Immunizations:Immunizations:Safe and Safe and VeryVery Neccessary Neccessary

Jeffrey R. Boscamp, MDJeffrey R. Boscamp, MDChair, Department of PediatricsChair, Department of PediatricsPhysician-in-ChiefPhysician-in-ChiefThe Joseph M. Sanzari Children’s The Joseph M. Sanzari Children’s HospitalHospitalHackensack University Medical CenterHackensack University Medical Center

Community Medicine and School Health:Community Medicine and School Health:Hot Topics For 2009Hot Topics For 2009American Academy of Pediatrics/ NJ ChapterAmerican Academy of Pediatrics/ NJ ChapterOctober 28, 2009October 28, 2009

Vaccine Refusal, Mandatory Immunization Vaccine Refusal, Mandatory Immunization and the Risks of Vaccine-Preventable and the Risks of Vaccine-Preventable DiseasesDiseases

Omer, SB, Salmon, DA, Orenstein Omer, SB, Salmon, DA, Orenstein WA, deHart, MP and Halsey, NWA, deHart, MP and Halsey, N

N Engl J Med, May 7, 2009; 360: N Engl J Med, May 7, 2009; 360: 1981-8 1981-8

CASE STUDY: ASHLAND, CASE STUDY: ASHLAND, OREGONOREGON

Population: 20,000; SW OregonPopulation: 20,000; SW Oregon 28% vaccine exemption rate; 28% vaccine exemption rate;

Alternative school: 67%Alternative school: 67% One mother: “One of the basic tenets One mother: “One of the basic tenets

of my decision-making is of my decision-making is mistrust of mistrust of the governmentthe government, a , a mistrust of the mistrust of the pharmaceutical companiespharmaceutical companies, and , and mistrust of the big-blanket thing that mistrust of the big-blanket thing that says says this is what everybody has to dothis is what everybody has to do””

““I get the public health standpoint; I I get the public health standpoint; I am still questioning am still questioning vaccines’ safetyvaccines’ safety””

New York Times, 10/20/09New York Times, 10/20/09

Audrey Opdyke, 27 year old waitress, pregnantAudrey Opdyke, 27 year old waitress, pregnant June 27, 2009, mild flu symptoms. Discharged June 27, 2009, mild flu symptoms. Discharged

from the hospital beginning of October.from the hospital beginning of October. 5 weeks in a coma, 6 ptx, seizure, prolonged 5 weeks in a coma, 6 ptx, seizure, prolonged

ventilator supportventilator support Delivered via c/s, 26 weeks, baby died in 7 Delivered via c/s, 26 weeks, baby died in 7

minutesminutes Opdykes wanted to publicize what they went Opdykes wanted to publicize what they went

through. “We have friends who get flu through. “We have friends who get flu symptoms and say, ‘Oh, I’m not going to a symptoms and say, ‘Oh, I’m not going to a doctor,’ Mr. Opdyke added. “And we say, ‘Do doctor,’ Mr. Opdyke added. “And we say, ‘Do you not understand what we went through? I you not understand what we went through? I can’t imagine why there is such nonchalance.”can’t imagine why there is such nonchalance.”

New York Times, 10/20/09New York Times, 10/20/09

That nonchalance strikes close to home. That nonchalance strikes close to home.

As they said this, Ms. Opdyke was doing her As they said this, Ms. Opdyke was doing her daily physical therapy, struggling to lift one-daily physical therapy, struggling to lift one-pound weights. Her therapist interrupted to pound weights. Her therapist interrupted to announce she opposed flu shots.announce she opposed flu shots.

““Have you ever read the labels?” she asked. Have you ever read the labels?” she asked. “They’re so full of toxins.”“They’re so full of toxins.”

Asked if she realized that a shot, had it existed Asked if she realized that a shot, had it existed in June, might have saved her client and her in June, might have saved her client and her baby, she frowned and went back to her baby, she frowned and went back to her clipboard.clipboard.

Those who cannot remember the Those who cannot remember the past are condemned to repeat past are condemned to repeat

it.it.

- George Santayana, 1905- George Santayana, 1905

Much of the decline in infant Much of the decline in infant mortality in the 20mortality in the 20thth century century was due to treatment and was due to treatment and prevention of prevention of infectious infectious

diseasesdiseases

DIPHTHERIADIPHTHERIA

Sore throat, fever, swollen neckSore throat, fever, swollen neck Throat membraneThroat membrane Pneumonia, heart failure, unable to swallow, Pneumonia, heart failure, unable to swallow,

kidney failure, deathkidney failure, death 5% die, many more with permanent damage5% die, many more with permanent damage 1920’s: 100,000 – 200,000 cases/year1920’s: 100,000 – 200,000 cases/year 1999: 1 case1999: 1 case Immunization rates downImmunization rates down (Eastern Europe, (Eastern Europe,

states of former USSR): Tens of thousands states of former USSR): Tens of thousands of casesof cases

TETANUSTETANUS

Toxin producing spores; soil and animal Toxin producing spores; soil and animal intestinesintestines

Not person-to-personNot person-to-person Contaminated wound, unimmunizedContaminated wound, unimmunized Severe muscle contractions, “Lockjaw”Severe muscle contractions, “Lockjaw” Late 1940’s: 500 – 600 cases per yearLate 1940’s: 500 – 600 cases per year Now: 40 – 60 cases per yearNow: 40 – 60 cases per year World War II, US troops: 12 Cases (6 not World War II, US troops: 12 Cases (6 not

immunized)immunized)

PERTUSSISPERTUSSIS

nn Bacteria, glueBacteria, glue--like respiratory secretionslike respiratory secretionsnn Severe coughing spells, Severe coughing spells, ““WhoopWhoop””nn Severity: 1Severity: 1stst 6 months of life6 months of lifenn Very contagious Very contagious -- 5050––80% infection rate in school/daycare80% infection rate in school/daycarenn 50 per 10,000 die of 50 per 10,000 die of pertussispertussisnn PrePre--vaccine: 200,000 cases; 1,000vaccine: 200,000 cases; 1,000––4,000 deaths4,000 deathsnn Current worldwide: 300,000 deaths/yearCurrent worldwide: 300,000 deaths/yearnn Adolescents/adults: 46% of casesAdolescents/adults: 46% of casesnn 1975: 1975: JapanJapan; ; immunimmun rates drop from 70% to 20rates drop from 70% to 20--40%40%

nn 1974: 393 cases, No deaths1974: 393 cases, No deathsnn 1979: 13,000 cases, 41 deaths1979: 13,000 cases, 41 deaths

nn Great BritainGreat Britain; 1974; 1974--1978, 1978, immunimmun rates from 80% to 30%rates from 80% to 30%nn 1977: Epidemic1977: Epidemic––100,000 cases, 36 deaths100,000 cases, 36 deaths

INFLUENZAINFLUENZA

Highly contagiousHighly contagious Fever, muscle aches, HA, nasal congestionFever, muscle aches, HA, nasal congestion PneumoniaPneumonia Annual: Annual: 36,000 deaths36,000 deaths; 200,000 ; 200,000

hospitalizationshospitalizations 1918 pandemic: 21 million deaths worldwide; 1918 pandemic: 21 million deaths worldwide;

500,000 in US500,000 in US Hospitalization rates: <12 month = >65 yearsHospitalization rates: <12 month = >65 years Flu activity in children <5 years old predictive Flu activity in children <5 years old predictive

of pneumonia deaths in general populationof pneumonia deaths in general population Children main source of transmissionChildren main source of transmission

Influenza A, Subtype Influenza A, Subtype H1N1H1N1

Novel H1N1 Virus (CDC)Novel H1N1 Virus (CDC) Pandemic H1N1/09 Virus (WHO)Pandemic H1N1/09 Virus (WHO) Swine FluSwine Flu

Reassortment of genes from different Reassortment of genes from different influenza virusesinfluenza viruses

Swine (American, Europe/Asia), Avian, Swine (American, Europe/Asia), Avian, HumanHuman

Mexico, April 2009Mexico, April 2009 Pandemic, WHO, June 11, 2009Pandemic, WHO, June 11, 2009

POLIOPOLIO

Intestinal virus, person to personIntestinal virus, person to person

Pre-vaccine:Pre-vaccine: 13,000–20,000 people 13,000–20,000 people paralyzed; 1000 diedparalyzed; 1000 died

Now eradicated from western hemisphereNow eradicated from western hemisphere

Ultimate herd immunity:Ultimate herd immunity: OPV immunized OPV immunized everyoneeveryone

Martha Mason, Who Wrote Martha Mason, Who Wrote Book About Her Decades in an Book About Her Decades in an

Iron Lung, Dies at 71Iron Lung, Dies at 71 (NYT, 5/9/09)(NYT, 5/9/09)

MENINGOCOCCAL MENINGOCOCCAL DISEASEDISEASE

BacteriaBacteria leads to life threatening leads to life threatening infectionsinfections

Bloodstream, meningitisBloodstream, meningitis Fever, stiff neck, HA, rash, shock, Fever, stiff neck, HA, rash, shock,

seizuresseizures If survive,If survive, 10-20% deaf, brain 10-20% deaf, brain

damage, circulation/gangrenedamage, circulation/gangrene 2600 cases/year, most < 5 years2600 cases/year, most < 5 years Vaccine not protective of all typesVaccine not protective of all types

HEMOPHILUS HEMOPHILUS INFLUENZAE, INFLUENZAE, TYPE B (HIB)TYPE B (HIB)

Bacteria causes Bacteria causes meningitismeningitis, epiglottitis, , epiglottitis, bloodstream infection, bones/jointsbloodstream infection, bones/joints

Person-to-person, respiratory dropletsPerson-to-person, respiratory droplets HIB meningitisHIB meningitis: blindness, deafness, learning : blindness, deafness, learning

disabilities, mental retardation, deathdisabilities, mental retardation, death Pre-vaccine: Pre-vaccine: 20,000 invasive infections20,000 invasive infections, 1,000 , 1,000

deathsdeaths Vaccines: 1985, 1987Vaccines: 1985, 1987 Now rare (<50 cases/year)Now rare (<50 cases/year) WorldwideWorldwide now: 203 million cases; 386,000 deaths now: 203 million cases; 386,000 deaths Vaccine decreases carriageVaccine decreases carriage

Hemophilus Influenzae, Type Hemophilus Influenzae, Type B, B, 2008-20092008-2009

Minnesota, 2008:Minnesota, 2008: 5 children, 5mo-3yr, 5 children, 5mo-3yr, invasive HIB disease. Most cases in invasive HIB disease. Most cases in Minnesota since 1992Minnesota since 1992

3 received no vaccine; 5 mo. old-2 3 received no vaccine; 5 mo. old-2 doses; 1 with hypogammaglobulinemiadoses; 1 with hypogammaglobulinemia

Philadelphia, 2008-2009:Philadelphia, 2008-2009: 5 cases HIB- 5 cases HIB- 2 deaths2 deaths

All unimmunized or underimmunizedAll unimmunized or underimmunized 1 child, unvaccinated 4 year old, died 1 child, unvaccinated 4 year old, died

of meningitis (3/09).of meningitis (3/09).

MEASLESMEASLES

Highly Highly contagiouscontagious virus virus Pneumonia, encephalitisPneumonia, encephalitis Survivors of encephalitisSurvivors of encephalitis: blindness, deafness, brain : blindness, deafness, brain

damagedamage SSPESSPE Pre-vaccine: Pre-vaccine: universaluniversal disease disease 19581958: 763,000 infections, 532 deaths: 763,000 infections, 532 deaths 20082008 (Jan-July): 131 cases; 42 in 2007 (Jan-July): 131 cases; 42 in 2007 Worldwide now: Worldwide now: 350,000-750,000 children die per year350,000-750,000 children die per year Priority for UNICEFPriority for UNICEF African mothers/naming of childrenAfrican mothers/naming of children Possible world eradication: need high % vaccine coveragePossible world eradication: need high % vaccine coverage

– Could eliminate need for future vaccineCould eliminate need for future vaccine

WHY IMMUNIZE?WHY IMMUNIZE?

To prevent To prevent common infectionscommon infections

To prevent infections that could To prevent infections that could easily easily re-emergere-emerge

To prevent infections that are To prevent infections that are common in common in other parts of the worldother parts of the world

Are Vaccines Safe?Are Vaccines Safe?

Risk vs. BenefitRisk vs. Benefit Vaccine Adverse Events Reporting System (VAERS)Vaccine Adverse Events Reporting System (VAERS) Vaccine Safety Data Link (VSD)- Vaccine Safety Data Link (VSD)- Background rate of side Background rate of side

effectseffects

Clinical Immunization Safety Assessment (CISA)- Clinical Immunization Safety Assessment (CISA)- Safety Safety collaborativecollaborative

Licensure:Licensure: FDA approval- Animals, adults, children FDA approval- Animals, adults, children Concomitant use studiesConcomitant use studies Recommendations: Recommendations:

Advisory Committee on Infectious Diseases-ACIP Advisory Committee on Infectious Diseases-ACIP Committee on Infectious Diseases-COID, AAP Committee on Infectious Diseases-COID, AAP

American Academy of Family Physicians-American Academy of Family Physicians-AAFPAAFP

Do Vaccines Overwhelm the Immune Do Vaccines Overwhelm the Immune System? System? Too Many Vaccines?Too Many Vaccines?

Children exposed to fewer immunologic Children exposed to fewer immunologic components of vaccines than in the pastcomponents of vaccines than in the past

Smallpox Smallpox (200 proteins)(200 proteins) vs. current vs. current recommended vaccines (about recommended vaccines (about 150 150 proteins/polysaccharidesproteins/polysaccharides))

30 years ago:30 years ago: 7 vaccines, 3000 proteins 7 vaccines, 3000 proteins Now:Now: 14 vaccines, 150 proteins/polysaccharides 14 vaccines, 150 proteins/polysaccharides 11 or 12 vaccines11 or 12 vaccines in 1 in 1stst 2 years of life is a 2 years of life is a

miniscule challenge compared to miniscule challenge compared to tens of tens of thousandsthousands of environmental challenges that of environmental challenges that babies manage every day babies manage every day

AluminumAluminum

Most abundant metal; 9% of earth’s crustMost abundant metal; 9% of earth’s crust Pots, pans, soda cans, foilPots, pans, soda cans, foil Food:Food: Adults ingest 7-9 mg/day Adults ingest 7-9 mg/day Adjuvant in vaccinesAdjuvant in vaccines Vaccine aluminum same as in 1 qt. infant Vaccine aluminum same as in 1 qt. infant

formulaformula Infants receive:Infants receive: 4.4 mg- vaccines 4.4 mg- vaccines

(1(1stst 6 months) 6 months) 7 mg-breast feeding 7 mg-breast feeding 38 mg-formula fed 38 mg-formula fed 117 mg-soy formula117 mg-soy formula

Important in developing fetus:Important in developing fetus: Blood level at birth> mother’sBlood level at birth> mother’s

FormaldehydeFormaldehyde

Concern:Concern: High concentrations can High concentrations can damage damage DNA; cause cancer in cells in DNA; cause cancer in cells in lablab

ResidualResidual formaldehyde in some formaldehyde in some vaccinesvaccines

Not shown to cause cancer in humans Not shown to cause cancer in humans or lab animalsor lab animals

FormaldehydeFormaldehyde

Formaldehyde Formaldehyde essential in human essential in human metabolismmetabolism; required for synthesis of ; required for synthesis of DNA/Amino acidsDNA/Amino acids

All humans have detectable All humans have detectable formaldehyde formaldehyde (2.5 micrograms/ml of (2.5 micrograms/ml of blood)blood)

Total formaldehyde in infant: 1.1 mgTotal formaldehyde in infant: 1.1 mg Avg. quantity in immunization at one Avg. quantity in immunization at one

time: time: 0.2 mg0.2 mg Animals have been safely given Animals have been safely given 600X 600X

the the amount in vaccine dosesamount in vaccine doses

MMR and AUTISMMMR and AUTISM

1998- 1998- Andrew WakefieldAndrew Wakefield, published in Lancet, published in Lancet Reported Reported 8 children who developed autism 8 children who developed autism

after MMRafter MMR Measles virus particles visualized in Measles virus particles visualized in

intestinesintestines All of the children had symptoms before MMRAll of the children had symptoms before MMR 2004: 10 of 13 authors of Lancet paper 2004: 10 of 13 authors of Lancet paper

requested paper be withdrawn; requested paper be withdrawn; “Data was “Data was insufficient”insufficient”

Later, hundreds of thousands of children Later, hundreds of thousands of children studied +/- MMR: studied +/- MMR: Autism rate the sameAutism rate the same

THIMEROSAL and THIMEROSAL and AUTISMAUTISM Ethylmercury (vaccine) vs. Ethylmercury (vaccine) vs.

methylmercury (environment)methylmercury (environment) Numerous studies +/- thimerosal: Numerous studies +/- thimerosal:

Autism rate the sameAutism rate the same Most thimerosal removed in USA by Most thimerosal removed in USA by

20012001 Denmark removed thimerosal in 1991; Denmark removed thimerosal in 1991;

increase in autism after removalincrease in autism after removal Exclusively breast-fed infant:Exclusively breast-fed infant:

Total ingestion: 2x the mercury ever Total ingestion: 2x the mercury ever in vaccines, 15x the amount in in vaccines, 15x the amount in influenza vaccineinfluenza vaccine

Top 10 Reasons Top 10 Reasons Why to Why to Immunize Immunize Your Child Your Child Against InfluenzaAgainst Influenza Children are at the epicenter of annual Children are at the epicenter of annual

outbreaksoutbreaks To prevent deathsTo prevent deaths To prevent hospitalizations and morbiditiesTo prevent hospitalizations and morbidities To protect fragile childrenTo protect fragile children To protect fragile adultsTo protect fragile adults Because it worksBecause it works Because it is safeBecause it is safe Because it is cost-effectiveBecause it is cost-effective Because it decreases ear infectionsBecause it decreases ear infections Because staph aureus and influenza go togetherBecause staph aureus and influenza go together

Might save a grandparent’s life…think about it!Might save a grandparent’s life…think about it!

Novel H1N1: StatisticsNovel H1N1: Statistics

Who knows? Who cares?Who knows? Who cares? Testing issuesTesting issues Age 25 and under; few cases over age 64 (<7% Age 25 and under; few cases over age 64 (<7%

of hospitalizations since 9/1/09, ? x-reactivity of hospitalizations since 9/1/09, ? x-reactivity with prior flu)with prior flu)

Projections:Projections: 2 billion cases next 2 years (WHO)2 billion cases next 2 years (WHO) U.S.: 1.8 million hospitalizationsU.S.: 1.8 million hospitalizations Up to 90,000 deaths (? young people)Up to 90,000 deaths (? young people) Up to 50% of U.S. population: 150 millionUp to 50% of U.S. population: 150 million ICU utilizationICU utilization

Novel H1N1 vs. Seasonal Novel H1N1 vs. Seasonal Flu:Flu:What’s different?What’s different?

Age distribution/severity (ARDS)Age distribution/severity (ARDS) Time of yearTime of year FeverFever Vomiting/diarrheaVomiting/diarrhea Rapid antigen testRapid antigen test

Novel H1N1: Novel H1N1: SymptomsSymptoms

Fever (? reliable)Fever (? reliable) CoughCough Sore throatSore throat Body aches, HABody aches, HA ChillsChills FatigueFatigue Vomiting/diarrheaVomiting/diarrhea Progression to respiratory distress, Progression to respiratory distress,

seizures, disorientationseizures, disorientation

Novel H1N1: Novel H1N1: When To Seek Medical When To Seek Medical Attention Attention

Rapid breathing or trouble breathingRapid breathing or trouble breathing Bluish skin color (cyanosis)Bluish skin color (cyanosis) Not drinking enough fluidsNot drinking enough fluids Not waking up or interactingNot waking up or interacting Child irritable to the point of not Child irritable to the point of not

wanting to be heldwanting to be held Flu-like symptoms improve but then Flu-like symptoms improve but then

return with fever, worsening coughreturn with fever, worsening cough Fever with a rashFever with a rash

Novel H1N1: Novel H1N1: AvoidanceAvoidance Wash handsWash hands Avoid contact with people who are illAvoid contact with people who are ill Cover cough/sneeze (not with hands!)Cover cough/sneeze (not with hands!) Stay home from school or work if ill Stay home from school or work if ill

-No fever for >24 hrs (off meds) -No fever for >24 hrs (off meds) -7 days if flu more severe than -7 days if flu more severe than spring ’09spring ’09

VaccineVaccine

Environmental sanitation Environmental sanitation (lives 2-8 hrs on surfaces)(lives 2-8 hrs on surfaces)

Novel H1N1: VaccineNovel H1N1: Vaccine

New vaccine, shipments now arrivingNew vaccine, shipments now arriving 45-50 million doses initially, then 20 mill/week45-50 million doses initially, then 20 mill/week Revised down to 30 mill doses by end Oct ‘09Revised down to 30 mill doses by end Oct ‘09 200 million doses total, possibly 800 mill doses200 million doses total, possibly 800 mill doses Younger than age 10, 2 doses, 3-4 weeks apartYounger than age 10, 2 doses, 3-4 weeks apart Inactivated vaccine vs. live vaccine (Flumist)Inactivated vaccine vs. live vaccine (Flumist)

Don’t forget about seasonal influenza vaccine!Don’t forget about seasonal influenza vaccine!

Novel H1N1: Vaccine Novel H1N1: Vaccine SafetySafety

Same manufacturing process as Same manufacturing process as seasonalseasonal

No adjuvant in U.S.No adjuvant in U.S.

ThimerosalThimerosal

Guillain-Barre SyndromeGuillain-Barre Syndrome

H1N1 Nasal Mist Vaccine: H1N1 Nasal Mist Vaccine: ContraindicationsContraindications

Younger than 2 yrs; 50 and olderYounger than 2 yrs; 50 and older Egg allergyEgg allergy PregnancyPregnancy ImmunodeficiencyImmunodeficiency Chronic illness: heart, lung kidney, liver Chronic illness: heart, lung kidney, liver

disease; diabetes, blood disorders, asthmadisease; diabetes, blood disorders, asthma Children < age 5 with 1 episode of wheezing Children < age 5 with 1 episode of wheezing

in the past yearin the past year Neuromuscular diseaseNeuromuscular disease Contact of severely immunocompromised pt.Contact of severely immunocompromised pt. Long term aspirinLong term aspirin

Novel H1N1: Initial Target Novel H1N1: Initial Target GroupsGroups

Persons aged 6 mo-24 yrs Persons aged 6 mo-24 yrs (20x more common than >65) (20x more common than >65)

Caretakers of infants < 6 months of Caretakers of infants < 6 months of ageage

PregnancyPregnancy Health care workersHealth care workers Non-elderly adults (25-65) with risk Non-elderly adults (25-65) with risk

factors (asthma, obesity, immune factors (asthma, obesity, immune compromised, etc.)compromised, etc.)

Novel H1N1: TreatmentNovel H1N1: Treatment

Oseltamivir (Tamiflu)Oseltamivir (Tamiflu) Zanamivir (Relenza)Zanamivir (Relenza) Oseltamivir resistanceOseltamivir resistance Treatment not indicated unless at Treatment not indicated unless at

high risk of complications or high risk of complications or hospitalizedhospitalized

Best if within 48 hrs of onset of Best if within 48 hrs of onset of symptomssymptoms

Novel H1N1: Novel H1N1: High Risk for High Risk for ComplicationsComplications

Children <2 years oldChildren <2 years old Adults 65 or olderAdults 65 or older PregnancyPregnancy Chronic medical conditionsChronic medical conditions Younger than 18 on aspirinYounger than 18 on aspirin ImmunosuppressedImmunosuppressed Obesity (BMI 40+)Obesity (BMI 40+)

Novel H1N1: Severe DiseaseNovel H1N1: Severe Disease

25% of hospitalized needed ICU; 10+% died25% of hospitalized needed ICU; 10+% died Children and teens >50% of hospitalized; more Children and teens >50% of hospitalized; more

than 50% with severe disease previously healthythan 50% with severe disease previously healthy Pregnancy: As of 8/09, 100 required ICU, 28 Pregnancy: As of 8/09, 100 required ICU, 28

deathsdeaths As of 10/15/09, 86 childhood deaths, usually 50 As of 10/15/09, 86 childhood deaths, usually 50

deaths in whole season; since 8/30/09, 43 deaths in whole season; since 8/30/09, 43 pediatric deathspediatric deaths

Life threatening pneumonia progressing to ARDS Life threatening pneumonia progressing to ARDS more common than in seasonal flumore common than in seasonal flu

? Young women> men, controlling for pregnancy? Young women> men, controlling for pregnancy Oscillators, ECMO Oscillators, ECMO

Novel H1N1: ResourcesNovel H1N1: Resources

www.cdc.gov

www.flu.gov

www.nj.gov/health/flu/h1n1

www.aap.orgwww.aap.org

FACT:FACT:

If a significant proportion of the If a significant proportion of the population opts-out of population opts-out of immunization programs, immunization programs, vaccine-vaccine-preventable diseases will re-preventable diseases will re-emergeemerge and cause childhood and cause childhood illnessillness and and deathsdeaths..

Been there, done that.Been there, done that.

FACT: FACT: Immunization is a Immunization is a critical public health issuecritical public health issue

No vaccine has 100% take.No vaccine has 100% take.

We depend on high immunization rates We depend on high immunization rates to protect to protect immunizedimmunized children and children and those who cannot be immunized.those who cannot be immunized.

We depend on vaccines for the overall We depend on vaccines for the overall health of our country and world.health of our country and world.

Thank you to Paul Offit, M.D Thank you to Paul Offit, M.D and the Vaccine Education and the Vaccine Education CenterCenter

Vaccine.Chop.eduVaccine.Chop.edu

If you would like a copy of If you would like a copy of this presentation, e-mail this presentation, e-mail me at :me at :

jboscamp@humed.comjboscamp@humed.com