Immunizations: Recommendations, Controversies, and Public Perception MARK H. SAWYER, MD RADY CHILDREN S HOSPITAL

Transcription

1 Immunizations: Recommendations, Controversies, and Public Perception MARK H. SAWYER, MD UCSD SCHOOL OF MEDICINE RADY CHILDREN S HOSPITAL

2 Vaccination is the top Public Health achievement of the 20th Century MMWR 1999; 48:241

3 Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial products or services discussed in this presentation My kids are fully immunized

4 Objectives Tell your colleagues what new immunization recommendations have been made in 2017 Explain what the impact of vaccines has been on health and how herd immunity/community protection works so that you can discuss the importance of parents and patients who decide not to immunize Explain how thoroughly researched and reviewed vaccine recommendations are so that you can convince parents and patients that vaccine recommendations are carefully developed with risks and benefits in mind List the common concerns about vaccine safety List some of the factors that have led to vaccine hesitancy Describe some talking points to address the concerns of those with vaccine hesitancy

5 One minute on what is new with vaccines in 2017 Two important new influenza products licensed Flulaval now licensed down to 6 months of age. Importantly this product is given as a 0.5ml dose rather than the 0.25ml dose for Fluzone in infants 6-35 months of age Fluad-adjuvented influenza vaccine for adults 65 years and older LAIV (nasal influenza vaccine) not recommended for any age this year New emphasis on giving the birth dose of hepatitis B within 24 hours of birth New zoster vaccine coming very soon 5

6 Influenza vaccine products Lots of products available Different types of vaccine Different presentations Different ages

7 CDC, Epidemiology and Prevention of Vaccine-Preventable Diseases, 9th ed., 2006

8 Vaccines even help those not immunized Pilishvili, CDC, ACIP meeting October

9 Impact of childhood vaccines ,000 Deaths 21,055,000 Hospitalizations 322,089,000 Illnesses MMWR:April 25, 2014 / 63(16);

10 But we for a while we were losing the battle Immunization Coverage Rates, months of age, U.S DTaP MMR Hep B cdc.gov/vaccines

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12 And then there are the other schedules.

13 Community Protection If a high enough percentage of the population is protected, disease does not spread The threshold immunization rate needed to prevent transmission varies based on both the disease and the characteristics of the vaccine The indication that we do not have community protection is outbreaks of disease Recent outbreaks Mumps Measles Pertussis In an outbreak even some of the immunized develop disease because no vaccine is 100% effective

14 Vaccine Policy-the CDC Advisory Committee on Immunization Practices ACIP Then ACIP Now

15 ACIP Function Advisory to CDC and HHS regarding the appropriate selection and use of vaccines and related agents for control of vaccine-preventable diseases in the civilian population. Establish the list of vaccines for administration through the Vaccines for Children Program (VFC)

16 ACIP Structure CDC Leadership from NCIRD Executive Secretary-Dr. Amanda Cohn 15 voting members with broad expertise Infectious Disease Pediatrics Family Practice/Internal Medicine Public Health Nursing Community Supported by hundreds of CDC experts

17 ACIP Structure-Liaison Members AAP AAFP ACP AMA ACOG SAM NMA ACHA AGS AHIP AOA APhA APTR SHEA HICPAC BIO PhRMA IHS DOD DVA HRSA CMS NIH FDA NVPO NACCHO NACI DOH, UK NICCHP, Mexico

18 Considerations for Recommending a New Vaccine Burden and risk of disease in the community Effectiveness of the vaccine Safety of the vaccine Cost-benefit analysis Feasibility/Vaccine Availability Cost/reimbursement for providers Patient/parental preferences

19 Vaccine Policy-review and dissemination Each professional society reviews and occasionally modifies the ACIP recommendations for its members AAP AAFP ACP ACOG State and local health departments review and occasionally customize ACIP recommendations for their jurisdiction Individual providers review and interpret the recommendations for their patient population and individual patients

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21 Vaccines and autism MMR Thimerosal Other vaccine ingredients Vaccines in general Adjuvants?????????? Too many vaccines overwhelm the immune system Diseases no longer exist or aren t that dangerous It is all a giant money-fueled conspiracy Individual rights vs. public health needs

22 How did we get here?

23 Real Vaccine Risks Vaccine Adverse Event Frequency 1976 influenza (swine flu) Guillain-Barre syndrome 9 cases per million doses Oral polio Paralytic poliomyelitis 1 case per 2.4 million doses Whole cell pertussis Acute encephalopathy 0-10 cases per million doses 1 st Rotavirus vaccine (Rotashield) Intussusception 1-2 cases per 10,000 doses Marshall G, personal communication

24 Some challenges in communicating about vaccines Vaccines don t always work Vaccines VERY rarely have serious adverse effects Vaccines make people lose sight of the reasons we give them It is human nature to assume a causal link between two things that are temporally associated Low scientific literacy Emotion trumps science

25 Factors that have increased concern Distrust Industry Government Doctors Uncertainty Rapid increase in the number of vaccines Rapid increase in the number of cases of autism Media/Celebrities

26 Temporal relationships 26

27 Mercury content of recommended vaccines Recommendation to reduce mercury exposure Delay in hepatitis B vaccination of newborns to minimize mercury exposure Once MMR couldn t be targeted as a cause of autism, thimerosal became an attractive target Thimerosal is now out of all vaccines yet autism rates are not going down

28 Know Your Source

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30 What has been the effect? Falsehood flies and the truth comes limping after so that when men come to be undeceived it is too late. The jest is over and the tale has had its effect Jonathan Swift, The Examiner Nov. 9, 1710

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32 Mumps is making a comeback! >6000 cases of mumps in the U.S. in 2016 County of San Diego HHSA, Monthly Communicable Disease Report 2017;1(2):1-4

33 Recent California Immunization Legislation AB Required that parents who wanted to exempt their children from schoolmandated vaccines needed to provide a form from their child s doctor that the parents had been informed about the risks and benefits of childhood vaccines. Allowed for a religious exemption SB Eliminates all but medical exemptions for school-mandated vaccines. No religious exemption, no personal-belief exemption. Went into effect in the fall of 2016.

34 Percentage of Children with PBE PERSONAL BELIEF EXEMPTIONS (PBE) KINDERGARTEN ENTRANCE ASSESSMENT CA SD School Year California kindergartners=562,924 (3,133 students with PBE status among 7,820 schools) San Diego kindergarteners=46,044 (655 students with PBE status among 624 schools) AB 2109 SB277

35 Percentage of Children with PME PERMANENT MEDICAL EXEMPTIONS (PME) KINDERGARTEN ENTRANCE ASSESSMENT CA SD School Year California kindergartners=562,924 (2,850 students with PME status) San Diego kindergarteners=46,044 (404 students with PME status)

36 Herd immunity depends on what herd you are in! 36

37 How can you respond?

38 General Talking Points The diseases are here now and remain dangerous Vaccines are safe/vaccines don t overwhelm the immune system Natural immunity is not better Adverse events do occur following immunization Protection through immunization is both an individual and a community endeavor A choice not to immunize leaves you/your child at risk and also places others at risk Know the source of your information

39 Vaccines Cause Autism Talking Points Genetic factors related to autism-autism is more heritable than breast cancer Symptoms of autism present before many vaccines are given Ongoing studies specifically looking at risk of vaccines: none identified Autism hasn t gone away despite thimerosal being taken out of vaccines Vaccine court has rejected the autism claim

40 Know Your SourceTalking Points Majority of sites found on an Internet search of Vaccines are antivaccine sites NNII site provides tips on how to evaluate the credibility of Web sites How to identify a credible web site Scientific studies cited and are current Lack of financial conflict of interest (selling a book) Experience in field Lack of anecdotes

41 Is natural immunity better? For some infections natural immunity is better because it lasts longer Natural immunity is not complete whooping cough, rotavirus Multiple types of some disease agents Natural immunity comes at a price deafness, brain damage, hospitalization, pneumonia, paralysis, permanent scars

42 Do vaccines overwhelm the Immune System? Your immune system responds to hundreds of things every day No evidence that children get more infections right after they are immunized Clinical trials test multiple vaccines Increased vaccine purity

43 Parents Choice vs. the Greater Good Not vaccinating puts your child at risk Not vaccinating your child also puts others at risk

44 Herd immunity is very important Elimination of H. flu disease Decrease in influenza and pneumococcal disease in elderly because of pediatric immunization Drop in Hepatitis A disease in California You can t hide in the herd

45 California Immunization Coalition materials ments/imm-917_web.pdf

46 Responses to those seeking delayed vaccine schedules Great deal of research, expertise, and effort behind the ACIP/AAP/AAFP schedule To delay vaccines is to put your child at risk Personal accounts of your patients who have suffered from vaccine-preventable disease Herd immunity is only as good as the herd you travel in

47 California Immunization Coalition materials nts/imm-988.pdf

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49 Summary Vaccine safety a major concern among parents Tools available to assist with the necessary communication Keep immunizing!!!

50 Information for Health-Care Professionals NNII ( VEC ( IAC ( CDC/NIP ( AAP ( AAFP ( IVS ( Vaccine Page ( Every Child by Two (