Peter N. Wenger, MD Saint Peter’s University Hospital New Brunswick, NJ 1
Pneumococcus 40,000 – 50,000 deaths annually in the US ~1 million deaths in children worldwide Polio 15,000 – 23,000 cases of paralytic polio annually in the US Candy Land (1948) Haemophilus influenzae type b Leading cause of bacterial meningitis in children <5 years Diphtheria Early 1990’s ~200.000 cases with 5000 fatalities in the former Soviet Union Abraham Lincoln’s 7 year -old son (1850) Grover Cleveland’s daughter (1904) Varicella One child and one adult dies every week in US Influenza 1918 Pandemic was responsible for more mortality than ongoing World War 40 to 100 million fatalities Smallpox ½ billion deaths in the 20 th Century
http://www.vaccines.com/why-vaccinate.cfm
World-wide distribution In developed world in prevaccine era >90% of people acquired measles by 15 years of age Globally in 2000 ~31 to 39.9 million infections Estimated 733,000 to 777,000 deaths 5 th most common cause of death in children <5 years of age
Measles vaccine introduced in 1963 United States Incidence of measles has decreased 99% Attack rates 1956 – 1960: 313 cases/100,000 population 1982 – 1988: 1.3 cases/100,000 population Early 1980s state laws requiring proof of measles immunity for school entry <1case/1 million population by 1990s Declared eliminated in the US in 2000 Interruption of year-round endemic transmission Between 2000 and 2007 an average of 63 annual cases were reported
Final total: 668 cases in 2014
The first 5 months of 2015 (as of May 29, 2015) 173 cases in 21 states 117 (70%) associated with Disneyland outbreak Reported measles cases through April 2, 2015 Unvaccinated – 45% Of these 43% were not vaccinated due to philosophic or religious exemptions 40% were ineligible due to age or medical contraindications Unknown vaccination status – 38% ⃰ Clemmons NS, et al. Measles-United States, January 4-April 2, 2015. MMWR 2015;64:373-6 . 9
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Vaccine hesitancy refers to delay in the acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and content specific, varying across time, place, and vaccines. It is influenced by factors such as complacency, convenience and confidence. MacDonald NE. VMacDaccine hesitancy: definition, scope and determinants. Vaccine 2015 [Epub ahead of print] 11
Interaction of 3 key elements Complacency Perception that the risks of vaccination > benefits Convenience Availability and ease of exemptions Confidence Trust Vaccines Healthcare system Policy makers who determine immunization policies and practices 12
Nationally representative cross-sectional survey of parents with children 6 months to 6 years of age in 2010* 13% of parents reported using an alternative vaccination schedule 80% of the above reported >1 change to the recommended schedule 55% delayed vaccines MMR – 54% Varicella – 44% 53% refused certain vaccines 17% reported refused all vaccines * Dempsey AF. et al. Alternative vaccination schedule preferences among parents of small children. Pediatrics 2011;128:848-56. 13 Tuesday, February 16, 2016
Dempsey AF, et al study Of the parents reporting fidelity to the recommended schedule 28% felt delaying vaccine doses was safer than the recommended schedule 22% disagreed that the best vaccination schedule to follow was the one recommended by vaccination experts 14
Children < 9 months of age Recommended Schedule – 154,150 (69.3%) Alternative (restrictive, selective and both) – 56,607 (25.4%) Unknown – 11,871 (5.3%) Nadeau, Journal of Pediatrics 2015;166:151 15
Total Percent NJ 2012-13 8,076 1.5 Hudson Cty 2012-13 242 0.6 NJ 2013-14 8,977 1.7 Hudson Cty 2013-14 310 0.7 NJ 2014-15 9,115 1.7 Hudson Cty 2014-15 310 0.8 NJ Division of Communicable Disease Service 16
In 2006, there were 1,644 religious exemptions to school immunization requirements in NJ An increase of 454% from 2006 to 2015!! 17
Encountered partial vaccine refusal – 85% Encountered complete vaccine refusal – 54% Flanagan-Klygis. Archives of Pediatric and Adolescent Medicine 2005;159:929 18
Vaccines are a victim of their success Today’s parents (and most of their physicians) have little to no experience with vaccine-preventable diseases Preventive measure Healthy people (infants, children, adolescents and adults) Vaccination Risks > Vaccination Benefits The rare adverse event looms large The implied non-exisitent adverse event looms even larger 19
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http://www.vaccines.com/why-vaccinate.cfm
Annual Prevented by Caused by Ratio Outcomes in Vaccination Vaccination¶ Birth Cohort† Hospitalization 53,444 45 1093:1 Death 14 0.2 71:1 †4.3 million infants followed over 5 years ¶Vaccine-associated intussusception *Desai. Pediatric Infectious Diseases Journal 2013;32:1 (estimates based on the risk of intussusception seen with RV1 in Mexican study) 23
1960 1980 2000 Vaccine Protein Vaccine Protein Vaccine Protein Smallpox ~200 Diphtheria 1 Diphtheria 1 Diphtheria 1 Tetanus 1 Tetanus 1 Tetanus 1 WC-Pertussis ~3000 AC-Pertussis 2-5 WC-Pertussis ~3000 Polio 15 Polio 15 Polio 15 Measles 10 Measles 10 Mumps 9 Mumps 9 Total ~3217 Rubella 5 Rubella 5 Hib 2 Total ~3041 Varicella 69 Pneumococcus 8 Hepatitis B 1 Total 123-126 Adapted from Offit, PA, et al. Addressing parents’ concerns: Do multiple vaccines overwhelm or Weaken the infant’s immune system? Pediatrics . 2002. 109:124-129
The ease of obtaining exemptions in any given state is directly associated with the percentage of exemptions* In 2010, a new rule in NJ stated authorities can’t question parents who declare their objection to a vaccine on religious grounds Non-medical exemptions to NJ immunization requirements for school attendance have dramatically increased since 2010 Omer. NEJM 2012;367(12):1170-1 25
Number of Adjusted States Incidence Rate Ratio (95% CI) Type of Exemption Only Religious 32 Reference Personal Belief 17 1.48 (1.03 – 2.13) Exemption Ease Difficult 19 Reference Medium 14 1.35 (0.96 – 1.91) Easy 15 1.53 (1.10 – 2.14) 1 Omer SB, et al. Nonmedical exemptions to school immunization requirements. JAMA 2006:296(14);1757-63
Exemptors were 22.2 x (95% CI, 15.9 – 31.1) more likely to acquire measles Exemptors were 5.9 x (95% CI, 4.2 – 8.2) more likely to acquire pertussis Frequency of exemptions in a county were associated with the incidence rate of: Measles RR: 1.6 (95% CI, 1.0 – 2.4) Pertussis RR: 1.9 (95% CI, 1.7 – 2.1) Schools with pertussis outbreaks had more exemptors (mean 4.3% of students) than those without outbreaks (mean 1.5% of students, p = 0.001) At least 11% of vaccinated in measles outbreaks acquired infection through contact with an exemptor. Feikin DR, et al. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA 2000;284(24):3145-3150. 27
Crisis of Trust (or Mistrust) Science Misunderstanding Religion vs Science Fear Healthcare system Uncaring Ulterior motives Influence of Big Pharm Government Erosion of individual rights Individual rights vs the public health 30
“The liberty secured by the Constitution of the United States…does not import an absolute right… to be wholly freed from restraint. There are manifold restraints to which every person is necessarily subject for the common good…Society based on the rule that each one is a law unto himself would soon be confronted with anarchy and disorder.” Justice John Marshall Harlan 31
Abrahamic religious texts predate vaccination Old Testament: 1400 – 400 BCE New Testament: 117 – 138 CE Qur’an: 610 – 632 CE Religious leaders from all organized religions have supported the value of vaccines for the well-being of the community Catholic Church has concluded the use of fetal embryonic cells in several vaccines should not preclude their use Islamic and Jewish scholars have determined that porcine-derived gelatin-containing vaccines are acceptable 32
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