When vaccine misconceptions jeopardize public health

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Applied Evidence

When vaccine misconceptions jeopardize public health

J Fam Pract. 2014 December;63(12):E1-E7

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References

1. Zhou F, Shefer A, Wenger J, et al. Economic evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics. 2014;133:577-585.

2. Centers for Disease Control and Prevention. Measles. Epidemiology and prevention of vaccine-preventable diseases. The Pink Book: Course Textbook. 12th ed. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/meas.html. Accessed March 4, 2012.

3. Centers for Disease Control and Prevention. Measles (Rubeola). Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/measles/. Accessed November 19, 2014.

4. Measles. In: Pickering LK, Baker CJ, Kimberlin DW, et al, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:444-455.

5. Atkinson WL, Orenstein WA, Krugman S. The resurgence of measles in the United States, 1989-1990. Annu Rev Med. 1992;43:451-463.

6. Centers for Disease Control and Prevention (CDC). Measles--United States, 1990. MMWR Morb Mortal Wkly Rep. 1991;40:369-372.

7. Gindler J, Tinker S, Markowitz L, et al. Acute measles mortality in the United States, 1987-2002. J Infect Dis. 2004;189(suppl 1): S69-S77.

8. Centers for Disease Control and Prevention (CDC). Measles: United States, January-May 20, 2011. MMWR Morb Mortal Wkly Rep. 2011;60:666-668.

9. Bernstein DI, Reuman PD, Schiff GM. Rubeola (measles) and subacute sclerosing panencephalitis virus. In: Gorbach SL, Bartlett JG, Blacklow NR (eds). Infectious Diseases. Philadelphia, PA: WB Saunders; 1998:2135.

10. Bellini WJ, Rota JS, Lowe LE, et al. Subacute sclerosing panencephalitis: more cases of this fatal disease are prevented by measles immunization than was previously recognized. J Infect Dis. 2005;192:1686-1693.

11. Centers for Disease Control and Prevention (CDC). Progress toward elimination of Haemophilus influenza type b invasive disease among infants and children—United States, 1998-2000. MMWR Morb Mortal Wkly Rep. 2002;51:234-237.

12. Centers for Disease Control and Prevention (CDC). Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book, Course Textbook, 12th ed. Haemophilus influenzae type b. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/hib.html. Accessed March 4, 2012.

13. Watt JP, Wolfson LJ, O’Brien KL, et al; Hib and Pneumococcal Global Burden of Disease Study Team. Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years: global estimates. Lancet. 2009;374:903-911.

14. Agrawal A, Murphy TF. Haemophilus influenzae infections in the H. influenzae type b conjugate vaccine era. J Clin Microbiol. 2011;49:3728-3732.

15. Chandran A, Watt JP, Santosham M. Prevention of Haemophilus influenza type b disease: past successes and future challenges. Informa Healthcare. 2005;4:819-827.

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17. McVernon J, Morgan P, Mallaghan C, et al. Outbreak of Haemophilus influenzae type b disease among fully vaccinated children in a day-care center. Pediatr Infect Dis J. 2004;23:38-41.

18. Hinman AR, Orenstein WA, Schuchat A; Centers for Disease Control and Prevention (CDC). Vaccine-preventable diseases, immunizations, and MMWR—1961-2011. MMWR Morb Mortal Wkly Rep. 2011;60 suppl 4:49-57.

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23. Centers for Disease Control and Prevention. Ensuring the safety of vaccines in the United States. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/vacsafe-ensuring-color-office.pdf. Accessed November 18, 2014.

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25. US Food and Drug Administration. Understanding the Vaccine Adverse Event Reporting System (VAERS). US Food and Drug Administration Web site. Available at: http://www.fda.gov/downloads/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM298183.pdf. Accessed October 15, 2014.

26. Centers for Disease Control and Prevention (CDC). Suspension of rotavirus vaccine after reports of intussusception--United States, 1999. MMWR Morb Mortal Wkly Rep. 2004;53:786-789.

27. Greene SK, Kulldorff M, Lewis EM, et al. Near real-time surveillance for influenza vaccine safety: proof-of-concept in the Vaccine Safety Datalink Project. Am J Epidemiol. 2010;171:177-188.

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Once licensure has been granted, the focus of safety then shifts to the “open system” of usual clinical practice. Vaccine recipients are unselected members of the general population and may have underlying medical conditions, and sometimes—such as with school entry mandates—are less volitional. In this sphere, the responsible parties for safety include the government, manufacturers, and health care systems.

Three ongoing systems function to assure vaccine safety: the Vaccine Adverse Event Reporting System (VAERS), the Vaccine Safety Datalink (VSD), and the Clinical Immunization Safety Assessment (CISA) Network.^23,24

VAERS serves as an early warning system for coincidental safety signals and can generate hypotheses for further investigation.^24,25It is characterized by high sensitivity but low specificity as it relies on voluntary reporting from health care personnel, parents, and others. This system was instrumental in identifying the initial cases of intussusception attributable to the rotavirus vaccine, RotaShield.²⁶

The VSD is a network of 10 large, geographically diverse and linked health maintenance organizations that cover about 3% of the US population. Within this “real time” network, vaccination (exposure) can be compared with outpatient, emergency department, hospital, and laboratory data (health outcomes), while accounting for demographic variables (confounders).^27,28VSD studies linked the measles, mumps, rubella, and varicella vaccine to febrile seizures²⁹and showed no relationship between cumulative vaccine antigen exposure and autism.³⁰

The CISA was established in 2001 to investigate the pathophysiologic mechanisms and biologic risks of adverse effects following immunization and to provide evidence-based vaccine safety assessments.

Based on all available evidence, routinely recommended vaccines have attained a very high level of safety. As with other preventive services, immunizations are generally provided to healthy individuals to maintain good health; thus, a low tolerance for significant adverse events exists. Well over 100 million doses of vaccines are given each year, yet the VAERS receives, on average, only 28,000 adverse event reports per year.

These reports comprise mild, moderate, and severe reactions to vaccines, but also adverse events that may not be related in any way other than chronologically to the vaccine’s administration. Despite this relatively low number of real safety concerns, it is still more likely that patients will know someone who has had a vaccine-related adverse event than someone who has had some of the diseases the vaccines prevent.³¹

Final thoughts

Current anti-vaccine sentiments appear to arise from varying perspectives.To appreciate the benefit  of vaccine acceptance,  we need only look to Europe, where high levels of vaccine refusal has led to a resurgence of vaccine-preventable diseases such as measles. Some are held by parents of children who have allegedly suffered a severe vaccine related adverse event; others by those opposed to government-mandated school immunization requirements; and some from those who have a dislike of vaccine manufacturers. These sentiments persist in part because of a low level of vaccine preventable diseases: When such illnesses are no longer deemed a threat, those who have concerns about vaccine safety, no matter how invalid, believe their concerns should trump all other considerations.

To appreciate the true benefit of vaccine acceptance, we need only look to Europe, where the anti-vaccine movement has led to high levels of vaccine refusal and a resurgence of vaccine-preventable diseases, such as measles, with their associated morbidity and mortality.³²In advocating for continued acceptance and widespread use of vaccines, family physicians can convey to patients and parents the magnitude of associated health benefits while confidently attesting to the effectiveness and safety of vaccines.

CORRESPONDENCE
John Epling, MD, MSEd, Department of Family Medicine, SUNY Upstate Medical University, 475 Irving Ave, Suite 200, Syracuse, NY 13210; eplingj@upstate.edu