Showing posts with label vaccination. Show all posts
Showing posts with label vaccination. Show all posts

Monday, June 8, 2015

New Vaccine Studies Deal with Parental Vaccine Hesitancy


By: Lewis First, MD, MS; Editor-in-Chief 

     Recently several states have been engaged in legislative debates regarding whether to pass legislation that would improve vaccination rates, such as removing philosophical exemptions.  Why parents opt for such exemptions is concerning and not well understood.  One thought is that perhaps our communication with families might be a way to improve vaccine rates in children assuming we had a successful way to improve such communication with vaccine-hesitant families. 
      Interestingly enough, Dr. Henrikson et al. (doi:10.1542/peds.2014-3199) share the results of a randomized trial using a physician-targeted communication intervention to reduce vaccine hesitancy and improve physician confidence in talking about vaccines.  56 clinics and almost 350 mothers participated in this study with 30 clinics getting the intervention trainings and the rest being controls.  So did the intervention reduce vaccine hesitancy and improve physician confidence in talking about vaccines?  Sadly—not really—but please read this study to understand why the desired results may not have been achieved. 
          So if better targeted communication strategies don’t work, what can we discern at a population level as to what groups of patients are asking for philosophical exemptions and how have these patterns changed over time with the hope that perhaps by targeting specific populations in the community, one could learn more about these populations and in turn develop better ways or legislation to make philosophical exemptions less possible.   
     Doctors Carrel and Bitterman (doi:10.1542/peds.2015-0831) opted to look at schools in California with high, medium and low rates of personal belief or philosophical exemptions and look at differences in those populations in an interesting study also being released this week in our journal.  While some of the highest philosophical exemptions occur in public schools with high percentages of white students, charter status as well as in private schools, there was also a high rate of personal or philosophical exemption when a school also had a high number of medical exemptions—setting that community up for being at risk due to possibly diminished herd immunity.  
      So should we give up on our quest to improve the declining vaccination rates in this country?  Not so fast—as per the opinion of Drs. Julie Leask and Paul Kinnersley who comment on the role of physician communication and vaccine-hesitant parents in a commentary accompanying the Henrikson study. Inject some time in reading both studies and the commentary and hopefully you’ll be reenergized to continue to educate your patients and populations of patients at school meetings as well as your legislators on the importance of making sure our children are vaccinated.

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Tuesday, June 2, 2015

Physician responsibility and “Personal medical Exemption” for vaccinations


By: Lydia Furman, MD,  Assistant Editor

     To vaccinate or not to vaccinate- that seems to be the question for a limited number of parents. In a unique approach to this problem, Doctors Carrel and Bitterman (doi: 10.1542/peds.2015-0831) have elegantly analyzed and mapped over time the distribution of California schools in which children have either a “Personal Belief Exemption” or a “Personal Medical Exemption” for vaccination. Certainly the issue is of intrinsic interest, but more pragmatically they ask whether there is enough overlap between high rates of vaccination refusal (“Personal Belief Exemption”) and vaccine ineligibility (“Personal Medical Exemption”) to undermine herd immunity and thus put vulnerable children who cannot be vaccinated at risk for highly communicable vaccine preventable diseases, specifically measles and pertussis.
     They classify clusters of schools by tertile, as “high, medium or low PBE (“Personal Belief Exemption”) areas. Certainly some results are predictable and all results are concerning. Higher rates of vaccine refusal, described somewhat euphemistically as “Personal Belief Exemption,” are not surprisingly associated with white students and with charter and private schools. However, not all results are as expected, and the subtleties are worth the read.
      Intriguingly the “hotspots” of higher “Personal Belief Exemption” rates co-map with higher rates of “Personal Medical Exemption,” and even more interestingly, the rates of “Personal Medical Exemption” range from 0-19.23% and do not decrease over time. Wait a minute - this sent me back to the books for a refresher on contraindications to vaccination.
     The Centers for Disease Control and Prevention treatise “General Recommendations on Immunization: Recommendations of the Advisory Committee on Vaccine Practices” (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm) clearly spells out the difference between Contraindications (don’t vaccinate) and Precautions (balance risk and benefit). There are very few Contraindications to vaccination: allergy to a vaccine or vaccine component, encephalopathy within 7 days of DTaP that cannot be otherwise explained (for pertussis containing vaccines only), pregnancy or severe immune deficiency (such a symptomatic HIV with less than 15% CD4 cells) for live viral vaccines, and additional contraindications for rotavirus vaccine (severe combined immune deficiency, intussusception)
     But these are truly uncommon situations. For example, the rate of anaphylactic reaction to measles containing vaccine appears to be less than 1 case per 1 million doses (http://www.cdc.gov/mmwr/PDF/rr/rr4708.pdf ), and safety data from the European trial of (accellular) DTaP showed no cases of encephalopathy in >25,000 doses (http://www.cdc.gov/mmwr/preview/mmwrhtml/00048610.htm). Certainly some physicians may exercise caution when an infant has a progressive neurologic condition of unknown etiology or a seizure disorder, and hold temporarily on DTaP, but resolution by 1 year of age is usually possible, with subsequent vaccination.
      This review led me to the uncomfortable conclusion that many of the “exemptions” described as “Personal Medical Exemptions” may actually be physician-assisted “Personal Belief Exemptions,” i.e. physician-enabled vaccine refusal. It’s really difficult to believe that up to 1 in 5 children could have a medical reason to avoid vaccines.  We can strategize about how to best support parents in coming around to vaccination, and can hope that careful, respectful dialogue will pave the way.  But in the case of high rates of potentially unwarranted medical exemption, there appears to be a “slippery slope” approach, in which physicians may give parents a medical “out” for vaccination, perhaps hoping parental beliefs will change with time and additional physician input. 
     Ultimately each of us has to practice in the way we believe is best and answer to ourselves- that is one of the many benefits of our vocation.  But I do raise for discussion the question of whether this approach helps anyone, and most of all, whether it benefits the individual child or other children, which is where our responsibility ultimately lies.

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Tuesday, April 28, 2015

Another Study Heralds Early Benefits of HPV Vaccine in Preventing Cervical Dysplasia and Anogenital Warts

By: Lewis First, MD, MS; Editor-in-Chief    

          Our journal, like others, has published a number of studies demonstrating the benefits of human papillomavirus (HPV) vaccine but there is minimal information published about the effectiveness of the vaccine using a large population-based cohort, that is until this week when we share the results of a large study by Smith et al. (doi: 10.1542/peds.2014-2961) of eighth grade girls in Ontario, Canada before and after an eighth grade vaccination program was instituted.   
     The authors chose to look at absolute risk differences, relative risks, and the 95% confidence intervals attributable to vaccination in girls eligible for this program and then examined these girls again in grades 10-12 for cervical dysplasia and anogenital warts comparing them to those who were unvaccinated.  The results are impressive and demonstrate strong evidence of the benefits of early vaccination against HPV. 
       If you need nice proof that the HPV vaccine can make a difference—check this study out and then share it with your teen patients and their parents who might be hesitant to consent to getting this important vaccine.


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Tuesday, April 14, 2015

Sir Yes Sir! Some Sharp Points About Vaccine Coverage Rates in Military Dependents




          Are you aware the Military Health System provides universal coverage of all recommended childhood vaccines?  Are you aware that despite this, 28% of young children of military parents are not up-to-date on their recommended vaccines?  So how can this be in the setting of such universal coverage?   
     Dunn et al. (doi:10.1542/peds.2014-2101) compared vaccine coverage in military dependents to other non-military insured and uninsured children and found some disappointing results for children in military families. So why is this finding happening?  
      The authors inject some key thoughts into the discussion section of this article with the hope of designing better strategies to improve vaccination rates in military infants and toddlers.  March over to this early–released study and learn more.

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