Peter N. Wenger, MD Saint Peters University Hospital New Brunswick, - - PowerPoint PPT Presentation

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

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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 ~200.000 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 20th Century

http://www.vaccines.com/why-vaccinate.cfm

 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

 5th most common cause of death in children <5 years of

age

 Measles vaccine introduced in 1963

 United States

 Incidence of measles has decreased 99%

 Attack rates  1956 – 1960: 313 cases/100,000 population  1982 – 1988: 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

Final total: 668 cases in 2014

 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, 2015. MMWR 2015;64:373-6.

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MacDonald NE. VMacDaccine hesitancy: definition, scope and determinants. Vaccine 2015 [Epub ahead of print]

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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.

 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

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 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

Tuesday, February 16, 2016 *Dempsey AF. et al. Alternative vaccination schedule preferences among parents of

small children. Pediatrics 2011;128:848-56.

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 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

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 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

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NJ Division of Communicable Disease Service

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Total Percent NJ 2012-13 8,076 1.5 Hudson Cty 2012-13 242 0.6 NJ 2013-14 8,977 1.7 Hudson Cty 2013-14 310 0.7 NJ 2014-15 9,115 1.7 Hudson Cty 2014-15 310 0.8

 In 2006, there were 1,644 religious exemptions

to school immunization requirements in NJ

 An increase of 454% from 2006 to 2015!!

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

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 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

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http://www.vaccines.com/why-vaccinate.cfm

*Desai. Pediatric Infectious Diseases Journal 2013;32:1 (estimates based on the risk of intussusception seen with RV1 in Mexican study)

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Annual Outcomes in Birth Cohort† Prevented by Vaccination Caused by Vaccination¶ Ratio Hospitalization 53,444 45 1093:1 Death 14 0.2 71:1

†4.3 million infants followed over 5 years ¶Vaccine-associated intussusception

1960 1980 2000 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 123-126 Adapted from Offit, PA, et al. Addressing parents’ concerns: Do multiple vaccines overwhelm or Weaken the infant’s immune system? Pediatrics. 2002. 109:124-129

 The ease of obtaining exemptions in any given

state is directly associated with the percentage

• f exemptions*

 In 2010, a new rule in NJ stated authorities

can’t question parents who declare their

• bjection 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):1170-1

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Omer SB, et al. Nonmedical exemptions to school immunization requirements. JAMA 2006:296(14);1757-63

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Number of States Adjusted Incidence Rate Ratio (95% CI) Type of Exemption

Only Religious 32 Reference Personal Belief 17 1.48 (1.03 – 2.13)

Exemption Ease

Difficult 19 Reference Medium 14 1.35 (0.96 – 1.91) Easy 15 1.53 (1.10 – 2.14)

 Exemptors were 22.2 x (95% CI, 15.9 – 31.1) more likely

to acquire measles

 Exemptors were 5.9 x (95% CI, 4.2 – 8.2) more likely to

acquire pertussis

 Frequency of exemptions in a county were associated

with the incidence rate of:

 Measles RR: 1.6 (95% CI, 1.0 – 2.4)  Pertussis RR: 1.9 (95% CI, 1.7 – 2.1)  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):3145-3150.

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 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

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Justice John Marshall Harlan

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“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.”

 Abrahamic religious texts predate vaccination

 Old Testament: 1400 – 400 BCE  New Testament: 117 – 138 CE  Qur’an: 610 – 632 CE

 Religious leaders from all organized religions have

supported the value of vaccines for the well-being

• f 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

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 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

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 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)

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 Physicians willing to spread out vaccines (n =

534 pediatricians and family physicians)

 Often/always – 37%  Sometimes – 37%  Rarely – 26%

• Kempe. Pediatrics 2015;135:DOI 10.1542/peds.2014-3474

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 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

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A B C A = Complacency B = Convenience C = Confidence A C B Family 1 Family 2 Family 3

Vaccine Hesitancy/Refusal

 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 vaccine-

hesitant 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):s127-33.

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 CDC For Parents: Vaccines for your Children -

http://www.cdc.gov/vaccines/parents

 Children’s Hospital of Philadelphia Vaccine Education

Center – http://www.vaccine.chop.edu/parents

 Immunization Action Coalition –

http://www.vaccineinformation.org

 New Jersey Immunization Network (NJIN) –

http://www.immunizenj.org

 Parents with Kids with Infectious Diseases –

http://www.pkids.org

 Vaccinate Your Baby –

http://www.vaccinateyourbaby.com

 Voices for Vaccines –

http://www.voicesforvaccines.org

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

American College of Pediatricians



National Vaccine Information Center

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The Alliance for Informed Choice in Vaccination

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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

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Evolution of Immunization Program and Prominence of Vaccine Safety

Maturity Incidence Disease Vaccine Coverage Adverse Events

Prevaccine Increasing Coverage

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Loss of Confidence

Outbreak

Vaccinations Stopped Eradication

Eradication 2 3 4

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Resumption of Confidence

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]