Fears About Vaccines 060210(2)
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Transcript of 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
Gould et al. Pediatr Infect Dis. 2009.
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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.
Gould et al. Pediatr Infect Dis. 2009.
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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