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Parents vaccine fears, and how to address them

Copyright 2010

The issue
All pediatricians and public health authorities recommend a series of immunizations for all children Some parents refuse immunizations for their children or want to alter the recommended schedule How should pediatricians respond to vaccine hesitancy or refusal?

How common is vaccine refusal?


Survey of 2521 parents with children <18 Jan 2009

Response rate: 62%


Outcome measures:
Parental view on vaccine safety Vaccine refusal

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

Parental views on vaccine safety


Vaccines offer good protection: I generally follow my doctors advice on vaccines: Im concerned about adverse effects: Parents should have the right to refuse any vaccines: Some vaccinations cause autism: My kids dont need to be vaccinated for rare diseases: 90%

88% 54% 31% 25%


11%

Freed et al. Pediatrics. 2010.

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

Will multiple vaccinations, especially in one visit, impair a babys immune system?

The number of vaccinations over the last century has steadily increased

Offit et al. Pediatrics. 2002.

But the total number of proteins and polysaccharides in the vaccines has diminished dramatically

Offit et al. Pediatrics. 2002.

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

What about newborns with impaired immune systems?

Can immunization cause illness


A live-virus vaccine can cause illness in an immunocompromised baby Live-virus vaccines are not routinely recommended before age 1* Even for immunocompromised children, the risk from live-virus vaccines is generally lower than risk of disease Check with an infectious disease specialist
*MMR is given to babies before international travel

Does illness impede bodys ability to react to antigen?

Many studies have looked at this


Led to comprehensive report by the Institute of Medicine:
Stratton KR, Wilson CB, McCormick MC. Immunization safety review: Multiple Immunizations and Immune Dysfunction.
Institute of Medicine. Washington, D.C: National Academy Press; 2002.

Studies find no increased risk of infection following multiple immunizations

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 after immunization in both groups

Otto et al. J Infect Dis. 2000.

More illness before vaccines, not after

Otto et al. J Infect Dis. 2000.

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.

Infection rate lowest right after MMR

Stowe at al. Vaccine. 2009.

MMR and autism


Association based upon one small study, published in The Lancet, in 1998 Since then, numerous studies have been done showing no association, the Lancet study has been retracted, and the author stripped of his license in the UK

MMR for kids with autism and controls

DeStefano et al. Pediatrics. 2004.

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.

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.

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 autism http://www.iom.edu/Reports/2004/Immunization-Safety-Review-Vaccines-and-Autism.aspx

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.

Is natural disease better than immunization?

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

Does immunity wane?


Evidence for waning immunity with some vaccines, not others
Varicella Pertussis

Varicella rates rise in older children after vaccine introduced

Chaves et al. N Engl J Med. 2007.

Risk of varicella infection increases with time after vaccination

Chaves et al. N Engl J Med. 2007.

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.

Waning immunity in pertussis


CDC now recommends a second varicella immunization at 4-6 years Many countries now recommend pertussis reimmunization every 10 years

Lopez. Pediatrics. 2006. AAP Committee on Infectious Disease. Pediatrics. 2006.

Is two doses enough?

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.

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.

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.

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 caring for vaccine refusers at least some of the time 32% of parents who initially refused a vaccine changed their mind

American Academy of Pediatrics

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 this is not recommended by the CDCs Advisory Committee on Immunization Practices)

Diekema and Committee on Bioethics. Pediatrics. 2005.

Approach to resistant parents


Keep talking about immunization at each visit; people change their minds Think very carefully before dismissing a family. Children need 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 the community

Diekema and Committee on Bioethics. Pediatrics. 2005.

Resources
Chaves SS, Gargiullo P, Zhang JX, Civen R, Guris D, Mascola L, Seward JF. Loss of vaccineinduced immunity to varicella over time. N Engl J Med. 2007 Mar 15;356(11):1121-9. Diekema DS. Choices should have consequences: failure to vaccinate, harm to others, civil liability. Michigan Law Review. Diekema DS and AAP Committee on Bioethics. Responding to parental refusals of immunization 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. A

Population-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. Addressing

parents concerns: do multiple vaccines overwhelm or weaken the infants immune system? Pediatrics. 2002 Jan;109(1):124-29.

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