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Home , Pox party, Vaccine hesitancy

Summer 2015 | Volume 14, Number 2

MUMPS meningococus pertussis ENCEPHALITIS PERTUSSIS ROTAVIRUS meningococus MUMPS meningococus MEASLES RUBELLA meningococus CHICKENPOX pneumococus meningococus rotavirus ENCEPHALITIS PNEUMOCOCUS TETANUS DIPHTHERIA TETANUS hepatitismumps encephalitis hepatitis measles pneumococus POLIO DIPHTHERIA FEVER CHICKENPOX tuberculosisRUBELLA tuberculosis diphtheria DIPHTHERIA meningococusMUMPS pneumococus encephalitis ENCEPHALITIS polio TETANUS diphtheria pertussis polio hepatitisRUBELLA meningococus ENCEPHALITIS DIPHTHERIA MEASLES YELLOW RUBELLA TETANUS measles MEASLESpolio meningococus PERTUSSIS MEASLES RUBELLA measles tetanus rubella YELLOW tuberculosisENCEPHALITIS pneumococus CHICKENPOX RUBELLA measles What physicians rubella pertussis PNEUMOCOCUS need to know encephalitis diphtheria MUMPS meningococustetanus pneumococus measles rubella tetanus measles rotavirus tetanus rubellaPOLIOmeningococus hepatitisHEPATITISFEVER PERTUSSIS RUBELLA FEVER hepatitis FEVER HEPATITIS chickenpox poliorubella encephalitisTETANUSpertussis rubella DIPHTHERIA rotavirus tuberculosis FEVERHEPATITIS POLIO yellow DIPHTHERIAYELLOW polio pneumococus YELLOW polio ENCEPHALITIS chickenpoxrubellaRUBELLA rotavirus ENCEPHALITIS pertussis ROTAVIRUS tetanus chickenpox hepatitisFEVER encephalitis ENCEPHALITIS POLIO rotavirus ROTAVIRUS DIPHTHERIA YELLOW pertussis PNEUMOCOCUS PERTUSSIS RUBELLA polio CHICKENPOX ROTAVIRUS pneumococus CHICKENPOXCHICKENPOX hepatitis pertussis chickenpox encephalitis pertussis FEVER TUBERCULOSIS ENCEPHALITIS RUBELLA pneumococusPOLIO YELLOWfever pneumococus RUBELLA POLIO poliofever ROTAVIRUS mumpsMENINGOCOCUS RUBELLA PNEUMOCOCUS RUBELLArubella CHICKENPOX tetanus POLIO FEVERmumps PNEUMOCOCUS chickenpox TUBERCULOSIS FEVER hepatitis tetanus MUMPS mumps ROTAVIRUS mumpsrotavirus TETANUS polio pneumococus MUMPS TETANUS rotavirusTUBERCULOSIS DIPHTHERIA pneumococusRUBELLA MUMPS

POLIO

PERMIT NO. 27 NO. PERMIT

LINCOLN, NE LINCOLN,

PAID

US POSTAGE US 233 South 13th Street

PRSRT STD PRSRT Ste. 1200 Lincoln, NE 68508 Nebraska Medicine is published quarterly by the Medicine Summer 2015 | Volume 14, Number 2 233 South 13th Street, Ste. 1200 Lincoln, NE 68508 Phone (402) 474-4472 An overview and introduction to this issue...... 3 Fax (402) 474-2198 www.nebmed.org My perspective...... 4

Nebraska Medical Association Overview of adolescent immunizations ...... 6 2014-2015 Board of Directors President Adult immunizations in 2015: what works...... 10 Richard Blatny, Sr., MD, Fairbury President-Elect Human papillomavirus (HPV) Harris Frankel, MD, Omaha Secretary-Treasurer and ...... 12 Todd Pankratz, MD, Hastings Immediate Past President and strategies to address it . . . . . 14 Kevin Nohner, MD, Omaha Board Members Parental decisions to not vaccinate: Ron Asher, MD, North Platte is it time to take a stand or understand? . . . . . 16 Jane Bailey, MD, Omaha Bo Dunlay, Jr., MD, Omaha Warning! Undervaccinated health care Deb Esser, MD, Omaha personnel in this facility!...... 18 Jose Friesen, MD, Grand Island Jim Gigantelli, MD, Omaha Shweta Goswami, Omaha Matthew Hrnicek, MD, Lincoln Logan Jones, Omaha Aparna Kailasam, Omaha Jason Kruger, MD, Lincoln Gerald Luckey, MD, David City Michelle Sell, MD, Central City Irsa Shoiab, Omaha Leah Svingen, Omaha Britt Thedinger, MD, Omaha Tod Voss, MD, Pierce Jordan Warchol, MD, Omaha Ex-Officio Board Member KC Williams, Lincoln

The Nebraska Medical Association in no way endorses any opinions or statements in this publication except those accurately reflecting official association actions.

Page 2 Nebraska Medicine | Summer 2015

An overview and introduction to this issue by Linda K. Ohri, Pharm.D., MPH Information System (NESIIS) as this medical director of Children’s Hospi- registry grows more complete. tal, Omaha, and staff from the Doug- e continue to confront many The reports in this issue are intended las County Health Department. The Wsocietal challenges related to to provide updates and commentary coalition began in response to control of vaccine preventable diseases on recommended immunizations in measles outbreaks and low im- (VPDs). U.S. measles outbreaks are childhood (Michelle Petersen, MD), munization rates identified in increasing in number and size (2013: adolescence (Shirley Delair, MD, MPH) Omaha and outstate Nebraska, 11 outbreaks; 187 cases; 2014: 23; 628; and for adults (Rudy Kotula, MD). To as well as across the country. 2015, to 6/26/15: 5; 178).1 Pertussis achieve the goal of “Optimal Immuniza- The goal of this coalition is is considered an endemic illness again, tion across the Lifespan,” prevention “Optimal across occurring across all 50 states, with through vaccination must be accepted as the Lifespan.” The website is 28,639 U.S. cases reported in 2013, and a responsibility of all health providers, located at: www.ImmunizeNebraska. 28,660 in 2014.2 Many more cases go regardless of specialty or patient popula- org. Associate membership is open to unreported. and tion served. Meera Varman, MD, ad- advocates from across Nebraska. I also continue as the eighth leading cause of dresses HPV vaccination, where there has encourage all providers to attend the death in the latest 2013 statistics, both in been slow acceptance by various medical annual Immunize Nebraska conference, deaths across the entire U.S. population providers as well as parents over the nine held in Omaha in early June each year. (56,979) and for Nebraska (343).3 years since first approval, despite its po- This conference provides approximately While overall daycare and school tential to prevent several in both seven hours of immunization-related mandated pediatric immunization genders. A report by Archie Chatterjee, continuing education credit for physi- rates are high, non-mandated child and MD, PhD, discusses factors involved in cians, NPs, PAs, nurses, and pharmacists; adolescent vaccination rates are less than vaccine hesitancy and refusal, and general more information may be found on optimal, and adult immunization rates approaches by providers to address this the website. in the U.S. are generally unsatisfac- problem. Katie O’Keefe, DNP, APRN- Over the years, one focus of ITF tory.4 Early season (November) 2014-15 NP, further discusses strategies on how to advocacy has been on legislation at the influenza immunization rates for the U.S. effectively promote vaccination in com- Nebraska Unicameral regarding immu- were estimated at 40.3% across all ages.5 munication with patients. Finally, Cathy nization issues. I encourage you to stay Furthermore, GPS (Geographic Posi- Carrico, NP, FNP-BC, will address the informed about current activities to: tioning System) population studies have need for and strategies to achieve a health 1) Oppose efforts to add a Philosophical demonstrated location / time clustering provider’s personal acceptance of optimal Immunization Exemption in Nebras- of pertussis or measles cases associated vaccination to protect both themselves ka. Research shows that states with with regions also showing increased rates and their patients. non-medical exemptions in place have of non-medical immunization exemp- Most of the authors for the articles in lower rates of vaccination and higher tions.6,7,8 While no such studies have this issue are members of the Immuniza- rates of VPDs.8 yet been published for Nebraska, we tion Task Force – Metro Omaha (ITF). 2) Add a requirement for meningococ- may look forward to the possibility of This all-volunteer coalition of immu- cal immunization for assessing such population trends through nization advocates was started in 1991, adolescent school entry (Legislative use of the Nebraska State Immunization through the efforts of Dr. Don Glow, (continued on Page 21)

Page 3 Nebraska Medicine | Summer 2015 My vaccine perspective

by Michelle Petersen, MD our long-term unit. Her mom had not the last few decades. Pertussis has a 1% Pediatrician been vaccinated and she had no immu- fatality rate in infants under two months NMA Past President, Lincoln nity as a newborn when her brother got of age with complications of pneumonia his kindergarten . She contracted (22%), (2%), and bradycardia, s a pediatrician, one of the most polio from him as he processed the oral apnea, encephalopathy and others. Re- Aimportant jobs I have is working ; she remained ventilator search found the spike in infant cases was together with parents to assure their chil- dependent and non-mobile when her mirrored in the 15-17 year age group. dren are healthy and protected. Illnesses paralytic polio did not improve. The This information has precipitated use of shift from season to season, but current inactivated polio vaccine avoids a reduced booster dose of the pertussis and the discussion vaccine-associated polio rarely related to portion of pediatric DTaP through Tdap that they bring are daily rou- the live oral polio vaccine. use beyond the initial childhood vaccine tine. When reviewing the vac- We took care of a 3 year old whose schedule. Of note, the Tdap version of cines with families, I have often mom had taken him to a neighborhood this vaccine is recommended for all new explained the diseases by telling “chicken .” Another child in parents, older siblings and caregivers to of my time as a resident and the the neighborhood had chicken pox so reduce the pertussis risk to newborns. diseases that we would see on other children were brought there to be The current immunization schedule a regular basis. I find that past informa- exposed. The child developed a second- is a collaborative effort between the Cen- tion is now more relevant in our current ary bacterial skin infection after getting ters for Disease Control, the American vaccine climate. Meningitis, measles, varicella from the party. After weeks of Academy of Pediatrics and the American varicella, and pertussis are on the verge of ICU care, the child died of overwhelming Academy of Family Practice. Prior to making major inroads into the immuni- sepsis. 1995, the schedule was reviewed on an ties our country has long enjoyed. In past decades, from January to June, as needed basis, and updated every two During my residency in the mid we had 4-6 cases of meningitis monthly. to three years. Since then, these three 1980s, measles was at an all-time low. Haemophilus influenza B and pneumo- groups review current research and data The MMR as a combined vaccine coccus bacteria were the leading causes. from multiple sources on a yearly basis started in 1971 and with widespread Hearing damage, developmental delays, and make changes if needed. This vaccine use, measles was nearly eradicated from seizures, and brain abscesses were con- schedule can be viewed on the CDC the United States. My closest memories stant reminders of the severity of these website at this address: http://www.cdc. of the disease then were when my sister illnesses. Septic joints, epiglottitis and gov/vaccines/schedules/easy-to-read/ and I were sick with measles as children. buccal and periorbital cellulitis from HIB child.html or on page 5 of this issue. Pictures in books are now being replaced were also common. With the present Your patients may be asking about with patients in our offices. The risk for vaccines, these are now rare reportable ill- an “Alternative ” deaths and disabilities from measles is nesses rather than routine. Another ben- that is published online on a yearly basis. rising. efit is that fewer children need a lumbar This is a schedule put together by Robert One child in our care during residen- puncture during illness evaluation. An- Sears, a pediatrician in California. His cy contracted tetanus when her mother other recent finding is that pneumococcal schedule has no research basis and can- pierced her ears at six weeks of age, before in adults have dropped since not verify that immunizations given at her vaccinations. She was purposely the start of the in his recommended intervals will produce paralyzed and ventilated for two months children. In my time as a pediatrician, adequate levels of in children to prevent the toxins from killing her. I have seen the HIB and pneumococcal on a timely basis. Unfortunately, many The resulting developmental and physical vaccines come into routine use and it has families request that their child’s vaccines damages were extensive. changed my practice significantly. be given in this manner. Consequences of There was a young girl with polio in Pertussis has been increasing over (continued on Page 5)

Page 4 Nebraska Medicine | Summer 2015

My vaccine perspective (continued)

this are that the children are not vacci- lies, I find it is important to be patient there may be children that are non-vacci- nated quickly enough to produce protec- but also factual and firm. Some families nated. Pediatricians and family medi- tion when needed. With minor illnesses, don’t understand or don’t have all the cine providers are responding to these often these immunizations are missed, information and once explained, will concerns by asking “vaccine limiters” to causing the schedule to fall behind even vaccinate their children. It seems that seek medical care at another office. Many more. This leaves our youngest patients reviewing the diseases, complications of offices are also requiring that the parents vulnerable to disease and death. those diseases, the longstanding research, sign a form stating that not vaccinating It has been difficult to understand constant new research and personal their child puts them at risk of injury some of the reluctance of parents to experience helps to guide families in their or death from any of the preventable immunize their children. I have heard decisions. Some of these families are set diseases and that they will not hold the many different reasons for parental in their decisions and will not vaccinate physician liable. This is a growing trend refusal, from concern for the number of their children despite the facts. On the and made relevant by the of shots given to safety fears to ethical issues other hand, many families whose chil- vaccine preventable diseases occurring of using aborted fetal tissue in vaccine dren are vaccinated are questioning the across the U.S. The ethical issues on both research. When working with these fami- safety of pediatric waiting rooms where (continued on Page 22)

Page 5 Nebraska Medicine | Summer 2015 Overview of adolescent immunizations

by Shirley Delair, MD, MPH FIGURE 1. Estimated vaccination coverage with selected vaccines and doses among ado- Assistant Professor of Pediatrics lescents aged 13–17 years, by survey year — National Immunization Survey-Teen, United University of Nebraska Medical Center States, 2006–2013 2.

he Advisory Committee on TImmunization Practices (ACIP) publishes yearly immunization recom- mendations to help ensure our adoles- cents receive protection through vaccines they need. These recommendations are endorsed by the American Academy of Pediatrics, the American Acad- emy of Family Physicians, the American College of Obstetri- cians and Gynecologists and the Society for Adolescent Health and Abbreviations: Tdap = tetanus , reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate, one or more doses; HPV = human papillomavirus. Medicine.

Table 1. Vaccines for Adolescents1 body aches and recover within a couple possible3. Vaccinations should continue of weeks. More severe illness can occur throughout the flu season especially if the Routine adolescent vaccines particularly in adolescents with chronic influenza virus continues to circulate3. > diseases such as asthma or diabetes. Ad- As shown in Figure 2 on the next > Meningococcal ditionally, adolescents are an important page, influenza vaccination rates tend > Tetanus, diphtheria, and acellular reservoir for spreading influenza within to decrease as children grow older, with their communities. 76.9% of children 6-23 months receiv- > Human papillomavirus vaccine Two types of influenza vaccines avail- ing the vaccine down to 42.5 % of 13-17 able are the live attenuated influenza vac- year olds, leading to an overall pediatric Catch-up adolescent vaccines if not fully cine (LAIV) and the inactivated influenza rate in 2013-2014 of 58.9% which is still immunized vaccine (IIV)3. In 2013, quadrivalent far from the Healthy People 2020 goal of > vaccine inactivated and live attenuated influenza 70% coverage 4,5. More recently, there has > Polio vaccine vaccines were introduced and provide been an increase in coverage among the > Measles, mumps, and protection against two influenza A 13-17 year old group by 8.8% from flu > strains and two influenza B strains3. The season 2011-12 to 2012-20134. Vaccines for adolescents at higher risk live, is administered Figure 3 shows the pattern by strains intranasally and is available for healthy, of influenza diagnosed more frequently in > Pneumococcal vaccines non-pregnant adolescents who do not this past 2014-2015 season through June > like injections3. Both LAIV and IIV have 27, 2015. been demonstrated to be effective in Meningococcal vaccines Routine adolescent vaccines adolescents3. is a bacterial Seasonal influenza vaccine Adolescents are recommended to get infection caused by Neisseria meningitides Most adolescents who contract the the flu vaccine every year as soon as the that can cause severe illnesses such as flu experience a self-limiting illness with vaccine becomes available, by October, if bacteremia or meningitis. The bacteria fever, cough, headache, sore throat, and (continued on Page 7)

Page 6 Nebraska Medicine | Summer 2015

Overview of adolescent immunizations (continued)

FIGURE 2. Seasonal Flu Vaccination Coverage by Age Group and FIGURE 3. Influenza Positive Tests Reported to CDC by U.S. WHO/ Season, United States, 2009-2014 4. NREVSS Collaborating Laboratories, National Summary, 2015-15 6.

colonize mucosal surfaces of the naso- common cause of meningococcal disease FIGURE 4. Rate of meningococcal disease, by pharynx and transmission occurs through in U.S. adolescents8. The ACIP recom- age group — United States, 2002–2011 7. direct contact with respiratory tract secre- mends this vaccine for those 10 years tions from symptomatic or asymptomatic and older at increased risk of infection carriers. Adolescents have the highest such as people with persistent comple- nasopharyngeal carriage rates and serve ment component deficiencies, or with therefore as an important reservoir for anatomic or functional asplenia8. During transmission. its June 2015 meeting, the ACIP made Meningococcal vaccination with a a category B (individual clinical decision quadrivalent conjugate vaccine that pro- making) recommendation for the use of a tects against four major meningococcal meningococcal B vaccine in patients ages has a higher disease case rate than the serogroups (A, C, W, and Y) is recom- 16-23, administered preferably between general population. The percentage of mended for all adolescents7. A single 16 and 18, for short-term protection adolescents aged 13-17 in the U.S. who dose of vaccine should be administered against the disease9. received at least one dose of meningococ- at age 11 or 12 years, with a booster dose Meningococcal serogroups B, C, and cal vaccine increased from 74% in 2012 at age 16 years for persons who receive Y are the major causes of meningococcal to 77.8% in 201310. There is, however, a the first dose before age 16 years7. If disease in the United States with each ac- significant gap with completing the sec- the first dose is administered at age 13 counting for approximately one third of ond dose of when through 15 years, a booster dose should cases. Though disease activity is currently needed, with only 29.6% of adolescents be administered at age 16 through 18 at historic lows, the case-fatality ratio achieving two doses2. years with a minimum interval of at least remains elevated at 10-14%10. Tetanus, diphtheria, and acellular eight weeks between both doses7. For The rate of meningococcal disease pertussis (Tdap) those who receive a dose after 16 years in adolescents aged 11-19 has decreased Routine adolescent Tdap vaccina- of age, a booster dose is not required7. from 0.27 to 0.05 from 2004-2005 (just tions are important to reduce pertussis Two newer meningococcal vaccines prior to routine vaccination), to 2010- transmission rates, especially to infants recently approved in the U.S. protect 20117. Figure 3 shows that outside of in the household or the community against serogroup B strains, now the most early infancy and the elderly, adolescence (continued on Page 8)

Page 7 Nebraska Medicine | Summer 2015

Overview of adolescent immunizations (continued)

that are particularly susceptible, espe- years of age, receive a three-dose series of A single dose of PCV13 is currently cially those who are too young to have 4-valent or 9-valent vaccine12. Immuniza- also recommended for all children six completed their primary immunization tion is recommended through age 26 for through 18 years old with certain medi- series. Adolescents who develop pertussis all females and high risk males; all males cal conditions, who have not previously usually have mild symptoms that may last may be vaccinated through 26 years12. received PCV13, regardless of whether for weeks, and thus serve as important Table 2 compares the adolescents who they have previously received PCV7 or vectors to transmit the illness. The main completed more than ≥1 HPV vaccine 23-valent pneumococcal polysaccharide objective of the Tdap is not only to re- dose in 2012 and 2013. Though there is vaccine (PPSV23)13. These conditions duce illness in the vaccinated individual, an increase in coverage, the percentage include sickle cell disease, HIV-infection, but additionally to reduce the pertus- completing all three doses remains low other immunocompromising condi- sis reservoir in the population at large, especially in adolescent males2. tions, cochlear implant, or cerebrospinal which would lead to less overall disease fluid (CSF) leaks13 . A dose of PPSV23, Table 2. HPV vaccination rates 2 with its ensuing complications. Addition- administered at least eight weeks after ally, Tdap vaccine administered during Females 2013 2012 PCV13, is also recommended for use in adolescence provides booster doses to the above high risk individuals if they ≥1 dose 57.3% 53.8% maintain protection against tetanus and have not previously received it; PPSV23 ≥2 dose 47.7% 43.4% diphtheria. should be repeated five years after the ≥3 doses 37.6% 34.4% Current recommendations for ado- first dose if the immune compromising lescents aged 11-18 is a Tdap booster Males 2013 2012 condition persists13 once, followed by the Td booster every ≥1 dose 34.6% 20.8% FIGURE 5. Annual average of 10 years11. Adolescents who have already ≥2 dose 23.5% 12.7% PCV13-type IPD in children aged 6–18 received a booster dose of Td should get ≥3 doses 13.9% 6.8% years, with and without selected underlying a single dose of Tdap as well for protec- immunocompromising conditions — United 13 11 States 2007–2009 . tion against pertussis . Tdap vaccina- Vaccines for adolescents at tion coverage in the U.S. increased from higher risk 84.6% in 2012 to 86.4% in 2013 among Pneumococcal vaccines 2 children 13-17 years . Forty-two states is a lead- met the Healthy People 2020 target in ing cause of and serious 2012, of 80% of adolescents aged 13-15 infections such as sepsis and meningitis, with at least one dose of Tdap, up from and causes significant morbidity and 2 36 states . mortality in the United States. Since their Human papillomavirus (HPV) introduction, the pneumococcal con- HPV is the most common sexually jugate vaccines have decreased the rates Abbreviations: PCV13 = 13-valent pneumococcal transmitted disease in the U.S. and it is of invasive pneumococcal disease (IPD) a known cause of genital warts; cervical, conjugate vaccine; IPD = invasive pneumococcal directly in vaccinated individuals and disease; RR = rate ratio; HIV/AIDS = human vaginal, vulvar, anal and penile cancers; indirectly by herd protection in unvac- virus/acquired immunodefi- ciency syndrome. as well as some cancers of the head and cinated persons 13. In 2010, the 13-va- neck. Currently there are 3 HPV vac- lent pneumococcal conjugate vaccine Hepatitis A cines available: a 2-valent, 4-valent and (PCV13) replaced the 7-valent conjugate Hepatitis A virus infects the liver. 12 a 9-valent vaccine . The ACIP recom- vaccine (PCV7) for prevention of IPD Though many infected remain asymp- mends all females, aged 11 to 12 years of and otitis media in infants and young tomatic some may develop loss of ap- age, receive a three-dose series of any of children13. petite, vomiting, nausea, fatigue and in these three, and that males, aged 11 to 12 rare cases liver failure resulting in death. (continued on Page 9) Page 8 Nebraska Medicine | Summer 2015

Overview of adolescent immunizations (continued)

FIGURE 6. Incidence of hepatitis A, by year. United States, 1980-201315. Aged ≥10 Years at Increased Risk for Serogroup B Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(22):608-612. 9) American Academy of Family Physicians. ACIP Issues New Recommendation for MenB Vaccina- tion. http://www.aafp.org/news/health-of-the- public/20150701acipmtg.html. Accessed July 1, 2015. 10) VPD Surveillance Manual, 5th Edition, 2011 Meningococcal Disease: Chapter 8-1. 11) Centers for Disease Control and Prevention. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acel- lular Pertussis (Tdap) Vaccine from the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2011;60(01):13-14. 12) Centers for Disease Control and Prevention. Use of 9-Valent Human Papillomavirus (HPV) Vac- cine: Updated HPV Vaccination Recommenda- Transmission from one person to another tions of the Advisory Committee on Immuniza- tion Practices (ACIP). MMWR Morb Mortal is through contaminated food or water or References 1) Strikas RA, ACIP, ACIP Child/Adolescent Immuni- Wkly Rep. 2015;64(11):300-304. sexual contact with an infected person. zation Work Group. ACIP Recommendations Im- 13) Centers for Disease Control and Prevention. Use of 13-Valent Pneumococcal Conjugate Vaccine The current vaccine recommendation is a munization Schedules for Persons Aged 0 Through 18 Years — United States, 2015. MMWR Morb and 23-Valent Pneumococcal Polysaccharide 2-dose series that may be given any time Mortal Wkly Rep. 2015;64(4):93-94. Vaccine Among Children Aged 6–18 Years with Immunocompromising Conditions: Recommen- after age one through 18 years, with doses 2) Elam-Evans LD, Yankey D, Jeyarajah J, Singleton JA, Curtis RC, MacNeil J, Hariri S; Immunization dations of the Advisory Committee on Immuniza- six months apart14. Additionally, recom- Services Division, National Center for Immuniza- tion Practices (ACIP) MMWR Morb Mortal Wkly Rep. 2013;62(25):521-524. mendations are extended for adolescents tion and Respiratory Diseases; Centers for Disease Control and Prevention (CDC). National, regional, 14) Centers for Disease Control and Prevention. Pre- engaged in international travel, and men state, and selected local area vaccination cover- vention of Hepatitis A Through Active or Passive Immunization. Recommendations of the Advisory who have sex with men are given higher age among adolescents aged 13-17 years--United States, 2013. MMWR Morb Mortal Wkly Rep. Committee on Immunization Practices (ACIP). risk status14. Since Hepatitis A vaccine 2014;63(29):625-633. MMWR Morb Mortal Wkly Rep. 2006;55(7):1- 23. first became available in 1995, hepatitis A 3) Centers for Disease Control and Prevention. Prevention and Control of Seasonal Influenza with 15) Centers for Disease Control and Prevention. rates in the U.S. have declined by 95% as Vaccines: Recommendations of the ACIP - U.S., Hepatitis A FAQs for Health Professionals http:// www.cdc.gov/hepatitis/hav/havfaq.htm. Accessed seen in Figure 6 above15. 2014-15 Influenza Season. MMWR Morb Mortal Wkly Rep. 2014;63(32);691-697. July 1, 2015. Importance of state immunization 4) Centers for Disease Control and Prevention. Report Flu Vaccination Coverage United States, 2012-13 mandates Influenza Season. http://www.cdc.gov/flu/fluvax- Across the U.S., there is a lack of view/coverage-1213estimates.htm. Accessed July 1, 2015. uniformity and consistent enforcement of 5) Healthy People 2020. Immunizations and Infec- individual state immunization mandates tious Diseases. IID-12.11 Data Details. http:// www.healthypeople.gov/node/6359/data_details. for school enrollment. State-based immu- Accessed July 1, 2015. nization laws using ACIP recommenda- 6) Centers for Disease Control and Prevention. Weekly U.S. Influenza Surveillance Report. http:// tion that time vaccinations to entry into www.cdc.gov/flu/weekly/. Accessed July 1, 2015. the sixth or seventh grade ensure more 7) Centers for Disease Control and Prevention. Prevention and Control of Meningococcal Diseases: consistent vaccination coverage early in Recommendations of the Advisory Committee on the adolescent years, as young an age as Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2013;62(2):1-22. possible to achieve maximum protection. 8) Centers for Disease Control and Prevention. Use of Serogroup B Meningococcal Vaccines in Persons l

Page 9 Nebraska Medicine | Summer 2015 Adult immunizations in 2015: what works

by Rudolf J. Kotula, MD, FACP, FIDSA ule, with helpful footnotes, is probably the Education of members of the Infectious Disease Consultant best resource for a busy clinician to provide practice team – Education can occur Epidemiologist Methodist Women’s Hospital “cutting edge” medical care to his or her through webinars, conferences, par- Asst. Clinical Professor of Medicine patients. http://www.cdc.gov/vaccines/ ticipation in coalition, training/technical Creighton University schedules/easy-to-read/adult.html assistance, distribution of information, So what is new in 2015? First, the templates, policies, etc. he need for immunizations does 13-valent pneumococcal conjugate vaccine Convenient vaccination services – Tnot end when you reach adult- (PCV 13) is now recommended for all This can include office-based vaccinations, hood. It is estimated that between 50,000 adults 65 years and older, in series with referrals to pharmacies, written informa- to 70,000 U.S. adults die each year as the the pneumococcal polysaccharide vac- tion for vaccines to take home and tell result of a disease that could cine (PPSV 23). When possible, PCV 13 others about. be prevented by vaccinations. should be administered prior to PPSV 23 Enhanced primary care/hospital For example, influenza is the for best immune response. Full guidelines systems to facilitate immunizations – sixth leading cause of death for on use of these two vaccines is available at This can be accomplished through educa- adults and contributes to at www.cdc.gov/vaccines/hcp/acip-recs/vacc- tion, electronic medical records alerts, least 200,000 hospitalizations specific/pneumo.html. standing orders or protocols. and 36,000 deaths annually. Secondly, the indicated age group for Establish an “immunizations The specific vaccines needed the recombinant influenza vaccine (RIV), champion” monitoring progress and as an adult depend not only on your age, which is egg free, has been expanded from adherence to vaccination guidelines – lifestyle, overall health, , immune ages 18 to 49 to include all individuals 18 These are individuals who make things competency status and travel plans, but and older. happen, whether they are physicians, also on whom you are in close contact with All adults are advised to receive in- nurses, allied health care practitioners, and what vaccines you had as a child. The fluenza vaccine yearly, one dose of TdaP pharmacists or others. goal of these increasingly evidence-based (tetanus, diphtheria, acellular pertussis) In my opinion, the power of the “white guidelines is to decrease morbidity and vaccine immediately (regardless of interval coat” is tremendous when communicat- mortality from vaccine preventable diseases since last Td), vaccine at age 60 ing the need for proper immunizations to (VPD). and the two different pneumococcal vac- patients. When asked to see an outpatient Each year the U.S. Advisory Commit- cines (PCV13 and PPSV23) at age 65, or inpatient in consultation, I make vac- tee on Immunization Practices (ACIP), or sometimes earlier, depending on the cinations a part of taking a patient’s history. the American College of Obstetrics and patient’s medical conditions. Unfortunately, stating to a patient that a Gynecologists (ACOG), the American However, missed opportunities and vaccine is recommended by the CDC to College of Physicians (ACP), the American quality gaps for vaccinations exist between prevent certain infections does not always Academy of Family Physicians (AAFP), the patients who are recommended to generate enthusiasm. People generally do and the American College of Nurse- Mid- receive vaccinations and those who actually not like “shots.” My strong recommenda- wives (ACNM) recommends a specific receive them. A variety of obstacles - at the tion can often convince patients that the immunization schedule. Other organiza- practice, economic, patient related, and protection is worth the pain. Infrequently, tions such as the Infectious Disease Society social levels - help explain the missed op- despite my efforts, some patients refuse of America (IDSA) tend to endorse these portunities. Numerous organizations have or postpone immunizations. In that case, guidelines. The updated schedule is avail- developed quality improvement programs I ask the office or hospital nurse to give able on the web page of the Center for to help clinicians and practice teams raise them written patient-oriented information Disease Control and Prevention (CDC) in awareness and improve immunizations for educational purposes to consider vacci- several versions. The printable table format rates in our communities. Suggestions nations in the future. Some patients prefer of the yearly Adult Immunization Sched- include: to talk to their primary care provider; (continued on Page 11) Page 10 Nebraska Medicine | Summer 2015

Adult immunizations in 2015: what works (continued) confirmation from both providers can rein- success of health promotion of the popula- tions of CDC, ACIP and other expert force the importance of vaccine protection. tion. Our current health care delivery entities involved in immunization practice, Raising awareness tends to be a good start system is oriented toward managing dis- and applying educational efforts at the for implementation! eases, with a few resources targeted towards community level by all participating team Immunizations are fundamental to the prevention. Reinforcing the recommenda- members can be a win-win situation. l

Page 11 Nebraska Medicine | Summer 2015 Human papillomavirus (HPV) infection and vaccination by Meera Varman, MD And every year in the U.S., more than 13 through 26 years for females and 13 Professor 330,000 women undergo cone or other through 21 years for males; ACIP states Pediatric Infectious Diseases gynecologic procedures due to HPV- that all males 22 through 26 years may Creighton University related cervical symptoms. be vaccinated. ACIP also recommends In men, HPV-attributable oropharyn- routine vaccination from 22 through 26 ore than 80% of people living in geal cancers are also on the rise. About years for men having sex with men and the world today will be exposed M 11,000 HPV-related oropharyngeal immunocompromised men (including to Human papillomavirus (HPV) in their cancers are diagnosed in the U.S. each HIV-positive men). The HPV series can lifetimes, making HPV by far the most year, 7,000 in men. Such cancers are be started as early as nine years of age. common sexually transmitted expected to surpass cervical There is non-inferiority of efficacy infection. In some circum- diagnoses by 2020. when the vaccines are co-administered stances, the virus progresses to Additionally, about 360,000 men and with other concurrent teen vaccines such intraepithelial neoplasia, includ- women suffer from genital warts annually as Tdap, MCV4 and influenza vac- ing cancerous and precancerous in the U.S. cines.4 In 2014, FDA approved 9 valent lesions in the cervix, vagina, HPV vaccine (9vHPV) covering HPV vulva, penis, anus, and orophar- What are the different types of oncogenic types 31, 33, 45, 52 and 58, ynx. HPV is also a major cause HPV vaccines? in addition to types 6, 11, 16, and 18. of genital warts. HPV vaccine is a noninfectious The 9vHPV vaccine reduces the risk HPV vaccination, however, can recombinant vaccine prepared from of disease caused by these five addi- dramatically reduce these cases and, in purified HPV viral-like particles (VLP) tional HPV types by 97%. The 9vHPV the U.S. alone, save more than $7 billion from capsid (L1) proteins of HPV types. vaccine is FDA approved in girls and annually in health care costs stemming In 2006, the FDA approved the quadri- young women nine through 26 years from oropharyngeal and genitourinary valent 4vHPV vaccine for females aged and in boys nine through 15 years. ACIP cancers and HPV-related gynecological nine through 26 years as a three-dose currently states 9vHPV can be used to procedures. Yet for all the protections series spaced at zero-, one-, and six- initiate, or complete the vaccine series the simple, three-dose HPV vaccine can month intervals. In 2009, 4vHPV was in both females and males through 26 give, the U.S. and the wider world lag in approved for males aged nine through years if the vaccination has been initiated administering it. 26 years, as was the bivalent 2vHPV vaccine for females. The 2vHPV vaccine with another HPV vaccine, but offers no How common is HPV and how protects against HPV types 16 and 18 preference for its use over other indicated serious is it? 5 which cause 70% of cervical cancers. The HPV vaccines. There are more than 100 identified 4vHPV vaccines, in addition to cover- In Australia, after the government strains of HPV. Worldwide in 2008, ing types 16 and 18, also protect against reported a 70% HPV vaccination rate, a more than 500,000 new cases of cervical types 6 and 11 which cause 90% of geni- near disappearance of genital warts was cancer and 275,000 deaths due to cervi- tal warts and recurrent respiratory papil- observed in males and females under 21 cal cancer were reported, many of these 6 lomatosis cases. The Advisory Commit- years. In the U.S. since the introduc- cases attributable to HPV.1,2 About 79 tee on Immunization Practices (ACIP) tion of HPV vaccination, there is a 56% million Americans are currently infected 7 recommends routine HPV vaccination decline in vaginal HPV. with HPV and 14 million new infections for 11- to 12-year-old males and females. The most common side effect of the are diagnosed in the U.S. every year. An- ACIP recommends 2vHPV, 4vHPV and HPV vaccine is mild to moderate pain at nually, 11,000 cases of cervical cancer are 9vHPV for female vaccination, whereas the injection site, erythema, swelling and diagnosed with 4,000 deaths reported.3 4vHPV and 9vHPV for male vaccina- syncopal episodes. Fifteen minutes

tion. The catch-up vaccination age is (continued on Page 13 ) Page 12 Nebraska Medicine | Summer 2015 Human papillomavirus (HPV) infection and vaccination (continued)

observation is recommended after the Nebraska HPV vaccination rate and eliminating the vaccination dispar- vaccine unless syncope develops when in 2013 ity. Across all ethnic groups, provider you observe until the patient recovers. Females 2013 recommendation has a strong impact on Among post-vaccination syncopal reports vaccine uptake among teens.14 ≥1 dose 65.1% 49% were females.8 More than 170 mil- ≥2 dose 55.3% How to improve? lion HPV vaccine doses worldwide and ≥3 doses 41.5% The wonderful news is that we have a 57 million doses in the U.S. have been cancer-preventing vaccine. Though edu- Males 2013 administered since 2006. Post-licensure cation is essential for parents and teens, national safety data monitoring shows the ≥1 dose 38.2% there is also a much-needed push to make HPV vaccine is safe and no increase in ≥2 dose 26.4% sure providers are creating every opportu- autoimmune diseases has been reported. ≥3 doses 19.7% nity to administer the vaccine. The goal

How are we doing with teen HPV is to increase awareness, vigilance and There is regional and racial dispar- vaccination rates? overall vaccination. National immuniza- ity in HPV vaccination rates. Girls 13 Despite having a safe and effective tion survey-teen (NIS-Teen) shows that to 17 years of age living in the Southern vaccine and plenty of opportunities if HPV vaccine had been given routinely U.S. were less likely to have initiated and to deliver it, HPV vaccination rates along with other teen vaccines, the cover- completed the series compared to girls in remain low for both males and females. age with at least one dose before 13 years the Northeastern U.S.10 A survey of 132 Overall, U.S. HPV vaccination rates of age would have reached about 91.3%. women aged 18 to 22 and of differing for adolescent girls remained about the All it may have taken to get these young ethnic backgrounds showed a three-dose same between 2011 and 2012, hovering people vaccinated was a strong positive completion rate as follows: 33% among around 53% for girls who received at recommendation from their provider. people of Haitian descent, 42% among least one dose of vaccine. Among females Policy changes at the organizational level African-Americans, 63% among Latinos, across the U.S. states in 2013, the pro- could also dramatically increase vaccina- and 65% among Caucasians.11 portion receiving one or more doses of tion rates. Being aware of vaccination a HPV vaccination ranged from 39.9% HPV awareness/hesitancy schedules, sending reminders via tele- to 76.6%. American females achieving There is a clear need for increasing phone call, text messages or email, having three-dose series completion ranged from HPV education for parents and teens. standing orders for vaccination and creat- 20.5% to 56.5%. For American males, At best, among those who go unvac- ing convenient hours for vaccinations coverage of one or more doses ranged cinated, there is little to no awareness of are just a few things providers can do to from 7.3% to 43.2% and those achieving the HPV vaccine. On the other end of increase overall vaccination rates. the three-dose completion cycle ranged the spectrum, parents are refusing the A strong cancer prevention message from 7.3% to 43.5%. vaccine because they feel it opens a door and recommendation from the provider to their teen’s sexual activity. CDC re- National HPV vaccination rate in is the key. Let us spread the word about 2012 and 20139 search has shown messages communicat- HPV to the community and increase not ing that HPV is preventable by vaccine Females 2013 2012 only HPV vaccination but all vaccination and does not increase the likelihood of rates across all age groups for a healthy ≥1 dose 57.3% 53.8% sexual activity at a younger age resonate future. l ≥3 doses 37.6% 34.4% well with parents.12,13 Providing public Males 2013 2012 health service announcements and social References 1) Parkin, D. and F. Bray., The burden of HPV - marketing, especially in populations ≥1 dose 34.6% 20.8% related cancers. Vaccine, 2006. 24(S3): p. 11-25. where vaccination is low, would be effec- ≥3 doses 13.9% 6.8% (continued on Page 22 ) tive in reaching underserved populations Page 13 Nebraska Medicine | Summer 2015 Vaccine hesitancy and strategies to address it

by Archana Chatterjee, MD, PhD factors including issues of confidence The Necessity of Vaccines Professor and Chair, Department of Pediatrics (do not trust a vaccine or a provider), Some parents believe that: Senior Associate Dean for Faculty Development complacency (do not perceive a need for • The diseases that vaccines are University of South Dakota Sanford School of a vaccine or do not value the vaccine), designed to prevent occur rarely Medicine/Sanford Children’s Specialty Clinic and convenience (access).” 7 Since vaccine • “Natural” immunity is better hesitancy may be viewed as a spectrum, • Many of the currently recommend- Introduction a “one size fits all” strategy to address it ed vaccines are unnecessary From the time that vaccines first is unlikely to succeed. Instead, public • Most vaccines don’t work/nor began to be used extensively, concerns health agencies, professional societies and provide long-term benefit have been expressed about their other vaccine advocates suggest tailoring The Freedom to Choose Vaccines safety and efficacy. Despite this, the message about the need for vaccines It has also been argued that: vaccines to prevent a number of and their safety profiles to the audience.8,9 • Parents have the right to choose deadly infectious diseases such whether to vaccinate their child or not as small pox and measles have Parental Concerns About Vaccines • Mandatory vaccination undermines been developed and deployed Various studies estimate that while parental authority successfully in the past century, most parents believe that vaccines protect • Vaccine risks outweigh benefits leading to a singular impact on their children from diseases, nearly half • Vaccination violates certain religious . Small pox has been eradi- have some level of concern about child- 10,11 beliefs cated from the world, and many other hood vaccines. These may be catego- The Mistrust of Vaccine Manufacturers vaccine-preventable diseases are rarely rized into four types of concerns: and Advocates seen today by either the public or health 1. The safety of vaccines Some members of the public are: care providers. The unparalleled success 2. The necessity of vaccines • Skeptical about vaccine that vaccines have enjoyed has led on 3. The freedom to choose vaccines manufacturers the one hand to complacency that these 4. The mistrust of vaccine manufac- • Distrustful of governmental agencies diseases have been conquered, and on the turers and advocates • Suspect the motives of vaccine other to rising concerns about the risks/ The Safety of Vaccines advocates benefits of current immunization strate- One of the most common concerns gies.1-3 The congruence of the disappear- that parents voice about vaccines is their Health Care Provider Perspective ance of these diseases from the public eye safety.12 The list of concerns includes: Primary care providers have been re- and increasing questions about vaccine • Possible association with and porting increasing vaccine hesitancy over safety, has led to increasing numbers of other neurodevelopmental disorders the past decade.13,14 Nationally, random people requesting alternative vaccination • Vaccine additives such as thimerosal, sample American Academy of Pediatrics schedules (AVS),4,5 postponing some aluminum, , etc. Periodic Surveys addressing vaccine refus- vaccines, or in the worst case scenario, • Too many vaccines “overloading” als, conducted in 2006 and 2013 with a declining vaccination altogether.6 the 53% response rate in both years, showed The phrase “vaccine hesitancy” has • Serious adverse reactions such the following13: emerged in recent years as the preferred as seizures Vaccine Refusals: The proportion of term to refer to individuals and groups • Potential for unknown long-term pediatricians reporting parental refus- who express varying degrees of concern adverse events als for vaccines increased from 75% in about some or all vaccines. Vaccine • Inadequate testing of vaccines 2006 to 87% in 2013 (adjusted OR hesitancy has been recently defined by • Pain due to multiple injections 3.07, p<.001); on average pediatricians the World Health Organization as “a • Fever associated with vaccination estimated 14% of parents refused ≥ one behavior, influenced by a number of • The vaccine actually causing disease vaccine (2013 data). Nearly all respond- such as varicella or measles (continued on Page 15)

Page 14 Nebraska Medicine | Summer 2015

Vaccine hesitancy and strategies to address it (continued) ing pediatricians in both survey years their practices.15 staff in the clinic (96%, 94%) reported attempts at educat- It is important to note that recent 9. Appoint a “vaccine champion” ing parents after refusal. The proportion surveys indicate that providers often within the clinic who will ensure that all of parents persuaded to give permission overestimate a parent’s vaccine hesitancy, team members are updated on vaccine- for a vaccine (32%, 34%) and who were or mistake a simple lack of knowledge related information dismissed for continually refusing permis- for hesitancy or opposition.16 Thus, 10. Consider providing informa- sion (6%, 9%) were similar across study while time-consuming, it is imperative tion regarding vaccination (such as the years. for health care providers to elucidate Centers for Disease Control and Preven- Requests for AVS: In 2013, most pe- the source and details of every vaccine- tion’s Vaccine Information Sheets) prior diatricians (87%) reported having parents hesitant parent’s issues surrounding vac- to the visit request an AVS; they estimated 16% of cination. It is also disturbing to note that 11. Supply a list of websites that pro- parents asked for an AVS for at least one only 55% of providers routinely provide vide accurate information about vaccine vaccine during the past year. Pediatricians parents with the rationale for why vac- safety e.g. Here is a list to get you started: in suburban (aOR 7.22, p<.01) and rural cines are administered and their potential • Immunization Action Coalition: areas (aOR 13.68, p<.05) were more side effects.17 http://www.immunize.org/ likely to report AVS requests. Nearly all Strategies to Address Vaccine • CDC provider resources for vaccine pediatricians (94%) discuss the impor- Hesitancy conversations with parents: http://www. tance of immunization with parents Clinicians who encounter vaccine cdc.gov/vaccines/hcp/patient-ed/conver- requesting an AVS. hesitancy should18: sations/index.html Providing vaccine information can 1. Acknowledge the varied concerns • Healthy Children from the Ameri- be time consuming. In one study it was of vaccine-hesitant parents using parent- can Academy of Pediatrics: http://www. reported that 53% of physicians spend centered motivational interviewing healthychildren.org/English/safety-pre- 10-19 minutes discussing vaccines with techniques vention/Pages/default.aspx concerned parents and 8% of physicians 2. Elicit specifics about their concerns • The Children’s Hospital of Philadel- spend 20 minutes or more with these 3. Optimize communication with phia’s Vaccine Education Center: http:// parents, scheduling longer well care visits, parents regarding the development and www.chop.edu/service/vaccine-educa- with some loss of overall efficiency and safety testing of vaccines, the reasons for tion-center/home.html 14 revenue. Some providers end up dis- immunizing, and the risks of not doing • American Academy of Pediatrics missing such patients from their practice, so immunization page: http://www2.aap. or simply not having the discussion and 4. Articulate clearly the message that org/immunization/pediatricians/pediatri- acceding to a parent’s request to defer, vaccines are safe and effective, and serious cians.html 14 delay or skip a vaccination. Addition- disease can occur if immunizations are 12. Review immunizations at all visits ally, pediatricians experience decreased deferred or not given and offer additional time for discussion if job satisfaction because of time spent 5. Explain why the recommended necessary with parents with significant vaccine con- immunization schedule is the best one for The above strategies may not be 14 cerns. Pediatricians are also becoming children and why alternative schedules needed or effective for all vaccine-hesitant concerned about the risk that unimmu- place children at risk parents. The health care provider needs nized/under-immunized children pose to 6. Recount personal experiences with to select the ones that are most likely other children in their practices includ- vaccine-preventable diseases to be successful for his/her patients. ing immunized children and those too 7. Emphasize that they and their fam- Most importantly, developing a trusting young to be immunized or with medical ily members are vaccinated relationship with the family, as well as contraindications, and some are electing 8. Utilize a team approach so that the conducting an open and honest discus- to dismiss those who refuse vaccines from parents hear the same message from all (continued on Page 23)

Page 15 Nebraska Medicine | Summer 2015 Parental decisions to not vaccinate: is it time to take a stand or understand? by Katie O’Keefe, DNP, APRN-NP including five with pneumonia (CDC, resurgence of vaccine preventable diseases? Associate Professor of Nursing & Pediatric 2015). Recently, it was reported that one There are many factors to consider when Nurse Practitioner woman in the state of died addressing this question. However, the Creighton University, College of Nursing from measles-related pneumonia. There scope of this article will be limited to a is also a worrisome increase in another discussion of parental decisions to delay vaccine preventable disease: pertussis. As and/or refuse vaccines for their children. he good news is that the major- of December 31, 2014, the provisional In addition, the role of health care provid- ity of the reporting states in the T 2014 count in the U.S. of pertussis cases ers when encountering a vaccine hesitant United States (U.S.) are at or near the was 28, 660 representing an 18% increase parent will be explored. 95% national Healthy People 2020 targets compared to the provisional numbers The way parents view vaccines has for 4 doses of DTaP, 2 doses of reported at the same time in the previous changed since the 1950s when children MMR, and 2 doses of varicella year. In 2012, there were 48,227 reported and their parents lined up at schools, vaccine (CDC, 2014). The bad cases of pertussis with 20 related deaths churches and community centers to re- news is that there has been a mostly infants under three months of age ceive the oral polio vaccine. There was no resurgence of clustered outbreaks (CDC, 2015c). question among parents as to whether they of vaccine preventable diseases Non-vaccinated individuals can present would vaccinate their children. They had largely induced and spread by a public health threat. When a child is seen the devastating paralysis of and deaths intentionally unvaccinated indi- not vaccinated against one or all of the 17 due to polio and were anxious to protect viduals. In 2014, the U.S. experienced 668 vaccine preventable diseases available in their children from this deadly disease. cases of measles from 27 states represent- the U.S., that child poses a real threat to Due to the success of large scale vaccina- ing the largest number of cases since 2000 continued offered by large tion programs in the U.S., parents today when measles was declared eliminated in pools of vaccinated individuals. However, have little or no familiarity with vaccine the United States. In the first five months they benefit from the herd immunity preventable diseases like polio and thus do of 2015, there were 173 laboratory created by those who were vaccinated. not understand the severity of these dis- confirmed measles cases (21 states and the Children who have immuno-compro- eases. This lack of understanding coupled District of Columbia) reported in the U.S. mising medical conditions often cannot with an unprecedented onslaught of social (CDC, 2015a; CDC, 2015b). Most of receive the full complement of vaccines to media reporting vaccine dangers has led to the 2015 cases have been traced to an out- prevent these diseases which may be life- a greater fear of the vaccines than the dis- break at a Disney theme park in California threatening to them. They are dependent eases (Siddiqui et al., 2013). Well-known during December 2014. In 2014, there upon herd immunity to protect them. and influential individuals ranging from were 23 measles outbreaks in the U.S. A child whose parents have decided to celebrities to politicians have represented which included one outbreak of 383 cases not vaccinate can endanger an immuno- themselves as experts in the area of vaccine in Ohio Amish communities affecting compromised child whose parents have no safety. Their messages have been taken primarily unvaccinated individuals. Many choice to vaccinate. to be the “truth” and have significantly of the 2014 and 2015 cases were found to contributed to the current anti-vaccine be imported from the Philippines which Parental Decisions to Vaccinate … movement. The pro-vaccination move- was experiencing a large measles outbreak or Not? ment has yet to identify similarly well- (2015b). The 2015 measles cases ranged Vaccinations have been lauded as among known celebrities to endorse childhood in age from six weeks to 70 years with the 10 great public health achievements in vaccine safety (Gowda & Dempsey, 2013). largest proportion (36%) from the 20 to the last century. Therefore, the question However, organizations such as Moms 39 years age group. Initially there were no must be asked – why is the most resource- Who Vax (http://momswhovax.blogspot. deaths but 22 people were hospitalized rich country in the world experiencing a (continued on Page 17) Page 16 Nebraska Medicine | Summer 2015 Parental decisions to not vaccinate: is it time to take a stand or understand? (continued) com/) are starting to create a digital foot- hesitancy and measure the nature and de- The medical and lay literature is replete print (Shelby & Ernst, 2013). gree of vaccine hesitancy. It is entitled the with described causes of parental hesi- The Centers for Disease Control and Parent Attitudes about Childhood Vac- tancy, delay or refusal to vaccinate their Prevention (CDC) and the American cines (PACV) survey. The PACV survey children. But there is a dearth of informa- Academy of Pediatrics (AAP) have at- explores the dimensions of: (1) immuniza- tion to inform providers as to effective tempted to counter the anti-vaccine activ- tion behavior; (2) beliefs about vaccine interventions to address parental concerns. ists by providing online resources to assist safety and efficacy; and (3) general at- In fact, recently published systematic parents and providers in discussing the titudes and trust (Opel et al., 2013). This reviews (Sadaf et al., 2013; Dube´ et al., topic vaccine-hesitancy. These resources survey has been used as a research tool to 2015) have revealed limited evidence can be found at http://www.cdc.gov/vac- measure the influence of interventions to available to guide providers in addressing cines/hcp/patient-ed/conversations/ and increase vaccination rates among vaccine the increasing incidence of parental delays https://www2.aap.org/immunization/ hesitant parents. However, it is limited by and/or refusal to vaccinate their children. pediatricians/refusaltovaccinate.html. the homogeneity of the samples represent- But what is known is that parents look However, parents may find it difficult to ing a higher-income status. Subsequently, to their child’s health care provider for determine what information is trustwor- with the PACV as a framework, Larson answers (Mergler et al., 2013). The parent thy and scientifically correct (Williams et et al (2015) sought to develop a tool with who is wavering along the vaccine deci- al., 2013). Health care professionals can a broader global relevance. The clinical sion making continuum is often looking have a profound influence on parental practicality of such tools remains untested. for validation of their concerns and what decisions to vaccinate (Gust et al., 2008; The reader is encouraged to read the they perceive as a respectful and unbiased Brown et al., 2010; Smith et al., 2006; original sources and the questions asked response from their child’s provider. This Benin et al., 2006). However, providers of the parents in order to gain insight into is a critical juncture in the provider-parent often lack confidence in addressing par- vaccine hesitance and the wide variation in relationship. A vaccine hesitant parent is at ents’ vaccine hesitancy (Healy et al., 2014; concerns expressed by parents. that moment poised to evolve into a vac- Leask et al., 2012; Sarnquist et al., 2013; Vaccine-Hesitant Parent – cine refuser or vaccine acceptor. Henrikson et al., 2015). Providers also cite Now What? The American Academy of Pediatrics inadequate time and resources to address Vaccine hesitance is complex and multi- (AAP) has addressed this difficult is- parent’s concerns about vaccines. dimensional and cannot be addressed by a sue (AAP, 2005; AAP, 2012). The AAP Reluctant, hesitant, conflicted—these single strategy. The traditional approach is recommends that pediatric providers not are all words used to describe parents who based on the assumption that the vaccine- dismiss families due to parental refusal to delay and/or refuse to have their child(ren) hesitant parent simply needs the correct vaccinate. The AAP policy suggests that vaccinated. However, these words are not information and then they will “see the building a relationship of trust with the synonymous but rather are descriptors of light” and vaccinate their child. However, family is paramount. Pediatric health care parents along a continuum of vaccination this suggests that parents are delaying and/ providers who follow the AAP policy must decision making from Refusal Acceptance or refusing vaccines solely based on a lack first assess where the parent(s) are along (Dube´ et al., 2013; Dube´ et al., 2015). of knowledge. When, in fact, there are the vaccine decision-making continuum, Parents cite innumerable reasons for either multiple psychosocial, cultural, religious and then tailor their vaccine discussion refusing or accepting vaccinations and or political factors in play (Dube´ at al., to the parent’s position at the time. This health care providers need a better under- 2013). Furthermore, past experiences, and charge can be challenging in today’s high standing of the contextual framework of perceived importance of vaccines coupled volume, production driven health care these vaccine decisions. Opel et al (2011) with perceived risk of disease must be con- environment. As office visits get shorter first developed and validated a tool used sidered (Dube´ et al., 2013; MacDonald et and shorter, parents and providers be- to identify the determinants of vaccine al., 2015). (continued on Page 24) Page 17 Nebraska Medicine | Summer 2015 Warning! Undervaccinated health care personnel in this facility! by Catherine Carrico, DNP, FNP-BC prior to onset of symptoms or may present health care workers since 1997. The cur- Assistant Professor with subclinical symptoms in adults. In rent (2011) ACIP recommended vaccines Creighton University College of Nursing turn, these uninformed, non-vaccinated, for HCP include hepatitis B, tetanus-diph- and infected HCP continue to work, theria-acellular pertussis (Tdap), varicella, arning: Undervaccinated despite recommendations to stay at home measles, mumps, and rubella (MMR), an Whealth care personnel in this when ill, and spread the pathogens to co- annual influenza, and meningitis vaccines facility! Should this sign be hanging as workers and patients (Russi, et al, 2013). (Shefer et al.). Table 1 (page 20) details the a warning to your patients and visitors Influenza is the most frequently trans- specific recommendation of each vaccine. where you work? The United mitted VPD, but pertussis, due to waning In addition to the CDC, several U.S. States (U.S.) currently employs immunity, has resulted in an upsurge of federal and organizational policies and rec- over 12 million health care the disease in the U.S., placing HCP and ommendations for the vaccination of HCP personnel (HCP), with Nebraska patients, especially pediatric patients, at in- have been published, including: Healthy employing over 84,000 persons creased risk. Hepatitis B, varicella, measles, People 2020, Department of Health and working in hospitals, medical mumps, and rubella are also VPDs with Human Services (DHHS), the Joint Com- clinics, home health agencies, great potential for transmission between mission, and the Occupational Safety and urgent cares, and long-term care HCP and patients. Those HCP who are Health Administration (OSHA). facilities.(Kaiser Foundation). Health care not fully vaccinated are putting themselves Healthy People 2020 has a target personnel are often thought of as those and others at risk for acquiring these rate of 90% for vaccination of HCP for providing direct patient care. The Centers diseases (U.S. Department of Health and hepatitis B (3 or more doses) and influenza for Disease Control and Prevention (CDC) Human Services). (annually), but does not address pertussis defines HCP as physicians, nurses, lab Infection of patients and coworkers or varicella. This is a lofty increase from technicians, emergency medical personnel, by HCP in hospitals, outpatient clinics, the actual vaccination rates in 2008, when dentists, administrative staff, pharmacists long-term care facilities and nursing homes hepatitis B was at 64.3% and influenza at and volunteers and environmental services. has been documented in the literature. 45.5%. OSHA requirements are in place All HCP are at increased risk for exposure Outbreaks such as pertussis, influenza, requiring employers to offer the hepatitis B to vaccine preventable diseases (VPD) on a measles and varicella have involved HCP vaccine series free of charge for all em- daily basis, either from patients or cowork- (Fitzsimmons, Hendrickx, Badur, & ployees whose job duties include potential ers. Unfortunately, this is one of the most Vorsters, 2014). Such outbreaks result in exposure to blood or other potentially undervaccinated groups in the U.S. and increased costs of health care due to labor infectious materials (Fitzsimmons, et al, globally. needed to trace the contact(s), cost of labo- 2014). The Joint Commission, in 2006, Although effective vaccines have been ratory testing and prophylactic required health care facilities to establish available for many years, VPD still remain and other vaccines and/or for an annual influenza vaccination program a major threat to health not only in the those that have been exposed to the VPD which, at minimum would offer onsite U.S., but worldwide (Galanakis, Jansen, (Russi, 2013). In addition, the loss of the vaccination, monitor vaccine coverage, and Lopalco, & Giesecke, 2013). However, employee to the workforce due to illness provide education for HCP (Joint Com- the past experiences and devastation of puts additional strain on the health care mission). In 2009, the Joint Commission infectious diseases prior to the availability system. published a monograph with recommen- of vaccines have never been experienced, Recommended HCP vaccines dations for Tdap for all HCP (Tan & Ger- or are long forgotten by some HCP. Many There is great support for the vaccina- bie). The National Action Plan to Prevent HCP remain uninformed regarding up- tion of HCP. The Advisory Committee Healthcare Associated Infections: Road dates to the vaccination schedules, and are on Immunization Practices (ACIP) has Map to Elimination, Phase 2 has made the unaware that these diseases are contagious published recommended vaccines for (continued on Page 19) Page 18 Nebraska Medicine | Summer 2015 Warning! Undervaccinated health care personnel in this facility! (continued) vaccination of HCP against influenza a HCP to determine the perceived barriers protect self, family, friends, and patients high priority. to vaccination. Perceived barriers of HCP from disease; and employer or physician Mandatory Vaccines for HCP to vaccines include concerns regarding recommendation (Corace et al. 2013). But In an effort to increase the vaccina- vaccine safety and effectiveness, medical for those not engaged by these motivators, tion rate of HCP, mandatory vaccination contraindications, adverse side effects, can mandatory vaccines be the answer? policies have been implemented. The most religious beliefs, inconvenience, have not Ethical questions include: Do institutions prominent mandates are for annual influ- been offered, cost, fear of obtaining the have an obligation to require vaccination enza vaccination. Several medical organiza- disease from the vaccine, and denial of of their employees to protect patient health tions support this mandate including: The being at risk (Christini, Shutt, Byers, 2007, and safety, as well as ensure adequate American Academy of Family Physicians, Fitzsimmons et al. 2014). Many of the staffing? Are mandatory vaccination pro- American Academy of Pediatrics, American perceived barriers to vaccination can easily grams an infringement on a HCP rights? College of Physicians, American Hospital be overcome through education of HCP. Gostin, Bayer, and Fairchild developed Association, the American Public Health Providing education to HCP as to the im- a framework of when mandatory public Association, and the Infectious Diseases portance of vaccination to protect self and health interventions can be justified. The Society of America, to name a few (Im- others is an important aspect to vaccine ac- framework includes some of the follow- munize.org). In 2014, a variety of health ceptance by HCP. Many vaccination pro- ing recommendations: There must be a care settings were surveyed to determine gram toolkits are available free of charge, compelling employee or patient safety the rate of vaccination among HCP for including those from ImmunizeNebraska. problem that is clearly communicated to the 2013-2014 influenza season (Black et org, Immunize.org and the CDC (cdc. the employees, the least restrictive means al). The survey addressed facilities who 1) gov/vaccines). Studies have proven the should be used to achieve the objective, require vaccination, 2) have no require- safety of vaccines and their minimal side there should be clear opt-out criteria for ment but promote vaccination, and 3) effects. Inconvenience, cost, and not being medical reasons, the process should be have neither a requirement nor promote offered are easily resolved through good transparent with a broad range of HCP vaccination. The range of influenza vaccine vaccination programs in the workplace. member perspectives in policy develop- uptake for those that required vaccination “When the perceived risk of vaccination ment, institutions should support HCP was 96.4-99.5%. For those that do not is high, vaccination is less likely; when the through the implementation of vaccina- require but promote vaccines, the range perceived risk of infection is high, vaccina- tion procedures that are free and easy to dropped to 61.5% for long-term care tion is more likely”(Betsch, 2013). access, and for those that opt-out or who facilities and 79.8% for hospitals. Finally, Ethics of HCP vaccination meet medical exclusion criteria, institutions for those facilities that neither required nor Ethically, it is the responsibility of should offer alternative means to achieve promoted vaccination, uptake was only health care facilities to provide a safe control of transmission of disease (Tilburt 44.5% for ambulatory care, 47.7% for environment for both patients and staff et al, 2008). long-term care, and 70.3% for hospitals. (Fitzsimmons et al, 2014). In addition, As previously discussed, in those It is easy to see from these numbers that HCP have the obligation to do no harm, facilities with little to no requirement or mandating vaccines does increase the and to put the patient’s interest before their promotion for their employees to get vac- uptake of vaccination, at least for influenza own concerns. Patients have the expecta- cinated, the rates of HCP vaccination were (Black et al.). tion that HCP and institutions will have considerably lower. These facilities (with the lowest rates reported from long term Perceived Barriers to Vaccines policies and procedures in place to ensure care), and their employees are exposing One may then wonder, why, despite they will have safe care (Tilburt, Mueller, high risk populations to VPD. Is this the all of the recommendations and published Ottenberg, Poland, and Koenig, 2008). fault of the facility and its administrators mandates, are HCP workers not being Surveyed HCP that accepted vaccination (continued on Page 20) vaccinated? Several studies have surveyed cited motivating factors as: wanting to Page 19 Nebraska Medicine | Summer 2015 Warning! Undervaccinated health care personnel in this facility! (continued) TABLE 1 Vaccine Recommended Vaccine/Evidence of Immunity Influenza Annual vaccine MMR - Documentation of 2 doses of live measles virus, and 1 dose of rubella OR - 1 dose of MMR, repeated in 28 days OR - Serologic evidence of immunity (IgG) OR - Lab confirmation of disease OR - If born prior to 1957 and unvaccinated, consider vaccination with 2 doses of MMR Avoid pregnancy after receiving rubella vaccine Varicella - Evidence of disease (varicella or herpes zoster) OR - Serologic evidence of immunity (preferred) OR - 2 doses of varicella vaccine 4 weeks apart Tdap - One time dose as adult - Pregnant HCW, one dose with each pregnancy Hepatitis B - 3 dose series at 0, 1, and 6 months - Serologic testing recommended at 1-2 months after dose #3 Meningococcal - 1 dose to those routinely exposed to isolates of Neisseria mengitidis. Boost every 5 years if continued risk. Adapted from ACIP 2012, (McClean, Fiebeldorn, Tempte & Wallace)

or of the HCP? Many HCP, as defined by References Kaiser Family Foundation (2015). Total Health Care Employment. Retrieved from Kaiser Family Founda- Betsch, C. (2014). Overcoming healthcare workers’ the CDC, may not think of themselves as tion Website: http: http://kff.org/other/state-indicator/ vaccine refusal-competition between egoism and altru- total-health-care- HCP. It is important to include clerical and ism. Euro Surveillance. 19(48). Office of Disease Prevention and Health Promotion. Black, C.L., Xin, Y., Ball, S.W., Donahue, S. M., environmental services personnel, and vol- Healthy People 2020, retrieved from http://www. Izrael, D., de Perio, M.A. (2014). Influenza vaccination healthypeople.org. unteers in education about VPD, encourage coverage among health care personnel- United States, 2013-2014 influenza season.Morbitity and Mortal- Russi, M., Behrman, A., Buchta, W.G., Budnick, L.D., their vaccination, and remind them of their ity Weekly Report. September 19, 2014 63(37). pp Hodgson, M.J., Spillman, S.J., Swift, M.D. (2013). importance as a member of the health care 805-811. Journal of Occupational and Environmental Medicine. 55(9). 1113-5. team. Christini, A.B., Shutt, K.A., & Byers, K.E. (2007). Influenza vaccination rates and motivators among Shefer, A., Atkinson, W., Friedman, C., Kuhar, D. T., Interventions to raise vaccination rates healthcare worker groups. Infection Control Hospital Mootrey, G., Bialek, S.,…..Wallace, G. (2011). Immu- , 28(2), pp 171-177. nization of health-care personnel: Recommendations include increasing HCP knowledge about of the Advisory Committee on Immunization Practices Corace, K., Prematunge, C., McCarthy, A., Nair, (ACIP). 60(RR07). 1-45. vaccine safety, VPD routes of transmission, R., Roth, V., Hayes… Garber, G. (2013). Predicting influenza vaccine uptake among healthcare work- Tan, T.Q. & Gerbie, M.V. (2010). Pertussis and patient and benefits of vaccination; as well as provid- ers: What are the key motivators. American Journal safety: Implementing Tdap vaccine recommendations ing easy access and incentives to vaccination. of Infection Control. 41(8). 679-684. Doi-10.1016/j. in hospitals. The Joint Commission Journal on Quality ajic.2013.01.014. Retrieved June 25, 2015. and Patient Safety. 36(4). 173-178. For those that continue to decline vaccine, Fitzsimmons, D., Hendrickx, G., Badur, S., Vorsters, A. Tilburt, J.C., Mueller, P.S., Ottenberg, A.L., Poland, the signing of a formal declination form and (2014). Incentives and barriers regarding immunization G.A., Koenig, B.A. (2008). Facing the challenges of against influenza and hepatitis of healthcare workers. influenza in healthcare settings: The ethical rationale for mandatory alternative infection control mea- Conference report. Vaccine. 32, 4849-4854. mandatory seasonal influenza vaccination and its im- plications for future . Vaccine. doi:10.1016/j. sures or even termination of employment Galanakis, E., Jansen, A., Lopalco, P.L., & Giesecke, J. vaccine.2008.070068. (2013). Ethics of mandatory vaccination for healthcare may influence vaccine acceptance (Zimmer- workers. Euro Surveillance. 18(45). United States Department of Health and Human Ser- vices. "National Action Plan to Prevent Healthcare-As- man, 2013). As administrators, the cost of Immunize Action Coalition. First do no harm: Manda- sociated Infections: Roadmap to Elimination. Updated tory Influenza Vaccination Policies for Healthcare providing vaccination needs to be looked Apr (2012R) Retrieved from http://www.health.gov/ Personnel Help Protect Patients. Retrieved from http:// hcq/prevent_hai.asp ). upon as an investment in their employees. As www.immunize.org/catg.d/p2014.pdf Zimmerman, R.K. (2013). Ethical analyses of institu- Joint Commission on Accreditation of Healthcare providers, it is important to not only discuss tional measures to increase health care worker influenza Organizations. (2006). Joint commission establishes vaccination rates. Vaccine. 31(52). 6172-6176. ttp:// and encourage vaccines with patients, but infection control standard to address influenza vaccines dx.doi.org/10.1016/j.vaccine.2013.10.066 for staff. news release, June, 13. with coworkers as well. l Page 20 Nebraska Medicine | Summer 2015

An overview and introduction to this issue (continued)

Bill, LB18). While 2013 first dose [GRADE] recommendations include December 31, 2014. URL: www.cdc.gov/nchs/data/ dvs/LCWK9_2013.pdf meningitis A/C/W/Y vaccination balance of benefits and harms, type or 4) Vaccination coverage rates and data. CDC. Na- rates in Nebraska were relatively quality of evidence, values and prefer- tional Center for Immunization and Respiratory 9 Diseases. Last updated December 12, 2014. URL: high (77.5%), this still leaves almost ences of the people affected, and health www.cdc.gov/vaccines/imz-managers/coverage/ one-quarter of students unprotected, economic analyses…… Evidence tables index.html 5) National Early Season Flu Vaccination Cover- and rates for the critical second dose are used to summarize the benefits and age, United States, November 2014. CDC. Last are only at 29.6% nationwide.10 harms and the strengths and limitations updated December 11, 2014. URL: www.cdc.gov/ flu/fluvaxview/nifs-estimates-nov2014.htm While meningococcal meningitis is a of the body of evidence.” (More informa- 6) Atwell JE, Van Otterloo J, Zipprich J, Winter relatively rare disease, we all know it tion on GRADE is available at: www. K, Harriman K, Salmon DA, et al. Nonmedical vaccine exemptions and pertussis in California, is unpredictable and devastating when cdc.gov/vaccines/acip/recs/GRADE/ 2010. Pediatrics. 2013; 132(4):624-30. URL: www. it occurs. Those who are interested in about-grade.html#about.) A review of pediatrics.org/cgi/doi/10.1542/peds.2013-0878 7) Lieu TA, Ray GT, Nicola P. Klein NP, Chung C, working with one of these legislative this evidence-based evaluation system and Kulldorff M. Geographic clusters in underim- advocacy efforts may contact me at should inform and prepare all health care munization and vaccine refusal. Pediatrics. February 1, 2015; 135(2):280-9. URL: pediatrics.aappublica- [email protected]. providers to authoritatively reassure their tions.org/content/135/2/280.full The ACIP (Advisory Committee patients about the efficacy and safety of 8) Omer SB, Pan WKY, Halsey NA, Stokley S, Moulton LH, Navar AM, et al. Nonmedical on Immunization Practices), a rotating the vaccines they are recommending. exemptions to school immunization requirements: group composed of private and nonprofit And, furthermore, it is heartening to Secular trends and association of state policies with pertussis incidence. JAMA. 2006: 296(14):1757- sector practitioner and academic vaccine know that most patients do respond 63. URL: jama.jamanetwork.com/article. experts, advises the federal Immuniza- to these recommendations from their aspx?articleid=203593 9) Estimated vaccination coverage with selected tion Program of the CDC (Centers for own personal and trusted health care vaccines among adolescents aged 13-17 years, by Disease Control and Prevention) on provider!11 state and selected area – National Immunization l Survey – Teen, United States, 2013. CDC. National evolving immunization policy. (Informa- Center for Immunization and Respiratory Diseases. tion on current members and charter of References: Last updated July 24, 2014. URL: http://www.cdc. 1) Measles cases and outbreaks. CDC. National gov/vaccines/imz-managers/coverage/nis/teen/data/ ACIP is at: www.cdc.gov/vaccines/acip/ Center for Immunization and Respiratory Diseases, tables-2013.html#overall committee/members.html). ACIP uses Division of Viral Diseases, Division of Viral Dis- 10) Survey Data – Coverage among adolescents 13 eases. Last updated June 30, 2015. URL: www.cdc. through 17 years of age – Meningococcal Conju- an evidence-based approach referred to gov/measles/cases-outbreaks.html gate Vaccine. CDC. National Center for Immu- as the GRADE (Grading of Recommen- 2) 2014 provisional pertussis surveillance report. nization and Respiratory Diseases. Last updated CDC. National Center for Immunization and July 24, 2014. URL: http://www.cdc.gov/vaccines/ dations, Assessment, Development and Respiratory Diseases, Division of Viral Diseases, who/teens/vaccination-coverage.html Evaluation) process to assess the quality Division of Bacterial Diseases. Last updated Febru- 11) PROTECT Newsletter: Strategies for improving ary 2015. URL: www.cdc.gov/pertussis/downloads/ immunization rates. University of Nebraska Medi- of evidence and the strength of recom- pertuss-surv-report-2014.pdf cal Center: The Foundation. URL: www. mendations they make to the CDC. 3) Deaths, percent of total deaths, and death rates protectcme.org/resources/newsletter.pdf for the 15 leading causes of death: United States According to ACIP guidelines, “Key and each State, 2013. CDC. National Center for factors considered in development of Health Statistics, National Vital Statistics System.

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My vaccine perspective (continued)

sides are hotly debated. vaccines through the registry and was us that deadly diseases can be eradicated. The Biologic Control Act passed in funded by taxing each vaccine dose. Polio has only a few endemic regions left; 1902 to regulate production of vaccines VAERS has been used to monitor current is now held in laboratories only. and other drugs and to reduce the risk vaccines, with the CDC vaccine pro- No vaccine is risk free, but the diseases of negligence after two tetanus outbreaks gram sometimes acting immediately to carry a much greater risk. Ben Franklin from contaminated diphtheria suspend a vaccine and sometimes using was reluctant to vaccinate his children and . In 1955, con- accumulated data to counter inaccurate against smallpox. Unfortunately, his 4 taminated polio vaccine caused multiple information. All vaccines used today year old son later died of the disease. illnesses and deaths. Lawsuits after this are subject to continued evaluation and “In 1736 I lost one of my Sons, a fine outbreak set the precedence of suing the research to prove effectiveness and safety. Boy of 4 Years old, taken by the Small manufacturers for adverse events. In the Currently, the pertussis vaccine schedule Pox in the common way. I long regretted 1970s and 1980s, large numbers of law- and composition are being reviewed in that I had not given it to him by Inocula- suits against DPT manufacturers caused light of increased pertussis cases across tion, which I mention for the Sake of all but one U.S. DPT supplier to leave the U.S. Manufacturers of new vaccines Parents, who omit that Operation on the market by 1984. must provide studies that show the vac- the Supposition that they should never The National Childhood Vaccine cine’s effectiveness and prove there is no forgive themselves if a Child died under Injury Act was passed in 1986 to ad- potential to decrease the immunity pro- it; my Example showing that the Regret dress this and included a mandate for duced by concurrent vaccines. By doing may be the same either way, and that manufacturer and provider adverse event this, the immunity produced by current therefore the safer should be chosen.” reporting and a national vaccine adverse immunizations is consistently proven and — Benjamin Franklin, quoted in event reporting system (VAERS). This protected. Franklin on Franklin by Paul Zall act established a process for families to Vaccines have improved the health of He was a wise man. l obtain compensation for adverse events both individuals and their communities associated with properly manufactured for years. History has been able to show

Human papillomavirus (HPV) infection and vaccination (continued)

2) Arbyn, M., et al., Worldwide burden of cervical MMWR.Recommendations And Reports: vaccination rates among low-income African- cancer in 2008. Ann Oncol, 2011. 22(12): p. Morbidity And Mortality Weekly Report. American, Haitian, Latina, and Caucasian 2675-86. Recommendations And Reports / Centers For young adult women. Journal of pediatric and 3) HPV vaccines. 2015; Available from: http:// Disease Control, 2014. 63(-05): p. 1-30. adolescent gynecology, 2014. 27(2): p. 83-92. www.cdc.gov/vaccines/vpd-vac/hpv/vac-faqs. 8) CDC, Fainting (syncope) after vaccination. 12) Bednarczyk, R.A., et al., Sexual Activity-Re- htm. 2015. lated Outcomes After Human Papillomavirus 4) Noronha, A.S., L.E. Markowitz, and E.F. 9) Human papillomavirus vaccination cover- Vaccination of 11- to 12-Year-Olds. Pediatrics, Dunne, Systematic review of human papilloma- age among adolescent girls, 2007-2012, and 2012. 130(5): p. 798-805. virus vaccine coadministration. Vaccine, 2014. postlicensure vaccine safety monitoring, 13) Casciotti, D.M., et al., Discussions of adoles- 32(23): p. 2670-2674. 2006-2013 - United States. MMWR.Morbidity cent sexuality in news media coverage of the 5) Petrosky, E. and e. al, MMWR Recomm Rep, And Mortality Weekly Report, 2013. 62(29): HPV vaccine. Journal of adolescence, 2014. 2015. 64(11): p. 300-304. p. 591-595. 37(2): p. 133-143. 6) Ali, H., et al., Genital warts in young Austra- 10) Rahman, M., C.J. McGrath, and A.B. Beren- 14) Ylitalo, K.R., H. Lee, and N.K. Mehta, lians five years into national human papil- son, Geographic variation in human papil- Health care provider recommendation, human lomavirus vaccination programme: national lomavirus vaccination uptake among 13-17 papillomavirus vaccination, and race/ethnic- surveillance data. BMJ, 2013. 346: p. f2032. year old adolescent girls in the United States. ity in the US National Immunization Survey. 7) Markowitz, L.E., et al., Human papillomavirus Vaccine, 2014. 32(21): p. 2394-2398. American Journal of Public Health, 2013. vaccination: recommendations of the Advisory 11) Pierre Joseph, N., et al., Racial and ethnic 103(1): p. 164-169. Committee on Immunization Practices (ACIP). differences in HPV knowledge, attitudes, and

Page 22 Nebraska Medicine | Summer 2015

Vaccine hesitancy and strategies to address it (continued) sion about the issues are vital in influenc- around vaccine hesitancy so that they can 2009. Pediatrics 2010;125(4):654-659. 12) Vaccinophobia and vaccine controversies of the ing vaccine-hesitant parents. best serve their patients. l 21st century. Ed. Chatterjee A. Springer, New Summary , NY 2013. References 13) Hough-Telford C, Kimberlin D, O’Connor K. While a majority of health care pro- 1) Omer SB, Salmon DA, Orenstein WA, deHart MP, Vaccine refusals and requests for alternate vaccine schedules (AVS): National surveys of pediatricians. viders report encountering vaccine hesi- Halsey N. Vaccine refusal, mandatory immuniza- tion, and the risks of vaccine-preventable diseases. Available at https://www.aap.org/en-us/profession- tancy, only a small minority of parents NEJM 2009;360(19):1981-1988. al-resources/Research/pediatrician-surveys/Pages/ Vaccine-Refusals.aspx Accessed June 29, 2015. refuse all vaccines for their children.19 It 2) Larson HJ, Jarrett C, Eckersberger E, Smith DM, Paterson P. Understanding vaccine hesitancy around 14) Kempe A, O’Leary ST, Kennedy A, Crane LA, is heartening to note that between a third vaccines and vaccination from a global perspective: Allison MA, Beaty BL, Hurley LP, Brtnikova M, Jimenez-Zambrano A, Stokley S. Physi- to half of initially vaccine-hesitant parents a systematic review of published literature, 2007- 2012. Vaccine 2014;32(19):2150-2159. cian response to parental requests to spread out ultimately accept vaccines that are recom- 3) Gust DA, Darling N, Kennedy A, Schwartz B. the recommended vaccine schedule. Pediatrics 2015;135(4):666-77. mended by their health care providers, Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics 2008;122(4):718-725. 15) Kluger J. Vaccinate or Leave. More pediatricians highlighting the important role of clini- 4) Robison SG, Groom H, Young C. Frequency of are firing families for not giving their kids shots. Available at http://content.time.com/time/maga- cians in influencing parental decision- alternative immunization schedule use in a metro- politan area. Pediatrics 2012;130(1):32-38. zine/article/0,9171,2088026,00.html Accessed making around immunizations.13,17 It is 5) Dempsey AF, Schaffer S, Singer D, Butchart A, June 26, 2015. 16) Healy CM, Montesinos DP, Middleman AB. Par- also encouraging that despite health care Davis M, Freed GL. Alternative vaccination sched- ule preferences among parents of young children. ent and provider perspectives on immunization: providers feeling like they are swimming Pediatrics 2011;128(5):848-856. are providers overestimating parental concerns? Vaccine 2014;32(5):579-584. against it, the tide of vaccine hesitancy 6) McCauley MM, Kennedy A, Basket M, Sheedy K. Exploring the choice to refuse or delay vaccines: a 17) Opel DJ, Heritage J, Taylor JA, et al. The may actually be turning. For example, in national survey of parents of 6- through 23-month- architecture of provider-parent vaccine discus- sions at health supervision visits. Pediatrics the wake of the recent Disneyland associ- olds. Academic Pediatrics 2012;12(5):375-383. 7) WHO: Immunization, Vaccines and Biologicals, 2013;132(6):1037-1046. ated outbreak of measles that ultimately SAGE working group dealing with vaccine hesi- 18) Sarnquist C, Maldonado YA. Communicating vaccine risks and benefits. In: Vaccinophobia and infected more than 150 people, the tancy. Available at http://www.who.int/immuniza- tion/sage/sage_wg_vaccine_hesitancy_apr12/en/ vaccine controversies of the 21st century. Ed. legislature in California moved swiftly Accessed June 26, 2015. Chatterjee A. Springer, , NY 2013, pp 87-95. to require mandatory vaccinations for 8) Leask J, Kinnersley P, Jackson C, Cheater F, Bed- ford H, Rowles G. Communicating with parents 19) Seither R, Masalovich S, Knighton CL, et al. all children enrolled in schools, except about vaccination: a framework for health profes- Vaccination coverage among children in kin- dergarten - United States, 2013-14 school year. those with medical exemptions.20 Similar sionals. BMC Pediatrics 2012;12:154. 9) Diekema DS, American Academy of Pediatrics MMWR. Morbidity and mortality weekly report legislation is pending in several other Committee on . Responding to parental 2014;63(41):913-920. 20) Mason M. California legislature passes mandatory states. Despite this, health care provid- refusals of immunization of children. Pediatrics 2005;115(5):1428-1431. vaccination bill. Los Angeles Times Available at ers need to continue to keep themselves 10) Kennedy A, Basket M, Sheedy K. Vaccine atti- http://touch.latimes.com/#section/-1/article/p2p- 83887787/ Accessed June 29, 2015. updated on the science basis upon which tudes, concerns, and information sources reported by parents of young children: results from the vaccines are licensed and recommended, 2009 HealthStyles survey. Pediatrics 2011;127 the robust vaccine safety infrastructure, Suppl 1:S92-99. 11) Freed GL, Clark SJ, Butchart AT, Singer DC, and effective communication strategies Davis MM. Parental vaccine safety concerns in

Page 23 Nebraska Medicine | Summer 2015 Parental decisions to not vaccinate: is it time to take a stand or understand? (continued)

come frustrated with the lack of time to tant, conflicted and hesitant parents. But, Measuring vaccine hesitancy: The development of a survey tool. Vaccine; http://dx.doi.org/10.1016/j.vac- adequately address vaccine concerns much unless we are willing to open our minds cine.2015.04.037 less build a trusting relationship. In addi- to novel and contextually contemporary Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. (2012). Communicating with parents about tion, patients and providers are now being approaches to the vaccine hesitant parent vaccination: A framework for health professionals. encouraged to engage in a shared deci- then we will be witness to persistent BMC Pediatrics; 12,154 MacDonald NE, the SAGE Working Group on Vaccine sion making model of health care. This vaccine refusals and continued outbreaks Hesitancy (2015). Vaccine hesitancy: Definition, scope requires a pre-existing mutual reciprocity of vaccine preventable diseases. and determinants. Vaccine; http://dx.doi.org/10.1016/j. l vaccine.2015.04.036 and understanding that can create role Mergler MJ, Omer SB, Pan WKY, et al. (2013). References confusion and anxiety on the part of both Association of vaccine-related attitudes and beliefs American Academy of Pediatrics [AAP] (2005). between parents and health care providers. Vaccine; 31, groups. For example, there will likely be Responding to parental refusals of immunizations of 4591-4595. children. Pediatrics, 115(5), 1428-1431. conflict if a beneficent provider encoun- Opel DJ, Mangione-Smith R, Talor, JA et al. (2011). American Academy of Pediatrics [AAP] (2013). Reaf- Development of a survey to identify vaccine-hesitant ters an autonomy-seeking parent. This firmation: Responding to parental refusals of immuniza- parents. Human Vaccines & Immunotherapeutics; 7(4): discord serves little purpose as the parent tions of children. Pediatrics, 131, e1696. 419-425. leaves unsatisfied and all too often with an Benin, AL, Wisler-Scher DJ, Colson E, Shapiro, ED, Opel DJ, Taylor, JA, Zhou, C et al. (2013). The Holmboe ES (2006). Qualitative analysis of mothers’ relationship between parent attitudes about childhood unvaccinated child. decisions-making about vaccines for infants: The im- vaccines survey scores and future child immunization portance of trust. Pediatrics, 117(5), 1532-1541. status: A validation study. JAMA Pediatrics; 167 (11), 1065-1071. Conclusion Brown, KF, Kroll JS, Hudson MJ, et al. (2010). Fac- In order to increase vaccination rates tors underlying parental decisions about combination Pichichero, ME. It’s time to take a stand against vaccine childhood vaccinations including MMR: A systematic refusers (2015).. Pediatric News; (March): 14. review. Vaccine; 28(26), 4235-4285 and sustain confidence in vaccination Sadaf A, Richards JL, Glanz J, et al. (2013). A systemat- programs pediatric health care providers Centers for Disease Control and Prevention [CDC] ic review of interventions for reducing parental vaccine (2014). Vaccination coverage among children in kinder- refusal and vaccine hesitancy. Vaccine; 31, 4293-4304. must develop appropriate strategies and garten—United States, 2013-14 school year. MMWR, Sarnquist C, Sawyer M, Calvin K, et al.(2013). Com- 63 (41), 913-920. policies to address the parental concerns municating about vaccines and vaccine safety: What Centers for Disease Control and Prevention [CDC] are medical residents learning and what do they want about vaccinations that may lead to delays, (2015a). Measles—United States, January 4—April 2, to learn? Journal of Public Health Management Prac- altered schedules, and/or refusal of vac- 2015. MMWR, 64 (14), 373-376. tice;19 (1),40-46 Centers for Disease Control and Prevention [CDC] Shelby A, Ernst K. (2013). Story and science: How cines (Larson et al, 2015). The growing (2015b). Measles cases and outbreaks. Retrieved from providers and parents can utilize storytelling to combat phenomenon of vaccine-hesitant parents http://www.cdc.gov/measles/cases-outbreaks.html anti-vaccine . Human Vaccines & Im- munotherapeutics; 9(8),1795-1801. has generated significant debate among Centers for Disease Control and Prevention [CDC] (2015c). Pertussis outbreak trends. Retrieved from Siddiqui M, Salmon DA, Omer SB. (2013). Epidemiol- pediatric health care providers. There are http://www.cdc.gov/pertussis/outbreaks/trends.html ogy of vaccine hesitancy in the United States. Human Vaccines & Immunotherapeutics; 9(12), 2643-2648. experts in the area of pediatric vaccine Dube´ E, Gagnon D, MacDonald NE, the SAGE Working Group on Vaccine Hesitancy (2015). Strate- Smith PJ, Kennedy AM, Wooten K, Gust DA, Picker- research who proclaim it is time to “take a gies intended to address vaccine hesitancy: Review of ing LK.(2006). Association between health care provid- published reviews. Vaccine, http://dx.doi.org/10.1016/j. ers’ influence on parents who have concerns about stand against vaccine refusers” (Pichichero, vaccine.2015.04.041 vaccine safety and vaccination coverage. Pediatrics; 118 (5): e1287-e1292 2015). They feel that the public health Dube´ E, LaBerge C, Guay M et al.(2013). Vaccine threat of unvaccinated children outweighs hesitancy: An overview. Human Vaccines & Immuno- Williams SE, Rothman RL, Offit PA et al. (2013). A therapeutics; 9(8), 1763-1773. randomized trial to increase acceptance of childhood vaccines by vaccine-hesitant parents: A pilot study. the individual rights of parents to choose. Gust, DA, Darling N, Kennedy A, Schwartz, B (2008). Academic Pediatrics; 13(5): 475-480. In the other camp are the pediatric health Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics; 122 (4), 718-725. Additional recommended reading: care providers who approach the parent Healy CM, Montesinos DP, Middleman AB (2014). How to communicate with vaccine-hesitant parents “where they are at” on the continuum of Parent and provider perspectives on immunization: are http://pediatrics.aappublications.org/content/127/ providers overestimating parental concerns? Vaccine; Supplement_1/S127.long vaccine decision making with the hope 32(5),579-584. American Academy of Family Physicians Child and of continuing to influence the parent to Henrikson NB, Opel DJ, Grothaus L, et al. (2015). Adolescent Immunization Office Champions Project Physician communication training and parental vaccine http://docs.google.com/viewerng/viewer?url=http:// eventually agree to vaccinate. It remains to hesitancy: A randomized trial. Pediatrics; 136 (1): doi www.aafp.org/dam/AAFP/documents/patient_care/im- be seen which approach is most successful 10 1542/peds 2014-3199. munizations/office-champions-final-report.pdf in increasing vaccine uptake among reluc- Larson HJ, Jarrett C, Schulz WS et al. (2015).

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Seeking Family Practice/ OB Physician Kearney Clinic located in Kearney Nebraska is seeking a full time Family Practice/OB physician. Kearney Clinic is a multi-specialty physician owned group consisting of 25 physicians. Specialties include: Family Practice with OB,Pediatrics, General Surgery and Vascular Surgery. Interested applicants should submit resume to: Family Practice Physician Position Attn:Administrator Kearney Clinic 211 West 33 St. Kearney,NE 68845

Page 25 Nebraska Medicine | Summer 2015 Focus on 5 Things You Can Control for Better Investment Results

by Ross Polking not increase the likelihood of success by allocation to apply across the entirety of Provided by the Foster Group choosing to get market-like returns? our accounts (401k, IRA, personal, trust) • Investors can diversify their portfolios. creates the risk and return profile of our ny golfers out there? Earlier this Effective diversification involves more total investment portfolio. Rebalancing Aspring I read Golf Is Not a Game of than having six mutual funds in a portfo- our total portfolio at regular intervals or Perfect (describing my game perfectly!) by lio. The global opportunity for investors according to pre-determined tolerances, sports psychologist Dr. Bob Rotella. In the today is enormous, with over half of all maintains stock-to-bond, domestic-to- book, he emphasized focusing on things available stock market value, and over foreign and other purposefully selected within the golfer’s control to achieve better two-thirds of all bond issuance, occur- ratios, managing the risk and return results. Rather than worrying about wind, ring outside the United States. The free profile of our investments over time. what other players are doing, or complain- flow of capital allows investors to access Maintaining appropriate cash and liquid ing about the speed of the greens or depth and benefit from thousands of possible assets to fund near- and intermediate- of the rough, he encouraged golfers to keep investments. term cash flow requirements is also in an a good attitude, follow a pre-shot routine, • Investors can lower the costs associated investor’s control. choose only to play a shot they have confi- with their investments. The average By choosing to focus on things within dence in, and focus on the smallest target. managed U.S. stock mutual fund has an our control as investors, we can signifi- Rotella’s advice regarding focusing on internal expense ratio of over 1.2% annu- cantly raise the probability of our long-term what golfers can control has some helpful ally. An index or asset class fund designed success as well as reduce the worry and parallels to achieving better investment to track the entire U.S. stock market can anxiety associated with those things we can’t results. be found today with an expense ratio control. First, what are things beyond the inves- of less than 0.10% annually. All things PLEASE NOTE LIMITATIONS: Please see tor’s control and, therefore, not helpful to being equal, the lower cost investor starts Important Educational Disclosure Information and the focus on? The daily direction of world stock limitations of any ranking/recognitions, at out with a 1.1% return advantage each www.fostergrp.com\disclosures. A copy of our current markets is beyond an investor’s control. year! Vanguard Chairman John Bogle’s written disclosure statement as set forth on Part 2A of Form ADV is available at www.adviserinfo.sec.gov. Interest rates are beyond an investor’s maxim still bears repeating, “The return control. Geo-political events are beyond of the market LESS COSTS equals the Foster Group Inc. is a fee-only investment an investor’s control. While there is plenty return to the investor.” adviser firm providing a holistic approach to wealth management and financial planning, of media attention given to these things, • Investors can use structure to manage as well as traditional investment and portfolio focusing on trying to control or predict risk and return. While no one seems able management offerings. The firm has more these things does not enhance an investor’s to predict what will happen from year than $1.4 billion in assets under management performance. Most often, it leads to worse to year in investment markets, the larger and services more than 900 clients across 39 performance and increased worry. body of academic work available today states, with a specialization for clients in the What is controllable by an investor and, indicates that investors can raise their medical profession. For more information please visit www.fostergrp.com/nma or call therefore, helpful to focus on? expected return in equities by emphasiz- 1-844-437-1102. • Investors can let markets work for them. ing value, company size (small), and The information and material provided Rather than trying to beat a market, stocks with certain profitability measures in this article is for informational purposes and investors today can make markets and in their portfolios. These “factors” can be is intended to be educational in nature. We asset classes their allies by investing in quantified and are available to investors recommend that individuals consult with a funds that closely track them. Research in a similar way to global diversification. professional advisor familiar with their particu- continues to show that markets regularly • Finally, investors can choose to effectively lar situation for advice concerning specific investment, accounting, tax, and legal matters beat the majority of managers, so why execute their portfolio. Choosing an asset before taking any action.

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