I see a lot of children in my practice and I’ve become a bit worried at hearing more and more moms voicing concerns about vaccines made here in China. Apparently the word on the street is that they have more side effects and many parents are considering delaying these vaccines until they go back to their home country, or they try to track down imported vaccines anywhere they can find. Is this reasonable? In general, I don’t think so, personally or professionally, and I’m perfectly fine with giving my 17 month old son the routine schedule with our available vaccines. But I really want the community to hear more reassuring words from other people they trust — their pharmacists. So I interviewed Helen Zhang, the Chair of our pharmacy here at Beijing United Hospital and a registered pharmacist both in China and in the USA (from UCSF). I’ve known her for many years, I trust her advice and I hope you do as well. Here are her answers, and I hope this helps reassure some worried parents:
Why are many imported vaccines no longer available in China?
In 2011, China raised standards for some of the vaccines e.g. antibiotic contents that are remaining in the vaccines. The imported vaccines that did not meet these standards would have to be withdrawn from the Chinese market. Some big global brands are now collaborating with Chinese manufacturers and market vaccines under the Chinese partner: e.g. Novartis took over Tianyuan and upgraded their Quality control in the “new” meningococcal ACWY vaccine. We will see this trend more.
Which vaccines at BJU are imported, which are joint venture made in China, and which are locally made?
Refer to the list attached (Excel spreadsheet)
Is there any evidence that vaccines made in China are more dangerous or less effective than the previously imported vaccines?
Refer to the vaccine FAQ on our website
Which previously imported vaccines are not available in China at all, and people should get in their home countries? (for example, Gardasil, Tdap, rotavirus…)
Previously available but not anymore: Tdap (Boostrix), MMR (imported), Varicella (Imported), DTap. Not yet available: Gardasil, Rotavirus, PCV 13, 6 in 1 vaccine.
The official vaccine schedule for children in China is a bit different than other countries; does this matter at all?
If the child is staying in China for a while, it is recommended to follow the local schedule, e.g. MR vaccine at less than 1 year old because of the epidemics.
If I partially started vaccines in another country and finish here with a locally made vaccine, is it the same effectiveness or do I need to start over? (for example, Twinrix (Hep A+B combo …)
It is best to finish the series with the same brand or type of vaccine. But if it is not available, then using the locally available vaccine will still work and there is no need to start over in most cases.
Finally, what would your major message be to worried parents — do they have anything to worry about, with vaccines made in China?
The Chinese government has made big steps forward to ensure safety and quality of vaccines, e.g. each batch of vaccine now has to go through quality assurance, more transparent surveillance for adverse events, high standards required for vaccine contents, cold chain assurance etc.
Parents in Beijing have many health questions, but one of the hottest topics is vaccinations. There are quite a few internationally standard vaccines, but there are also some Beijing-specific vaccines.
For routine vaccines, which start during childhood, most countries cover the same basics. If you are unsure if your vaccines are up-to-date, check your home country’s vaccination schedule. A typical problem with adults is that they may not know about adult boosters or new recommendations. For example, most need a tetanus booster every ten years. Also, many countries, including the US, are recommending a pertussis booster for adults. Fortunately, there’s Tdap, an easy combination booster for adults that combines tetanus and pertussis into one quick jab. Unfortunately, at this time the international private clinics in China are not allowed to give imported vaccines such as the Tdap, and there is no Chinese version yet. I now recommend adults try to get this back in their home country when traveling. This booster is especially important given the recent waves of pertussis infections in California and other areas.
Another common issue involves people who began their Hepatitis B vaccine series but never finished the three-shot series. It’s very important that people are fully vaccinated for this, as chronic HBV infections are a serious public health issue in China. Also, for all my patients, I recommend a vaccine against Hepatitis A.
The rabies vaccine is the most controversial. The following scenario is common in clinics: a parent comes in and their unvaccinated child was bit by a neighbor’s dog while playing around. Unfortunately, if we don’t know the dog’s history, the child needs the entire five-shot rabies series, plus a painful and very expensive rabies immunoglobulin shot. If the child had already been vaccinated against rabies, he would only need a post-bite treatment.
Rabies is not common but is found all over China, especially in rural areas, and a few thousand people die from it annually. The scary thing about rabies is that it may take over a year to develop symptoms — and it is 100 percent fatal. And yes, expats in Beijing have died of rabies. The vaccine is a three-shot series given over one month.
I often recommend a rabies vaccine for patients, especially children. Children are the most vulnerable to rabies as they often play with stray dogs and cats, and parents may not even be aware that their child was bitten. However, it’s a risk-and-benefit analysis each family needs to make. If you think your exposure is very small, then the vaccine may not be for you. But if you plan to hike around rural China and India for a few weeks, you should definitely consider it.
Another controversial vaccine is Japanese Encephalitis. It protects against a mosquito-born virus that can cause a serious brain infection, and is fatal in some cases. It’s more of an issue in southern China and tropical Asia, but Beijing has had cases, and it’s a required vaccine for Beijing infants. This vaccine series is good if you plan to live here for a few years, and will also protect you during your travels around Asia.
For those of you concerned about vaccine safety and side effects, I always recommend you read the evidence-based sources online, including the US CDC vaccine page at www.cdc.gov/vaccines. All vaccines have side effects, but I am convinced that vaccines have been dramatically effective all over the world in eradicating many terrible childhood diseases, saving millions of lives.
For more information on vaccines, please read my previous articles about vaccines.
Having a pet can be a wonderful experience for kids and families. I loved growing up with a series of cats and dogs, and my older brother also had an enormous Habitrail full of gerbils. I wouldn’t trade away any of these memories! During all those years, I often was scratched up from playing with my pets, but not once did we ever worry about rabies. It’s simply not something we have to deal with in America, as almost all pets are properly vaccinated against this deadly disease. In America, less than a handful die each year from rabies, and most cases are from bats or other wildlife.
But the situation in China is very different and much more serious. Each year, over 3,000 people in China die from the rabies virus, the vast majority from dog bites. And children by far are the most vulnerable population, as they love to play with animals, and many wouldn’t even mention a slight bite or scratch to their parents.
That’s why it’s crucial for expat families to seriously think about getting the 3-shot rabies vaccine series now, for all of their children, before they get exposed. The vaccine protects them from the 100% fatality rate of this all-to-common disease in China. The vaccination rate among expat families is quite low, but rabies is common in the Beijing area among both stray and pet dogs. And those who feel “protected” in your Shunyi communities need to know that expats have died of rabies in China. In one sad case, an expat husband and father died 10 months after buying a harmless-appearing puppy from their local pound. He didn’t even report ever being bitten by their pet, and most likely got infected from playful licking and innocuous-appearing scratches. Please don’t let this happen to you or your loved ones! Rabies is 100% fatal, there is no cure, and it’s a painful and slow death.
The American Academy of Pediatrics also mentions some helpful tips to share with your kids to prevent pet bites, especially dogs:
- Socialize your pet. Gradually expose your puppy to a variety of people and other animals so it feels at ease in these situations; continue this exposure as your dog gets older.
- Train your dog. Commands can build a bond of obedience and trust between the dog and owner. Avoid aggressive games with your dog.
- Vaccinate your dog against rabies and other diseases.
- Neuter or spay your dog. These dogs are less likely to bite.
- Never leave a baby or small child alone with a dog.
- Teach your child to ask a dog owner for permission before petting any dog.
- Let a strange dog sniff you or your child before touching it, and pet it gently, avoiding the face and tail.
- Never bother a dog if it is sleeping, eating or caring for puppies.
- Do not run past a dog.
- If a dog threatens you, remain calm. Avoid eye contact. Stand still or back away slowly until the dog leaves. If you are knocked down, curl into a ball and protectyour face with your arms and fists.
Rabies is a serious issue but definitely not the most common pet-related problem I see. I often treat serious skin infections from bacteria such as staph, especially in the hands, from pet bites and scratches. In almost all cases, the cuts were from typical playful fun with their own pet. The #1 treatment in all cases of bites and scratches is immediate washing out with soap and water!
Last October I had a fantastic week in Boston for the annual convention of the American Academy of Pediatrics, and I still vividly remember the excitement and energy of these thousands of doctors. One common theme from their many discussions was the serious problem of vaccine underuse in America; more specifically, the alarming increase of American parents who are refusing to get vaccinations for their children. As the Wall Street Journal reported, a report last year in the AAP’s Pediatrics journal stated that 13% of Americans are now either “spacing out” vaccines or refusing some or all vaccines for their children. This is alarming data for many pediatricians and family doctors such as myself, who deeply believe both from training and first-hand experience that vaccinations are the cornerstone of childhood health and are the backbone of prevention against previously deadly diseases worldwide. And no matter what we do with our evidence-based publications and earnest pleading to the public, we face an even larger foe from the media and “celebrity experts” who have now totally confused many well-meaning parents who really don’t know who to believe anymore.
It’s getting so bad in parts of America that many pediatricians are starting to fight back in the strongest way possible; a new survey shows that 21% of all US pediatricians have fired families and patients from their practice for refusing to take all vaccines for their children. This certainly may come as a harsh surprise for many readers, and it’s not endorsed by the CDC or the AAP, but I do understand my colleagues’ sentiments and frustrations. I personally have never fired any family for this, nor do I plan to do so, even though quite a few parents in the Beijing community are skeptical of vaccines. I think a better approach is to keep these concerned parents in your “medical home” and keep trying to allay fears, which includes giving them handouts from websites such as the CDC’s outstanding PDF handouts on “Diseases and the vaccines that prevent them”. But if the parents still refuse to give the standard set of vaccines, doctors could get the parents to read the CDC handout about Vaccine Refusals, and then sign the American Academy of Pediatrics “Refusal to Vaccinate” form (PDF here), which details the very real risks they are subjecting their child to, including the increasing risk of getting pertussis or measles from another child.
I understand this is a complicated issue for parents, but in most doctor’s eyes, it’s not complicated, and it’s not a two-sided debate. Most of us feel the evidence is overwhelming in favor of vaccine effectiveness in wiping out polio, smallpox and a handful of other still-deadly diseases, and there are few truly legitimate reasons not to vaccinate. Of course there are some side effects, which were exhaustively reported in the important recent review from the Institute of Medicine, which I discussed last year. Pediatricians and family doctors need to provide concerned parents with the evidence. I strongly feel that if parents still refuse to vaccinate their child despite all the overwhelming evidence, then those parents really need to understand that they are putting their child’s health at risk — and also threatening the health of vulnerable infants and others in their community. Many parents indeed have deeply regretted not vaccinating their child. Here are some sad stories from victims of vaccine-preventable diseases for you to read. You can also read a few sobering articles from the CDC’s “Unprotected Stories” series, including this true story of pertussis (AKA whooping cough, now making a comeback):
“A Preventable Tragedy”: A True Story
Preventing whooping cough—and saving lives in the process—must be a community-wide effort to vaccinate infants, children, adolescents, and adults. Pertussis vaccine has saved thousands upon thousands of lives, but we need to keep up the fight against whooping cough by using vaccines. Here is one family’s story.
On Christmas Eve 2009, Katie and Craig welcomed their daughter Callie Grace into the world. After trying for 5 years to have a child—and suffering several miscarriages—the couple considered Callie their miracle baby. Callie was born 6 weeks early, but she was healthy and strong and came home after only 2 weeks in the hospital.
In January, when she was a month old, Callie developed a soft, dry cough. “It sounded like when a child mimics their parent to get attention. I took her to the doctor,” Katie recalls. The doctor did not find any serious signs of illness, so he sent them home. However, over the next couple of days, Callie’s condition worsened. She continued to cough, and she also became pale, didn’t move around much, and suddenly lost her healthy appetite. Katie took Callie back to the doctor, and while they waited, Callie stopped breathing. A nurse was able to get Callie breathing again, and they were rushed to the hospital by ambulance.
“At the hospital, nurses and doctors flocked to our room,” Katie remembers. “It was truly overwhelming. I was scared and Callie was screaming.” Callie was admitted to the Pediatric Intensive Care Unit, where the staff ran tests to try to find out what was wrong. After a couple of days of monitoring, they started her on antibiotics, while still waiting on test results.
During Callie’s second day at the hospital, she seemed to be doing OK and her parents were hopeful that she’d recover. According to Katie, “Callie was alert and would smile. She kept sticking her feet in the air so we could rub them for her. We never really thought her life was in danger.” But the next night, Callie stopped breathing again. Family members watched helplessly from behind a glass wall as doctors tried for 45 minutes to revive her. Tragically, Callie could not be saved. She was only 5 weeks old. “We never dreamed we’d lose her,” Katie said. “Callie was a more loved, more wanted baby than you’d ever find.”
A few days later, the family found out that whooping cough was the cause of Callie’s death. “We could not believe it,” Katie says, “We were so careful to not expose her to a lot of people. She never left the house except to go to the pediatrician,” Katie says.
The first dose of DTaP vaccine is recommended at 2 months of age but babies are not fully protected until they get all the recommended doses. Callie was too young to even get her first dose of DTaP. Babies need whooping cough vaccination on time, but there’s another important way to protect them. Family members and others who are around babies should be vaccinated—children should be up to date with DTaP, and everyone 11 years of age and older should get Tdap, the booster shot that prevents pertussis.
“Callie could have caught whooping cough from any of the few people that she had contact with—even from someone in the hospital right after she was born. People with even a slight cough might have whooping cough but not know it. I urge everyone to make sure their children have all their DTaP shots on time. I also encourage people to be sure they get the Tdap booster shot,” Katie says. “Getting that shot could save a life.”
It’s that time of year again: flu shot season! Yes, your offices and schools are filled with plans for “flu shot days”. I’m sure you’re debating right now whether or not you or your kids need it. So, here’s my tip on the flu vaccine: It’s basically the same advice I gave last year, which is also consistent with the U.S. CDC: I think all healthy persons should consider the vaccine, especially if you are pregnant or in contact with infants. But — as I mentioned last year — please do not assume that the vaccine protects you 100% and that you can simply touch door handles and smile when someone sneezes in your face, falsely reassured that you’re protected.
I said this last year because of a large meta-analysis from the esteemed Cochrane group, which found only about a 73% reduced risk of the flu — in the most ideal situation. Plus, it barely seemed effective for kids under 2 years of age. Now, just this week, an even more specific meta-analysis just published in the Lancet Infectious Diseases shows an even less effective prevention: 59%. During the recent H1N1 years, it was a bit better at 69%. Here’s a bit from their abstract:
Interpretation: Influenza vaccines can provide moderate protection against virologically confirmed influenza, but such protection is greatly reduced or absent in some seasons. Evidence for protection in adults aged 65 years or older is lacking. LAIVs consistently show highest efficacy in young children (aged 6 months to 7 years). New vaccines with improved clinical efficacy and effectiveness are needed to further reduce influenza-related morbidity and mortality.
So there you have it. So the question is; do you like those odds? No, it’s not 100% but it’s still darn good, in my opinion. We all hope a better vaccine is just around the corner with new technology, but let’s just get to the point:
- I definitely plan to get the vaccine, as I am surrounded by sick adults and kids and I don’t want to give the flu to them.
- In the same vein, any person in close contact to our most vulnerable patients (kids under 2; the very old; and people with chronic diseases) should really consider getting the vaccine, again to prevent you from giving it to your vulnerable loved one.
- Pregnant women should definitely get the vaccine
- Anyone who wants it should get it.
For those of you who don’t have people coming to your office or school, you can drop by our Beijing clinics (United Family Healthcare) anytime and get it for 99 RMB total, no other fees added. All international clinics now offer similar services.