"Vaccines, measles and myths"- 2015 James Todd, MD

Disclosures

I have no financial interests relevant to this topic...

…but

The State of Colorado and its parents could save a lot of $$$ and further reduce the morbidity and mortality of Vaccine-preventable Diseases if more of their children

were completely vaccinated.

Objectives

Learn that Colorado data confirms vaccine safety and efficacy.

Debunk the myths related to vaccine safety.

Explore the limits of herd immunity.

Explore what can you do to improve vaccination rates in Colorado?

AAP 2015 Vaccination Schedule

It’s complicated!

Where are we? Colorado has made some progress but can’t seem to get above 80%!

45th out of 50 states Differences

between ranks not always significant

Only 72% fully vaccinated by 3 yrs.

Why are immunization coverage levels low in some communities?

Multiple Reasons Poverty Disparities in access Fear of being identified by the

government Risk-benefit misperceptions

How Did We Get Here?• Vaccines as victims of their own success

• Loss of diseases’ visibility.• Loss of a sense of urgency.• Lack of fear

• The assault on science• Facts and evidence are seen as just a matter of

opinion, rather than proven truth• Simple ‘belief’ is often considered as valid as

critical thinking

Hypothetical Pros and Cons of VaccinationPros

Protects children from:DeathHospitalizationComplicationsPain and suffering

Protects others from:All of the aboveLoss of workCosts of care

ConsVaccines don’t work

Lots of shotsToo many antigens

Major adverse eventsAutismBrain damageTransmit HIV

Costs of prevention

Vaccines work in Colorado

There is a strong health and business case for vaccination in Colorado

Vaccines are effective and safe in Colorado

Number of CasesHospital Charge

EstimateColorado Hospitalized Vaccine Adverse Event (any diagnosis code) 3* $29,938Colorado Hospitalized Vaccine Preventable Diseases (Table 1) 538 $29,208,885*Primary or secondary diagnosis codes: 978x, 979x, E948x, E949x (see Methods), actual hospital charges reported.

Table 3: Annual case and charge estimates for vaccine preventable disease and vaccine-related adverse event hospitalizations among Colorado children 0-19 years of age in 2013

Parental Refusal of Varicella Vaccination and theAssociated Risk of Varicella Infection in Children

“Children of parents who refused varicella immunizations were at a greatly increased risk of varicella infection requiring medical care (odds ratio, 8.6; 95% confidence interval, 2.2-33.3) compared with children of parents who accepted vaccinations (P=.004).”

Arch Pediatr Adolesc Med. 2010;164(1):66-70

Pertussis in Colorado156 laboratory-confirmed pertussis cases and 595

matched controls. 18 (12%) pertussis vaccine refusers among the cases 3 (0.5%) pertussis vaccine refusers among the controls.

Children of parents who refused pertussis immunizations were at an 24x increased risk for pertussis compared with children of parents who accepted vaccinations.

Glanz, Jason M.; McClure, David L.; Magid, David J.; Daley, Matthew F.; France, Eric K.; Salmon, Daniel A.; Hambidge, Simon J. (2009): Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children. In Pediatrics 123 (6), pp. 1446–1451

Pertussis – Not just Boulder!

Risks: Many self-perpetuating myths

Pertussis vaccine causes encephalopathy.Measles vaccine causes autism.Thimerosal causes autism/brain damage.Aluminum causes autism/brain damage.Vaccines don’t work.Vaccines aren’t safe.Big government/corporate/physician conspiracy.Too many antigens at once overwhelm the infant’s

immune system.Vaccines cause AIDS.

Wakefield, A.J., et al. Lancet 351: 637-641, 1998.

MMR-Autism: Scientific Studies

Taylor, B, et al. Lancet 1999;351:2026-29 Dales L, et al. JAMA 2001;285:1183-85 Kaye JA, et al. Brit Med J 2001;322:460- Madsen KM, et al. N Engl J Med 2002;347:1477-82 Peltola H, et al. Lancet 1998;351:1327-8. Makela A, et al. Pediatrics 2002;110:957-63 DeStefano R, et al. Pediatrics 2004;113:259-66 Farrington CP, et al. Vaccine 2001;19:3632-5 Fombonne E, et al. Pediatrics 2001;108:e58 Taylor, B, et al. British Med J 2002;324:393-6

Thimerosal

Many pseudo-scientific hypotheses came after this, the most common being that children with autism metabolize mercury differently and therefore are more prone to its effects.

The evidence: there is no scientific evidence to support this hypothesis, and many studies refuting it.

Court panel of special masters: “…the evidence advanced by the petitioners has fallen far short” of showing a link between thimerosal and autism.

So what about aluminum? Found in numerous foods and beverages, baby

formulas, honey Typical adults ingest 7-9 milligrams of aluminum per day

Aluminum contained in vaccines is similar to that found in a liter of infant formula

Infants receive about 4.4 milligrams of aluminum in the 1st six mths of life from vaccines

Breastfed infants ingest about 7 milligrams Formula-fed infants ingest about 38 milligrams Soy fed infants ingest about 117 milligrams

Do Multiple Vaccines Overwhelm or Weaken the Infant’s Immune System?

Infant has theoretical capacity to respond to about 10,000 vaccines at any one time! (107 B cells per mL by 103 epitopes per vaccine)

Most vaccines contain fewer than 100 antigens, therefore if 11 vaccines given at one time then 0.1% of the immune system would be “used up”

Children are Exposed to Fewer Antigens Than in the Past

Actual Pros and Cons of VaccinationPros

Protects children from:DeathHospitalizationComplicationsPain and suffering

Protects others from:All of the aboveLoss of workCosts of care

ConsVaccines don’t work

Lots of shotsToo many antigens

Major adverse eventsAutismBrain damageTransmit HIV

Costs of prevention

Herd Immunity

What is the herd immunity threshold?Does Colorado meet it?

86%

81%

Colorado 2013: 19-35mth

85%? 88-90%

Young Colorado children are under the herd immunity threshold

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0 3 5 7 13 19 240

10

20

30

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50

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80

90

100

Figure 8: Colorado Vaccination Compliance from Birth to 24 Months of Age, 2010

DTaP

MMR

VAR

AGE in Months

% C

ompl

ete

Measles PertussisVaricella

The Problem of the mini-Herd

Colorado’s Children

Immune Not immune Not immune, exposed, disease

Mini-Herd

Uncommon external exposure

Common internal

exposure

Mini-Herd Dynamics

Congregate togetherDay CarePlay Dates

Common vaccine philosophyAlternative schedulesDelay in (spacing) vaccinationBiased view of vaccine risk and VPD severity

Frequent Travel – external exposure

Alternative health care beliefsDelay in diagnosis/treatment/secondary prophylaxis

Colorado is below 90% compliance for most individual vaccines

0

10

20

30

40

50

60

70

80

90

100

Perc

ent V

acci

nate

d

Year

Figure 3: NIS Vaccination Percentage, 19-35 months: Colorado, 1995-2010

DTaP4 Polio3MMR1 HIB3HepB3 Varicella1Pneumococcus4

Non-compliance gaps suggest alternative schedule effect

• Significant vaccination gaps in youngest children

• Influenza vaccine gap probably higher

Youngest children are at the highest risk!

Vaccination Goals for ColoradoImprove and expand CIIS:

Better measure current ratesMeasure by region

Improve access to primary care and vaccinationImprove vaccination pro/con education of all parentsMaximize on-time vaccination of all children

Especially very young childrenInfluenza! Reduce costs & minor morbidity of vaccination

Minimize PBEDay care and school reporting of rates (? Adults too)Market “protect your kids”

Market: Safety, Efficacy & Exposure Risk

What About Colorado’s Personal Belief Exemption Law?

Most Exemptions in Colorado are PBE

PBE – Much easier than vaccinating

VOID

Resourceshttp://www.immunizeforgood.com/http://www2.aap.org/immunization/pediatricians/pdf/

TopStrategiesforIncreasingCoverage.pdfhttp://www2.aap.org/immunization/pediatricians/

communicating.html http://www.cdc.gov/vaccines/hcp/patient-ed/conversatio

ns/index.html

http://pediatrics.aappublications.org/content/127/Supplement_1/S127.full.html

http://www.thecommunityguide.org/vaccines/index.html

Questions?

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For pre-kindergarten children attending a licensed child care facility, non-medical immunization exemption forms will be submitted following each age immunizations are recommended on the schedule developed by the Advisory Committee on Immunization Practices (ACIP).

For students attending kindergarten through 12th grade, non-medical immunization exemption forms will be submitted during annual enrollment/registration.

Schools with children birth through 12th grade will be required to annually report aggregate immunization and exemption information to CDPHE via an online form by December 1 of each year.

CDPHE will publish school and child care immunization rates annually.

Additionally, the proposal adds rules regarding the contents of an online learning module to meet the requirements of House Bill 14-1288.

BOH Immunization Exemption Rule Changes

http://sierrasraceagainstmeningitis.com/

Sierra’s Race Against Meningitis