fears about vaccines 060210(2)

7/28/2019 Fears About Vaccines 060210(2)

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Parents vaccine fears,

and how to address them

Copyright 2010


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The issue

All pediatricians and public health authoritiesrecommend a series of immunizations for allchildren

Some parents refuse immunizations for theirchildren or want to alter the recommendedschedule

How should pediatricians respond to vaccinehesitancy or refusal?


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How common is vaccine refusal?

Survey of 2521 parents with children


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Results

11.5% of parents had refused at least one

recommended vaccine

Of those whod refused at least one:

56% HPV

32% varicella

32% meningococcal conjugate 18% MMR


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Parental views on vaccine safety

Vaccines offer good protection: 90%

I generally follow my doctors

advice on vaccines: 88%

Im concerned about adverse effects: 54%

Parents should have the right to

refuse any vaccines: 31%

Some vaccinations cause autism: 25%

My kids dont need to be vaccinatedfor rare diseases: 11%

Freed et al. Pediatrics. 2010.


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Why do parents refuse vaccines?

Common fears about vaccines Too many immunizations overwhelm the immune system

Vaccines (especially MMR) cause autism

Vaccines contain mercury Vaccine-induced immunity will wane. Natural infection is better

We address each of these


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Will multiple vaccinations,especially in one visit, impair a

babys immune system?


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The number of vaccinations over the last

century has steadily increased

Offit et al. Pediatrics. 2002.


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But the total number of proteins and

polysaccharides in the vaccines has

diminished dramatically

Offit et al. Pediatrics. 2002.


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Bottom line

Kids today get more vaccines but fewer antigens

to challenge their immune system

Their immune systems can handle it

The average child could respond adequately to

10,000 antigens at once

10 vaccinations use up about 0.1% of a childs

immunologic capability


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What about newborns with

impaired immune systems?


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Can immunization cause illness

A live-virus vaccine can cause illness in animmunocompromised baby

Live-virus vaccines are not routinelyrecommended before age 1*

Even for immunocompromised children, the riskfrom live-virus vaccines is generally lower thanrisk of disease

Check with an infectious disease specialist

*MMR is given to babies before international travel


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Does illness impede bodysability to react to antigen?


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Many studies have looked at this

Led to comprehensive report by the Institute of

Medicine:

Stratton KR, Wilson CB, McCormick MC.

Immunization safety review: MultipleImmunizations and Immune Dysfunction.

Institute of Medicine. Washington, D.C: National

Academy Press; 2002.

Studies find no increased risk of infectionfollowing multiple immunizations


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Study of vaccines and illness

496 children

randomized to early or late vaccination

Early group DPT/IPV at 60 days

Late group DPT/IPV at 90 days

Studied all illnesses before and afterimmunization in both groups

Otto et al. J Infect Dis. 2000.


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More illness before vaccines,

not after

Otto et al. J Infect Dis. 2000.


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Incidence of illness after MMR

2025 children 12-23 months who were admitted

with an infection

1865 control cases who had received an MMR

Compared the two groups to see if infection was

related to the MMR shot

Stowe at al. Vaccine. 2009.


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Infection rate lowest right after MMR

Stowe at al. Vaccine. 2009.


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MMR and autism

Association based upon one small study,

published in The Lancet, in 1998

Since then, numerous studies have been doneshowing no association, the Lancet study has

been retracted, and the author stripped of his

license in the UK


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MMR for kids with autism and

controls

DeStefano et al. Pediatrics. 2004.


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Danish study

Retrospective follow-up study

All 537,303 children born, 1991-98

440,655 (82%) had received MMR

316 children diagnosed with autism

422 children diagnosed with autism spectrum

disorders

Madsen et al. N Engl J Med. 2002.


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No association

between the age at the

time of vaccination,

the time since

vaccination, or the

date of vaccination

and the development

of autistic disorder.

Madsen et al. N Engl J Med. 2002.


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IOM review

No epidemiological evidence for

association or MMR and autism

No plausible biologic model No animal model

IOM

Immunization and safety review: vaccines and autismhttp://www.iom.edu/Reports/2004/Immunization-Safety-Review-Vaccines-and-Autism.aspx


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What about thimerosal?

Thimerosal is a mercury-containing preservative

that used to be in many vaccines

Since 2001, it is not used in any vaccine except

multi-dose vials of influenza vaccine

Gross L. PLoS Biol. 2009.


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Is natural disease better thanimmunization?


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Is natural disease better than

immunization?

Natural disease may confer more lasting

immunity (though not 100% immunity)

Natural disease associated with dangers that

are not seen with vaccines, e.g.

Mumps orchitis

Measles

meningitis Varicella pneumonia


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Does immunity wane?

Evidence for waning immunity with some

vaccines, not others

Varicella Pertussis


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Varicella rates rise in older children after vaccine introduced

Chaves et al. N Engl J Med. 2007.


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Risk of varicella infection increases with time after vaccination

Chaves et al. N Engl J Med. 2007.


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Pertussis cases on the rise in adolescents U.S. 2003

Hopkins RS, et al. Centers for Disease Control and Prevention. Summary of

notifiable diseases-United States 2003. MMWR 2005;52:55.


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Waning immunity in pertussis

CDC now recommends a second varicella

immunization at 4-6 years

Many countries now recommend pertussis re-immunization every 10 years

Lopez. Pediatrics. 2006.

AAP Committee on Infectious Disease. Pediatrics. 2006.


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Is two doses enough?


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Outbreak in Arkansas

Sept, 2006

97% of students had been vaccinated

39% had received two doses

Allowed comparison of 1 versus 2 doses

Gould et al. Pediatr Infect Dis. 2009.


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Outbreak in Arkansas

Of the 85 children who got varicella

53 had received one dose of vaccine

25 had received two doses 6 had no vaccine but prior varicella disease



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2nd dose increases immunity

Attack rates among children with:- One dose of vaccine and no disease history: 14.6%- Two doses and no disease history: 10.4%

Vaccine efficacy:- 85.4% among those with one dose

- 89.1% among those with two doses

Two doses better, but not 100% effective. Natural

immunity is not 100% effective, either.


M t di t i i h i


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Most pediatricians have experience

with vaccine hesitancy or refusal

74% of physicians have had parents refuse

vaccinations during the past year

16% of pediatricians refuse to continue caringfor vaccine refusers at least some of the time

32% of parents who initially refused a vaccinechanged their mind

American Academy of Pediatrics


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How to approach a resistant parent

Listen carefully and respectfully Honestly share what is and isnt known about risks

Discuss vaccines one by one

Present the risks of vaccine not in isolation, but compared

to risks of no vaccine Take steps to reduce the pain of the shots

Consider scheduling shots one at a time (even though thisis not recommended by the CDCs Advisory Committeeon Immunization Practices)

Diekema and Committee on Bioethics. Pediatrics. 2005.


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Approach to resistant parents

Keep talking about immunization at each visit; peoplechange their minds

Think very carefully before dismissing a family. Childrenneed and deserve access to good care, regardless of

their parents decisions about vaccination Contact state authorities only in the event of possible

imminent harm, like an outbreak of disease in thecommunity

Diekema and Committee on Bioethics. Pediatrics. 2005.

R


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ResourcesChaves SS, Gargiullo P, Zhang JX, Civen R, Guris D, Mascola L, Seward JF. Loss of vaccine-induced immunity to varicella over time. NEngl J Med. 2007 Mar 15;356(11):1121-9.Diekema DS. Choices should have consequences: failure to vaccinate, harm to others, civilliability. Michigan Law Review.

Diekema DS and AAP Committee on Bioethics. Responding to parental refusals ofimmunization of children.Pediatrics. 2005 May;115(5):1428-1431 .

Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Parental vaccine safety concerns in 2009.

Pediatrics. 2010 April;125(4): 654-9.Epub 2010 Mar 1.

Gross L.A broken trust: lessons from the vaccine-autism wars. PLoS Biol. 2009 May;7(5):1-7.

Madsen KM, Hviid A, Vestergaard M, Schendel D, Wohlfahrt J, Thorsen P, Olsen J, Melbye M. APopulation-Based Study of Measles, Mumps and Rubella Vaccine and Autism. N Engl J Med.2002 Nov 7;347(19):1477-82

Offit PA, Quarles J, Gerber MA, Hackett CJ, Marcuse EK, Kollman TR, Gellin BF, Landry S.Addressingparents concerns: do multiple vaccines overwhelm or weaken the infants immune system?Pediatrics. 2002 Jan;109(1):124-29.
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