Wednesday, October 12, 2016

The Longest 7 Weeks

The coughing was mild at first. Not a nagging cough, not a juicy or wet cough, just a mild cough. I stared at my 16 year old son across the table from dinner and asked him if he was feeling well, he shrugged and said yes, he was fine. That night the cough continued, I contributed it to end of summer weather, allergies perhaps, maybe mold? I gave my son cough syrup for nighttime. I took his temperature which was normal (hint #1) and both of us went to sleep. I did hear him cough occasionally through the night and this marked the beginning of the longest months of our lives.

My son is a healthy 16-year-old, middle linebacker for his varsity football team, he jet skis, is a avid boater, plays Lacrosse off season. My son is into working out, eating healthy and exercising. He had a milk protein allergy as an infant, a bout with apnea as an infant, and other than childhood colds, only one ear ache his entire sixteen years, a fractured clavicle and nasal bone, he was never sick.

The mild cough continued for a week, no sputum, it was dry and still occasional. He stayed afebrile, ate normally, was taking fluids, and had no complaints. I myself developed a cough, I do have a history of asthma and thought I was coming down with my yearly bronchitis. I was thinking maybe my son was also developing a case. I went to urgent care, and got myself a Medrol dose pack and a antibiotic, when I came home, I decided that I wasn't going to take the antibiotic that was prescribed, (doxycycline) and I opted to take a Z-Pak that I had filled 8 months before but didn't take. I didn't realize it then, but it was a good call on my part. In this time my sons cough remained mild, but in the days that followed I noticed it was worsening. He was coughing all through the night, and it was making him very short of breath. I dropped him off at school and a couple of hours later he called me and asked me to pick him up. I took him right over to urgent care, where they diagnosed him with bronchitis, gave him amoxicillin, put him on prednisone 20 mg daily x 5 days and gave him an inhaler, as I gave him a few puffs off of my inhaler the night before to which his breathing improved.

That night was the real beginning of this nightmare, he coughed so violently became short of breath, and was gasping and choking. He began vomiting (hint #2) phlegm and whatever he ate that remained undigested. And this type of coughing, gagging, shortness of breath and vomiting continued for the next day and night. He was exhausted. I was exhausted. I felt helpless. I am a nurse and part of me was telling him not to be so dramatic, as vomiting with him was always a big production, ( I liken my son to the Seinfeld episode where Jerry proudly states he hasn't vomited in 13 years, only to toss his cookies later) and the other part of me was getting very very nervous.

I took him to the local Emergency Department. I was happy to see the pediatric Physican that was on call was a doctor that I loved and respected. They gave him a albuterol neb and a chest X-ray. She came back to tell me that his chest x-ray was crystal clear (hint #3) and that they would discharge him, but I was not happy with that. The vomiting had me very concerned, she stated it was probably a gag reflex. But she did decide to keep him for a while after seeing my face. The gave him a bolus of normal saline for dehydration , and did bloodwork and urine. All of his blood work came back fine except for his neutrophils, and his monocytes. They were only slightly elevated (hint #4). The mycoplasm, wasn't resulted but she didn't think it would show anything. She then decided she was going to treat him as an atypical pneumonia. Thank God for that. She discontinued the amoxicillin. And put him on Zithromax 500 mg daily x five days. She said to continue the prednisone until finished. We left.

During the next 10 days, as he completed the medications, my son continued to have these bouts of uncontrollable violent coughing, always resulting in vomiting, choking on phlegm and gasping. Still he remained with no temperature, he would eat, but vomit whatever food if the coughing started right after he finished. He was losing weight. He was in and out of school, going in late if he was up all night coughing. One evening he vomited in the basin where I noticed black stringy flecks, of course the nurse in me immediately thought blood, he is assured me he had eaten fried Oreos. OK I thought to myself that makes sense. But the next morning first thing in the morning, he vomited again, this time it was phlegm with blackened red strings (hint #5). I put the vomit in a baggie and I threw him in the car and took him again right back to the emergency room. This time it was the Doctor who I did not know. And I did not care for her as she was dismissive, and told me it wasn't blood, and did not want to hear his story. Well guess what?, it was positive for blood. They gave him three back to back nebulizer treatments, they upped his prednisone to 60 mg a day, repeated the chest x-ray which of course came back clear, told us to do the inhaler every four hours and released him. They did not draw labs. Dismissed.

With the increased prednisone, the cough did slow down a bit, he still was vomiting phlegm and gasping but no more blood. Still not happy, I made a follow up appointment with his physician. I saw the nurse practitioner in the office. She listened to what I had to say. She did a very thorough exam, and it was the nurse practitioner who believed it was pertussis. Pertussis? Really?? Nah. He was vaccinated. I was pro-vaccine, he was up to date. No way was it whooping cough. But my son was so sick and had lost 10 pounds. She was so concerned that she sent right us over to the lab to have blood work drawn. The weekend came and went, he was feeling somewhat better, less coughing, but still coughing nonetheless. On Monday, I followed up with his pediatrician, the labs were still pending, but she cleared him to return to school and football. She assured me he was not contagious as he completed the medication often prescribed for pertussis. Later in the afternoon the Dr. called, his results were in and Bordeltella Pertussis and Mycoplasma were elevated, positive.

Pertussis! Bingo. Wait, what??

 How did my healthy, so healthy never sick kid get whooping cough?? How did three different doctors miss this???? He has a pro-vaccine mom who diligently took him for his appointments. I am a community visiting nurse, I might have seen this in my poorer neighborhoods. I ruled myself out as I've been home on a shoulder injury and a surgery for 5 months. Meanwhile, I waited for the dreaded Department of Health call.

The call came, and the nurse assigned to my sons case was lovely. We went over my sons symptoms and created a timeline. She was convinced it was mid to end of August when he was exposed. Most likely from another child during practice or from the gym. I was safe as I took the z-pak when I had bronchial symptoms. My immediate family also showed no symptoms and remain well. They were not exposed to my son until after he did his course of antibiotics. She explained that they were treating it as a probable, not confirmed case. To get a confirmation you need to do a nasal swab. No swab was taken, just blood. She explained that the pertussis vaccine last approximately 3 to 6 years, as it weakens. My son had a Tdap 5 years prior, so his booster lasted just 5 years.
Dtap is given as a vaccine, Ttap is given as a booster and is offered as the tetanus booster. She also explains how the bacteria goes into what are called "pockets." Pockets are areas where the disease can lays dormant. Anti-vaccine parents create these pockets when they miss vaccinations as they leave their communities vulnerable to outbreaks of vaccine preventable disease. Anti-vaccine parents rely on community immunity, and this is the very reason why you should not rely on community immunity. A unvaccinated child, or an adult who was carrying exposed my son, who fits in the profile of who is at risk. Children that are at risk are my sons age as this is the year where their vaccination would be weakening and wearing off. I never knew this vaccine could wear off just like that.

Pertussis is a highly contagious bacterial respiratory disease. It is spread by contact with respiratory droplets, like cough, sneezing, saliva, handshakes and hugs. It is called "Whooping Cough" because of the sound that is made when they gasp for air after fits of coughing. The cough is mild in the beginning, mimics a cold and there is no fever. If you have a cough and are running a 101° temperature, chances are, you do not have pertussis.

Pertussis can be life-threatening especially to babies, and can cause serious illness in children, teens and adults. 90% of deaths from pertussis are in infants less than 1 year old.
What I learned:
  • Vaccinated children and adults can become infected with the disease, but it's less serious in vaccinated people.
  • Vaccination and booster shots are the most effective way to prevent pertussis. Dtap for infants, Tdap for children and adults. 
  • Pregnant mothers should get the Pertussis booster vaccine with every pregnancy. The Centers for Disease Control and Prevention (CDC) now recommends that pregnant women receive the whooping cough, vaccine for adolescents and adults (called Tdap vaccine) during the third trimester of each pregnancy ideally in the 27th through 36th week.
  • You are not considered communicable if you complete the course of antibiotic therapy.
  • It is recommended that you complete the course of antibiotic, and still remain contained for at least five days after completion.
  • It is also called the cough of 100 days, as you can have coughing symptoms for up to three months.

Healthcare providers need to be educated that whooping cough or being exposed to whooping cough is prevalent in our communities and our patients are at risk. They need to do nasal swabbing if suspected as this is the true test to confirm. My child had every sign and symptom, he was textbook. Yet all three doctors missed it.. His course could have been shortened if only they knew the signs.

It is been a difficult few weeks, a letter went out to the parents of the school, (of course omitting his name). I had to talk with my teen about who he could have infected with close contact (including kissing), and that they needed to be told. I promised that I would talk to the parents. So far no one else has shown signs, although believe me, I listen to every cough now and know the symptoms.

It's been a long 7 weeks, but we're finally seeing improvement. My son is still coughing a lot, but he's no longer vomiting, he's eating, has returned to school and is returning to football this weekend.

Carolyn M. is a Home Health Community Nurse, member of Nurses Who Vaccinate and mom.

Thursday, October 6, 2016

In this modern world, being immunized is, at its heart, a social issue.

I never know what to say.

I’ve been a nurse for over two decades, I’ve given hundreds of vaccines and never seen a serious side effect or evidence of the development of a chronic disease related to vaccines. I’ve spent years studying the vaccine debate, written a website on the subject, spoken at national conferences, and yet, I am still stumped by the simplest statement made by parents: “I’m not anti-vaccine.”

You’ve just refused a vaccine for your child and then made that statement.

 For the life of me, I don’t know how to respond. You see, I don’t want to have an argument with you, I just want your child to be healthy and safe. I really do. I truly believe you want the very best for your child. I do too.

I don’t think I’m right about everything, but I do know a thing or two about the safety of vaccines and the risks of disease.
I don’t make a penny more or a penny less if you choose to immunize or not.
I understand your fears.
I have children of my own.
I don’t think your decision to not vaccinate your child implies you would intentionally disregard the welfare of those in our community who can’t be vaccinated, or who need protection against preventable diseases.

But actually, it does.

I do think you are an intelligent person who just might have been swayed by misinformation or by well-intentioned peers. I don’t think you are the first; I have been too. But in the end, you are against the receiving of vaccines for your child who is both precious and vulnerable. You’ve refused an amazing medical gift. And, it’s hard for me to understand that.

Would you refuse chemo if your child had cancer?
An antibiotic for a life-threatening infection?
The same science and quest for better health is behind vaccines. So what am I to think?

You might not be “anti-vaccine” but from my perspective you’re not exactly pro-community.
You might not know those in your community who are physically fragile.

Because of my job, I do, and that changes the way I view your decision.

Through immunization it’s possible that you might see the complete eradication of polio in your lifetime. Maybe even measles. Surely, in your child’s. But it takes a universal and monumental effort to keep children from being crippled and disabled.

It’s ok to be fearful.
Just fear the right thing.

You want to make a difference in your community? Vaccinate.
Smallpox didn’t go away by itself and neither will hepatitis B, polio, and Hib.
You want to have some small impact on the life of a child in a developing country? Vaccinate.

It’s a lifetime of giving. In this modern world, being immunized is, at its heart, a social issue.

Eula Biss writes in On Immunity, “Immunity is a shared space… a garden we tend together.”
I like to think we do the same for our community.

Rebekah Sherman RN, BSN, MPH
Author of

Rebekah Sherman BSN, MPH is the primary author of; a website for vaccine hesitant parents. Her real job is working as a clinical RN/RN Educator at La Clinica de Valle where she provides immunization counseling for vaccine hesitant/refusing parents. She lives in Ashland, OR with her family.