Talking with parents about immunisation- developing trust and - - PowerPoint PPT Presentation

Talking with parents about immunisation- developing trust and providing information Redbridge 29-09-2011

David Elliman (Whittington Health) with acknowledgements to Helen Bedford

Immunisation process

• Research shows:-

– Most parents satisfied, even if consented to immunisation – However, a small but significant minority have criticisms

Lack of information

Parents’ questions and concerns are predictable

• Are vaccines safe?
• Why does my baby need all these vaccines when you don’t hear

about the diseases anymore?

• Why do we need to immunise babies at such a young age?
• I am breastfeeding won’t that protect my baby against these

infections?

• Don’t all these vaccines overload the immune system?
• Won’t the other things in vaccines harm my baby?
• I use homeopathy and do not want my baby to have conventional

vaccines

• I am worried that MMR causes autism
• Professionals need to be well informed about specific issues
• Many resources available-have them to hand and use them

Are vaccines safe?

• Generic answer

– What do you mean by safe? - Nothing effective is without side effects. – Extensive trials before licensing – Batch testing before release – Postmarketing surveillance – yellow card, etc. – Specific studies

• Specific issues

– Particular response

Why does my baby need all these vaccines when you don’t hear about the diseases anymore?

Why does my baby need all these vaccines when you don’t hear about the diseases anymore?

• Incidence of diseases reduced BECAUSE
• f vaccines
• When vaccine uptake falls diseases re-

emerge

• Travel to and from countries where many

diseases endemic

Diphtheria

• May 2008 – first death for over a decade

from C.diphtheriae

• Unimmunised school age child
• Moved to the UK from Europe in late 2007
• No carriers found
• One family member had travelled to Africa

earlier that year, returning to UK one month before the child became unwell

• Last previous death in UK from C .diphtheriae

was in 1994 – an unimmunised school child from the Indian subcontinent

Diphtheria

• December 2009
• Teenager presented with a severe sore, pustular

tonsils and abdominal pain in the right upper quadrant.

• Admitted to hospital and treated with IV

antibiotics

• Diagnosed as glandular fever
• Toxigenic strain of C. diphtheriae identified,

– born in the United Kingdom with no recent history of travel or known contact with a case of diphtheria or a carrier – partially vaccinated (no PSB, but booster Jan 2009)

Polio

• Eliminated from Western

hemisphere

• 1349 cases worldwide in 2010

(1659 in 2008)

• Remains endemic in four

countries:

• Nigeria (21) India (42) Pakistan

(144) Afghanistan (25)

• Total this year (to 6th July 2011)

401 – was 663 at this point last year

http://www.polioeradication.org/casecount.asp

1597 cases 2009

Polio in Tajikistan - 1st importation since Europe certified polio-free (2002)

• In 2010, there was an outbreak of disease in Tajikstan,

with a total of 458 cases of paralytic polio reported.

• The virus was most closely related to virus from Uttar

Pradesh, India

• Subsequently, the Russian Federation reported 14

cases, Turkmenistan reported three and Kazakhstan one

• case. The infection was most likely imported from India.
• As at the beginning of 2011, the outbreak seemed to

have been terminated.

• This emphasises the importance of continuing

immunisation until the disease has been eradicated.

I think 8 weeks is too early to start giving my baby vaccines. I would prefer to wait until he is 6 months old, after all he was premature. In any case he is breastfed so he will be protected by that.

Age of immunisation

• vaccines used to be given-3,5 & 9 months
• 1990-changed to 2,3,4 months
• early protection is important
• whooping cough kills v young babies

Pertussis notifications and deaths with a mention

• f pertussis in age group >1 year: 1994-2010

(HPA)

Pertussis notifications and deaths with a mention of pertussis in infants: 1994-2010 (HPA)

Age of immunisation

• vaccines used to be given-3,5 & 9 months
• 1990-changed to 2,3,4 months
• early protection is important
• whooping cough kills v young babies
• peak age for Hib (6-12 months)

Age of immunisation

• vaccines used to be given-3,5 & 9 months
• 1990-changed to 2,3,4 months
• early protection is important
• whooping cough kills v young babies
• peak age for Hib (6-12 months)
• fewer reactions when vaccines given at younger age

particularly with whole cell pertussis vaccine, less so with acellular (Ramsay et al. BMJ 1992; Miller et

• al. Vaccine 1997)

Prematurity - Efficacy

• Very premature infants may have a

reduced response to some vaccines and need serology to check response at neonatologist’s discretion

• Less of a problem now we have boosters
• f conjugate vaccines at 12 months

Prematurity – Adverse Effects

• Mostly not a problem, in fact fewer adverse

reactions

BUT

• Infants born very prematurely (born ≤ 28 weeks of

gestation) and with a history of respiratory immaturity are at greater risk of apnoea after primary immunisations

• If still in hospital at time of first immunisation should

have cardiorepsiratory monitoring for 48-72 hours.

• If have cardiorespiratory problems with first set of

immunisations, should be readmitted and monitored for second set.

Breastfeeding

• breast milk reduces risk of GI, respiratory

and middle ear infections

• some protection against Hib,

meningococcal and pneumococcal disease

• ? Better response to Hib vaccine in

breastfed babies

• therwise little if any protection against

vaccine preventable infections

• breastmilk not an alternative to

immunisation

9 Feb 2006

I am worried that giving my baby all these vaccines at the same time will

• verload my child’s immune system.

I would prefer her to have them separately.

Vaccines and “immune overload”

• immune system constantly challenged
• cells of immune system constantly being replenished

Number of bacteria in human body

Part of body Number of bacteria Scalp 1,000,000/cm2 Surface of skin 1000/cm2 Saliva 100,000,000/g Nasal mucus 10,000,000/g Faeces Over 100,000,000/g

The Human Immune System: Barriers to infection (non-specific immunity) http://www.schoolscience.co.uk/content/4/biology/abpi/immune/immune3.html

Vaccines and “immune overload”

• immune system constantly challenged
• cells of immune system constantly being replenished
• no increase in serious bacterial or viral infections following

MMR vaccine (Miller et al. Arch Dis Child 2002; ).

• no increase in hospitalisation for infections following other

vaccines (Hviid et al. 2005 JAMA)

• fewer minor infections following vaccination (Otto et al

2000 J.Infect)

• no evidence to support link with atopy or autoimmune

diseases

Vaccines and “immune overload”

• babies given vaccines against 10 diseases in first 13

months:

diphtheria/tetanus/pertussis/polio/Hib/PCV/menC/measles/mumps/rubella

• 25 separate injections
• ? interval between doses
• child older when fully protected
• distressing for baby and parent/carer
• more local reactions
• additives in all vaccines-fewer if given in combination

Number of different immunogenic proteins and polysaccharides in vaccines (from Offit 2002)

1960

• Smallpox

~200

• Diphtheria 1
• Tetanus 1
• Pertussis (WC) ~3000
• Polio

15 Total vaccines 5 Total antigens ~3217

1980

• Diphtheria 1
• Tetanus

1

• Pertussis (WC) ~3000
• Polio

15

• Measles

10 Total vaccines 5 Total antigens ~3027

Number of different immunogenic proteins and polysaccharides in vaccines ( fromOffit 2002)

2004 2011

Diphtheria 1 Diphtheria 1 Tetanus 1 Tetanus 1 Pertussis (ac) 5 Pertussis (ac) 5 Polio 15 Polio 15 Hib 1 Hib 2 Meningococcal C 2 Men C 2 Measles 10 PCV 13 Mumps 9 MMR 24 Rubella 5 Total vaccines 9 Total vaccines 10 Total antigens 49 Total antigens 63

The Sun, August 10, 2004. Page 3

NEWS IN BRIEFS

Katie understands parents concerns over the new five-in-one jab. She said: “Tony Blair has done the right thing by publicly reassuring mums and dads. The experts seem to agree that the five-in-one is a positive step so I think most parents will put their faith in the government.”

Won’t the other things in vaccines harm my baby?

Mercury in vaccines (Thiomersal)

• Thiomersal is 50% wfw mercury
• Small quantity in some vaccines in the past
• Studies in UK and US have shown no

evidence of harm.

• It is wise not to add anything to vaccines that

is not needed (precautionary principle)

• Therefore thiomersal should be phased out of

vaccines, where they are equally safe and effective as thiomersal containing vaccines.

Egg in vaccines – MMR(1)

• Small quantity of egg protein in measles and mumps

components-

• in past (1992) egg allergy was a contraindication to MMR
• advice changed in 1996
• Evidence from numerous studies that it is not a problem

so advice is:

“Children with egg allergy should have MMR vaccine” Green Book 2006

• Anaphylactic reactions to MMR vaccine not associated

with hypersensitivity to egg antigens but to other components of vaccine e.g. gelatin

Egg in vaccines – MMR (2)

• All egg allergic children, even those who

have had an anaphylactic reaction to egg, can be immunised safely in primary care.

• Where parents are concerned (usually

because professionals have raised concerns) immunisation can be undertaken in a secondary care setting.

Egg in vaccines – Yellow Fever

• Egg allergic individuals who require yellow

fever vaccine should be referred for specialist assessment in a clinic well in advance of the date of travel.

Egg in vaccines – seasonal ‘flu(1)

• The higher risk group should be

immunised in a secondary care setting and includes individuals with

• Anaphylaxis or respiratory involvement

during previous reactions to egg

• Moderate to severe asthma (on BTS

SIGN treatment step 3 or above – long acting beta agonists such as salmeterol or formometerol in addition to other asthma inhalers)

Egg in vaccines– seasonal ‘flu(2)

• Other egg allergic children should be

considered in the lower risk group. They can be safely immunised with a very low egg containing vaccine in primary care.

Miscellaneous items in vaccines

• Gelatine
• Albumen
• Other animal products

Major religions say not a problem

• Products with their origins in terminations

Major religions say not a problem if no alternative

We use homeopathy and I do not want my child to have the conventional vaccines.

We use homeopathy and I do not want my child to have the conventional vaccines.

• No evidence that homeopathic prophylactics prevent the

diseases against which we immunise.

• The Faculty of Homeopathy-represents medical and

allied healthcare professionals and vets who integrate homeopathy into their practice,

– immunisation should be carried out in the normal way using the conventional and approved vaccines unless there is a genuine medical contraindication.

• The Society of Homeopaths- represents professional

homeopaths

– “acknowledges that the evidence to support the use of homeopathic prophylactics is largely anecdotal and therefore the use of this method is currently speculative”. The Society advises patients to discuss immunisation with their GP and homeopath.

Talking with parents about immunisation

• Parents should be given all the facts and

information they require to make an informed decision

• This includes:

– the risks of the disease – the benefits and risks of vaccinating – the risks of not vaccinating



equipped to make decisions in best interests of

the child

Immunisation process

parents’ views of health professionals

Value advice from health professionals Appreciate time and one to one advice Want more information

• up-to-date experts
• translate science

Talking with parents about immunisation–developing trust

• Professionals need to:
• be very well informed
• be confident, consistent
• assess pre-existing knowledge “What have you

read?”

• explore any specific concerns
• answer parents’ questions and allay fears
• give parents time
• know when and where to refer for further

information

Talking with parents about immunisation-developing trust

• Helpful strategies to maintain a positive relationship

– take concerns seriously and be empathetic – Respectful of concerns – Consistent in information given – Be open and honest – make sure parents understand you are concerned, as they are, for their child’s health and wellbeing – can be valuable to share your own immunisation decisions with parents

• Unhelpful strategies

– strong persuasion – argument – calling into question parents’ concern for their children

RECOMMEND IMMUNISATION

A comparative view of the Natural Small- pox, Inoculated Small-Pox, and Vaccination and their effects on Individuals and Society. Philadelphia 1803

A comparative view of the Natural Small-pox, Inoculated Small-Pox, and Vaccination and their effects on Individuals and Society. (Philadelphia 1803)

Natural Small-pox Inoculated Small-Pox Vaccination One in three dangerous, ONE IN SIX DIES One in forty has a dangerous disease, ONE IN THREE HUNDRED DIES. – And in London one in 100 NEVER FATAL It is attempting to cross a rapid stream by swimming, when one in six perish. It is passing the river in a boat subject to accidents. Where one in 200 persish, and one in 40 suffer partially. It is passing over a safe bridge

Sources of information about Immunisation

• Offer written information as

appropriate e.g.

• Factsheets, leaflets and posters

www.immunisation.nhs.uk

• Journal articles
• Vital Signs, Vital issues

Meningitis Research Foundation www.meningitis.org

The Internet

“Thanks to the Internet it is now possible to be extremely well informed and completely wrong at the same time”

The power of the Internet

• Scullard et al 2010. Looked for advice via

Google for 5 common paediatric problems-35%

• f websites searched gave incorrect information

re MMR and autism.

• Betsch et al 2010. Viewing vaccine critical

material for 5-10 minutes significantly increased perception of vaccine risk and reduced perception of risk of not having vaccine

Immunisation Information for the public

http://www.nhs.uk/planners/vaccinations/pages/landing.aspx

GOSH immunisation website http://www.gosh.nhs.uk/immunisation/

Immunisation information for health professionals

• Department of Health

– Immunisation against Infectious diseases (The Green Book)

• available online @

http://www.dh.gov.uk/en/Publichealth/Immunisation/ Greenbook/index.htm

http://www.dh.gov.uk/en/Publichealth /Immunisation/index.htm

The Immunisation Team newsletter To get Vaccine Update emailed direct to you, email vaccine.supply@dh.gsi.gov.uk

Sources of information about immunisation

• Health Protection Agency

http://www.hpa.org.uk/

• Assess your knowledge of

UK immunisation policy and practice-online assessment @ http://www.hpa.org.uk/infections/topics_az/vacci nation/training_menu.htm

• Useful publications about immunisation

I don’t want to risk MMR vaccine because I am worried that it causes autism and I want my son to have the vaccines separately. He doesn’t need rubella as he’s a boy and its

• nly dangerous for pregnant women/mumps
• nly dangerous for boys.

Measles

• Caused by a virus-spread by

droplets

• Early signs and symptoms-fever,

cough & cold, conjunctivitis

• Koplik’s spots
• Rash (4th day)
• Complications-1 in 15 cases:

convulsions, otitis media, pneumonia, encephalitis, SSPE, death

Annual measles notifications & vaccine coverage England and Wales 1950-2008

0.000 200.000 400.000 600.000 800.000 1950 1960 1970 1980 1990 2000

Year Notifications ('000s)

20 40 60 80 100

Vaccine coverage (%) MMR vaccine Measles vaccine MR campaign

Sources: The Information Centre and Health Protection Agency

Mumps

• Caused by a virus-spread by droplets
• Early signs and symptoms-flu like
• Parotid swelling-unilateral/bilateral

abdominal pain, headache

• 1/3rd cases sub clinical
• Complications: higher rate in over 15

year olds

• Meningitis, encephalitis, epididymo-
• rchitis adults, sensorineural hearing

loss, oophoritis, pancreatitis, mastitis

• 5 deaths per year pre-vaccine era

Mumps incidence in England and Wales

1960-2000

200 400 600 800 1000 1200 1960 1970 1980 1990 2000

Year

Laboratory reports a GP consultation rat

GP consultations Lab reports

MMR introduced MR campaign

NCRSP / ICH / Oct 2000

Confirmed cases of Mumps England & Wales 1995-2009

5000 10000 15000 20000 25000 30000 35000 40000 45000 50000

95 97 99 2001 2003 2005 2007 2009

year number

Confirmed cases

HPA 2010

Number of laboratory confirmed mumps cases in England and Wales by year of birth and quarter

Source: Health Protection Agency 2010

Year of Birth

Rubella

• Caused by a virus-spread by droplets
• Often asymptomatic-swollen lymph

glands, low fever, malaise, rash

• Complications-arthralgia,

arthritis, encephalitis, ITP,

Image: CDC

Congenital Rubella Syndrome

• Infection in first 10 weeks of pregnancy 90%

probability of damage

CLASSIC TRIAD – Sensorineural deafness – Heart abnormalities – Eye abnormalities-cataracts, retinal problems OTHER SIGNS – Growth retardation – Microcephaly – Learning problems LATE APPEARING PROBLEMS – Diabetes mellitus – Thyroid dysfunction – Evolving hearing loss and eye conditions – Possibly psychiatric and behavioural disorders

Congenital rubella births (NCRSP) 1971-2010 and rubella associated terminations* (ONS) 1971-2000

10 20 30 40 50 60 70 80 71 73 75 77 79 81 83 85 87 89 91 93 95 97 99 '01 '03 '05 '07 '09 200 400 600 800 1000

CR births (England, Scotland, Wales) Rubella-associated terminations (England & Wales) MMR

*Terminations data not published since 2000 because of very low numbers CR births (n) Terminations (n)

MMR vaccine

• Live attenuated

vaccine-introduced to UK in 1988

• 1st dose 12-13 months
• 2nd dose before school

entry (or shorter interval)

• Protection from one

dose of MMR

• Measles-90%
• Mumps 85%
• Rubella-98%

Adverse effects of MMR vaccine

• soreness, redness, swelling common

(soon after)

• mild measles with rash (7-10 days) 1 in 10
• fever (7-10 days)

1 in 15

• mild mumps (3 weeks)

1 in 50

Complications of 1st dose of MMR vaccine cf. Measles disease 1* 200 – 1,000 Encephalitis 1-10 Anaphylaxis 35 330 ITP 330 2-5,000 Convulsions

Due to first dose

• f vaccine

(per 1 million doses)

Due to disease

(per 1 million cases)

* Same as background rate, but recent evidence suggests a causal association

12 consecutive children

• 10 suspected autism/ autistic

spectrum

• ? bowel symptoms
• 12 abnormalities of bowel

structure 8 onset of symptoms associated with MMR:

• Behaviour-24 hours to 2

weeks

• Bowels-2 weeks to 12

months

“ We did not prove an association between measles, mumps and rubella vaccine and the syndrome described.”

Wakefield AJ et al..Lancet 1998;351:637-641

Uptake of MMR by 24 months of age 1995-2009

72 76 80 84 88 92 96 100

Q1 1996 Q1 1997 Q1 1998 Q1 1999 Q1 2000 Q1 2001 Q1 2002 Q1 2003 Q1 2004 Q1 2005 Q1 2006 Q1 2007 Q1 2008 Q1 2009

England* Wales Scotland

Measles confirmed cases England and Wales 1996-2010

200 400 600 800 1000 1200 1400 1 9 9 6 1 9 9 8 2 2 2 2 4 2 6 2 8 2 1

2009 & 2010* (provisional data) Source: Health Protection Agency 2011

Daily Telegraph 19-11-07

Measles 2010-11

• Jan-April 2011 334 cases measles reported cf

33 for the same period 2010

• Cases are associated with either recent travel

abroad or small clusters in mainly unvaccinated children and young adults between the ages of 10-24.

• 2010-Outbreaks in France, Italy, Germany,

Ireland, Spain -30,367 cases-21,877 hospital admissions, 21 deaths

Daily Express. Feb 7th 2002

MMR-autism and bowel disease

• 1998-2011 - Significant body of research-at least

13 sound epidemiological studies

• evidence of no link between MMR

vaccine and autism and bowel disease.

Other events

• Andrew Wakefield and two

colleagues referred to General Medical Council

• Concerns over ethics of

research and financial irregularities

• Andrew Wakefield and one

colleague struck off medical register

The Lancet, Early Online Publication, 2 February 2010

Following the judgment of the UK GMC's Fitness to Practise Panel on Jan 28, 2010, it has become clear that several elements of the 1998 paper by Wakefield et al are incorrect, contrary to the findings of an earlier investigation. In particular, the claims in the original paper that children were "consecutively referred" and that investigations were "approved" by the local ethics committee have been proven to be

• false. Therefore we fully retract this

paper from the published record.

British Medical Journal-Jan 2011

• Three part series in which investigative journalist Brian

Deer provides evidence that ‘MMR scare’ was a fraud.

• No single case of the 12 reported in 1998 paper can be

reconciled with the medical records-i.e. facts altered to provide the results wanted.

MMR concerns

• diseases potentially serious
• evidence of no link between MMR and autism or

bowel disease

• MMR very effective and rarely gives rise to

serious side effects

• science can never prove a negative but there is

certainty of severity of the diseases

MMR concerns-single vaccines

• Why did demand for single vaccines begin?
• Statement by Andrew Wakefield at press conference in 1998-no

evidence produced to support suggestion

• Only available on a private basis
• Single vaccines never been given in way he suggested (at yearly

intervals)

• no evidence from either trials or use to show efficacy and safety

– scientific evidence for appropriate interval? – any gap leaves individual child at risk – lower uptake generally allow diseases to circulate – loss of herd immunity – puts susceptible people at risk – rubella transmission-boys can pass on infection – mumps equally serious for girls