Good evening and welcome to Doctors on Call.

I'm Dr.

Ray Christensen, a faculty member with the department of family medicine and biobeavior health at the University of Minnesota Medical School.

I'm also a family physician at Gateway Family Health Clinic in Moose Lake.

I am your host for our season premiere tonight.

number of what I can't remember 40 plus but tonight we're going to talk about immunizations this season we will arrange we will again be rotating hosts from the medical school including doctors Mary Owen Dr.

Ryan Harden Dr.

Chris AOY and myself the success of this program is very dependent upon you the viewer so please make sure you call in your questions or send them to our email address askpbsnorth.org org.

Our panelists this evening include Dr.

Gracia Pitcher, hospitalist and chief medical officer from Essentia Health in Duth, Dr.

Charnell Valentine, pediatrician from Essentia Health in Duth.

Our medical students answering the phones tonight are Nicholas Christensen from Albert Lee, Minnesota, Jent Christensen from Rapid City, North or South Dakota, and Jared Cyp from Badet, Minnesota.

And now on to tonight's program on immunizations.

Dr.

Valentine, uh this is the first night that we've met.

We haven't had a chance to talk before.

Can you tell us a little bit about your practice and uh yourself?

Sure.

I've been a pediatrician in the community for 24 years and I see infants all the way up to about 18 or 19 years old and happy to be here tonight.

Thank you.

And Dr.

Pitcher, um, we talked a little bit earlier, but tell us about the work that you're doing over at Essentia.

You're both from Essentia, if I remember right.

Okay.

Yeah.

So, I've been with Essentia for 10 years.

I've been in clinical practice for 15 years uh, in Duth.

I've worked both at Essentia and at St.

Luke's.

I'm an internal medicine doctor by background and currently I practice in the hospital.

So this topic is uh very important to me in that um preventing hospitalization and keeping you well is is key to your health.

We struggled as to which program to start with when we put together the list this year and we've chose immunizations up front because this is usually a busy time of the year and this is the beginning of the respiratory season.

The kids are back in school and we're all back maybe back in our offices or working somewhere.

Um, uh, Charnell, what's what's the, uh, main ones main things that we should be worrying about now as we come back together from an immunization standpoint?

And why don't you go ahead and work at it from the pediatric standpoint because we don't do that very often.

Sure.

Thank you.

Well, kids are coming back in from summer vacation and all gathering together, so it does tend to seem like there's one viral infection after another at the start of the season.

And we haven't seen influenza hit town yet, but we know it typically does starting in end of October through December.

So, it's a great time to think about having your child protected against influenza.

And we sure encourage you to contact your doctor's office and come on in to get your child protected against influenza and whatever other vaccines um that your child's due for.

So, short of vaccines, are there other things that we can do to protect ourselves uh as individuals?

Well, it's important not to go to school and go to work when you're ill.

It's good to stay home.

Of course, when we're out in the community, we want to mask if it's appropriate.

Wash your hands.

All those common sense things.

Dr.

Pitcher, let's move to um let's go to the adults now.

What should we be looking out for?

So just like our pediatric population certainly getting the influenza vaccine as an adult and and co 19 um uh though COVID does not have seasonality to it.

We know that when we're close together as as Char said and indoors more as the winter months come on the the likelihood that we'll share and spread our germs is is higher.

Certainly adults um as they age are more at risk for um severe disease from influenza and co 19 and so vaccination is one way uh to help uh make that disease less severe uh in as we age.

One of the I'm going to start with co 19 and the reason is there's been a lot of controversy back and forth about that over time.

Uh, we've got a really good immunization I think for it and I'm just wondering where we should be at the present time as we go into the fall.

I'm old so now I'm thinking I I have to have my double dose of flu and I need a COVID shot and I do I need that RSV shot too and I don't know, help me out.

Yeah.

So, I would say yeah, I would go for all three.

And I understand some people are hesitant to have all three due to concerns about side effects.

Um, and side effects certainly are something to consider.

And if you've had influenza and you've had a side effect with arm pain or achiness, then then having the vaccine spaced out is a reasonable approach to that.

But it is safe to administer them at the same time.

So one of the first questions is on RSV and RSV is new and I've been struggling with it with my patients and practice and personally what I want to do about it also.

Uh I know that for children it's been a serious illness in the past and where where are we at with kids?

They're getting that one now, aren't they?

The Yes.

Yes.

This is so exciting.

This RSV uh immunization that we are able to give um kids right in the first week of life is so important.

It's really really effective.

So what RSV is, it's a common respiratory illness that causes uh difficulty breathing, cough, wheezing.

and it can even make your infant not breathe u called apnea and so the uh RSV u immunization and it's not a vaccine interestingly it's preformed antibodies that the infant receives so that they if they see RSV uh infection those antibodies will attach to the virus and allow the virus not to replicate and it's extremely effective um we're looking at 80% reduction in RSV V infection rates.

We're looking at 80% less hospitalization and 90% uh less infants going into the pediatric ICU after RSV infection.

Uh so it's very important and at the same time pregnant women can get an RSV uh vaccination.

So that one is a typical vaccination that you're given when you're um pregnant and it's given between 32 and 36 weeks and in that way it protects the mom against RSV infection that she might receive in the community.

Um but also then antibodies are made in the mom passed to the baby that would protect the baby in the first six months of life.

So it's uh it's it's thrilling actually um about the RSV um you know uh you know advancements um in pediatrics and I know that you guys protect adults um with RSV vaccine um starting at 50.

Yes.

So uh adults aged uh 50 to 74 who are higher risk should be vaccinated with RSV and certainly those 75 and older.

I'm happy to share um a personal story though it ends uh sadly my grandmother actually died from RSV.

Um she had uh advanced COPD and uh was in a nursing home and contracted it.

And so uh not dissimilar to children and adults and in my practice uh in the hospital I often see people who are the sickest with influenza COVID and RSV um which tend to be uh common this time of year and it can be severe.

So it's shortness of breath, cough, fevers, um uh then oxygen levels can drop and and even adults can end up needing ventilator support uh from RSV.

It can be quite a serious infection.

So it's exciting to have uh a vaccine that can help protect.

So then the next question to that is how often do I have to take the RSV shot?

So it's a once it's a once in a lifetime.

So I don't know if you know or not.

I've heard it's very expensive.

Is that true or not?

Do you guys know?

So, most vaccines are um covered and still covered.

Um so, I know that with uncertainty in um and things that are going on as far as our federal funding, I can say that our uh support for people who don't have insurance or who have uh inability to pay are still covered.

Um and certainly health systems such as ours have even had discussions if someone isn't able to pay the benefit um of charity care uh is is also something that we provide.

How much time as the questions are coming in I'm trying to follow a little bit and try to pull them together too.

But how much time is needed between and I it's nice to see these pediatric ones.

We might be out of this.

This might be Charl char.

But how much time is needed between the flu shot and the TEDP shot?

You can give them on the same day.

So how when I grew up in med school, we can have as many as you want the same day.

Otherwise, they have to be two months apart.

Then I think there's a viral com a live viral component in there somewhere, too.

Help me out.

Sure.

Sure.

Live vaccines need to be separated by a month.

uh if if they're not given on the same day.

So interestingly at age one we give MMR which is alive and we give vericella which is alive.

So it's okay if they are given on the same day but if you don't give them on the same day we need to space them out by a month.

Why is why is hepatitis B vaccine I'm sorry I'm picking on you.

Not at all.

But why is hepatitis B vaccine recommended at birth?

Hepatitis V viral infection to an infant is extremely serious.

There are 2.4 million Americans living with chronic hepatitis B infection.

And we need to protect our infants um from caregivers who may not even know they carry hepatitis B. If an infant receives or contracts hepatitis B, they have a 90% lifelong risk of either developing chronic liver disease or liver cancer.

So that's completely preventable if they're protected right at birth.

We give a birth dose and then it's included in our typical childhood vaccine schedule at two, four, and six months.

Gracie, do you have anything to add on hepatitis B adults?

Well, so certainly for um adults that know that they're hepatitis B negative and or I we still vaccinate um everybody who's going to be at high risk, healthcare workers being one of those populations.

And so uh certainly uh if you haven't had a vaccine or you chose not to be uh vaccinated as a as a child, um the recommendation would still be that you would have it as an adult.

For one of the hepatitises, is it be that there's a treatment for that?

Also, which one is it?

I can't remember.

So, there's treatment now for hepatitis C. Yep.

There's medication uh treatment for those with hepatitis C, but not hepatitis B. Either one of you can jump on this.

Can too many vaccines overload the immune system?

And what's too many?

I don't know.

And so, we're back to the original question.

I liked your answer before, but is there is there a limit?

What's what's your limit?

I follow the typical CDC schedule for childhood vaccinations and all these years the American Academy of Pediatrics and the CDC schedule have been the same.

So, uh much scientific research went into creating the current pediatric vaccination schedule.

So, uh I I don't believe you can overwhelm a child's immune system.

when they come in at two months old, uh they'll get one poke in one leg, two pokes in the other, and a vaccine that they swallow.

Now, if it's RSV season and they haven't been protected yet, we'll add an additional um RSV um shot on for that.

But remember, that's pre-formed antibodies, not a not a vaccine.

So, uh it's comp complex.

Um but typically at the four month check, when I ask, "Hey, how did those two month shots turn out?"

The most common thing I hear from families is we didn't have any side effects.

And when I do hear about side effects, it's low-grade fever and perhaps they woke up a little bit more at night.

Um other typical side effects could be uh redness at the injection site.

Um fever as I mentioned, but overall the childhood vaccine uh are are very well tolerated.

Let's talk for a moment about HPV.

Uh, so I was really heavy in practice 20 years ago.

I've been at the med school for a while now and I'm not taking care of the young people like I used to, but there was a big push for HPV for young women and now the it's also for young men also.

Do you want to either one of you do you want to talk about that a little bit?

Gracia, we've been ignoring you a little bit.

If you want to jump in whichever way you're both experts on this.

Yeah.

No, so I certainly can.

certainly um our HPV vaccine rates is something that we actually monitor um from a quality uh standpoint in broadly in the state of Minnesota and certainly at Essentia Health.

Uh and really the reason for the push for vaccine and you know sh can add to this is because we know that HPV is related to um cancer and it is a vaccine that can literally prevent cancer in women uh cervical cancer but certainly there are HPV related cancers that are in the head and neck as well and so that that really is the reason to do so.

Um, and we're they're looking at changing recommendations and even uh people who hadn't had them as a child can have them and extending that into adulthood.

SH, anything to add?

Uh, yes.

I it's it's an amazing vaccine as well.

Really any vaccine that prevents cancer from hepatitis B vaccine that we give as an infant to your teen uh receiving an anti-cancer vaccine.

Uh it's very very important.

And now head and neck cancers have um uh eclipsed uh cervical cancer in the number of cancers associated with HPV.

Uh so I would just encourage um you to have a discussion when your child comes into um the doctor.

We start at age nine um and we give one at nine and one at 10 and then you're fully protected.

If you chose to start a little bit later and start after age 15, it's a threedosese series.

So, that always puts a smile on somebody's face when you tell them that um we can we only have to do two shots instead of three.

I want to reinforce, we've already gone over this one already, but a grandparent called in about their new grandchild who was just born and received the RSV shot uh with the first clinic visit.

And again, the question is what is RSV?

You've pretty much summarized that in the past.

How does it help him?

Maybe that's the part.

Just hit that again a little bit.

Sure.

uh the RSV shot that we try to give in the first week of life has pre-formed antibodies so that if that infant happens to uh be around somebody with RSV and RSV does look like a cold you know it looks like cough or any nose um and it may in adults um who are healthy again not elderly and and not have having an underlying medical condition RSV for us is a is a cold and so it's really hard to know um how serious serious it can be.

So by protecting that infant with those antibodies um like I said 80% reduction in hospitalization.

That's great.

Really gracia this is this is the harder one.

How is vaccine development different now compared to 20 years ago and as we go back and look at the mRNAs and others coming through what what are your thoughts on development versus the past?

Well, so certainly what we've learned about the mRNA vaccine and even though it is uh a new it was new to the market um during the co 19 pandemic, it actually is not new technology.

It's been around since the 80s.

Um and so it's just how do you use um the different techniques to to create vaccines?

Um and and what is the utility?

And sometimes it's it's that we don't we the medical community don't know um how how it can be used.

And so I will say that yes, you know, and and Char talked about kind of live virus vaccines.

There's certainly different types of vaccines.

We talked about immunization which is a little bit different and it is complex about vaccines.

Uh but how they're developed um is not necessarily predictive of kind of side effects um or complications from them.

I want to go back.

I'm old and I I came into life just as polio was really being addressed way back when.

So if we go back and look at the history of humanizations, we look at smallpox and we've all been educated in smallpox in the past and then polio came along.

I remember that first shot.

I couldn't walk for a week, but my mother insisted that we had to go get those.

But polio was really really bad uh as to what it could do to a person and a lot of changes happened.

The polio vaccine has changed and now the other one that was the most infectious disease of all is measles.

Uh you walk in a room where there's measles and you've got it basically.

Uh what's happening with measles?

Char, I'm going to lean on you a little bit.

Where are we with measles in Minnesota these days?

Uh well unfortunately there's 10 cases right now.

Yes.

in uh Dakota County.

So that's, you know, South St.

Paul, Lakeville um area.

Uh so it's it's here.

Unfortunately, um our herd immunity is is going away with um people um choosing not to um vaccinate as often.

You know, in Minnesota, we're at less than 93% of the students entering kindergarten being fully vaccinated and back in 2020, we were at 95%.

So we are seeing uh less children vaccinated and we know that we need that herd immunity to keep measles rates down.

And one of the questions that just rolled in is right along that same line uh is the the fact that it's coming back and then the herd immunity piece of that and and that that seems to be a big struggle.

Uh how do we change that?

What's what's the message you use in your office when you're talking to people regarding measles and some of these shots?

Well, I think vaccines are a little bit of victim of their own success when Americans don't have a knowledge of what the disease can do.

Uh they they don't view it as as crucial as um perhaps they should.

Um, so it's a good conversation to have with your um, you know, provider if if you're on the fence.

And we're really good at having open-ended uh, questions and conversations to address any type of um, hesitancy you might have.

And we we recognize that folks can be worried about the disease, but also worried about a side effect of the vaccine at the same time.

And we want to help by giving statistics, giving personal stories, and um try to help alleviate fears and really emphasize um benefit of the vaccine um versus versus the risk.

And I think we do a really good job in clinic of that.

The vast majority of the patients in my clinic do vaccinate against measles.

It's a it's a twod dose series.

You get it once at a year and then a booster at age four.

And those of us who are lucky enough to have both of our measles um vaccines, we have 97% lifelong immunity against measles, which is um amazing.

Truly, it really is.

I think back to when H flu came along when we first started practice.

I think the first year uh that Dr.

Dr.

Peterson and I started practice in Moose Lake.

We had like five H flu menitises and after the imunization came none never saw another one from that from that point on.

Gracia are vaccines safe and this is a the big discussion that's always out there.

Are they safe?

And uh what are your thoughts on this one?

Well, so I think that when you talk about the vaccines, you have to talk about what is the um disease that we're trying to prevent or augment.

And so when we talked about HPV, we're talking about eliminating cancer.

Um and it particularly, as Char mentioned, head and neck cancer.

When we're talking about um the elderly and RSV, you know, I see people who are hospitalized from RSV instead of in their home with a a cold because, you know, I see people with complex conditions.

And so the risk of the vaccine is certainly uh less than the disease.

When we talk about measles, mumps and reubella, we know that that measles one in a thousand children uh died from measles.

It isn't an insignificant risk uh to our um children and it isn't an insignificant risk to our adults uh who have chronic disease.

And so I think you have to have that shared decision- making with your provider, your physician, your um APRN, your pediatrician, your family doc uh to really talk about, you know, what are your hesitencies, what are you concerned about so that um we can have that open discussion.

One of the questions that just came in too is why are so many shots given to children?

So the real question maybe that we need to address a little more than that is how do we determine what in what infections what illnesses we should do immunizations for?

Uh how do we decide that?

Well the vaccine schedule as it as it has been um created uh is is very well studied.

We know that giving these vaccines at the same time produces um excellent immunity and that they're safe.

uh uh we there's going to be a graphic that's shown which is going to give an excellent um recommendation for an app and the app is from Children's Hospital of Philadelphia and it's called vaccines on the go.

So I would encourage anybody who's has an interest in the number of uh vaccines that a child is given, what the schedule is, what the diseases are, what the safety profile is.

check out that app and look at the different sections and hopefully um you'll gain an understanding and you'll be able to formulate any questions you may have to bring up to your medical professional and you know we look forward to that conversation and that's being broadcast now.

Thank you for bringing that up.

What at what point should we be worried about a fever from an immuniz at what point should we be be worried about a fever from an immunization?

How high?

You know, I always say with kids, yeah, I always say treat the kid, not the number.

So, if your if your child has had a vaccine and they're eating and drinking well and they they slept pretty well, but they have 1023, that child doesn't need to be seen.

But on the other hand, if the if the temperature is lower, you know, 101, but they're not eating, they're fussy, they can't sleep, that child needs to be seen.

Gracia, vac can vaccines interact with other medications in your current work and internal medicine?

So, in general, no, vaccines aren't related to to most medications that people are prescribed, but if ever you have a question or concern, please, I'd encourage you to share that with your your provider.

Someone wants to travel across the world.

Are there any special vaccines they need?

And I think we're almost out of time.

I I think both Essentia I know Essentia has uh people available as does uh Aspirus has people available also.

You should go talk to the people that know something about immunizations.

They want to know where you're going and they can tell you what you should or you shouldn't probably use.

I want to thank our panelists Dr.

Gracia Pitcher and Dr.

Charnell Valentine.

Please join doctors on call next week where Dr.

Christa Quite leads a program on women's health with a panel of experts including Dr.

Quinn Dr.

Jonah Quinn from Aspirus St.

Luke's clinic in Duth.

Thank you for joining us and for joining us for our season 44.

There's the number of doctors on call.

Thank you all so much.

The questions were great.

Hope you enjoyed the show.

Good night.