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Adult Vaccines and Vaccine Controversies

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Adult Vaccines and Vaccine Controversies Adult Vaccines and Vaccine Conflicts: Controversies Speakers Bureau for Allergan Michael Angarone, DO Pharmaceuticals Assistant Professor Division of Infectious Diseases Northwestern University Feinberg School of Medicine @mangarone23 Objectives Vaccines • Vaccines are one of the great public health achievements of the 20th century. 1. Understand the anti‐vaccine controversy • Vaccines are safe and effective. 2. Describe the safety and risks of vaccination • They are neither perfectly safe nor perfectly effective. 3. Recognition of Measles and understand appropriate reporting and - Vaccine Adverse Effects Reporting Service (VAERS): 40,588 US management strategies reports of AEs following immunization annually 4. Review the adult vaccine recommendations by the CDC • To put the number of reports of AEs in perspective • Each year over 317 million doses of vaccine are distributed in the US • Type and severity of events reported vary from minor local reactions to death • 2012 and 2016, 0.4% reported death, 5% reported a serious nonfatal AE, and 94.6% reported non‐serious AE https://www.cdc.gov/vaccines/pubs/surv‐manual/chpt21‐surv‐adverse‐events.html#f2 Vaccine benefits Comparison of Pre‐Vaccine and Current Reported Morbidity of Vaccine‐ Preventable Diseases and Vaccine Adverse Events, U. S. • Reduction in multiple infectious disease Disease Pre‐vaccine 2014 Vaccine % decrease Era date(s) • Reduction in morbidity form these diseases Diphtheria 175,885 1 1928‐1943 99 • Reduction in mortality form these disease Measles 503,282 667 1963 99 • Near eradication of certain disease Mumps 152,209 1223 1940s 99 - Polio is now rare in the developed world and continues to Pertussis 147,271 32,971 1914 77 decrease in the developing world Polio (paralytic) 16,316 0 1955 100 - Eradication of Smallpox: last case 1977, certified eradicated 1979 Rubella 47,745 11 1969 99 - Potential to eradicate other infections as well Tetanus 1314 25 1933 98 H. influenzae type b 20,000 306 1985 98 Roush, et al JAMA 2007;298:2155‐63 https://www.cdc.gov/vaccines/pubs/surv‐manual/chpt21‐surv‐adverse‐events.html#f2 Varicella Vaccine Polio Vaccine Measles Vaccine Rubella Vaccine Why the push back and opposition to Mumps Vaccine vaccines? MMWR 2013;62(RR04);1‐34 N Engl J Med 2005;352:450‐8 What is the Controversy with Vaccines • Fear of vaccination has been present since the 19th C. - Vaccines referred to as “the devil’s work” • 20th C. vaccines become more widespread and mandatory in children - London: Anti‐Vaccination League • Mission: protect individual liberties form being “invaded” by government • Fear of adverse effects of vaccine - 1980s United Kingdom marked reduction in Pertussis vaccination • Due to reports of neurologic adverse effects • Vaccine rates decreased form 81% in 1974 to 31% 1980 Vaccine Controversies • Vaccine overload –too many vaccines given early in childhood “overload” and MMR Vaccine and Autism “overwhelm” the immune system • Initiated by Andrew Wakefield and colleagues - It is estimated the immune system can respond to >10,000 antigens • Thimerosal –the mercury based preservative increases the risk of autism and other - Wakefield AJ, Murch SH, Anthony A, et al. Ileal‐lymphoid‐nodular hyperplasia, neurodevelopmental diseases non‐specific colitis, and pervasive developmental disorder in children. - Contains ethylmercury (not methylmercury) which does not accumulate • Refuted by - After thimerosal removal, autism rates continued to increase - Institutes of Medicine (IOM) • Aluminum – accumulation can lead to auto‐immune diseases - Centers for Disease Control and Prevention (CDC) - Aluminum containing vaccines led to AL levels well below toxic levels - National Institutes of Health (NIH) • Vaccination can cause: - Food and Drug Administration - SIDS, epileptic seizures, allergies, MS, type 1 DM, and transmit bovine spongiform • encephalopathy, hepatitis C virus, and HIV Editors of BMJ declared Wakefield’s work “an elaborate fraud” Lancet 1998: 351(9103): 637–41 BMJ 2011;342:c7452 Vaccine Failures • 1901‐ St. Louis incident: diphtheria antitoxin contaminated with tetanus - 13 children died of tetanus (DeHovitz Pediatrics 2014;133(6):964‐5) • 1929 – Lubeck Disaster: 251 infants vaccinated with BCG contaminated with virulent stain of M tuberculosis - 245 developed tuberculosis, 72 died (Fox et al PLoS Pathog 2016;12(1):e1005271) • 1955 –Cutter Incident: Cutter Laboratories produced 120,000 doses Salk polio vaccine, some contaminated with live polio virus - 40,000 cases of polio, 53 cases paralysis, 5 deaths (Fitzpatrick, M J R Soc Med 2006;99(3):156) - Secondary spread lead to 113 additional cases or paralytic polio and 5 deaths • 2017 – Dengvaxia Controversy - Philippine DOH launched a Dengue vaccine campaign - Risk of severe Dengue increase in children with no prior history of Dengue; led to 10 deaths (Fatima et al J Glob Health 2018;8:020312) Vaccine Hesitancy Events Following Reductions in Vaccination • Estimated that 5‐10% of the US population have strong anti‐vaccine convictions • Smallpox epidemic: Stockholm (1873‐74) • Many more are “vaccine hesitant” • Pertussis epidemics: UK, Sweden (1970s‐1990s) • Vaccine hesitant individuals • Measles epidemics: Netherlands, UK and Ireland (1999‐2000); U.S. (2005, 2013‐ - May refuse some vaccines, but agree to others present) - May delay vaccines or accept vaccines according to the recommended • Polio resurgence: Nigeria (2001‐ 2013) schedule, but be unsure in doing so • Cause is multifactorial - Trust or mistrust for the medical establishment - Personal beliefs regarding vaccines - True and perceived problems with vaccines - Media influence (news media, social media, etc.) Dube et al Hum Vaccin Immunother 2013;9(8):1763‐77 How to Enhance Vaccine Acceptance Healthcare Provider Communication Tips • Population level • Provide reassurance that the patient’s, or their child's, health is your top priority - Transparency in policy‐making decisions regarding vaccination programs • Emphasize that as a health care provider, your personal and professional opinion us - Education and information about the rigorous process that leads to approval of new that vaccines are safe and important in preventing disease vaccines • Remind patients that there are ongoing efforts by the FDA and CDC to ensure the - Diversified post‐marketing surveillance of vaccine related events safety of vaccines • Individual level • Remind the patient that multiple years of study of the various ingredients in vaccines - Listening to the concerns of the individual have not been found to be harmful to humans - Understanding the perceptions of the individual • Provide information to the patient on the seriousness of vaccine preventable - Incorporate public perspectives in planning vaccine policies and programs diseases • Provider level • Acknowledge that symptoms of autism spectrum disease coincides with timing of - Research to understand doubts regarding the safety and effectiveness of vaccination vaccines, but well designed studies have shown no link between MMR and autism Dube et al Hum Vaccin Immunother 2013;9(8):1763‐77 Tan, TQ, et al The Vaccine handbook: A Practitioner’s Guide to Jacobson et al Mayo Clin Proc 2015;90(11):1562‐8 Maximizing Use and Efficacy across the Lifespan, Oxford Press Which statement about measles infection is true: A. A person with measles infection is contagious only during the period of a visible rash B. The manifestation of a rash marks the end of the contagious period for Measles: Diagnosis & Recognition measles C. A single person can infect as many as 15 other individuals D. The primary route of transmission of measles is via direct contact and/or fomites Measles Infection • Highly contagious Which statement about measles infection is true: • Became a disease in humans 5000‐10,000 years ago • Prior to vaccine introduction, leading cause of childhood morbidity and A. A person with measles infection is contagious only during the period of a mortality visible rash • Still remains an important vaccine preventable illness B. The manifestation of a rash marks the end of the contagious period for - >100,000 deaths/year worldwide measles • WHO data: C. A single person can infect as many as 15 other individuals - Doubling of cases form 2018 to 2019 D. The primary route of transmission of measles is via direct contact and/or fomites • 2018: 250,677 cases • 2019: 568,573 cases - 80% decrease in deaths from 2000 to 2017 (545 000 to 110 000) Moses WJ Lancet 2017;390(10111):2490‐2502 https://www.who.int/news‐room/fact‐sheets/detail/measles Measles Cases: United States of America: Aug 2017 to Sept 2019 400 Year Confirmed Cases 2008 140 300 2009 71 2010 63 200 2012 55 2013 188 100 2014 668 Number of cases Number 2015 208 0 2016 80 2017 120 Discarded 2018 372 Clinical 2019 1234 Epi 2017-08 2017-09 2017-10 2017-11 2017-12 2018-01 2018-02 2018-03 2018-04 2018-05 2018-06 2018-07 2018-08 2018-09 2018-10 2018-11 2018-12 2019-01 2019-02 2019-03 2019-04 2019-05 2019-06 2019-07 2019-08 2019-09 Lab Month of onset https://www.who.int/immunization/monitoring_surveillance/burden/vpd/s https://www.cdc.gov/measles/cases‐outbreaks.html urveillance_type/active/measles_monthlydata/en/ Measles in 2019 • Greatest number of cases since 1992 in US • >75% of the cases linked to outbreaks in New York • Majority of cases are among people who were not vaccinated against measles • As of September 26, 2019, - 131 of the people hospitalized - 65 reported having complications, including pneumonia and encephalitis. https://www.cdc.gov/measles/cases‐outbreaks.html
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