Child : United States VS. Philippines

Matthew Quillen | Dr. Caprice Knapp HPA 499 | Health and Health Systems in the Philippines The Pennsylvania State University | Spring 2016

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Abstract

Participating in the HPA 499: Health and Health Systems in the Philippines study abroad program was an amazing experience. While in country, we were able to immerse ourselves in their health care system and overall culture. To more fully understand the Filipino health care system, our group visited numerous private and public health care clinics and hospitals. There is a large distinction between the private and public healthcare sector in the Philippines. Subsequently, the level of care received can vary greatly depending on a citizen’s income, level of insurance coverage, etc. This directly correlates with the children receive and the rate at which children in country are “fully-immunized”. We were given a lecture at St. Paul’s University-Iloilo on the type of immunizations Filipino children receive, however the extent at which these children actually receive the varies by socioeconomic status. While similarities can be drawn between the type of vaccines children in both the U.S. and Philippines receive, finance and access issues make it harder for children in the Philippines to obtain proper immunizations. Overall, my experience visiting both public and private clinics and hospitals in the Philippines was informative. I was able to more fully understand the Filipino health care system in terms of public vs. private sector, thus informing me as to why the Philippines might struggle to fully immunize children.

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United States Children Immunizations

There are numerous vaccines recommended for children from birth to the age of six (as referenced in the Appendix on a chart published by the Center for Disease Control and Prevention). While each state in the U.S. has its own requirement to attend kindergarten and public school, most states require that a child receive DPT, , MMR, and Varicella (or Chicken Pox) immunizations. These immunizations can also be referenced in the personal immunization medical record provided in the Appendix.

Philippines Children Immunizations

Immunizations recommended by the Philippine Foundation for include MMR, Varicella, and DPT amongst others (referenced in the Appendix on the Childhood Immunization Schedule 2015). Additional vaccines such as typhoid, cholera, pneumococcal, and meningococcal are recommended for special groups or “at-risk” children depending on their place of residence.

Social Controversy Surrounding U.S. Childhood Immunizations

While the benefits of early childhood vaccination are apparent, a certain level of controversy surrounds the idea of vaccinating children at such an early age. Ultimately, a majority of U.S. citizens realize the rarity of complication and how the possibility of injuries related to vaccination are unimportant in comparison to the benefits vaccines provide individuals (Vaccine Awareness of North Florida, 2010). Indeed, CNN Health reports that 95% of children in U.S. kindergarten have had vaccines for preventable diseases (CNN, 2015).

However, CNN states that those children are not spread evenly across the country. Colorado, for example, reports 82% of children receive proper MMR vaccination whereas Mississippi reports a 99.7% MMR vaccination rate. In total, a surprising 26 states have not reported meeting the 95% MMR vaccination rate set by the federal government (CNN, 2015).

Parents present a wide variety of reasons for not properly vaccinating their children. Most notable, perhaps, was the perceived link that certain vaccine components had with autism diagnosis. Jenny McCarthy, an American actress and model, was most vocal in her concern about the vaccine-autism link following her son being diagnosed with autism at the age of 2 and 1/2. Though she stresses that her movement is “not anti-vaccine” (PBS, 2015), McCarthy’s vocal remarks against vaccination held weight within the realm of American media (and perhaps lends itself to decreased MMR vaccination rates, seeing as McCarthy notes her sons diagnosis immediately followed his MMR vaccine). Since McCarthy’s remarks, the CDC has CHILD IMMUNIZATION COMPARISON Quillen 4 made sure to cite research denoting the link between (CDC, 2015), however the stigma surrounding the vaccine remains.

Other reasons parents cite backing their decision not to fully vaccinate their children, though denoted by the National Institute of Health (NIH), are listed in the table below alongside NIH published responses:

Parents’ Reason against Vaccination NIH Published Response Young children receive too many Adverse effects from vaccines are mild in vaccines (19 injections in the first 2 years comparison to the effects that infectious of life is recommended by CDC) diseases would have on the child Child will not be having premarital sex The Hep B vaccine is administered to thus they do not need the Hep B vaccine combat “high risk behaviors”, which include attending school and playing sports (not just sexual contact) Child has died from DPT Vaccine DPT Vaccine has a 1% mortality rate in early infancy while Pertussis remains a serious threat poses threats but Pneumococcal Vaccine protects against does not protect against all symptoms of the most virulent serotypes of Strep as Strep throat opposed to common ones. Since 2000, the incidence of Strep has decreased by 80% for those under 2 years of age Flu Shot Contains Thimerosal which can Theories linking Thimerosal to brain lead to brain damage damage are unsubstantiated. Infants exclusively breast-fed are exposed to 15 times the mercury found in the flu shot My child should get natural chicken pox Varicella (chicken pox) cost society $399 so it won’t recur in Adulthood when it is million per year in the United States more dangerous

Table: Cites U.S. parents’ reasoning against vaccination along with the National Institute of Health’s response to said opposition (http://www.ncbi.nlm.nih.gov /pmc/articles/PMC3096324/)

Controversy Surrounding Filipino Childhood Immunization

Similar to the United States, the Philippines have seen some opposition to childhood vaccination based upon myths. While doctors cite major problems with obtaining enough resources and reaching enough of the population, they also note a challenge of administering proper vaccination to be the myths and speculations surrounding immunization. Misguided concerns not grounded on CHILD IMMUNIZATION COMPARISON Quillen 5 science and research, doctors note, distract some of the general public from receiving proper vaccination (Cruz, 2015).

In the Philippines, a link between Autism and the MMR vaccine is also prevalent. While the World Health Organization says there is no scientific evidence to support claims that MMR may be a risk factor for autism, some Filipinos still have a problem giving the MMR vaccine to their child.

More specific to the Philippines might be their issue with administering the HPV vaccine. While reasons against vaccination remain the same (parents do not think child will be sexually active), the health outcomes of those decisions are more prevalent in the Philippines. About 12 Filipino women die daily because of cervical cancer, which is known to be caused by HPV in most cases (Cruz, 2015). Overall, studies show that cervical cancer is the third leading cause of mortality among females in the Philippines (Cruz, 2015). This lends itself to a mortality rate of 1 per 10,000 women in the country. Dr. Rosa Maria Nancho, an adviser of the Society of Adolescent medicine of the Philippines, states that doctors should no longer present the HPV vaccine as optional. “We really need to improve our communication. The HPV vaccine is presented as optional. Now, we are trying to teach our doctors. They should not say there are other options….They have to be very firm” (Nancho, 2015). She then goes on to say, “Doctors sometimes want to please their clients. It should not be the case. Doctors have to be really firm (in their administering of )”.

While simple change of mindset may not be the best way to combat this problem, the Philippines Health Department is taking measures to improve HPV vaccination rates specifically. The Health Department plans to provide HPV vaccines to Grade 4 female students in the 20 poorest provinces in 2015 (Cruz, 2015). Health Secretary Janette Garin made remarks in response to the Health Department’s initiative: “It will not be implemented on a nationwide basis because our funds are limited at the moment…We are correlating HPV vaccination with the socio-economic strata of the province because cervical cancer is one of those that have created a huge reduction in terms of upliftment from poverty” (Cruz, 2015).

Conclusion

Relating the United States and Philippines Controversies

It is evident that both countries have a similar problem with controversy surrounding proper childhood vaccination. Ultimately, social myths stemming from misguided and uneducated comments have surfaced unnecessary problems with vaccines. However, a distinction can be drawn between the two countries’ issues. While the United States has a problem with the controversy, government mandated programs (i.e. requiring parents to show immunizations when they CHILD IMMUNIZATION COMPARISON Quillen 6 enroll in schools) paired with the NIH denoting blatant myths help thwart the problem.

The Philippines, on the other hand, does not have similar mandates. They do not always require proof of immunization. Additionally, only 2 of 10 children attend pre-school or day care services in the Philippines (which may lead to low immunization rates at an early age) (Unicef, 2016). On top of that, problems with finances and access make it even harder vaccinate children. While controversy surrounding vaccination may seem like less of a social issue in the Philippines (more of a financial issue), all factors seem to play a role in the problems the country is having with proper vaccination (70% fully-immunized children compared to the United States 90%). Increased requirement of proof of immunization or similar NIH type studies backing full immunization may help the Philippines increase the prevalence of vaccinated children.

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AppendixAt 1 month of age, HepB (1-2 months), At 2 months of age, HepB (1-2 months), DTaP,2016 PCV, Hib, Polio, Recommended Immunizations for Children from Birth Through 6 Years Old and RV At 4 months of age, DTaP, PCV, Hib, Polio, and RV At 6 months of age, HepB (6-18 months), DTaP, PCV, Hib, Polio (6-18 months), RV, and Infuenza 1 2 4 6 12 15 18 19–23 (yearly, 6 months through 18 2–3 4–6 years)* Birth month months months months months months months months years years At 12 months of age, MMR (12-15 HepB † HepB HepB months), PCV (12-15 months) , Hib (12-15 months), Varicella (12-15 months), HepA (12-23 RV RV RV months)§, and Infuenza (yearly, 6 months through 18 years)* DTaP DTaP DTaP DTaP DTaP At 4-6 years, DTaP, IPV, MMR, Varicella, and Infuenza (yearly, 6 Hib Hib Hib Hib mnthso through 18 years)* Is your family PCV PCV PCV PCV growing? To protect your new baby and

yourself against whooping IPV IPV IPV IPV cough, get a Tdap vaccine * in the third trimester Infuenza (Yearly) of each pregnancy. Talk to your doctor for more MMR MMR details. Varicella Varicella Shaded boxes indicate the vaccine can be given during HepA§ shown age range.

NOTE: If your child misses a shot, FOOTNOTES: * Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years of See back page you don’t need to start over, age who are getting an infuenza (fu) vaccine for the frst time and for some other children in this age group. for more just go back to your child’s information on § Two doses of HepA vaccine are needed for lasting protection. The frst dose of HepA vaccine should be doctor for the next shot. given between 12 months and 23 months of age. The second dose should be given 6 to 18 months later. vaccine- Talk with your child’s doctor HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and preventable if you have questions adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA. about vaccines. diseases and the I f your child has any medical conditions that put him at risk for or is traveling outside the vaccines that United States, talk to your child’s doctor about additional vaccines that he may need. prevent them.

For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit http://www.cdc.gov/vaccines Vaccine-Preventable Diseases and the Vaccines that Prevent Them Disease Vaccine Disease spread by Disease symptoms Disease complications Infected blisters, bleeding disorders, encephalitis (brain protects against chickenpox. Air, direct contact Rash, tiredness, headache, fever Chickenpox swelling), pneumonia (infection in the lungs) Sore throat, mild fever, weakness, swollen Swelling of the heart muscle, heart failure, coma, DTaP* vaccine protects against . Air, direct contact Diphtheria glands in neck paralysis, death Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis protects against Haemophilus May be no symptoms unless Air, direct contact (life-threatening infection that can block the windpipe Hib infuenzae type b. enter the blood and lead to serious breathing problems), pneumonia (infection in the lungs), death May be no symptoms, fever, stomach pain, Direct contact, contaminated Liver failure, arthralgia (joint pain), kidney, pancreatic, HepA vaccine protects against hepatitis A. loss of appetite, fatigue, vomiting, jaundice Hepatitis A food or water and blood disorders (yellowing of skin and eyes), dark urine May be no symptoms, fever, headache, Contact with blood or HepB vaccine protects against . weakness, vomiting, jaundice (yellowing of Chronic liver infection, liver failure, liver cancer Hepatitis B body fluids skin and eyes), joint pain Fever, muscle pain, sore throat, cough, Flu vaccine protects against influenza. Air, direct contact Pneumonia (infection in the lungs) Infuenza (Flu) extreme fatigue Encephalitis (brain swelling), pneumonia (infection in MMR** vaccine protects against measles. Air, direct contact Rash, fever, cough, runny nose, pinkeye Measles the lungs), death Meningitis (infection of the covering around the brain Swollen salivary glands (under the jaw), fever, MMR**vaccine protects against mumps. Air, direct contact and spinal cord) , encephalitis (brain swelling), inflam- Mumps headache, tiredness, muscle pain mation of testicles or ovaries, deafness DTaP* vaccine protects against pertussis Severe cough, runny nose, apnea (a pause in Air, direct contact Pneumonia (infection in the lungs), death Pertussis (). breathing in infants) Air, direct contact, through May be no symptoms, sore throat, fever, Polio IPV vaccine protects against polio. Paralysis, death the mouth nausea, headache May be no symptoms, pneumonia (infection Bacteremia (blood infection), meningitis (infection of Pneumococcal PCV vaccine protects against pneumococcus. Air, direct contact in the lungs) the covering around the brain and spinal cord), death Rotavirus RV vaccine protects against rotavirus. Through the mouth Diarrhea, fever, vomiting Severe diarrhea, dehydration Children infected with rubella virus sometimes Very serious in pregnant women—can lead to miscar- MMR** vaccine protects against rubella. Air, direct contact Rubella have a rash, fever, swollen lymph nodes riage, stillbirth, premature delivery, birth defects Stiffness in neck and abdominal muscles, DTaP* vaccine protects against tetanus. Exposure through cuts in skin Broken bones, breathing difficulty, death difficulty swallowing, muscle spasms, fever * DTaP combines protection against diphtheria, tetanus, and pertussis. ** MMR combines protection against measles, mumps, and rubella. -BTUVQEBUFE+BOVBSZt$4% -

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Figure: CDC recommended Immunizations from Birth-6 Years (http://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf)

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Figure: Personal Immunization Record detailing all immunizations received from birth (Born 05/11/1995) (Personal Medical Record)

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Figure: Childhood (Birth to 18) Immunization Schedule for the Philippines (presented by the Philippine Foundation for Vaccination from http://www.philvaccine .org/vaccinat ion-sched ules/childhood-immunization- schedule)

Immunization U.S. Rate (% of children Philippines Rate (% of ages 12-23 months) children ages 12-23 months) DPT (Diphtheria, 94 79 Pertussis, Tetanus) Measles 91 88

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Table: Data regarding the percent of children vaccinated with certain immunizations by country

Reference

Bronfin, D. R. (n.d.). Childhood Immunization Controversies: What Are Parents Asking? Retrieved April 10, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096324/

FRONTLINE. (n.d.). Retrieved April 10, 2016, from http://www.pbs.org/wgbh/frontline/article/jenny-mccarthy-were-not-an-anti- vaccine-movement-were-pro-safe-vaccine/

Immunization, DPT (% of children ages 12-23 months). (n.d.). Retrieved April 10, 2016, from http://data.worldbank.org/indicator/SH.IMM.MEAS

Immunization, measles (% of children ages 12-23 months). (n.d.). Retrieved April 10, 2016, from http://data.worldbank.org/indicator/SH.IMM.MEAS

The unvaccinated, by the numbers. (n.d.). Retrieved April 10, 2016, from http://www.cnn.com/2015/02/03/health/the-unvaccinated/

Vaccination Facts. (n.d.). Retrieved April 10, 2016, from http://www.parents.com/health/vaccines/facts/vaccination-facts/

Vaccines Do Not Cause Autism. (2015). Retrieved April 10, 2016, from http://www.cdc.gov/vaccinesafety/concerns/autism.html

| K.N.O.W. Vaccines | KNOW...The Vaccine Controversy |. (n.d.). Retrieved April 10, 2016, from http://www.know-vaccines.org/?page_id=456