without consequences in the vast majority of cases in childhood (cf. the description for mumps, p. 166ff.). The only reason for the vaccination is the lasting damage from a rare hearing disorder which does, however, also occur after vaccination. The orchitis associated with mumps occurs almost only after puberty (in the cases where it does occur before, there is never any permanent damage). It is extremely painful but leads to infertility only in the rarest of cases. It is, nevertheless, difficult to judge the actual risk of orchitis without and with vaccination. Apart from differences in the seriousness of and susceptibility for the disease during epidemics, the following should be considered with the current state of knowledge in mind : let us assume the question of a mumps vaccination arises for a one-and-a-half-year-old boy. In most cases a child up to the age of fifteen could expect to be infected before the vaccination was introduced. Seventy to 90% of adults have antibodies and were immunised before the vaccination era. Let us assume that the child was not one of these and retained its receptivity for mumps into adulthood ; the question arises once again whether the latter would really fall ill when infected with the wild virus or would go through the illness “occultly”. In the case of illness, a unilateral orchitis could be expected in 10% to 14% of cases (see also p. 167). Doctors cannot be more precise than that at the moment. The lay person should know this when making the vaccination decision because the simple statement : “Mumps can cause orchitis with permanent infertility” does not adequately reflect the actual risk.
Permanent damage to the inner ear is also mostly unilateral and is frequently not diagnosed until later. Hence the information about frequency is also unreliable. One serious case of hearing damage is expected in 15,000 cases of mumps without complications. During more than 30 years of work as paediatricians we have only come across one such child. Because of the greater number of vaccinations now, the disease peak among those without the vaccination has shifted towards adulthood in which such complications are more frequent. The vaccination can also cause hearing disorders in very rare cases.
A rare (the information about frequency varies) encephalitis (not to be confused here with meningitis, which occurs frequently and mostly without consequences) can be associated with long-term damage in the form of permanent nerve and brain damage. The course is thought to be more favourable than with measles. We have not yet observed such a patient.
The length of vaccination protection is unknown, but probably about 10 to 15 years ; in accordance with the recommendations for rubella and measles, the vaccination should be given twice. There can be no doubt that the previous high level of immunisation in adulthood is no longer achieved with the current vaccination strategy. Hence we consider the general vaccination recommendation to be misguided. For male adolescents, immunity against mumps is, however, desirable – either by having gone through the disease or through vaccination.
Permanent damage to the inner ear is also mostly unilateral and is frequently not diagnosed until later. Hence the information about frequency is also unreliable. One serious case of hearing damage is expected in 15,000 cases of mumps without complications. During more than 30 years of work as paediatricians we have only come across one such child. Because of the greater number of vaccinations now, the disease peak among those without the vaccination has shifted towards adulthood in which such complications are more frequent. The vaccination can also cause hearing disorders in very rare cases.
A rare (the information about frequency varies) encephalitis (not to be confused here with meningitis, which occurs frequently and mostly without consequences) can be associated with long-term damage in the form of permanent nerve and brain damage. The course is thought to be more favourable than with measles. We have not yet observed such a patient.
The length of vaccination protection is unknown, but probably about 10 to 15 years ; in accordance with the recommendations for rubella and measles, the vaccination should be given twice. There can be no doubt that the previous high level of immunisation in adulthood is no longer achieved with the current vaccination strategy. Hence we consider the general vaccination recommendation to be misguided. For male adolescents, immunity against mumps is, however, desirable – either by having gone through the disease or through vaccination.
Measles vaccination
The measles vaccination has been officially recommended in Germany since 1973 as an injectable live vaccination together with the mumps and rubella vaccination. It is part of a worldwide step-by-step strategy by the World Health Organisation and its regional groups to eradicate measles by 2010. Nowadays, vaccination is recommended from the twelfth month of life with a booster after four weeks at the earliest, the latter in order to cover those in whom the vaccination did not work and those who have not been vaccinated or who had a weak reaction.
Reasons for the measles vaccination in the tropics and countries with a low standard of living include the high mortality rate particularly through pulmonary complications. In the rich countries in the temperate zones, reasons include rare pulmonary complications and, even more rarely, encephalitis (on its frequency, see p. 153).49 The infectious diseases protection act, combined with the obligation to report anyone suffering from the disease by name, means that unvaccinated children can be kept off school by the health authorities for weeks during an upsurge of measles. Children who have had measles are only recognised as being protected if serologically documented (i.e. determination of measles antibodies in the blood) and are only allowed back to school in that event. The health authorities can order so-called lockdown vaccinations in the vicinity of children with the disease.
What we do know is that in liberal democracies excessive vaccination propaganda can reduce the willingness of the population to vaccinate. Everyone in a position of responsibility must therefore be clear that the planned eradication of measles can, ultimately, only be achieved through compulsory measures, namely statutory mandatory vaccination. But if the ratio between people who have been vaccinated and who have not been vaccinated remains similar to Germany, those who have been vaccinated can acquire repeated additional protection with the least possible isolation of those infected with the disease while the freedom to decide whether or not to vaccinate is preserved. It must, however, be borne in mind that fatalities do occur in every measles epidemic.
The upsurge of measles mainly in the Ruhr region in the spring of 2006 was not an epidemic but corresponded to the natural seasonal spread of measles every few years, as used to happen before the introduction of vaccination – but with the difference that as a result of the lack of infectious opportunities more adolescents were now affected. Vaccinated persons would be able to acquire permanent protection from the former as long as they are infectious. No serious courses of the disease were reported at the time.
On a psychological level it should be taken into account that parents who vaccinate their children a lot, including against measles, have a greater fear of this and other diseases. It has happened that at kindergarten age unvaccinated children were no longer allowed to travel in the same car as vaccinated ones. Yet it would be sensible for the vaccinated children to improve their limited protection through contact with the wild virus. And if the vaccination had not been successful, a measles outbreak in the vaccinated child would be less dangerous at this age than later.
Once parents have been thoroughly informed (see also the book recommendations on p. 252), the decision for or against vaccination always remains with them and it should be supported by the doctor.
We recommend looking at the question of vaccination once more at school age between nine and twelve for children who have neither been vaccinated nor fallen ill with the disease, as the risks of the disease increase in later years.
Not as part of the general recommendation but as a vaccination indicated by special circumstances, a measles vaccination can successfully be administered within three days of known measles contact, as immunity from the vaccination occurs more rapidly than the development of the clinical picture (see also p. 153).
A very recent problem is catching measles in the first year of life. Because mothers were vaccinated in childhood, they did not catch measles and therefore cannot give very good passive immunity to their children. Recent observations have shown that after measles in infancy the feared panencephalitis (SSPE) happens much more frequently at 1:5000 than if measles occurs at a later time, i.e. this is another reason to consider vaccination because my child could infect an infant and place him or her at risk.50
Reasons for the measles vaccination in the tropics and countries with a low standard of living include the high mortality rate particularly through pulmonary complications. In the rich countries in the temperate zones, reasons include rare pulmonary complications and, even more rarely, encephalitis (on its frequency, see p. 153).49 The infectious diseases protection act, combined with the obligation to report anyone suffering from the disease by name, means that unvaccinated children can be kept off school by the health authorities for weeks during an upsurge of measles. Children who have had measles are only recognised as being protected if serologically documented (i.e. determination of measles antibodies in the blood) and are only allowed back to school in that event. The health authorities can order so-called lockdown vaccinations in the vicinity of children with the disease.
What we do know is that in liberal democracies excessive vaccination propaganda can reduce the willingness of the population to vaccinate. Everyone in a position of responsibility must therefore be clear that the planned eradication of measles can, ultimately, only be achieved through compulsory measures, namely statutory mandatory vaccination. But if the ratio between people who have been vaccinated and who have not been vaccinated remains similar to Germany, those who have been vaccinated can acquire repeated additional protection with the least possible isolation of those infected with the disease while the freedom to decide whether or not to vaccinate is preserved. It must, however, be borne in mind that fatalities do occur in every measles epidemic.
The upsurge of measles mainly in the Ruhr region in the spring of 2006 was not an epidemic but corresponded to the natural seasonal spread of measles every few years, as used to happen before the introduction of vaccination – but with the difference that as a result of the lack of infectious opportunities more adolescents were now affected. Vaccinated persons would be able to acquire permanent protection from the former as long as they are infectious. No serious courses of the disease were reported at the time.
On a psychological level it should be taken into account that parents who vaccinate their children a lot, including against measles, have a greater fear of this and other diseases. It has happened that at kindergarten age unvaccinated children were no longer allowed to travel in the same car as vaccinated ones. Yet it would be sensible for the vaccinated children to improve their limited protection through contact with the wild virus. And if the vaccination had not been successful, a measles outbreak in the vaccinated child would be less dangerous at this age than later.
Once parents have been thoroughly informed (see also the book recommendations on p. 252), the decision for or against vaccination always remains with them and it should be supported by the doctor.
We recommend looking at the question of vaccination once more at school age between nine and twelve for children who have neither been vaccinated nor fallen ill with the disease, as the risks of the disease increase in later years.
Not as part of the general recommendation but as a vaccination indicated by special circumstances, a measles vaccination can successfully be administered within three days of known measles contact, as immunity from the vaccination occurs more rapidly than the development of the clinical picture (see also p. 153).
A very recent problem is catching measles in the first year of life. Because mothers were vaccinated in childhood, they did not catch measles and therefore cannot give very good passive immunity to their children. Recent observations have shown that after measles in infancy the feared panencephalitis (SSPE) happens much more frequently at 1:5000 than if measles occurs at a later time, i.e. this is another reason to consider vaccination because my child could infect an infant and place him or her at risk.50
Tuberculosis vaccination (BCG vaccination)
The tuberculosis vaccination offers neither assured protection against infection and disease nor against its serious course, as has often been said. More important in this respect is:
the identification, treatment and monitoring of patients with open tuberculosis,
their isolation from small children,
the vaccination of cows and pasteurisation of milk if it originates from cowsheds which are not certainly free of tuberculosis.
A tuberculosis detection test (tuberculosis test) gives a positive result for vaccinated and ill persons so that it is more difficult to determine a person who has nevertheless been infected, i.e. a “vaccine failure”. If a person with open tuberculosis is suspected of being in the vicinity of a newborn, isolation measures must be implemented as a first step. Since 1998 the vaccination commission STIKO has withdrawn the vaccination recommendation altogether because of a lack of efficacy of the vaccine on the one hand and deaths in infants with weak immunity on the other.
the identification, treatment and monitoring of patients with open tuberculosis,
their isolation from small children,
the vaccination of cows and pasteurisation of milk if it originates from cowsheds which are not certainly free of tuberculosis.
A tuberculosis detection test (tuberculosis test) gives a positive result for vaccinated and ill persons so that it is more difficult to determine a person who has nevertheless been infected, i.e. a “vaccine failure”. If a person with open tuberculosis is suspected of being in the vicinity of a newborn, isolation measures must be implemented as a first step. Since 1998 the vaccination commission STIKO has withdrawn the vaccination recommendation altogether because of a lack of efficacy of the vaccine on the one hand and deaths in infants with weak immunity on the other.
Hepatitis A prevention
If cases of jaundice occur in kindergartens and schools today, an incubation vaccination with active hepatitis A vaccine is recommended for those who have not yet fallen ill with the disease.
We recommend careful toilet hygiene and an individual decision. Active hepatitis A vaccination is otherwise recommended in Germany by the vaccination commission STIKO for children before travel to countries where there is a high chance of being infected with hepatitis A (not covered by the health insurance funds). Basic immunisation comprises two injections at an interval of six months. A booster vaccination is required after ten years at the earliest.
We recommend careful toilet hygiene and an individual decision. Active hepatitis A vaccination is otherwise recommended in Germany by the vaccination commission STIKO for children before travel to countries where there is a high chance of being infected with hepatitis A (not covered by the health insurance funds). Basic immunisation comprises two injections at an interval of six months. A booster vaccination is required after ten years at the earliest.
Hepatitis B vaccination
Since 1996, the hepatitis B vaccination, which until then had only been intended for persons at particular risk of infection, has been recommended by the vaccination commission STIKO at the start of the third month of life and specifically for adolescents in general. The reason is the spread of the disease in adolescence and adulthood and chronically ill and infectious persons (see p. 172f.).
The vaccine contains a non-proliferating surface antigen of the hepatitis B virus which stimulates antibody formation. Three vaccinations are considered necessary. According to various sources, about 95% of vaccinated persons respond to the vaccination. Germany has stopped recommending a refresher vaccination at school age. The vaccine is injected into the muscle. Hexavalent combination vaccines have been developed for infants. Side effects are listed in the package leaflet for the vaccine (regarding possible complications and fatalities, see note 51).
The vaccination commission STIKO hopes that the extended vaccination recommendation will lead to the eradication of hepatitis B. But to achieve that, more than 90% of the population would have to be vaccinated, which is hardly realistic. The serious complications, although rare, should also be considered. For tiny tots it represents an additional vaccination factor – and that at an age in which they normally build up their immune system in relation to the external world and not in relation to substances which suddenly – as content of the vaccination ampoule – appear in their muscles. Furthermore, the risk of falling ill in infancy is extremely low in central Europe. We will, of course, seek to protect a newborn whose mother is infectious with hepatitis B against this disease with passive and active vaccination. Otherwise we are cautious about the use of this vaccination in infancy and childhood if no special risk exists.
The vaccine contains a non-proliferating surface antigen of the hepatitis B virus which stimulates antibody formation. Three vaccinations are considered necessary. According to various sources, about 95% of vaccinated persons respond to the vaccination. Germany has stopped recommending a refresher vaccination at school age. The vaccine is injected into the muscle. Hexavalent combination vaccines have been developed for infants. Side effects are listed in the package leaflet for the vaccine (regarding possible complications and fatalities, see note 51).
The vaccination commission STIKO hopes that the extended vaccination recommendation will lead to the eradication of hepatitis B. But to achieve that, more than 90% of the population would have to be vaccinated, which is hardly realistic. The serious complications, although rare, should also be considered. For tiny tots it represents an additional vaccination factor – and that at an age in which they normally build up their immune system in relation to the external world and not in relation to substances which suddenly – as content of the vaccination ampoule – appear in their muscles. Furthermore, the risk of falling ill in infancy is extremely low in central Europe. We will, of course, seek to protect a newborn whose mother is infectious with hepatitis B against this disease with passive and active vaccination. Otherwise we are cautious about the use of this vaccination in infancy and childhood if no special risk exists.
Pneumococcal vaccination
For some years a vaccine has been available in Germany against pneumococci which, like Haemophilus influenzae b (Hib), can cause a purulent meningitis in rare cases. As with Hib, such meningitis occurs most frequently in the first months of life and as good as never happens again after the fourth birthday. Beyond that, the pneumococci above all cause infections of the middle ear and pneumonia. They are a very large group of closely related bacteria (serogroups), i.e. one vaccine has to contain antigens of various serogroups. Here it must be taken into account that the various pneumococcal strains occur with varying frequency in different countries. The vaccines currently approved in Germany comprises thirteen serogroup characteristics (from a total of approx. ninety possible ones). This means that they cannot with any certainty protect against a purulent pneumococcal meningitis. The level of the protection rate is still unknown. The vaccination commission STIKO recommends the vaccination for all children from the third month of life, three times at an interval of four weeks in parallel to the “normal” combination vaccines starting with the third month of life, and once at 15 months. Another vaccine which has been available for a long time is only used for particular basic diseases (e.g. after splenectomy). It contains 23 of the pneumococcal antigens common in our latitudes and is intended to prevent serious infections in these patients.
Meningococcal vaccination
Meningococci (Neisseria meningitidis) are bacteria which can trigger various clinical pictures. About ten percent of the population carry these bacteria in their nose without falling ill. The infection is transmitted between humans through droplets when people cough, sneeze or kiss. If there is a weaknesses of the immune system, meningitis and blood poisoning (septicaemia) with internal bleeding can occur, sometimes life-threateningly within hours.
As with the pneumococci, there are various types of meningococci. Until 2006, the vaccination commission STIKO recommended the vaccination only for specific people: in diseases of the immune system and for travellers to high-risk countries, particularly the countries of the Sahel zone in Africa. Thus Saudi Arabia for example demands a vaccination certificate covering two vaccinations before allowing entry to the country.
Since July 2006, the vaccination commission STIKO has recommended a meningococcal vaccination for all children from the thirteenth month of life. The currently available vaccination from the thirteenth month of life only protects against the C subtype. There is not yet a vaccine against the much more common B subtype which means that the vaccination only protects against about 25% of all possible diseases. The dead vaccine consists of components of the meningococcal capsule and is given once from the thirteenth month of life. Vaccination protection only lasts for a short time : infants are only adequately protected for one year, older children and adolescents for up to five years. Thus targeted vaccination for specific possible risks (immunodeficiency) or a visit to certain countries appears sensible after individual consideration with the parents – but a general vaccination for all children from the age of two does not.
As with the pneumococci, there are various types of meningococci. Until 2006, the vaccination commission STIKO recommended the vaccination only for specific people: in diseases of the immune system and for travellers to high-risk countries, particularly the countries of the Sahel zone in Africa. Thus Saudi Arabia for example demands a vaccination certificate covering two vaccinations before allowing entry to the country.
Since July 2006, the vaccination commission STIKO has recommended a meningococcal vaccination for all children from the thirteenth month of life. The currently available vaccination from the thirteenth month of life only protects against the C subtype. There is not yet a vaccine against the much more common B subtype which means that the vaccination only protects against about 25% of all possible diseases. The dead vaccine consists of components of the meningococcal capsule and is given once from the thirteenth month of life. Vaccination protection only lasts for a short time : infants are only adequately protected for one year, older children and adolescents for up to five years. Thus targeted vaccination for specific possible risks (immunodeficiency) or a visit to certain countries appears sensible after individual consideration with the parents – but a general vaccination for all children from the age of two does not.
HPV vaccination (human papilloma virus)
The German Standing Vaccination Commission has since July 2007 recommended vaccination against humane papilloma viruses (HPV) for all girls aged 12 to 17 before their first sexual encounter. The human papilloma virus (HPV) is the virus which is most frequently transmitted through sexual intercourse worldwide. There are more than 100 different HPV types, of which more than 30 affect the female genital tract and 19 are currently considered to be carcinogenic. HPV can be detected in every third woman within 24 months of first sexual contact. More than 70% of all women will be infected with one of the various HPV types in the course of their life. The HPV infection mostly proceeds without symptoms and abates spontaneously in over 90% of cases within one to two years. The younger the woman when infected, the more likely it is that the disease will heal naturally in this way. After one year, HPV can no longer be detected in 80% of the affected women. Once there has been one HPV infection, it unlikely to recur.
As genetic material from HPV viruses can be detected in women with cervical cancer, a causal link is suspected. This depends mainly on the individual disposition of the woman and less on the infection. Years to decades can pass between the permanent entrenchment of the virus and changes in the mucosal cells. Cervical cancer can be detected at a very early stage through gynaecological early detection screening with the so-called Pap smear. Hence the greatest importance should be placed on regular preventive medical checkups for the adult woman.
There is some debate as to whether the harmless HPV types 6 and 11, which the vaccine Gardasil® is aimed at among others, may protect against cancer. It is also known that the virus characteristically mutates. Hence there are first medical studies which take a critical view of the vaccination. Furthermore, the vaccine is decidedly expensive, money which is then not available in other parts of the health system. Although HPV is included in the vaccination schedule in Austria, it is not paid for by the state health system. The vaccination does not in any way replace regular early detection screening !
As genetic material from HPV viruses can be detected in women with cervical cancer, a causal link is suspected. This depends mainly on the individual disposition of the woman and less on the infection. Years to decades can pass between the permanent entrenchment of the virus and changes in the mucosal cells. Cervical cancer can be detected at a very early stage through gynaecological early detection screening with the so-called Pap smear. Hence the greatest importance should be placed on regular preventive medical checkups for the adult woman.
There is some debate as to whether the harmless HPV types 6 and 11, which the vaccine Gardasil® is aimed at among others, may protect against cancer. It is also known that the virus characteristically mutates. Hence there are first medical studies which take a critical view of the vaccination. Furthermore, the vaccine is decidedly expensive, money which is then not available in other parts of the health system. Although HPV is included in the vaccination schedule in Austria, it is not paid for by the state health system. The vaccination does not in any way replace regular early detection screening !
Recommended reading
There is an information sheet on vaccination from the Gesellschaft Anthroposophischer Ärzte (Society of Anthroposophic Physicians) : www.anthroposophischeaerzte.de
Flu (influenza) vaccination
Flu epidemics occur every year – mostly originating in China. The most serious one was in 1918, the most recent major one in 1977. These epidemics are triggered by a group of very viruses capable of great variation. Thus the vaccines – made of split antigens – must be newly formulated each year depending on the virus type which occurs. There is always a degree of uncertainty as to whether the relevant antigens are contained in the respective vaccine. The protective flu vaccine is recommended for patient, age and professional groups which are particularly at risk.
The independent Cochrane Institute judges the efficacy studies published so far to be qualitatively bad and the efficacy of the vaccination not to have been proven.
The independent Cochrane Institute judges the efficacy studies published so far to be qualitatively bad and the efficacy of the vaccination not to have been proven.
Tick-borne encephalitis vaccination
Early summer meningoencephalitis (ESME), a meningitis and encephalitis, is a viral disease transmitted by ticks (not to be confused with Lyme disease, cf. p. 173 f.). It occurs in a broad belt from central Europe to eastern Asia depicted on special maps which are available from local health authorities and on the Internet.
The vaccination is recommended for agricultural and forestry workers as well as outdoor activists in the known risk areas. The frequency of falling ill in a German high-risk area was specified in 1999 to be between 1 : 1 000 and 1 : 2 000 tick bites.
As the disease generally takes a milder course in children and only rarely leaves permanent damage, while on the other hand febrile reactions have frequently been observed in infants after vaccination, it tends not to be recommended for children under the age of three. One vaccine had to be withdrawn for children shortly after being introduced because of the febrile reaction. Another potential passive vaccine for after a tick bite may no longer be used because of the occurrence of serious ESME in children.
For sufficient vaccination protection, three vaccinations are required at an interval of half a month to three months and nine to twelve months or in a fast-track procedure on the first, seventh and twenty-first day, with a booster one year later. If there is permanent residence in risk areas, the vaccination should be repeated every three to five years. But in this situation the occurrence of a high fever after the vaccination is common.
Tick bites can largely be avoided by clothing which covers up the body and tick repellents (e.g. clove oil/Aetheroleum caryophylli). These methods can also be used to prevent Lyme disease which is transmitted by ticks as well. It frequently takes a serious course and there is no vaccination against it (see p. 173f.).
The vaccination is recommended for agricultural and forestry workers as well as outdoor activists in the known risk areas. The frequency of falling ill in a German high-risk area was specified in 1999 to be between 1 : 1 000 and 1 : 2 000 tick bites.
As the disease generally takes a milder course in children and only rarely leaves permanent damage, while on the other hand febrile reactions have frequently been observed in infants after vaccination, it tends not to be recommended for children under the age of three. One vaccine had to be withdrawn for children shortly after being introduced because of the febrile reaction. Another potential passive vaccine for after a tick bite may no longer be used because of the occurrence of serious ESME in children.
For sufficient vaccination protection, three vaccinations are required at an interval of half a month to three months and nine to twelve months or in a fast-track procedure on the first, seventh and twenty-first day, with a booster one year later. If there is permanent residence in risk areas, the vaccination should be repeated every three to five years. But in this situation the occurrence of a high fever after the vaccination is common.
Tick bites can largely be avoided by clothing which covers up the body and tick repellents (e.g. clove oil/Aetheroleum caryophylli). These methods can also be used to prevent Lyme disease which is transmitted by ticks as well. It frequently takes a serious course and there is no vaccination against it (see p. 173f.).
Vaccination recommendations and individual vaccination decisions
Parents have the space to decide for or against a vaccination and thus also bear the responsibility for that decision. Since the state, i.e. the body of experts, in Germany only makes official recommendations, the responsibility ultimately lies with the parents and the doctor carrying out the vaccination who are entrusted with the child’s destiny. Here the individual situation of the child and his or her social context must be taken into account.
Parents who are cautious about vaccination, mostly seek advice from doctors practicing homoeopathy, naturophathy or anthroposophic medicine, as well as from the paediatric departments of the Herdecke, Filderklinik or Berlin-Havelhöhe community hospitals.
We explain the procedure of the paediatricians in these departments below, a procedure we also advocate and recommend :
The information meeting with the doctor begins with an attempt to obtain an understanding of the thinking of the parents, rectify preconceptions and wrong information, and introduce basic aspects which can widen the perspective while not exercising any moral pressure. The next step is to come to a vaccination decision which is appropriate for the individual case.
If we are asked by the parents to assist in coming to a decision, we recommend a precautionary tetanus and diphtheria vaccination from about the twelfth, but sometimes also from the ninth month of life, with vaccination for infantile paralysis only if there is travel to a corresponding region.
With regard to the whooping cough vaccination, it is clearly stated that what the latter does not do in the first three months of life – when whooping cough poses the greatest threat to the child – is offer protection. The vaccination is given if desired.
With the Hib vaccination, attention is drawn to the particular characteristics of serious Hib diseases and the vaccination is also given if desired.
The rubella vaccination is recommended for all girls in puberty, but sometimes only if there is a negative determination of antibodies.
The measles vaccination requires detailed discussion: given the absence of or reduction in passive immunity in mothers who have not had the disease or who have only been vaccinated, there is an increasing prevalence of creeping, fatal SSPE encephalitis in infected infants and small children (see p. 154).
The hepatitis A vaccination is not recommended – apart from rare travel indications – because the illness as good as always takes a benign course in childhood.
The newborn of a mother suffering from hepatitis B is actively and passively vaccinated against hepatitis B directly after birth, as this is the only way to intercept the infection in most newborns. Preventive hepatitis B vaccination is recommended if there is a particular risk; the necessary education of the young person about the risk of infection is undertaken in puberty.
If there are serious congenital or acquired heart, lung or other diseases and syndromes, the parents are made aware of the vaccinations which are important and possible in such a context.
Parents who are cautious about vaccination, mostly seek advice from doctors practicing homoeopathy, naturophathy or anthroposophic medicine, as well as from the paediatric departments of the Herdecke, Filderklinik or Berlin-Havelhöhe community hospitals.
We explain the procedure of the paediatricians in these departments below, a procedure we also advocate and recommend :
The information meeting with the doctor begins with an attempt to obtain an understanding of the thinking of the parents, rectify preconceptions and wrong information, and introduce basic aspects which can widen the perspective while not exercising any moral pressure. The next step is to come to a vaccination decision which is appropriate for the individual case.
If we are asked by the parents to assist in coming to a decision, we recommend a precautionary tetanus and diphtheria vaccination from about the twelfth, but sometimes also from the ninth month of life, with vaccination for infantile paralysis only if there is travel to a corresponding region.
With regard to the whooping cough vaccination, it is clearly stated that what the latter does not do in the first three months of life – when whooping cough poses the greatest threat to the child – is offer protection. The vaccination is given if desired.
With the Hib vaccination, attention is drawn to the particular characteristics of serious Hib diseases and the vaccination is also given if desired.
The rubella vaccination is recommended for all girls in puberty, but sometimes only if there is a negative determination of antibodies.
The measles vaccination requires detailed discussion: given the absence of or reduction in passive immunity in mothers who have not had the disease or who have only been vaccinated, there is an increasing prevalence of creeping, fatal SSPE encephalitis in infected infants and small children (see p. 154).
The hepatitis A vaccination is not recommended – apart from rare travel indications – because the illness as good as always takes a benign course in childhood.
The newborn of a mother suffering from hepatitis B is actively and passively vaccinated against hepatitis B directly after birth, as this is the only way to intercept the infection in most newborns. Preventive hepatitis B vaccination is recommended if there is a particular risk; the necessary education of the young person about the risk of infection is undertaken in puberty.
If there are serious congenital or acquired heart, lung or other diseases and syndromes, the parents are made aware of the vaccinations which are important and possible in such a context.
Recommended reading
Goebel, Wolfgang : Schutzimpfungen selbst verantwortet. Grundlagen für eigene Entscheidungen. Stuttgart 42009.
Hirte, Martin : Impfen – Pro & Contra. Das Handbuch für die individuelle Impfentscheidung. Munich 2011.
Ratgeber Impfungen der Arbeitsgruppe für differenzierte Impfungen. Stiftung für Konsumentenschutz, Postfach CH-3000 Bern 23, Tel. ++41-31-370 24 24, Fax 372 00 27
Kummer, Karl-Reinhard : Impfungen im Kindesalter – Hilfen zur individuellen Entscheidung, gesundheit aktiv : Bad Liebenzell 62007, Aktuelle Themen Heft 2/2 2007.
Website of Ärzte für individuelle Impfentscheidung : www.individuelle-impfentscheidung.de, www.impf-info.de
Hirte, Martin : Impfen – Pro & Contra. Das Handbuch für die individuelle Impfentscheidung. Munich 2011.
Ratgeber Impfungen der Arbeitsgruppe für differenzierte Impfungen. Stiftung für Konsumentenschutz, Postfach CH-3000 Bern 23, Tel. ++41-31-370 24 24, Fax 372 00 27
Kummer, Karl-Reinhard : Impfungen im Kindesalter – Hilfen zur individuellen Entscheidung, gesundheit aktiv : Bad Liebenzell 62007, Aktuelle Themen Heft 2/2 2007.
Website of Ärzte für individuelle Impfentscheidung : www.individuelle-impfentscheidung.de, www.impf-info.de
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