Immunization--Have We Become Victims of Our Own Success

Immunization: Have We Become Victims of Our Success? ANA 2002 Biennial Convention Philadelphia, Pennsylvania Bruce Gellin, MD,MPH Executive Director National Network for Immunization Information Vanderbilt University School of Medicine Vanderbilt University School of Nursing Nashville, Tennessee Ten Great Public Health Achievements-United States 1900-1999           Vaccination Motor-vehicle safety Safer workplaces Control of infectious diseases Decline in deaths from coronary heart disease and stroke Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as health hazard Comparison of 20th Century Annual Morbidity and Current Morbidity, Vaccine-Preventable Diseases 20th Century Annual Morbidity 2000 (Provisional) Percent Decrease Diphtheria Measles Mumps 175,885 503,282 152,209 4 81 323 99.9 99.9 99.8 Pertussis Polio (paralytic) Rubella Congenital Rubella Syndrome 147,271 16,316 47,745 823 6,755 0 152 7 95.4 100 99.7 99.1 Tetanus 1,314 26 167 98.0 99.1 H. influenzae, type b and unknown (<5 yrs) 20,000 Source: CDC Vaccine Concerns: As Old As Vaccines Themselves ―The Cow Pock – or – the Wonderful Effects of the New Inoculation!‖ J. Gillray, 1802 It’s no longer enough to say, ―Trust us, we’re the experts.‖ Physicians and health educators must deal fully and respectfully with the vaccine safety concerns of parents and patients. Number of articles 100 150 200 250 300 350 50 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Medline Search: ―Vaccine Safety‖ 1980-2000 True: Vaccines are Not Without Risk  No vaccine is 100% safe  No vaccine is 100% effective  All vaccines have possible side effects, most mild, rarely severe  The risk of disease far outweighs the risk of vaccine False: Avoiding Vaccines Would Be "Safer"  By choosing not to vaccinate one takes on the risk of disease  Both vaccinating and not vaccinating carry risks  Children unvaccinated against measles are 35 times more likely than immunized children to catch the disease Salmon DA. Health consequences of religious and philosophical exemptions from immunization laws. JAMA 1999 Temporal Associations Between Vaccinations and Serious Illnesses Cause Public Concern         Arthritis Asthma ADD Autism Brain Damage Cancer Chronic Fatigue Syndrome Diabetes  Gulf War Syndrome  Infantile Spasms  Inflammatory Bowel    Disease Multiple Sclerosis Neuroimmune Dysfunction Sudden Infant Death Syndrome Temporal vs. Causal Associations: Is Sequence Consequence? A Exposure (Vaccine, Drug, Diet, Occupation Others)? B Disease Time •Direct and only cause? •One of multiple potential causes? •Co-factor/indirect cause, trigger? •Coincidental? From: Pless, CDC Risk Perception  Science is secondary to value judgments that people make concerning risks.  None of the leading factors of how people make decisions are technical or scientific.  Source credibility is key.  As a result, communication about risk must be developed through a process that essentially works backwards from the value judgments people make about risk information. Features of a Postmodern Society • • • • Distrust of science Greater attention to risk Better access to real-time information Readiness to recur to the judiciary J.A. Muir Gray Lancet 1999; 354:1550-1553 Risk communication ―The difficulty does not lie with our audience. Rather, we have failed to understand our audience. We repeat what they know and and neglect what they don’t. Our job is to figure out what has the greatest value to our audience and relay it clearly.‖ Baruch Fishoff Carnegie Mellon University Presenting Risk Information: What’s Best? (unpublished 2001 data, CDC working paper) 1. “A serious reaction to this vaccine occurs about 1 to 3 times per 10,000 doses.” 2. “About 1 to 3 children out of 10,000 who receive this vaccine will experience a serious reaction.” 3. “This vaccine rarely causes serious reactions-- about 1 to 3 children out of 10,000 who receive it.” 4. “This vaccine is very safe-- 9,997 children out of 10,000 who receive it will experience no adverse reaction.” Presenting Risk Information: The Findings (unpublished 2001 data, CDC working paper) 1. “A serious reaction to this vaccine occurs about 1 to 3 times per 10,000 doses.” 2. “About 1 to 3 children out of 10,000 who receive this vaccine will experience a serious reaction.” 16% 27% 3. “This vaccine rarely causes serious reactions-about 1 to 3 children out of 10,000 who receive it.” 4. “This vaccine is very safe-- 9,997 children out of 10,000 who receive it will experience no adverse reaction.” 24% 33% Factors important in risk perception INCREASE CONCERN DECREASE CONCERN  Unclear benefits  Uncontrollable  Involuntary  Children at increased risk  Delayed effects  Risk to future generations  Lack of trust in responsible institutions Much media attention  Clear benefits  Controllable  Voluntary  Children risk not increased  Immediate effects  No risk to future generations  Trust in responsible institutions Little media attention    Effects irreversible  Effects reversible  Caused by human actions  ―Acts of nature/God‖ or failures Do Parents Understand Immunization? A National Telephone Survey in the US The majority of parents understand the benefits of immunizations and support existing policies and programs. Gellin et al. Pediatrics 2000;106:1097-1102 Do Parents Understand Immunizations? A National Telephone Survey in the US -84% would not opt out of any vaccines -84% believe school immunization mandates protect their children -83% immunize to prevent disease -79% do not believe unimmunized children should be allowed in schools But… Gellin et al. Pediatrics 2000;106:1097-1102 Do Parents Understand Immunizations? Many parents have important misconceptions about vaccines and immunization practices and policies that could erode their confidence in immunizations. -25% believe immune systems are weakened by too many vaccines -23% think children get more vaccines than are good for them -19% of parents do not think vaccines are proven safe prior to use in the US Gellin et al. Pediatrics 2000;106:1097-1102 Recommended childhood immunization schedule: 1985 Recommended Childhood Immunization Schedule United States 2001 Vaccines are listed under routinely recommended ages. Bars indicate range of recommended ages for immunization. Any dose not given at the recommended age should be given as a "catch-up" immunization at any subsequent visit when indicated and feasible. Ovals indicate vaccines to be given if previously recommended doses were missed or given earlier than the recommended minimum age. Age Vaccine Hepatitis B Birth 1 mo 2 mos 4 6 mos mos 12 15 mos mos 18 24 mos mos 4-6 11-12 14-18 yrs yrs yrs Hep B #1 Hep B #2 Hep B #3 DTaP Hib IPV PCV MMR Var MMR MMR Var Hep A — in selected areas IPV DTaP Hep B Diphtheria, Tetanus, Pertussis H. Influenzae type b Inactivated Polio Pneumococcal Conjugate Measles, Mumps, Rubella Varicella Hepatitis A DTaP DTaP DTaP Hib IPV PCV Hib IPV PCV PCV Hib Td Approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Immunogenic Proteins, Polysaccharides in Vaccines 1900 Vaccine Proteins smallpox ~200 1960 Vaccine Proteins smallpox ~200 diphtheria 1 tetanus 1 wc-pertussis ~3000 polio 15 1980 Vaccine Proteins diphtheria 1 tetanus 1 wc-pertussis ~3000 polio 15 measles 10 mumps 9 rubella 5 2000 Vaccine Proteins diphtheria 1 tetanus 1 ac-pertussis 2-5 polio 15 measles 10 mumps 9 rubella 5 Hib conj. 2 varicella 69 pneumo conj. 8 hepatitis B 1 TOTALS: 1 ~200 5 ~3217 7 ~3041 11 123-126 Modified from Offit PA, et al. Pediatrics January 2002 Immunogenic Proteins, Polysaccharides in Vaccines Year # Vaccines # Antigens ~ ~ 1900 1960 1 5 200 3217 1980 2000 7 11 ~ ~ 3041 123-126 ―If concerned, where would you go first for information about your concern?‖ (unpublished 2001 data, CDC working paper) %1st Choice Physician Friend w/ med or nurse training 3% 34% 22% 81% %2nd 10% %3rd 3% Family member Internet site Magazine/newspaper Friends Religious/spiritual source 10% 2% 1% 1% 1% 21% 12% 8% 4% 2% 22% 11% 12% 10% 2% Attitudes of Vaccinators in Canada (Quebec, 1998) In general, the vaccines that are recommended for use in infants and children are: GPs Peds Nurses  Safe 87%  Effective 77%  Necessary 92% Dionne, 2001 88% 85% 57% 52% 94% 68% Key Voices in the Immunization Dialogue Health Care Professionals Policy Makers and Legislators Parents/Patients/Families Intermediaries Insurers Employers Media Advocacy Groups ―Then we’ve agreed that all of the evidence isn’t in, and that even if all of the evidence were in, it still wouldn’t be definitive‖ Improving the Immunization Dialogue All health-care workers, from general practitioners to midwives, need to be kept up to date with developments in the debate and learn how to discuss, rather than dismiss, parents' fears. The Economist February 14, 2002 National Network for Immunization Information www.immunizationinfo.org Infectious Diseases Society of America Pediatric Infectious Diseases Society American Academy of Pediatrics American Nurses Association American Academy of Family Physicians National Association of Pediatric Nurse Practitioners American College of Obstetricians and Gynecologists Immunization Resources  www.immunizationinfo.org  Resource Kit: Communication with Patients About Immunizations  Immunization Newsbriefs