My 4-year-old cowered in a corner and let out a shrill scream.
The nurse and I exchanged worried glances. My 1-year-old, unknowing what lay ahead, nevertheless stiffened in my arms.
Measles, mumps, rubella, diphtheria, tetanus, pertussis, hepatitis B, influenza, Haemophilus influenza type b. You name it. We've had it.
I am thankful that my children have protection from many dreadful diseases. But while restraining my daughter for the shot, I couldn't help lamenting at how complex and costly the childhood immunization schedule has become.
And yet today's vaccines represent only a portion of what could be available by the turn of the century, health experts say.
The science and technology of vaccination is advancing so rapidly that the number of diseases covered by childhood vaccines may leap from 10 now to 15 or more by the end of the decade.
But that may not mean more than the current total of six shots.
Advances will include combining many vaccines into one dose called a cocktail or super shot. Experts are also researching delivering the vaccines orally or by skin patch. And efforts to develop one time-released vaccine might prevent the need for booster shots.
Finally, these new vaccines are considered safer than ever.
"We're in the midst of an explosion right now," says Dr. Regina Rabinovich, a vaccine expert at the National Institute of Allergy and Infectious Diseases. "We have new products coming on-line. And manufacturers are thinking of new ways to present these products."
Much of the effort is being powered by the Children's Vaccine Initiative, an international effort to create more and better vaccines.
Founded in 1990, the CVI's goals are two-pronged: to increase the number of children receiving vaccines and to add to the vaccine arsenal. The intent is to eradicate diseases that cause many deaths worldwide as well as diseases that cause great expense and inconvenience.
"We need new vaccines and we have the technology to develop them," Rabinovich says.
But the discussions on the future of immunization don't center just on science. Health officials admit that technological advances won't matter unless people have access to vaccines and can afford them.
Even now in the United States, half of all preschool-age children don't get all the recommended vaccines. This failure is blamed on the need for multiple trips to the doctor's office and high costs, which are rarely covered by insurance, says Dr. Philip K. Russell of the Johns Hopkins University School of Hygiene and Public Health.
"The vaccines currently available, while effective, are a major hindrance to efficient vaccination programs," he says.
Vaccine manufacturers agree.
"There are going to have to be changes in the way we deliver immunizations," says Ronald J. Saldarini, president of Lederle-Praxis Biologicals. "We should be immunizing every kid and not missing any."
Thirty years ago when the measles vaccine was introduced, cases plummeted from 400,000 to 700,000 a year to about 3,000 a year by 1988.
After the poliomyelitis vaccine was introduced in 1955, cases fell from 21,000 annually to seven in 1974--considered the benchmark year because cases fell to less than 10. No cases of wild polio were reported in the United States last year. ("Wild polio" is caused by the virus itself, as opposed to polio caused by the vaccination--which occurs in rare instances.)
The Haemophilus influenza type b (Hib) vaccine that became available in 1987 for children ages 2 to 5 has led to a sixfold drop in cases in three years, according to the Centers for Disease Control and Prevention. A Hib vaccine for infants, approved in 1990, has led to a 94% reduction in bacterial meningitis, which can lead to mental retardation.
"You never heard about it, but Hib caused 18,000 cases of bacterial meningitis each year and about 1,000 infants died each year," Saldarini says.
Within reach are similar declines in other serious diseases, experts say.
The 1992 recommendation for universal immunization of all infants with the hepatitis B vaccine should dramatically curtail the 300,000 new cases seen each year in the United States. The disease can cause liver failure in adults.
The distribution of hepatitis B vaccines to infants and children is a new tactic in combatting disease in adults by immunizing children. Hepatitis B is primarily a sexually transmitted disease contracted in adolescence or early adulthood. But public health officials are not certain if the tactic will be supported by physicians. Early surveys indicate that many pediatricians are not recommending the vaccine for infants.
"The rationale of immunizing children to prevent disease as adults has been set," Rabinovich says. "It's going to be a matter of how palatable this is."