Peter N. Wenger, MD Saint Peter s University Hospital New Brunswick, NJ

Transcription

1 Peter N. Wenger, MD Saint Peter s University Hospital New Brunswick, NJ 1

2 Pneumococcus 40,000 50,000 deaths annually in the US ~1 million deaths in children worldwide Polio 15,000 23,000 cases of paralytic polio annually in the US Candy Land (1948) Haemophilus influenzae type b Leading cause of bacterial meningitis in children <5 years Diphtheria Early 1990 s ~ cases with 5000 fatalities in the former Soviet Union Abraham Lincoln s 7 year-old son (1850) Grover Cleveland s daughter (1904) Varicella One child and one adult dies every week in US Influenza 1918 Pandemic was responsible for more mortality than ongoing World War 40 to 100 million fatalities Smallpox ½ billion deaths in the 20 th Century

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6 World-wide distribution In developed world in prevaccine era >90% of people acquired measles by 15 years of age Globally in 2000 ~31 to 39.9 million infections Estimated 733,000 to 777,000 deaths 5 th most common cause of death in children <5 years of age

7 Measles vaccine introduced in 1963 United States Incidence of measles has decreased 99% Attack rates : 313 cases/100,000 population : 1.3 cases/100,000 population Early 1980s state laws requiring proof of measles immunity for school entry <1case/1 million population by 1990s Declared eliminated in the US in 2000 Interruption of year-round endemic transmission Between 2000 and 2007 an average of 63 annual cases were reported

8 Final total: 668 cases in 2014

9 The first 5 months of 2015 (as of May 29, 2015) 173 cases in 21 states 117 (70%) associated with Disneyland outbreak Reported measles cases through April 2, 2015 Unvaccinated 45% Of these 43% were not vaccinated due to philosophic or religious exemptions 40% were ineligible due to age or medical contraindications Unknown vaccination status 38% Clemmons NS, et al. Measles-United States, January 4-April 2, MMWR 2015;64:

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11 Vaccine hesitancy refers to delay in the acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and content specific, varying across time, place, and vaccines. It is influenced by factors such as complacency, convenience and confidence. MacDonald NE. VMacDaccine hesitancy: definition, scope and determinants. Vaccine 2015 [Epub ahead of print] 11

12 Interaction of 3 key elements Complacency Perception that the risks of vaccination > benefits Convenience Availability and ease of exemptions Confidence Trust Vaccines Healthcare system Policy makers who determine immunization policies and practices 12

13 Nationally representative cross-sectional survey of parents with children 6 months to 6 years of age in 2010* 13% of parents reported using an alternative vaccination schedule 80% of the above reported >1 change to the recommended schedule 55% delayed vaccines MMR 54% Varicella 44% 53% refused certain vaccines 17% reported refused all vaccines *Dempsey AF. et al. Alternative vaccination schedule preferences among parents of small children. Pediatrics 2011;128:

14 Dempsey AF, et al study Of the parents reporting fidelity to the recommended schedule 28% felt delaying vaccine doses was safer than the recommended schedule 22% disagreed that the best vaccination schedule to follow was the one recommended by vaccination experts 14

15 Children < 9 months of age Recommended Schedule 154,150 (69.3%) Alternative (restrictive, selective and both) 56,607 (25.4%) Unknown 11,871 (5.3%) Nadeau, Journal of Pediatrics 2015;166:151 15

16 Total Percent NJ , Hudson Cty NJ , Hudson Cty NJ , Hudson Cty NJ Division of Communicable Disease Service 16

17 In 2006, there were 1,644 religious exemptions to school immunization requirements in NJ An increase of 454% from 2006 to 2015!! 17

18 Encountered partial vaccine refusal 85% Encountered complete vaccine refusal 54% Flanagan-Klygis. Archives of Pediatric and Adolescent Medicine 2005;159:929 18

19 Vaccines are a victim of their success Today s parents (and most of their physicians) have little to no experience with vaccine-preventable diseases Preventive measure Healthy people (infants, children, adolescents and adults) Vaccination Risks > Vaccination Benefits The rare adverse event looms large The implied non-exisitent adverse event looms even larger 19

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23 Annual Outcomes in Birth Cohort Prevented by Vaccination Caused by Vaccination Ratio Hospitalization 53, :1 Death :1 4.3 million infants followed over 5 years Vaccine-associated intussusception *Desai. Pediatric Infectious Diseases Journal 2013;32:1 (estimates based on the risk of intussusception seen with RV1 in Mexican study) 23

24 Vaccine Protein Vaccine Protein Vaccine Protein Smallpox ~200 Diphtheria 1 Diphtheria 1 Diphtheria 1 Tetanus 1 Tetanus 1 Tetanus 1 WC-Pertussis ~3000 AC-Pertussis 2-5 WC-Pertussis ~3000 Polio 15 Polio 15 Polio 15 Measles 10 Measles 10 Mumps 9 Mumps 9 Total ~3217 Rubella 5 Rubella 5 Hib 2 Total ~3041 Varicella 69 Pneumococcus 8 Hepatitis B 1 Total Adapted from Offit, PA, et al. Addressing parents concerns: Do multiple vaccines overwhelm or Weaken the infant s immune system? Pediatrics :

25 The ease of obtaining exemptions in any given state is directly associated with the percentage of exemptions* In 2010, a new rule in NJ stated authorities can t question parents who declare their objection to a vaccine on religious grounds Non-medical exemptions to NJ immunization requirements for school attendance have dramatically increased since 2010 Omer. NEJM 2012;367(12):

26 Number of States Adjusted Incidence Rate Ratio (95% CI) Type of Exemption Only Religious 32 Reference Personal Belief ( ) Exemption Ease Difficult 19 Reference Medium ( ) Easy ( ) 1 Omer SB, et al. Nonmedical exemptions to school immunization requirements. JAMA 2006:296(14);

27 Exemptors were 22.2 x (95% CI, ) more likely to acquire measles Exemptors were 5.9 x (95% CI, ) more likely to acquire pertussis Frequency of exemptions in a county were associated with the incidence rate of: Measles RR: 1.6 (95% CI, ) Pertussis RR: 1.9 (95% CI, ) Schools with pertussis outbreaks had more exemptors (mean 4.3% of students) than those without outbreaks (mean 1.5% of students, p = 0.001) At least 11% of vaccinated in measles outbreaks acquired infection through contact with an exemptor. Feikin DR, et al. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA 2000;284(24):

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30 Crisis of Trust (or Mistrust) Science Misunderstanding Religion vs Science Fear Healthcare system Uncaring Ulterior motives Influence of Big Pharm Government Erosion of individual rights Individual rights vs the public health 30

31 The liberty secured by the Constitution of the United States does not import an absolute right to be wholly freed from restraint. There are manifold restraints to which every person is necessarily subject for the common good Society based on the rule that each one is a law unto himself would soon be confronted with anarchy and disorder. Justice John Marshall Harlan 31

32 Abrahamic religious texts predate vaccination Old Testament: BCE New Testament: CE Qur an: CE Religious leaders from all organized religions have supported the value of vaccines for the well-being of the community Catholic Church has concluded the use of fetal embryonic cells in several vaccines should not preclude their use Islamic and Jewish scholars have determined that porcine-derived gelatin-containing vaccines are acceptable 32

33 Christian Science Illness is a spiritual, not a physical disorder and therefore should be treated with prayer, not medicine or surgery Precludes all medical interventions, not just vaccination Religious belief is a personal matter and not necessarily tied to an organized religion Although the constitution does not require exemption from mandatory immunization requirements for school attendance on religious grounds, states may allow exemptions 33

34 82% of parents report that their child s healthcare provider is their source of information concerning immunizations* Parents generally follow the doctor s recommendations** *Kennedy, Pediatrics 2011;127:S92 **Freed. Pediatrics 2010;125:654 (N = 1552 parental respondents) 34

35 Physicians willing to spread out vaccines (n = 534 pediatricians and family physicians) Often/always 37% Sometimes 37% Rarely 26% Kempe. Pediatrics 2015;135:DOI /peds

36 Parental vaccine hesitancy is a moving target Incorporates the concerns Total refusniks Use alternative schedule Refuse select vaccines Initial resistors who eventually accept vaccination Refer to a single, multiple, or all vaccines Specific safety concerns may vary from family to family 36

37 A = Complacency B = Convenience C = Confidence A A C B C B Family 1 Family 2 Family 3 Vaccine Hesitancy/Refusal

38 Establish honest and respectful dialogue Acknowledge that vaccine risks do exist, but balance those against the risk of disease Provide other information sources, such as reputable internet sites Maintain ongoing discussions with vaccinehesitant families Lead by example Vaccinate yourself, office staff, and your family Healy CM, et al. how to communicate with vaccine-hesitant parents. Pediatrics 2011;127(Suppl 1):s

39 CDC For Parents: Vaccines for your Children - Children s Hospital of Philadelphia Vaccine Education Center Immunization Action Coalition New Jersey Immunization Network (NJIN) Parents with Kids with Infectious Diseases Vaccinate Your Baby Voices for Vaccines 39

40 American College of Pediatricians National Vaccine Information Center The Alliance for Informed Choice in Vaccination Pennsylvania Parents for Vaccine Awareness Concerned Parents for Vaccine Safety Citizens for Healthcare Freedom Vaccine Information Resource Center Coalition for Informed Choice People Advocating Vaccine Education Future Generations Vaccination Alternatives Natural Immunity Information Network Ohio Parents for Vaccine Safety Healthy Alternatives The Canary Party 40

41 Evolution of Immunization Program and Prominence of Vaccine Safety 1 Prevaccine Increasing Coverage Loss of Confidence Resumption of Confidence Eradication Disease Vaccinations Stopped Incidence Vaccine Coverage Outbreak Adverse Events Eradication Maturity

42 In 1736 I lost one of my Sons, a fine Boy of 4 Years old, by the Smallpox taken in the common way. I long regretted bitterly and still regret that I had not given it to him by Inoculation. This I mention for the Sake of Parents who omit that Operation on the Supposition that they should never forgive themselves if a Child died under it; my Example showing that the Regret may be the same either way, and that therefore the safer should be chosen. Benjamin Franklin Autobiography [Part III, p. 83]