Transcript VACCINE – PREVENTABLE DISEASES

Immunizations:
Safe and Very Neccessary
Jeffrey R. Boscamp, MD
Chair, Department of Pediatrics
Physician-in-Chief
The Joseph M. Sanzari Children’s Hospital
Hackensack University Medical Center
Community Medicine and School Health:
Hot Topics For 2009
American Academy of Pediatrics/ NJ Chapter
October 28, 2009
Vaccine Refusal, Mandatory Immunization and
the Risks of Vaccine-Preventable Diseases
Omer, SB, Salmon, DA, Orenstein WA,
deHart, MP and Halsey, N
N Engl J Med, May 7, 2009; 360: 1981-8
CASE STUDY: ASHLAND, OREGON
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Population: 20,000; SW Oregon
28% vaccine exemption rate;
Alternative school: 67%
One mother: “One of the basic tenets of my
decision-making is mistrust of the
government, a mistrust of the
pharmaceutical companies, and mistrust of
the big-blanket thing that says this is what
everybody has to do”
“I get the public health standpoint; I am still
questioning vaccines’ safety”
New York Times, 10/20/09
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Audrey Opdyke, 27 year old waitress, pregnant
June 27, 2009, mild flu symptoms. Discharged from
the hospital beginning of October.
5 weeks in a coma, 6 ptx, seizure, prolonged
ventilator support
Delivered via c/s, 26 weeks, baby died in 7 minutes
Opdykes wanted to publicize what they went
through. “We have friends who get flu symptoms
and say, ‘Oh, I’m not going to a doctor,’ Mr.
Opdyke added. “And we say, ‘Do you not
understand what we went through? I can’t imagine
why there is such nonchalance.”
New York Times, 10/20/09
That nonchalance strikes close to home.
As they said this, Ms. Opdyke was doing her daily
physical therapy, struggling to lift one-pound
weights. Her therapist interrupted to announce she
opposed flu shots.
“Have you ever read the labels?” she asked. “They’re
so full of toxins.”
Asked if she realized that a shot, had it existed in
June, might have saved her client and her baby,
she frowned and went back to her clipboard.
Those who cannot remember the
past are condemned to repeat it.
- George Santayana, 1905
Much of the decline in infant
mortality in the 20th century was
due to treatment and prevention
of infectious diseases
DIPHTHERIA
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Sore throat, fever, swollen neck
Throat membrane
Pneumonia, heart failure, unable to swallow,
kidney failure, death
5% die, many more with permanent damage
1920’s: 100,000 – 200,000 cases/year
1999: 1 case
Immunization rates down (Eastern Europe,
states of former USSR): Tens of thousands of
cases
TETANUS
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Toxin producing spores; soil and animal
intestines
Not person-to-person
Contaminated wound, unimmunized
Severe muscle contractions, “Lockjaw”
Late 1940’s: 500 – 600 cases per year
Now: 40 – 60 cases per year
World War II, US troops: 12 Cases (6 not
immunized)
PERTUSSIS
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Bacteria, glue-like respiratory secretions
Severe coughing spells, “Whoop”
Severity: 1st 6 months of life
Very contagious - 50
50–
–80% infection rate in school/daycare
50 per 10,000 die of pertussis
Pre-vaccine: 200,000 cases; 1,000–4,000 deaths
Current worldwide: 300,000 deaths/year
Adolescents/adults: 46% of cases
1975: Japan;
Japan; immun rates drop from 70% to 2020-40%
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 1974: 393 cases, No deaths
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 1979: 13,000 cases, 41 deaths
Great Britain;
Britain; 19741974-1978, immun rates from 80% to 30%
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 1977: Epidemic–
Epidemic–100,000 cases, 36 deaths
INFLUENZA
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Highly contagious
Fever, muscle aches, HA, nasal congestion
Pneumonia
Annual: 36,000 deaths; 200,000 hospitalizations
1918 pandemic: 21 million deaths worldwide;
500,000 in US
Hospitalization rates: <12 month = >65 years
Flu activity in children <5 years old predictive of
pneumonia deaths in general population
Children main source of transmission
Influenza A, Subtype H1N1
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Novel H1N1 Virus (CDC)
Pandemic H1N1/09 Virus (WHO)
Swine Flu
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Reassortment of genes from different
influenza viruses
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Swine (American, Europe/Asia), Avian, Human
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Mexico, April 2009
Pandemic, WHO, June 11, 2009
POLIO
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Intestinal virus, person to person
Pre-vaccine: 13,000–20,000 people paralyzed;
1000 died
Now eradicated from western hemisphere
Ultimate herd immunity: OPV immunized
everyone
Martha Mason, Who Wrote Book
About Her Decades in an Iron Lung,
Dies at 71
(NYT, 5/9/09)
MENINGOCOCCAL DISEASE
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Bacteria leads to life threatening
infections
Bloodstream, meningitis
Fever, stiff neck, HA, rash, shock,
seizures
If survive, 10-20% deaf, brain
damage, circulation/gangrene
2600 cases/year, most < 5 years
Vaccine not protective of all types
HEMOPHILUS INFLUENZAE,
TYPE B (HIB)
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Bacteria causes meningitis, epiglottitis, bloodstream
infection, bones/joints
Person-to-person, respiratory droplets
HIB meningitis: blindness, deafness, learning
disabilities, mental retardation, death
Pre-vaccine: 20,000 invasive infections, 1,000 deaths
Vaccines: 1985, 1987
Now rare (<50 cases/year)
Worldwide now: 203 million cases; 386,000 deaths
Vaccine decreases carriage
Hemophilus Influenzae, Type B,
2008-2009
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Minnesota, 2008: 5 children, 5mo-3yr,
invasive HIB disease. Most cases in
Minnesota since 1992
3 received no vaccine; 5 mo. old-2 doses; 1
with hypogammaglobulinemia
Philadelphia, 2008-2009: 5 cases HIB- 2
deaths
All unimmunized or underimmunized
1 child, unvaccinated 4 year old, died of
meningitis (3/09).
MEASLES
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Highly contagious virus
Pneumonia, encephalitis
Survivors of encephalitis: blindness, deafness, brain
damage
SSPE
Pre-vaccine: universal disease
1958: 763,000 infections, 532 deaths
2008 (Jan-July): 131 cases; 42 in 2007
Worldwide now: 350,000-750,000 children die per year
Priority for UNICEF
African mothers/naming of children
Possible world eradication: need high % vaccine coverage
– Could eliminate need for future vaccine
WHY IMMUNIZE?
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To prevent common infections
To prevent infections that could easily
re-emerge
To prevent infections that are common
in other parts of the world
Are Vaccines Safe?
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Risk vs. Benefit
Vaccine Adverse Events Reporting System (VAERS)
Vaccine Safety Data Link (VSD)- Background rate of side effects
Clinical Immunization Safety Assessment (CISA)- Safety
collaborative
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Licensure: FDA approval- Animals, adults, children
Concomitant use studies
Recommendations:
Advisory Committee on Infectious Diseases-ACIP
Committee on Infectious Diseases-COID, AAP
American Academy of Family Physicians-AAFP
Do Vaccines Overwhelm the Immune System?
Too Many Vaccines?
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Children exposed to fewer immunologic
components of vaccines than in the past
Smallpox (200 proteins) vs. current recommended
vaccines (about 150 proteins/polysaccharides)
30 years ago: 7 vaccines, 3000 proteins
Now: 14 vaccines, 150 proteins/polysaccharides
11 or 12 vaccines in 1st 2 years of life is a miniscule
challenge compared to tens of thousands of
environmental challenges that babies manage every
day
Aluminum
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Most abundant metal; 9% of earth’s crust
Pots, pans, soda cans, foil
Food: Adults ingest 7-9 mg/day
Adjuvant in vaccines
Vaccine aluminum same as in 1 qt. infant formula
Infants receive: 4.4 mg- vaccines
(1st 6 months)
7 mg-breast feeding
38 mg-formula fed
117 mg-soy formula
Important in developing fetus:
Blood level at birth> mother’s
Formaldehyde
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Concern: High concentrations can damage
DNA; cause cancer in cells in lab
Residual formaldehyde in some vaccines
Not shown to cause cancer in humans or lab
animals
Formaldehyde
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Formaldehyde essential in human
metabolism; required for synthesis of
DNA/Amino acids
All humans have detectable formaldehyde
(2.5 micrograms/ml of blood)
Total formaldehyde in infant: 1.1 mg
Avg. quantity in immunization at one time:
0.2 mg
Animals have been safely given 600X the
amount in vaccine doses
MMR and AUTISM
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1998- Andrew Wakefield, published in Lancet
Reported 8 children who developed autism
after MMR
Measles virus particles visualized in intestines
All of the children had symptoms before MMR
2004: 10 of 13 authors of Lancet paper
requested paper be withdrawn; “Data was
insufficient”
Later, hundreds of thousands of children
studied +/- MMR: Autism rate the same
THIMEROSAL and AUTISM
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Ethylmercury (vaccine) vs. methylmercury
(environment)
Numerous studies +/- thimerosal: Autism
rate the same
Most thimerosal removed in USA by 2001
Denmark removed thimerosal in 1991;
increase in autism after removal
Exclusively breast-fed infant:
Total ingestion: 2x the mercury ever in
vaccines, 15x the amount in influenza
vaccine
Top 10 Reasons Why to Immunize
Your Child Against Influenza
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Children are at the epicenter of annual outbreaks
To prevent deaths
To prevent hospitalizations and morbidities
To protect fragile children
To protect fragile adults
Because it works
Because it is safe
Because it is cost-effective
Because it decreases ear infections
Because staph aureus and influenza go together
Might save a grandparent’s life…think about it!
Novel H1N1: Statistics
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Who knows? Who cares?
Testing issues
Age 25 and under; few cases over age 64 (<7% of
hospitalizations since 9/1/09, ? x-reactivity with prior
flu)
Projections:
2 billion cases next 2 years (WHO)
U.S.: 1.8 million hospitalizations
Up to 90,000 deaths (? young people)
Up to 50% of U.S. population: 150 million
ICU utilization
Novel H1N1 vs. Seasonal Flu:
What’s different?
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Age distribution/severity (ARDS)
Time of year
Fever
Vomiting/diarrhea
Rapid antigen test
Novel H1N1: Symptoms
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Fever (? reliable)
Cough
Sore throat
Body aches, HA
Chills
Fatigue
Vomiting/diarrhea
Progression to respiratory distress, seizures,
disorientation
Novel H1N1:
When To Seek Medical Attention
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Rapid breathing or trouble breathing
Bluish skin color (cyanosis)
Not drinking enough fluids
Not waking up or interacting
Child irritable to the point of not wanting to
be held
Flu-like symptoms improve but then return
with fever, worsening cough
Fever with a rash
Novel H1N1: Avoidance
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Wash hands
Avoid contact with people who are ill
Cover cough/sneeze (not with hands!)
Stay home from school or work if ill
-No fever for >24 hrs (off meds)
-7 days if flu more severe than spring ’09
Vaccine
Environmental sanitation
(lives 2-8 hrs on surfaces)
Novel H1N1: Vaccine
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New vaccine, shipments now arriving
45-50 million doses initially, then 20 mill/week
Revised down to 30 mill doses by end Oct ‘09
200 million doses total, possibly 800 mill doses
Younger than age 10, 2 doses, 3-4 weeks apart
Inactivated vaccine vs. live vaccine (Flumist)
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Don’t forget about seasonal influenza vaccine!
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Novel H1N1: Vaccine Safety
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Same manufacturing process as seasonal
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No adjuvant in U.S.
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Thimerosal
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Guillain-Barre Syndrome
H1N1 Nasal Mist Vaccine:
Contraindications
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Younger than 2 yrs; 50 and older
Egg allergy
Pregnancy
Immunodeficiency
Chronic illness: heart, lung kidney, liver disease;
diabetes, blood disorders, asthma
Children < age 5 with 1 episode of wheezing in the
past year
Neuromuscular disease
Contact of severely immunocompromised pt.
Long term aspirin
Novel H1N1: Initial Target Groups
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Persons aged 6 mo-24 yrs
(20x more common than >65)
Caretakers of infants < 6 months of age
Pregnancy
Health care workers
Non-elderly adults (25-65) with risk
factors (asthma, obesity, immune
compromised, etc.)
Novel H1N1: Treatment
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Oseltamivir (Tamiflu)
Zanamivir (Relenza)
Oseltamivir resistance
Treatment not indicated unless at high
risk of complications or hospitalized
Best if within 48 hrs of onset of
symptoms
Novel H1N1:
High Risk for Complications
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Children <2 years old
Adults 65 or older
Pregnancy
Chronic medical conditions
Younger than 18 on aspirin
Immunosuppressed
Obesity (BMI 40+)
Novel H1N1: Severe Disease
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25% of hospitalized needed ICU; 10+% died
Children and teens >50% of hospitalized; more than
50% with severe disease previously healthy
Pregnancy: As of 8/09, 100 required ICU, 28 deaths
As of 10/15/09, 86 childhood deaths, usually 50
deaths in whole season; since 8/30/09, 43 pediatric
deaths
Life threatening pneumonia progressing to ARDS
more common than in seasonal flu
? Young women> men, controlling for pregnancy
Oscillators, ECMO
Novel H1N1: Resources
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www.cdc.gov
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www.flu.gov
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www.nj.gov/health/flu/h1n1
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www.aap.org
FACT:
If a significant proportion of the
population opts-out of immunization
programs, vaccine-preventable
diseases will re-emerge and cause
childhood illness and deaths.
Been there, done that.
FACT: Immunization is a
critical public health issue
No vaccine has 100% take.
We depend on high immunization rates to
protect immunized children and those who
cannot be immunized.
We depend on vaccines for the overall
health of our country and world.
Thank you to Paul Offit, M.D and
the Vaccine Education Center
Vaccine.Chop.edu
If you would like a copy of this
presentation, e-mail me at :
[email protected]