Table of contents
MEASLES
Highly infectious viral disease, endemic worldwide. Catastrophic courses of measles have been described in particularly “susceptible” populations (e.g., 9); measles also played a major role in the near-complete eradication of Indigenous peoples. Epidemic outbreaks occur at intervals of 2–4 years. The virus survives only in humans. Incubation period: 10–12 days. This is followed by a non-specific prodromal stage with dry cough, moderate fever, runny nose, and conjunctivitis. In this unclear phase, the risk of infection is highest. This is followed by discoloration of the mucous membrane (enanthem) and white spots in the mouth resembling splashes of lime (Koplik spots). Then there is a rapid rise to very high fever and a typical dark-red, coarse-spotted rash, starting behind the ears and on the face and spreading over the entire body. The child then appears seriously ill for about 2–3 days, followed by a relatively rapid reduction in fever. Bleeding into the rash is common; abdominal pain and diarrhea are also common due to swelling of the abdominal lymph nodes. Complications of measles are relatively common: otitis media, pneumonia, and encephalitis are the most frequent, with measles pneumonia in older children and especially adults potentially taking a very severe course. Encephalitis (measles encephalitis), the most feared complication, is reported at about 1/1000 (10) or 0.5/1000 (11 and 12). More precisely (16), it is between 1:1000 in older children and 1:15000 in younger children. About one in three children with this encephalitis is left with permanent damage. It occurs around the third to fifth day after the onset of the rash. With these statistics, it is important to know that they represent all measles cases, regardless of age. However, age is decisive for the frequency of complications in many so-called childhood diseases (16). Thus, severe complications of measles are very common if the child is infected in the first year of life, and then again from early school age onward. Encephalitis in particular is common in these two age groups. The cause of encephalitis is considered to be not the virus but misdirected immune responses (16), a problem we also face with complications of other diseases. The malignant form of pneumonia (bronchiolitis) is extremely rare in the first years of life, but very common in adulthood (approx. 4/1000 cases) (all data taken from 12 and 16). Since 1960, vaccination has led to a clear shift of measles to older ages; children today are mostly of school age. The observed increase in measles complications can largely be explained by this alone. Measles epidemics can be severe in adolescents and adults; such outbreaks are repeatedly reported, especially in fully vaccinated populations (6/13/17). So far, such outbreaks among vaccinated individuals have not been observed in Germany because our vaccination compliance is quite low, meaning that vaccinated people usually come into contact with wild measles at some point via unvaccinated individuals and cases, thereby boosting their vaccine protection. A rare complication is subacute sclerosing panencephalitis (SSPE), a slowly progressive inflammation of the entire brain that leads to complete destruction of the brain within years. With one exception (see below), SSPE is extremely rare (1:1 million cases). In this complication, the measles virus or the measles vaccine virus probably settles in the brain, is not eliminated by the immune system, and leads to slow destruction. This means that SSPE is not caused by the virus, but by the individual’s specific immune situation (predisposition). A relatively new problem is the lack of passive maternal immunity in newborns and children in the first year of life: because mothers have been vaccinated, they no longer experienced measles as children and therefore do not pass on passive protection to their newborns. These infants can contract measles from birth, unfortunately often with catastrophic complications. In this age group, SSPE (see above) is alarmingly common at approx. 1:2000 (98). The last important complication after measles should also be mentioned: as after all other severe diseases (scarlet fever, chickenpox, etc.), measles leaves a pronounced immune weakness for 6 weeks, i.e., the child is highly susceptible to infections during this time. With childhood diseases, the observation that there are phases in which the disease runs a more malignant course is not unusual; in the 1960s, scarlet fever was feared because of its fatal complications—despite antibiotics—and today it is very harmless (82) (there are currently no deaths!). Pathogens change, and often people’s living conditions change as well, so disease courses evolve. The above data were compiled by anthroposophic physicians—doctors who are actually critical of measles vaccination. For us as well, this has led to a re-evaluation of the rejection of measles vaccination, which is based on the fact that it can clearly exacerbate asthma and allergies. Before addressing the question of measles vaccination, a brief note on therapy: rest and seclusion in the acute phase are basic prerequisites for measles to run as complication-free as possible. Even after the fever subsides, children must still be spared for about 10–14 days; early return to daycare or the booked Caribbean trip are out of the question during this time. However, these simple measures are considered “unreasonable hardships” by most parents today, so a measles infection hardly seems justifiable. Therefore, when deciding against measles vaccination, it must be clear: the child will be ill for about 4 weeks, and appropriate care and rest must be ensured. On measles vaccination: weighing the options is certainly most difficult here. It is a severe disease with a high risk of complications, but it is also one of the most problematic vaccinations! In view of developments in recent years, measles vaccination should rather be carried out.If any vaccine is quite reliably known to trigger autoimmune diseases and allergies, it is the measles vaccine. The connection between measles vaccination and asthma, as well as ulcerative colitis, has already been mentioned (2, 3, 4, and 60). These studies are, in part, highly controversial, yet they cannot simply be dismissed. The measles vaccine can also cause encephalitis (12), though there is no consensus in the literature regarding its frequency; however, encephalitis after vaccination is certainly rarer than after infection in older school-aged children. 3-5% of vaccinated individuals develop “vaccine measles” after about 5-8 days, a weakened form of the measles disease. For a long time, vaccine-critical circles debated whether vaccinations could be partly responsible for autistic syndrome. Children with autistic syndrome make almost no contact with their environment, are restless, and show significant delays in language development. In 1999, the prestigious journal “The Lancet” raised this question, as corresponding observations were made in children after measles-mumps-rubella vaccination (85). The author of this study later had to admit to having falsified all data; there is no connection between measles vaccination and autism . This falsification caused considerable damage to vaccine-critical doctors! And, unfortunately, this study still circulates widely on the internet, unrefuted! An interesting large study from Sweden is relevant to measles vaccination. It compared 12-year-old students from Waldorf schools with those from state schools regarding the frequency of allergic diseases (hay fever, asthma). The excellent study showed that Waldorf students clearly had fewer allergic diseases. Three factors most clearly distinguished the two groups; in the Waldorf school group, almost 90% of all children were not vaccinated against measles, and most had experienced measles as a disease, whereas in the state school group, almost 90% were vaccinated. In the Waldorf school group, the vast majority had not needed antibiotics by their 12th birthday, while in the control group, almost all had taken them multiple times. The last difference related to diet (56). In a large, international study (97), the observations in Sweden were confirmed in almost all Western countries. This work will now be used as an opportunity to examine more closely the influence of measles vaccination and disease, and of antibiotic use in childhood, on the development of allergies (hay fever and asthma) (57). A problem often forgotten: vaccination does not provide lifelong protection, but diseases in adulthood are severe (6, for example). If vaccinated, regular revaccination must be considered. Today (2016), the STIKO recommends that all adults born after 1970 be revaccinated once against measles! Almost no one knows this (and risks dying from measles at 50). Another problem: infants of mothers who had measles are protected by so-called maternal immunity, but after vaccination, there is no maternal immunity. As recent observations show, measles in newborns often has catastrophically long-term consequences (98). Finally, measles vaccination, as already mentioned, is the main reason for the shift of the disease to later school age and thus for the increase in complications; that is, the population is already living with an unacknowledged complication of vaccination. Both problems could be solved if almost 100% vaccination coverage could be achieved, because then the measles virus would be eradicated. Such 100% vaccination coverage was the WHO’s goal until 2000; it was not achieved in many countries and is not enforceable without massive coercive measures. Currently, the WHO is trying to achieve measles eradication in the near future. Whether such coercive measures are possible and desirable in a democracy, I dare to doubt. A relatively disturbing aspect in the discussion about measles eradication is the observation by Damien in Luxembourg and Sonoda in Japan that wild-type measles viruses, i.e., not vaccine viruses, were found in the blood of a fully vaccinated population group. This means that measles viruses can survive even in a vaccinated population, and are therefore not eradicable. It is completely unclear whether these people can infect others. (14/15)At present, it is clear that the severity of measles courses, especially in infancy, has increased. Courses have become unpredictable in all age groups, so, in my view, early vaccination against measles must be recommended. Please also remember the above-mentioned booster vaccination for yourselves as parents.
DIPHTHERIA
Diphtheria has become a very rare disease in Western Europe thanks to high vaccination compliance. Carriers are people who harbor the bacterium in the throat, and there are clinically healthy carriers. The incubation period ranges from hours to a few days; then, due to the toxin of the bacteria (Corynebacterium diphtheriae), either a greasy skin infection occurs, e.g., around the navel in newborns (umbilical diphtheria), common especially in Africa, or a rapidly progressing throat infection with rapid swelling of the tonsils, up to swelling shut of the airways. High fever is present. Because of the very acute course, rapid action is required. This is often prevented because the disease is considered too late. Swelling shut of the airways often requires ventilation; the necessary intubation (placing a tube into the trachea) is extremely difficult for those without experience. Once the diagnosis is made, an antitoxin must be injected immediately to stop the disease process. Currently, the antidote, which was obtained from the serum of infected horses, is no longer available, i.e., there is no conventional medical therapy. Even then, involvement of the heart muscle occurs quite frequently, which is the most important cause of permanent damage or death in diphtheria. After surviving diphtheria, paralysis of the soft palate or diaphragm is not uncommon. In Europe and the USA, only isolated diphtheria cases have been described since the 1970s. Until the 1990s, this also applied to the USSR and its successor states. Since then, due to the collapse of the vaccination system, an epidemic has broken out that has not been brought under control (also due to the use of an incorrect vaccine lacking the component for adult boosters (67)); in 1990 alone, 47,000 cases and 1,700 deaths were reported to the WHO (a threefold number of unreported cases must be assumed) (cited from 10). Complete eradication of diphtheria by the year 2000 was also pursued, initially only in the USA (10). This seems possible because humans are the only reservoir for the pathogen. However, the course in the former USSR shows how uncertain such targets can be under unstable political conditions, because due to centralized compulsory vaccination in the preceding decades, diphtheria was considered eradicated there. Further current examples are the “failed states” in Arabia. Vaccination against diphtheria is one of the oldest vaccinations. This means there is very long experience showing that significant side effects are very rare. The vaccine is an inactivated vaccine made from the bacterial toxin, which explains the low complication rate. Neurological consequences such as seizures and paralysis have been described very rarely; “very rarely” means only individual case reports (e.g., 12). Vaccine protection is quite reliable and lasts, after three doses, at least 10 years. At present (2018), there is no single diphtheria vaccine approved for preschool children. This means that in childhood, diphtheria can only be vaccinated against with a combination vaccine. One option to vaccinate only against diphtheria and tetanus is a vaccine approved in Switzerland. It must be obtained via an international pharmacy. Reimbursement in Germany via statutory health insurance is not possible; in the case of private health insurance, it is possible upon application. It is important to know that the German federal government is not liable for recognized vaccine injuries involving vaccines not approved in Germany. The Swiss federal government also rejects liability for vaccination outside Switzerland. An alternative has been possible since 02/2016 with the adult vaccine REVAXIS. In a statement, STIKO has approved this option (115). However, STIKO does not say how often boosters should be given or how long the effect lasts. REVAXIS is a vaccine not approved for children, i.e., there is no liability for vaccine injury by the Federal Republic of Germany or the vaccine manufacturer. The main problem with REVAXIS is that the amount of diphtheria toxoid is 10 times lower than in the tested pediatric vaccines. Whether this reduced amount of toxoid is sufficient to provide reliable protection is unclear (whereas this is well substantiated for pediatric vaccines). Personally, I would not choose this option, even if it appears more cost-effective. If so, I would vaccinate four times, at intervals of four to six weeks and after one year. I would recommend the first booster after five years, analogous to the recommendations for combination vaccines. The effectiveness of tetanus and polio with REVAXIS is, incidentally, predictably good, as these are the same vaccines as in the approved pediatric vaccines.
TETANUS
Similar to diphtheria, tetanus (lockjaw) is a disease caused by the toxin (exotoxin) of a bacterium (Clostridium tetani). Tetanus toxin is considered the second most toxic naturally occurring substance on earth (10). This bacterium lives everywhere in soil under anaerobic conditions. It can be introduced through minor abrasions and lead to tetanus after 10 days to weeks; muscle cramps occur, with severe facial spasms, swallowing disorders, and respiratory arrest. In tetanus, anesthesia with relaxation of all muscles must be maintained for a prolonged period. At the same time, an antidote is administered. Nevertheless, well over 30% of patients still die today. Non-conventional medical treatment has been described repeatedly, but there are no documented cases. A special form is neonatal tetanus, which is quite common in unvaccinated populations in the so-called “Third World”. About 500,000 cases per year are reported worldwide, with a mortality rate of 70–100% (10). The mother’s vaccine protection is transferred to the newborn (10 and 12). Tetanus vaccination is also one of the oldest vaccinations; vaccine complications are well documented and rare (here too, it is an inactivated vaccine based on the toxin). Kidney complications (glomerulonephritis), nerve disorders with paralysis (Guillain-Barré syndrome), and decreases in platelets (thrombocytes) have been described in individual cases. Vaccine protection is quite reliable and lasts at least 10 years after three doses. In some countries, after proper tetanus vaccination in childhood, no routine booster is recommended at all; instead, revaccination is given only in the event of injuries (Netherlands and Great Britain). In recent years, an increasing number of over-vaccinated patients with sometimes significant neurological and kidney problems have been observed, so unnecessary revaccination before 10 years should definitely be avoided (10).
POLIO, INFANTILE PARALYSIS
The pathogen causing infantile paralysis belongs to the large group of enteroviruses. These are the pathogens responsible for “common” gastrointestinal infections. We experience over a hundred such infections in our lives, usually without significant complications. Only dehydration in early childhood is a common life-threatening complication; worldwide, dehydration due to gastrointestinal infection is now the leading cause of death in childhood. Polioviruses are a subgroup, and even with infection by them, uncomplicated gastrointestinal infections are expected in over 90% of cases. Only a small proportion develop so-called “abortive” polio, with meningitis, sore throat, and more severe vomiting. This abortive polio also heals without complications. Only about 0.1% to 1% of polio patients develop the typical paralysis, asymmetrical and ascending from the legs. In these cases, diaphragmatic paralysis and thus sudden shortness of breath must be expected. In maximal severity, all so-called cranial nerves and spinal nerves can be affected, so that in addition to respiratory paralysis, swallowing disorders and circulatory problems must be expected. This phase must be bridged with intensive care methods such as ventilation. After varying periods of time, symptoms then regress, with more or less extensive deficits and paralysis remaining lifelong. As with many diseases mentioned here, the main question in polio is why about 1 in 100 to 1,000 patients does not merely experience a gastrointestinal infection but develops the above complications. The cause is not the poliovirus, but rather our immune processes (predisposition). Thus, there are indications that after removal of the tonsils (tonsillectomy) and/or so-called adenoids (adenoidectomy), the propensity for neurological polio disease, i.e., the above form of paralysis, increases (10). Polio had completely disappeared in the Western world for years and has been eradicated throughout Europe since spring 2002; when cases occurred, they were either imported from countries in the so-called “Third World” or triggered by the oral live vaccine used in Germany, for example, until May 1998 (such vaccine-associated polio occurred in 1 case per 3.5 million vaccinated individuals, i.e., very, very rarely). Since 2013, isolated polio cases have again been reported in Syria and Israel (RKI: Epidemiologisches Bulletin 28/10/2013, No. 43), i.e., renewed importation of polio into Germany must be expected. (Think of the refugee crisis; via this route, one must expect unrecognized polio cases (only gastrointestinal symptoms—then you can become infected unnoticed in any public restroom!).) Finally, there is another argument for the recommendation to be vaccinated against polio: since 2003, no oral polio vaccinations have been given in the Western world (as these could be contagious), i.e., for more than 15 years. Those vaccinated against polio by injection certainly cannot become ill, but can, for example via a public restroom, take up the germs in the intestine and spread them further. This means that an unvaccinated person can become infected even from vaccinated individuals who had this contact without realizing it. Whether the quasi-eradication of polio in our latitudes is actually causally related to vaccination, or is not solely a consequence of our increased standard of living and improved hygiene measures, is highly controversial (this discussion is presented in detail in 18, pages 107–111).
WHOOPING COUGH, PERTUSSIS
Whooping cough is a bacterial disease in unvaccinated preschool populations. It begins with a non-specific cough, usually with a low fever, which lasts a good three weeks. This phase is caused by the bacterium Bordetella pertussis itself. This is followed by a phase no longer caused by the bacterium, but by scarring on the mucosa caused by it: the typical whooping cough stage with paroxysmal coughing, gasping for air, and subsequent retching and vomiting of mucus. This phase also lasts about 3 weeks. This is followed by an interval of varying length with partly typical whooping cough phases and partly non-specific coughing. This interval can last for months, as a neurotic fixation of the cough often persists for a long time. Complications are mainly to be feared in the first year of life: the most serious are sudden, unpredictable respiratory arrests, described almost exclusively in the first six months. In addition, pneumonia, seizures, and, in very rare cases, meningitis or encephalitis (encephalopathy) can occur. An important complication is an immune weakness for about 6 weeks after the illness, also observed after measles, chickenpox, and scarlet fever. In the 1920s, whooping cough was one of the most common causes of death in children in the USA. There, whooping cough declined significantly in the 1930s, before the vaccination era, probably due to improved hygiene conditions (10). In contrast to most childhood diseases, the course of whooping cough becomes increasingly milder with age; in adulthood it usually presents as an uncomplicated cough. However, this is one of the dangers: an adult could unknowingly infect an infant—especially a vaccinated adult, since vaccination does not provide lifelong protection. This risk has been increasingly discussed recently (47); before the vaccination era there were hardly any adults with pertussis (about 2% of all pertussis patients), whereas with high vaccination coverage this is 12–16%. This means that vaccination leads to more adults who can infect infants without knowing it. This represents a high risk for infants who are not yet fully vaccinated. The disease itself does not confer lifelong immunity. In this context, it is interesting that whooping cough can be caused not only by one pathogen, but by at least one more (Bordetella parapertussis). While illness with one pathogen provides some protection against the other (cross-immunity), this does not appear to apply to vaccination with the new so-called acellular vaccine, as increasing numbers of whooping cough cases after vaccination caused by Bordetella parapertussis have been described recently (19). Swedish studies show an effectiveness after three doses of 54–64%, i.e., at most 64 out of 100 children vaccinated three times were protected; therefore, reliable protection cannot be assumed (20/21). Japanese studies, however, show higher protection in children over 2 years of age, i.e., outside the main risk period (22). The current STIKO vaccination recommendation includes 4 vaccinations within one year. Since early 2006, the Standing Committee on Vaccination has recommended a booster for pertussis vaccination between the ages of 5 and 6, 10 and 17, as well as catch-up vaccination for previously unvaccinated children (51). An interesting option to protect newborns against pertussis is vaccination of pregnant women in the third trimester (last three months) of pregnancy. Protection in the newborn is apparently higher (91%) than with any other vaccination later. Protection lasts for about 6 months (118). Few side effects of the acellular vaccine are known. Individual cases of so-called “apathy syndromes” after pertussis vaccination have been described (23): after vaccination, children do not respond, stare into space, and are stable from a circulatory standpoint. This condition lasts a few hours and then disappears; long-term damage has not been observed in these children. An unusual accumulation of febrile seizures after whooping cough vaccination has also been observed (68). In the USA, where the acellular vaccine has been approved for longer, these “apathy syndromes” are also observed; at the same time, cases of so-called “focal encephalitis” (regional encephalitis) are described (24). Finally, it should be noted that the acellular vaccine apparently does not protect against parapertussis infection, which runs the same course in terms of complications as pertussis infection. The very questionable vaccine protection makes the decision difficult. Vaccination against pertussis is predominantly a solidarity vaccination, i.e., by vaccinating I protect other infants because my child is less likely to get whooping cough and thus less likely to infect others. In individual cases in which children have a severe underlying lung disease, e.g., after long-term ventilation as a former premature infant, severe asthma, etc., pertussis vaccination will certainly be easier to accept. However, in these cases, improvements in the underlying disease after having had whooping cough have also occasionally been reported (27).
HAEMOPHILUS INFLUENZAE type B infection, HIB
Haemophilus influenzae type B is a bacterium from the large Haemophilus influenzae group. All bacteria in this group are part of the normal flora of our nasopharynx; HIB (Haemophilus influenzae type B) could be detected in about 5% of all schoolchildren without any signs of illness. In preschool age, HIB is a common pathogen in uncomplicated otitis media. In a small group of young children, however, HIB causes not only otitis media but the most severe form of purulent meningitis. In HIB infection in particular, it is now well documented that it is not the pathogen but a particular predisposition—namely an immune defect—that causes purulent meningitis to develop (8 and 10). The specific immune defect has not yet been fully clarified; a so-called “complement defect” is likely. The fact that purulent HIB meningitis (like meningococcal and pneumococcal meningitis) occurs only in preschool age suggests that the causative immune defect is only temporary, i.e., immunity to HIB is learned. This also explains why HIB vaccination, which is widely accepted in Germany, has not led to a sustained decline in severe purulent meningitis. Today, meningococci and pneumococci—pathogens very similar to HIB—have taken the place of HIB. The prognosis of purulent meningitis is very serious: even with all intensive care measures, 5–20% of children die; in 30%, permanent damage such as severe hearing loss, visual disturbances, balance problems, or epilepsy must be expected (10 and 16). A completely different, very rare complication of HIB infection has, however, almost completely disappeared due to vaccination: acute epiglottitis acutissima. In this disease, with high fever, there is a very rapid massive swelling of the epiglottis with swelling shut of the airways. The disease must be recognized immediately and distinguished from uncomplicated pseudocroup. Life-saving is the immediate placement of a ventilation tube under anesthesia, a difficult undertaking even for experienced anesthetists. This swelling is treated with antibiotics; after the swelling subsides, no permanent damage is expected. While other pathogens have evidently replaced HIB for meningitis, this has not happened for epiglottitis acutissima after the introduction of HIB vaccination. All other diseases caused by HIB, such as inflammation of the heart (pericarditis), sinusitis, osteomyelitis, and otitis media, have not been influenced by HIB vaccination, i.e., they are still observed just as often today, caused by HIB, as before. The vaccination apparently does not protect against the HIB pathogen itself, but only against its spread to the meninges and the epiglottis. Why this is so is still unclear (10 and 16). HIB vaccination was introduced in Germany in 1990 and is generally well accepted as a “vaccination against meningitis” (that this statement—”vaccination against meningitis”—an official part of the HIB vaccination campaign (16), is clearly false should, it is hoped, be evident from the above). The fact is, however, that HIB is now virtually absent as a cause of purulent meningitis and epiglottitis acutissima, and that this change coincides with the introduction of vaccination in Germany (50). Side effects of HIB vaccines are difficult to attribute to this vaccine alone because a combination vaccine is almost always used, with diphtheria, tetanus, and often a pertussis component, and more recently also with polio and hepatitis B vaccine. Two complications have been found after the above combination vaccines: Guillain-Barré syndrome (an acute paralysis ascending from the legs, associated with sometimes considerable pain and partially temporary respiratory paralysis) (15, 32 and 33) and transverse myelitis, an asymmetrical temporary paralysis of the legs (15). Both complications are very rare and have been observed only in individual cases. These are common, non-specific changes after interventions in the immune system; therefore, a link to HIB vaccination alone cannot be established with certainty. In general, HIB vaccination is considered one of the lowest-complication and safest vaccinations (12); it is an inactivated vaccine consisting only of a part of the pathogen. For some time, it has been suspected that childhood diabetes (juvenile diabetes mellitus) occurs more frequently after Hib vaccination. Recently, these indications have become stronger (49). As a vaccination against a major cause of severe purulent meningitis in infancy and early childhood, the overall well-protective and well-tolerated HIB vaccination is certainly recommended.
PNEUMOCOCCI
Meningococci and pneumococci are, alongside the Haemophilus influenzae bacteria discussed above, bacteria that can lead to purulent meningitis in infancy and early childhood. As discussed there, since the near-eradication of Haemophilus influenzae as a cause of purulent meningitis, they are now the main pathogens of this disease in early childhood (first four years of life). Also like Haemophilus influenzae, meningococci and pneumococci are normally pathogens of purulent otitis media, a very common childhood disease, and only under certain unpredictable circumstances, or after removal of the spleen, in sickle cell anemia, and in severe heart defects, does meningitis occur. This means that here too, the pathogens are not causally responsible for meningitis. In contrast to Haemophilus influenzae, where about one in 1,000 children who experience otitis media can be expected to develop purulent meningitis, the tendency with meningococci and pneumococci is significantly lower (about 1:10,000) (61). The reason for the official recommendation for pneumococcal vaccination in the USA is therefore not the possible meningitis, but the increasing resistance to antibiotics in pneumococci as pathogens of otitis media (62). STIKO recommends three vaccinations against pneumococci in infancy and early childhood. If one looks at how antibiotic resistance in otitis media bacteria develops, it quickly becomes clear that vaccination against it will be pointless: about 80% of all otitis media cases are caused not by bacteria but by viruses, i.e., they should not actually be treated with antibiotics (e.g., KV-Arzneimittelbulletin 2000). Nevertheless, it is common practice to treat every otitis media case with antibiotics, i.e., in 80% of cases these drugs are given unnecessarily. Pneumococci belong to the large streptococci family (scarlet fever pathogens) and themselves consist of over 80 different bacteria (i.e., pneumococci are not a single pathogen but an entire group of pathogens) that are characterized by particularly rapid development of resistance, with resistance arising via intestinal bacteria: these come into contact with the multitude of antibiotics in childhood; if they do not die, they develop resistance factors against the antibiotics that enable them, upon renewed contact, to destroy the antibiotic. An important group of these intestinal bacteria are enterococci, which also belong to the streptococci family. If the child then comes into contact with pneumococci, a very rapid “exchange of information” takes place within the “streptococci” family within hours, so that resistance factors are transferred. The cause of the alarming resistance development in the streptococci family (pneumococci, enterococci, streptococci (scarlet fever), streptococci (tonsillitis)) is the far too generous and unnecessary use of antibiotics, especially in childhood. Pneumococcal vaccination will not change this use, nor will it significantly change the frequency of otitis media in childhood, because, as stated, 80% are caused by viruses and only about 7% by pneumococci (the rest are caused by other bacteria such as meningococci and streptococci). The pneumococcal vaccine introduced in Germany currently includes 10 (Synflorix) or 13 (Prevenar 13) different pneumococcal antigens (out of over 40 possible). It covers only about 40% of the pathogens occurring here, i.e., an effectiveness of about 40% can be assumed after complete vaccination (64 and 88). For otitis media, the frequency is reduced by about 6–34% (64). An interesting new study from the USA shows that penicillin resistance of pneumococci has decreased in the period since the introduction of pneumococcal vaccination (96). In 2013, various studies on the new vaccine and its effectiveness were published (111): assessment remains difficult; while infections with the vaccinated serogroups decrease significantly in vaccinated children, a replacement by serogroups not included in the vaccine is reported in virtually all countries from which studies are available, i.e., the total number of meningitis cases is only slightly affected (111). Data discussed in the cited arzneimitteltelegramm 44, No. 4 2013 (111) are available from the USA, France, Spain, Germany, and Finland and relate only to the 10-valent vaccine Synflorix. There are no effectiveness studies for Prevenar 13 to date (111). No statement can yet be made about long-term side effects of these new vaccines. However, an interesting observation has been made: if paracetamol is given at the same time as vaccination to treat fever, the effectiveness of the vaccination decreases (105).
MENINGOCOCCI
Meningococci are the third group of pathogens causing purulent meningitis. Following widespread vaccination against Hib and, in some countries, pneumococci (e.g., England and Belgium), meningococci have become the primary group of pathogens for purulent meningitis in those regions. In some African countries, within the so-called “meningitis belt,” they lead to large, severe epidemics. Like Hib and pneumococci, meningococci are a large family; there are various subgroups that differ in their antigenic properties and vary in prevalence across different regions of the world. We distinguish 13 groups; “A”, “B”, “C”, “W135”, and “Y” play a role as pathogens in Europe, Africa, Asia, and the USA. In the USA, groups “A”, “Y”, and “C” are prevalent; in Europe, it is predominantly “B” (40%) and “C” (20%); in Africa and Asia, group “A” (87%). Since 2011, vaccination against meningococci has been recommended in Germany by the STIKO during the second year of life. The vaccine covers the risk for meningococcal group “C”, a strain that plays a minor role in Germany (approx. 20% of meningococcal cases). A single vaccination is recommended, although it remains unclear how long this single dose remains effective. A similar approach is taken in the Netherlands, where no vaccine breakthroughs have been observed so far, whereas in England, three doses are administered (103). Nevertheless, the STIKO has only recommended this vaccination once. Even in circles favorable to vaccination, this recommendation has met with incomprehension (70). Described side effects include restlessness, sleep disturbances, fever, redness, and rarely, Stevens-Johnson syndrome (a severe allergic reaction involving the detachment of skin and mucous membranes) (64). A vaccine against the primary pathogen “B” has been approved since August 2013, and a recommendation by the STIKO is expected. Since meningococcal type “B” accounts for a good 70% of cases in Germany and is the most important pathogen for meningococcal meningitis, vaccination with this vaccine would make significantly more sense than with the group C meningococcal vaccine (113). Meningococci can still cause severe meningitis in adolescence, particularly in “mass accommodations,” such as boarding schools.
MUMPS
Mumps is one of the “classic childhood diseases.” After an incubation period of approximately three weeks, a slight fever is followed by an often painful swelling of the parotid glands and frequently the salivary glands located under the tongue. Additional symptoms include fatigue and headaches. The duration is approximately 3–7 days. Mumps is caused by a virus for which humans are the only reservoir. Approximately 40% of infections are “silent,” meaning they occur without visible illness. According to all authors, complications before puberty are very, very rare and increase significantly after puberty (10, 11, 12, and 16). While meningitis (meningoencephalitis) is frequently found in the acute stage (1:1,000 to 1:5,000), it predominantly leaves permanent damage, such as inner ear deafness (1:20,000), in adults over 18 years of age. The most feared complication is orchitis (inflammation of the testicles), which occurs almost exclusively after puberty (10 and 12), but then unilaterally in approximately 25% of cases. In cases of bilateral occurrence, it can lead to infertility in individual instances! Recently, a connection between mumps and later diabetes mellitus has become known, although no frequency can yet be specified. However, the vaccination itself is also suspected of causing diabetes mellitus (12, 15, and 34). Due to the long period between the illness (mumps) or vaccination and the onset of diabetes mellitus, clear frequencies cannot be provided in either case. However, it is a fact that the incidence of juvenile diabetes mellitus is increasing; if mumps were a significant factor, a decrease would be expected! By no means, however, is the reverse conclusion correct: that the occurrence of juvenile diabetes mellitus is observed more frequently because of the vaccination, which is not widely accepted in Germany; the development of this possibly autoimmune disease is far too complex. (Autoimmune diseases are conditions in which the immune system recognizes the body’s own tissue as foreign and begins to destroy it; classic “rheumatism,” for example, is one of them. Generally, a significant increase in these complex diseases has been observed in recent decades). Complications of the mumps vaccination are surprisingly frequent (12), which is due to the fact that, like the measles and rubella vaccinations, it is a live vaccine using attenuated germs: “Vaccine mumps” is a harmless complication in 5:1,000 cases. This vaccine-induced mumps is somewhat milder than the actual disease. In 1:1 million cases, the vaccination can also cause orchitis; so far, this has only been observed unilaterally. Gait instability has been observed in individual cases; the cause of this disorder, which disappears completely after 2–3 days, remains unclear. Meningitis or encephalitis has also been described in individual cases, with the frequency stated as 1:10,000 to 1:1 million. The issue of diabetes mellitus was addressed above (all data taken from 12 and 18). One complication of the vaccination must not go unmentioned: the shift of the disease into later adolescence and early adulthood. Current studies (2018) show that the group of adults who no longer have mumps protection after regular vaccination is increasing significantly. A booster vaccination against mumps is recommended in adulthood (analogous to the measles vaccination) (119 and 120). In the case of mumps, one is dealing with a disease that carries few complications in childhood, but the vaccination causes problems relatively frequently. Many parents decide to wait until the onset of puberty. If no antibodies are detectable in the blood at that point (as mentioned, 40% of mumps cases are silent), then vaccination could be considered.
RUBELLA
Rubella is also a viral disease. The incubation period is 14–21 days. Rubella is most contagious a few days before the rash appears, which is particularly dangerous for unprotected pregnant women! Usually, non-specific signs such as headache, slightly elevated temperature, and a cold occur first, followed very briefly by an unimpressive rash starting from the head. Swollen lymph nodes in the neck are typical. The most important complication of this disease, which is otherwise generally regarded as harmless, is so-called embryopathy—a severe malformation if infection occurs during early pregnancy, when many mothers often do not yet know they are pregnant. People who have had rubella are protected for life against reinfection, meaning that pregnant women who have had rubella also protect their unborn child. Other very rare complications of rubella include: A joint disease, so-called rubella rheumatoid, which occurs more frequently with increasing age and leaves permanent joint damage in individual cases (described only in adults (12 and 10)). Encephalitis without permanent damage in 1 out of 6,000 cases (10), and a drop in blood platelets in 1 out of 3,000 cases, which sometimes leads to spontaneous skin bleeding. This complication always resolves on its own! (10 and 12). The main reason for introducing the rubella vaccination was not to protect children from the rather harmless disease, but to protect the approximately 5–10% of unprotected women of childbearing age. Despite the now two-fold vaccination, it has not been possible to reduce this proportion of unprotected young women. This protection of others must be included in the consideration for or against rubella vaccination, meaning that after contact with rubella or if rubella is suspected, the unvaccinated child must stay at home, even though they may not seem that ill! They must not even be taken briefly to the post office or the shop, as they could infect a pregnant woman there!! However, this simple measure is increasingly less accepted, as the large group of contagious and feverish children in kindergartens makes shockingly clear every day. How reliable the protection after rubella vaccination is remains unclear (10). The persistently large number of unprotected women raises some doubts about the effectiveness of the vaccination. Lifelong protection is rather unlikely, meaning that booster vaccinations are probably necessary on a regular basis. Nevertheless, since 1974, the rubella vaccination in the USA, together with a very good educational campaign and the penalty-free possibility of terminating a pregnancy after questionable rubella contact, has led to an impressive decline in malformations caused by rubella embryopathy. However, the contribution of the vaccination to this success is unclear (10). Complications of the vaccination are again somewhat more frequent, as it is an attenuated live virus: Since the rubella virus is a virus that survives particularly long in our bodies (12), it can also be detected as a vaccine virus for a very long time. In connection with the vaccination, isolated cases of so-called “Chronic Fatigue Syndrome” have been observed, a disease belonging to the rheumatoid conditions, associated with fatigue, muscle pain, and slightly elevated temperatures (12). Chronic Fatigue Syndrome is still a rather unclear autoimmune disease that is certainly based on many factors, so that proving the rubella vaccination as the sole cause is unlikely. This syndrome has also been observed after the rubella disease itself (12). Joint complaints up to and including rheumatoid arthritis have often been described after rubella vaccination (12, 35, 36, 37). The frequency is roughly equivalent to that of the rubella disease itself (36). In very rare cases, encephalitis has been observed (12 and 18). Guillain-Barré syndrome, an ascending paralysis of the legs, in rare cases with respiratory paralysis, has also been described (12 and 38). These are individual cases. When combined with measles and mumps vaccines, isolated seizures have also been observed, which are likely caused by the measles component (12 and 68). In the case of the rubella vaccination, the decision is not entirely simple when considering unprotected pregnant women. Rubella disease provides lifelong protection, while the protection provided by the vaccination is quite controversial (detailed discussion in 18). However, the vaccination shifts the main age of illness into the dangerous period of young adulthood! Vaccination after not having had rubella during puberty may make more sense than the currently recommended early vaccination. However, the aforementioned hygiene measures must be strictly observed.
HEPATITIS (INFLAMMATION OF THE LIVER)
Hepatitis is a collective term for a large group of liver infections caused by a variety of different viruses. These viruses, of which new ones are constantly being discovered, are numbered according to the letters of the alphabet. For the discussion of vaccination in childhood, it is important to distinguish between four forms of hepatitis: Hepatitis A: This is an infection common in southern countries, acquired through contaminated food (unwashed fruit, salad, etc.). After an incubation period of 15–45 days, malaise, slight jaundice, light and thin stools, and abdominal pain occur. In early childhood, hepatitis A is often asymptomatic; in adulthood, it presents with a severe feeling of illness. There is no permanent damage in childhood. The disease leaves lifelong protection. The children’s stool is contagious. A vaccine with inactivated live viruses has been available for hepatitis A since 1993. Vaccination is only recommended for travel to endemic areas (Turkey, Middle East, India, Africa). Due to the limited experience to date, no clear statement can be made regarding side effects. Hepatitis C: This is an inflammation of the liver caused by a virus transmitted only through body secretions (blood and semen, saliva and breast milk). Together with HIV viruses, the Hep. C virus spread rapidly throughout the world, primarily among adolescents (10 and 39). In an as yet unknown percentage of cases, chronic liver disease occurs, followed by liver cirrhosis or liver cell cancer (39). In Japan and the USA, hepatitis C is considered the main cause of liver cancer, while in Europe, it is still Hep. B (3, 9). A vaccine for Hep. C is not yet available; due to the rapidly spreading infection worldwide and the rather malignant course, it is assumed that Hep. C will represent the main problem among hepatitides in the future (10, 39). Hepatitis E: This is also a virus that has only been known for a short time, which is excreted in the stool and causes infection through it. The course is as benign as that of Hep. A. Increased cases of Hep. E were observed in the USA after underwater birth became fashionable (39). Hep. E cases acquired during birth also apparently proceed without problems (39). There is no vaccine. In Europe, hepatitis B still plays the most important role in childhood. It is also caused by a virus transmitted through body secretions. Overall, hepatitis has become very rare in childhood in Germany since all pregnant women have been screened for it. It begins with fatigue and slight jaundice. Particularly in childhood, it can lead to a fulminant course with sudden liver failure, but also to chronic hepatitis with liver cirrhosis and destruction of the liver after years. Newborns are particularly at risk for this malignant course of Hep. B (90%), which is why active vaccination (with genetically engineered viral antigen) and passive vaccination (with antibodies from people who have had hepatitis B) have been recommended for years immediately after birth if the mother is positive for Hep. B. This has almost always prevented the malignant courses. Since the end of 1995, a genetically engineered inactivated vaccine has been included in the general vaccination campaign. From the beginning, this decision was very controversial, and the Hep. B vaccination has so far been among the least accepted vaccinations in Germany and Switzerland. The probability of infection in childhood after birth is vanishingly small, as 1) Hep. B is very rare and 2) Hep. B can only be transmitted via blood-to-blood contact (or body secretions). Transmission via saliva is virtually impossible (52). By screening pregnant women, the largest risk group could be identified and protected with the vaccination described above. The second risk group consists of adolescents of reproductive age; up to 50,000 new cases are identified in this group in Germany. Whether vaccination in early childhood provides such long-lasting protection is unclear; according to the vaccine manufacturers, immunity after complete vaccination is assumed to last 10 years (information in the package inserts). From long-term experience with Hep. B vaccination among clinical staff, it is known that vaccine protection is quite inconsistent; after titer controls, many had to be revaccinated several times until a sufficient titer was present. Furthermore, there is also lack of clarity regarding the value of titer determination as a means of measuring vaccination success (40). Reports of Hep. B infections after complete vaccination and sufficient titer are frequent (e.g., 41). A special feature of the hepatitis B vaccination is that mutant viruses are increasingly observed during vaccination, which remain infectious despite vaccination and whose clinical courses tend to be more “aggressive” than the normal variant (20 and 28). Side effects of the Hep. B vaccination are predominantly neurological complications: In addition to Guillain-Barré syndrome (ascending paralysis) (14 and 12), diseases similar to multiple sclerosis are occasionally seen in connection with the new genetically engineered vaccine (42 and 43); furthermore, in individual cases, visual disturbances due to an autoimmune reaction on the optic nerve have been described recently (53). These are individual cases, and the connection is quite controversial (12). Given the low risk of infection and the still unclear side-effect situation of hepatitis B, a general vaccination in early childhood should, in my opinion, be carefully weighed. Since even the vaccine manufacturers only assume a vaccine protection of approx. 10 years and then recommend a booster vaccination, I consider the STIKO recommendation (66) to be dangerous, as adolescents vaccinated in infancy and early childhood falsely assume protection against hepatitis B (and also equate this with protection against Hep. C). Personally, I consider Hep. C to be the much greater danger in adolescence, which can only be averted through education. From my point of view, a hepatitis B vaccination in adolescence, e.g., as part of the J1 (12–14 years), is sensible. For mothers with Hep. B, simultaneous vaccination within the first 6 hours after birth should definitely be carried out. Vaccination can also be sensible in risk families with a member who has contagious Hep. B, although hygiene measures are just as effective here as they are for Hep. C and HIV.
CHICKENPOX VACCINATION (VARICELLA)
Chickenpox (varicella) is an actually harmless viral disease, usually occurring in preschool age. The incubation period after infection is relatively long at 14–28 days, and the risk of infection (contagiousness) is high; almost everyone who has not yet had chickenpox becomes ill after contact. After the illness, lifelong protection remains. Chickenpox is spread via the wind, in addition to direct contact with the blisters. The viruses are not excreted but survive in the nerve ganglia (viral persistence). Under certain conditions (e.g., short-term immune deficiency), they can be reactivated there and cause a blister-like rash along the nerve belonging to that ganglion (so-called “shingles”). The chickenpox disease itself often begins with some fever, a cold, and a headache. The blister-like, severely itchy rash follows quickly, typically starting on the scalp and spreading over the entire body. The mucous membranes are also affected, so that blisters can also occur in the mouth and genitals, which can then be very painful. In general, children are little affected; after an average of five days, the blisters heal by drying out, and the crusts later fall off. There is no consensus on the possibility of infection; according to the generally applicable rules of the German Society for Pediatric Infectious Diseases (DGPI) (92), children may return to kindergarten when all blisters have crusted over. For people with immune deficiencies, however, the crusts can still be infectious, meaning that the child may only have contact, for example, with children with cancer who are currently receiving chemotherapy, once all crusts have fallen off (87). Complications of chickenpox are very rare in childhood: mostly, scars are seen after chickenpox if the child had to scratch severely. In about 5% of cases, bacterial infections of the blisters occur. The remaining complications are very rare: in 1/4,000 cases, the cerebellum is affected, resulting in temporary dizziness and an unsteady gait (cerebellitis). This cerebellitis leaves no permanent damage in children (87 and 92). Middle ear infection and pneumonia are rare complications, but occur in the percentage range. Very rarely, 1/25,000, inflammation of the cerebrum can occur, which can lead to permanent damage (paralysis and deafness). Chickenpox is dangerous for the unborn child (8th–21st week of pregnancy); severe malformations (similar to those in rubella) can occur if the mother herself has not had chickenpox before. However, in Europe, over 96% of all pregnant women are protected because they had chickenpox as children. The newborn of a mother who did not have chickenpox is also at risk. If the mother had chickenpox, there is no danger, as maternal protection (nest protection) exists. Within the framework of the recommended chickenpox vaccination, we will have a generation of mothers who cannot pass on maternal protection against chickenpox to their children. As with many childhood diseases, the complications of the disease increase with the age of the patient; adults with chickenpox are often severely ill and sometimes have to be treated in the hospital. The risk of dying from chickenpox (extremely rare in childhood) is 25 times higher for adults (87). However, concrete figures are not available (87). The chickenpox vaccination was introduced for young children in the USA in 1993. Like the vaccine now introduced in Germany, it is a live virus vaccine. After about 10 years of experience in the USA, the effectiveness of this vaccine is assumed to be approx. 97% (87). However, it is recommended to perform a booster vaccination in adolescence, as this vaccine protection probably does not last longer than 10–20 years (87). (Japanese studies are said to prove longer effectiveness, cited in 92, without source reference). In the USA, the introduction of the chickenpox vaccination was never justified by the danger of the chickenpox disease, but by the social costs caused by the absence of parents from the work process (93). The STIKO in Germany also recommended the chickenpox vaccination from this point of view (94). As with measles, humans are the only virus carriers of the varicella-zoster virus, so that eradication would be possible and is being pursued (94). In 2004, the Standing Committee on Vaccination (STIKO) decided to recommend vaccination against chickenpox (varicella) in addition to vaccination against measles, mumps, and rubella starting in August 2004 (4). A four-fold vaccination against the mentioned diseases is then planned at 12–15 months, with a second vaccination after 4–6 weeks. Long-term side effects of the chickenpox vaccination are still unclear: since it is a virus that remains in the body (persists), it cannot be compared with other vaccinations. Since the vaccine virus is a live virus, it persists, like the wild virus, in the nerve ganglia (92). At least two papers have expressed the suspicion that the vaccine virus can promote the development of cancer. In both papers, laboratory animals were injected with the vaccine virus and cell changes were observed (95 and 96). Such experiments are to be taken seriously but are often not directly transferable to humans. Immunologically, the development of cancer is a long-term process lasting more than 10 years. Therefore, the observation that no increase in cancer cases has been observed in the good 10 years in the USA since the introduction of the chickenpox vaccination does not provide certainty. It is completely unclear what will happen if, as with measles, the age of illness increases. It is to be assumed that the complications of chickenpox will then increase massively, similar to the observations after the introduction of the measles vaccination. Additionally, it must be assumed that more vulnerable pregnant women will not have chickenpox protection, so the pressure to vaccinate one’s child will increase. We were able to observe this with the measles vaccination. Epidemiological measures, such as temporary suspension of the freedom from vaccination within the framework of the Health Protection Act (mandatory vaccination is provided for measles in the event of an epidemic), are to be expected. Also, as with measles, humans are the only virus carriers of the varicella virus, so that eradication would be possible and is also being pursued (94).
HUMAN PAPILLOMAVIRUS (HPV)
The Human Papillomavirus is a group of viruses transmitted through sexual intercourse that can lead to either genital warts (condylomata) or changes in the cervix, which can rarely become malignant (cervical cancer, cervical carcinoma). Since 2006, there has been a vaccine against some of these viruses, which has been “pushed” in all Western countries with an unprecedented advertising effort (99). In mid-2007, this vaccine was approved in Germany and, also unprecedentedly, directly recommended by the STIKO. At that time, the studies examining the effectiveness and tolerability of the vaccine were not yet available; they had not yet been completed!! (99). This procedure is, as mentioned, unique and shows the pressure the pharmaceutical industry is now exerting to make an excellent business (the vaccine costs, also uniquely, over €400, making it more expensive than all recommended vaccines combined!). After the actual approval study was presented, it turned out that the first vaccine (GARDASIL) has an effectiveness of 17% when it comes to changes in the cervix (cervical dysplasia); a reduction in cervical cancer could not be found (study duration too short). This means that the GARDASIL vaccine only works against a small group of HP viruses; the effect against cervical cancer is completely unclear, and a maximum of 17% could theoretically be prevented. In the meantime, the company has developed a new vaccine that now covers 9 relevant germs instead of the previous 4 (2016). This makes a significantly higher effectiveness possible: changes that can lead to cancer in the cervix decrease by nearly 43% in initial studies (116). What is certain, however, is that this new vaccine is significantly better than the old one; while about 1/5 of vaccinated women were possibly protected before, it is now 2/5. In 2018, Finnish data showed for the first time a decrease in cervical carcinomas in HPV-vaccinated women (121). In the Finnish Cancer Registry (which records all cancer cases in Finland), no HPV-dependent cervical carcinomas were found in vaccinated women in the period from 2007 to 2015, while 10 cases per year were found in the unvaccinated group. This proves for the first time that the HPV vaccination effectively protects against cervical CA, which changes my assessment of the vaccination to the extent that I can now issue a recommendation. Side effects of the HPV vaccination are relatively unclear; in the USA, 371 serious complications were reported after GARDASIL (out of several million doses), including seizures, facial nerve paralysis, and Guillain-Barré syndrome (99). 15 deaths were reported, although some of the young women were taking the “pill,” which per se increases the risk of death (99 and 100). Finally, in the case of a vaccine, the causal, i.e., proven, relationship between the death of the vaccinated person and the vaccine is usually not provable. In connection with the CERVARIX vaccine against HPV, which came onto the market at the end of 2007, no deaths have been reported so far, although there is less experience with it and it only covers 2 of the relevant germs. Nevertheless, the vaccination was recommended by the STIKO from the age of 11. Recently, the Arzneimitteltelegramm (one of the very few specialist journals on medication in Germany that is not dependent on advertisements from the pharmaceutical industry and is therefore one of the few trustworthy sources) took up this recommendation, which has since been questioned by many experts, and called for the resignation of the STIKO (101). In 2010, this resignation then took place. In 2011, the first study results were published that say something about the long-term effectiveness of the two approved HPV vaccines: in young women vaccinated between the ages of 12 and 17, the occurrence of high-grade cervical dysplasias (precursors to cervical cancer found during screenings) decreases. But in women vaccinated after their 17th birthday, no decrease is seen! Perhaps because these women were already “vaccinated” through sexual contact beforehand? However, even in women vaccinated between the ages of 12 and 17, dysplasias increase again after their 18th birthday, which could suggest a relatively short effectiveness of the vaccination! What could a sensible decision look like? If there are family members with HPV-dependent cervical cancer, I would tend more towards vaccination, but then with Gardasil 9. A possible reduction of this familial risk by a maximum of 43% is likely. I would vaccinate as late as possible (before the first sexual contact), as the vaccine is effective for an unpredictably long time, possibly 10–15 years. The search for a partner with frequently changing partners (and a high risk of infection) today lasts until about the mid-20s, sometimes longer (no one thinks about the “second edition” when it comes to vaccination anyway). For adolescents who have no family history regarding cervical cancer, I would consider longer whether the vaccination is sensible. I would always involve the daughter in this decision and value her vote strongly; it is about her future. However, since the first good data in 2018 showed the effectiveness of the vaccination against cervical CA caused by HPV, I would also tend to recommend vaccination here. New (2018) is the STIKO recommendation to also vaccinate boys (122). This is justified by the fact that, naturally, boys are transmitters of the HPV virus during sexual intercourse and the protection of girls can be significantly increased by vaccinating boys. This reasoning is logical. Additionally, the STIKO argues (122) with the very rare tumors of the penis and throat caused by HPV in men, which could likely be reduced.
ROTAVIRUS ENTERITIS
Rotavirus is a group of viruses that cause a severe gastrointestinal infection; in Germany, alongside the NORO virus, it is probably the most common germ leading to inpatient admission due to a gastrointestinal infection with dehydration. Since 2006, there has been a vaccine that is taken as drops and provides good protection. Previously, there was another oral vaccine, but it was taken off the market due to serious complications (bowel obstruction). Regarding the new vaccine, there are again reports of acute bowel obstruction after vaccinations (www.fda.gov/cber/safety/phnrota021307.htm). Rotavirus vaccination has been recommended in Germany by the STIKO since August 2013. The aim of the STIKO vaccination recommendation is to reduce the number of hospital stays for infants and young children with gastrointestinal infections (112). The STIKO considers a slight increase in intussusceptions (bowel obstructions) caused by the vaccine to be acceptable (112), whereby this risk increases with age, meaning that vaccination as early as possible (from the 6th week) would be sensible here. It is a live vaccination; in the intestine, the vaccine viruses can “back-mutate,” and the child is then contagious to other people via the stool for a few days. This must be taken into account if the child has contact with other children (PEKIP) or vulnerable people (grandparents with illnesses)! From my point of view, this vaccination is still dispensable, especially since other gastrointestinal infections (e.g., caused by Noro or Astroviruses) have similarly severe courses.
TICK-BORNE ENCEPHALITIS (TBE)
Tick-borne encephalitis (TBE) is a viral disease of the brain and meninges transmitted by a tick bite. This disease should not be confused with the much more common tick-borne Lyme disease or ehrlichiosis. TBE only occurs in circumscribed areas; in our region, only in the Birkenfeld area and, since summer 2012, also in the area of the Rohrbacher Weiher (Saar-Pfalz district) (109). (Otherwise in the Bavarian Forest, Austria, parts of Baden-Württemberg, and Thuringia). An area is defined as a risk area for TBE if five or more TBE cases occurred there within 4 years that were not acquired in other regions. For the Saarland, 3 cases occurred in 2008, and 1 case each in 2009 and 2011 in the area of the Rohrbacher Weiher (109). Thus, the Saar-Pfalz district has been established as a risk area for the next 20 years (109). In childhood, after a tick bite by a TBE-positive tick, massive encephalitis occurs only very rarely; usually, headaches and symptoms similar to the flu occur (66). Permanent damage or deaths do not occur in children (66). The STIKO recommends a particularly careful risk-benefit assessment for children under 3 years of age; otherwise, vaccination in childhood is recommended for longer stays in risk areas with prolonged contact in the forest (e.g., forestry internship) (87). For the Saarland, a vaccination recommendation by the STIKO has applied since summer 2012 (109). The vaccination against TBE is among the poorly tolerated vaccinations; side effects relate predominantly to the nervous system: seizures, nerve paralysis, headaches, and fever are (rarely) reported (110). Given the changed risk situation in the Saar-Pfalz district, the vaccination decision should be thoroughly weighed. Since permanent damage from TBE infection almost exclusively affects adults and adolescents aged 12 and over, parents should be vaccinated before their small children! (114)
TUBERCULOSIS
Tuberculosis is a bacterial disease that previously caused severe epidemics—epidemics that, alongside smallpox, depopulated entire regions in Europe and America. Even today, tuberculosis is one of the most common diseases leading to death worldwide, especially in the so-called Third World. Within the framework of the HIV epidemic, it is also spreading increasingly in the Western Hemisphere again. No disease has shown so clearly that poverty, malnutrition, and poor hygienic conditions are essential factors for the spread of infections. With increasing prosperity in Europe and the USA, and with better nutritional and housing conditions, the incidence of tuberculosis decreased rapidly. Neither vaccination, which was one of the first recommended vaccinations ever, nor the use of very potent antibiotics are primarily responsible for the massive decline of tuberculosis in our latitudes. Despite these measures, a worrying increase in tuberculosis has been seen again in the last 10 years. The history of tuberculosis vaccination shows that patient and well-founded education is not ignored in conventional medical circles; after many years with many small studies that repeatedly showed the ineffectiveness of the side-effect-prone BCG vaccination, it was removed from the general recommendation for Germany in May 1998 following a comprehensive so-called meta-analysis (44). Today, BCG vaccination is no longer carried out in Germany; since 2007, it has also been banned in France. Author: Bernhard Ulrich, Specialist in Pediatrics and Adolescent Medicine, Specialist in Anesthesiology and Intensive Care Medicine.
