Vaccines

Since the measles outbreak in the Pacific Northwest (where I did my training and remain in touch with colleagues and patients), parents with infants ages 6 to 11 months are requesting vaccinations before 12 months—the standard age to start immunizations.¹ But physicians decline to provide inoculation, citing institutional policy on the risks of early vaccination. What are these risks, and how should we respond when parents ask about early vaccination?

The safety and efficacy of early vaccination are well documented. Early vaccination is a technique employed to curb outbreaks both in the United States and worldwide. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend vaccinating infants at 6 months of age if they will be traveling,² and the World Health Organization (WHO) recommends vaccinations during a measles outbreak as part of intensified service delivery or in settings, such as daycare facilities, in which there is an increased risk for disease exposure during an outbreak.³ Any dose given before 12 months is considered supplemental, and the child must still complete the regular 2-dose vaccine schedule. Studies on the adverse effect profiles of vaccines show that the younger the infant, the fewer adverse events occur—because adverse events reflect the increasingly robust immune response that comes with age.⁴

Many physicians are concerned about adequate immune response. In vaccine research, this is gauged by the proportion of patients with seroconversion after vaccination. This is also reflected in vaccine efficacy (VE), which gradually increases with age and maturity of the immune system. For example, measles VE is 60% to 70% in 6-to-8-month cohorts⁵ and 70% to 80% in 9-to-11-month cohorts.⁶ VE at 12 months is in the 90% range, and completion of the 2-dose series yields a VE of ≥ 95%.⁷ Thus, while the vaccine is more effective at later ages, it still provides protection to younger cohorts.

Early vaccination has few risks and significant benefit. Therefore, relaxing the lower boundary for the measles vaccine is appropriate.

“Blunting” (ie, a reduced immune response to the second dose of vaccine³) is another concern with early measles vaccination, but a WHO meta-analysis proved this concern to be unfounded.^1,3 Twelve papers examining seropositivity in children who received a second measles vaccine after early primary vaccination found a pooled proportion of seropositivity of 97%.^1,8,9 Furthermore, evidence shows that children have sustained measles-specific T-cell responses after early primary measles immunization.¹⁰

Early vaccination has few risks and significant benefit. Therefore, in light of the recent measles outbreak, relaxing the lower boundary for the measles vaccine is appropriate. In addition to physically protecting the patient and general population, honoring parents’ requests for vaccination respects their autonomy and fosters trust. Synthesis of good science with a trusting doctor–patient relationship is key to ending the measles outbreak.

Rachel Roth, MD
Tel Aviv, Israel

Since the measles outbreak in the Pacific Northwest (where I did my training and remain in touch with colleagues and patients), parents with infants ages 6 to 11 months are requesting vaccinations before 12 months—the standard age to start immunizations.¹ But physicians decline to provide inoculation, citing institutional policy on the risks of early vaccination. What are these risks, and how should we respond when parents ask about early vaccination?

The safety and efficacy of early vaccination are well documented. Early vaccination is a technique employed to curb outbreaks both in the United States and worldwide. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend vaccinating infants at 6 months of age if they will be traveling,² and the World Health Organization (WHO) recommends vaccinations during a measles outbreak as part of intensified service delivery or in settings, such as daycare facilities, in which there is an increased risk for disease exposure during an outbreak.³ Any dose given before 12 months is considered supplemental, and the child must still complete the regular 2-dose vaccine schedule. Studies on the adverse effect profiles of vaccines show that the younger the infant, the fewer adverse events occur—because adverse events reflect the increasingly robust immune response that comes with age.⁴

Many physicians are concerned about adequate immune response. In vaccine research, this is gauged by the proportion of patients with seroconversion after vaccination. This is also reflected in vaccine efficacy (VE), which gradually increases with age and maturity of the immune system. For example, measles VE is 60% to 70% in 6-to-8-month cohorts⁵ and 70% to 80% in 9-to-11-month cohorts.⁶ VE at 12 months is in the 90% range, and completion of the 2-dose series yields a VE of ≥ 95%.⁷ Thus, while the vaccine is more effective at later ages, it still provides protection to younger cohorts.

Early vaccination has few risks and significant benefit. Therefore, relaxing the lower boundary for the measles vaccine is appropriate.

“Blunting” (ie, a reduced immune response to the second dose of vaccine³) is another concern with early measles vaccination, but a WHO meta-analysis proved this concern to be unfounded.^1,3 Twelve papers examining seropositivity in children who received a second measles vaccine after early primary vaccination found a pooled proportion of seropositivity of 97%.^1,8,9 Furthermore, evidence shows that children have sustained measles-specific T-cell responses after early primary measles immunization.¹⁰

Early vaccination has few risks and significant benefit. Therefore, in light of the recent measles outbreak, relaxing the lower boundary for the measles vaccine is appropriate. In addition to physically protecting the patient and general population, honoring parents’ requests for vaccination respects their autonomy and fosters trust. Synthesis of good science with a trusting doctor–patient relationship is key to ending the measles outbreak.

Rachel Roth, MD
Tel Aviv, Israel

Since the measles outbreak in the Pacific Northwest (where I did my training and remain in touch with colleagues and patients), parents with infants ages 6 to 11 months are requesting vaccinations before 12 months—the standard age to start immunizations.¹ But physicians decline to provide inoculation, citing institutional policy on the risks of early vaccination. What are these risks, and how should we respond when parents ask about early vaccination?

The safety and efficacy of early vaccination are well documented. Early vaccination is a technique employed to curb outbreaks both in the United States and worldwide. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend vaccinating infants at 6 months of age if they will be traveling,² and the World Health Organization (WHO) recommends vaccinations during a measles outbreak as part of intensified service delivery or in settings, such as daycare facilities, in which there is an increased risk for disease exposure during an outbreak.³ Any dose given before 12 months is considered supplemental, and the child must still complete the regular 2-dose vaccine schedule. Studies on the adverse effect profiles of vaccines show that the younger the infant, the fewer adverse events occur—because adverse events reflect the increasingly robust immune response that comes with age.⁴

Many physicians are concerned about adequate immune response. In vaccine research, this is gauged by the proportion of patients with seroconversion after vaccination. This is also reflected in vaccine efficacy (VE), which gradually increases with age and maturity of the immune system. For example, measles VE is 60% to 70% in 6-to-8-month cohorts⁵ and 70% to 80% in 9-to-11-month cohorts.⁶ VE at 12 months is in the 90% range, and completion of the 2-dose series yields a VE of ≥ 95%.⁷ Thus, while the vaccine is more effective at later ages, it still provides protection to younger cohorts.

Early vaccination has few risks and significant benefit. Therefore, relaxing the lower boundary for the measles vaccine is appropriate.

“Blunting” (ie, a reduced immune response to the second dose of vaccine³) is another concern with early measles vaccination, but a WHO meta-analysis proved this concern to be unfounded.^1,3 Twelve papers examining seropositivity in children who received a second measles vaccine after early primary vaccination found a pooled proportion of seropositivity of 97%.^1,8,9 Furthermore, evidence shows that children have sustained measles-specific T-cell responses after early primary measles immunization.¹⁰

Early vaccination has few risks and significant benefit. Therefore, in light of the recent measles outbreak, relaxing the lower boundary for the measles vaccine is appropriate. In addition to physically protecting the patient and general population, honoring parents’ requests for vaccination respects their autonomy and fosters trust. Synthesis of good science with a trusting doctor–patient relationship is key to ending the measles outbreak.

Rachel Roth, MD
Tel Aviv, Israel

The mean number of office visits for otitis media in children younger than 5 years dropped significantly after the introduction of the 13-valent pneumococcal conjugate vaccine, according to findings published in the International Journal of Pediatric Otorhinolaryngology.

KatarzynaBialasiewicz/Thinkstock

Previous studies have shown that more than half of children with otitis media (OM) have serotypes included in the PCV7 vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F), wrote Xiaofeng Zhou, MD, of Pfizer, New York, and colleagues.

To assess the impact of PCV13, with the additional serotypes 1, 3, 5, 6A, 7F, and 19A, the researchers analyzed data from the U.S. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for three time periods: pre-PCV7 (1997-1999), after the introduction of PCV7 (2001-2009), and after the introduction of PCV13 (2011-2013).

Between the pre-PCV7 and PCV13 time periods, the researchers found significant reductions in the mean rates of OM visits of 48% and 41% among children younger than 2 years and younger than 5 years, respectively; reductions were 24% and 22%, respectively, when comparing PCV13 and PCV7. Ambulatory care visits for skin rash and trauma were not significantly different among the study periods.

Comparing the PCV7 and PCV13 time periods, the mean number of OM visits per 100 children declined from 84 to 64 per 100 children younger than 2 years, 41 to 34 per 100 children between ages 2 and 5 years, and from 59 to 46 per 100 children younger than 5 years.

The study findings were limited by several factors including the use of an ecologic study design, which was chosen to help reduce selection bias, but that did not show evidence of the field effectiveness of the PCV13 vaccine. Another limitation was the potential misclassification of patients with OM given clinician variability in diagnostic criteria, the researchers noted.

“Our results in this study, while not providing direct evidence of causality, nonetheless suggest a significant and positive impact of the PCV13 vaccination program on otitis media for children less than 5 years of age in the U.S., with further reductions in OM visits observed in PCV13 period following a decade of PCV7 use,” Dr. Zhou and associates said.

The investigators are employed by Pfizer, which funded the study.

SOURCE: Zhou X et al. Int J Pediatr Otorhinolaryngol. 2019 Apr. 119:96-102.

The mean number of office visits for otitis media in children younger than 5 years dropped significantly after the introduction of the 13-valent pneumococcal conjugate vaccine, according to findings published in the International Journal of Pediatric Otorhinolaryngology.

KatarzynaBialasiewicz/Thinkstock

Previous studies have shown that more than half of children with otitis media (OM) have serotypes included in the PCV7 vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F), wrote Xiaofeng Zhou, MD, of Pfizer, New York, and colleagues.

To assess the impact of PCV13, with the additional serotypes 1, 3, 5, 6A, 7F, and 19A, the researchers analyzed data from the U.S. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for three time periods: pre-PCV7 (1997-1999), after the introduction of PCV7 (2001-2009), and after the introduction of PCV13 (2011-2013).

Between the pre-PCV7 and PCV13 time periods, the researchers found significant reductions in the mean rates of OM visits of 48% and 41% among children younger than 2 years and younger than 5 years, respectively; reductions were 24% and 22%, respectively, when comparing PCV13 and PCV7. Ambulatory care visits for skin rash and trauma were not significantly different among the study periods.

Comparing the PCV7 and PCV13 time periods, the mean number of OM visits per 100 children declined from 84 to 64 per 100 children younger than 2 years, 41 to 34 per 100 children between ages 2 and 5 years, and from 59 to 46 per 100 children younger than 5 years.

The study findings were limited by several factors including the use of an ecologic study design, which was chosen to help reduce selection bias, but that did not show evidence of the field effectiveness of the PCV13 vaccine. Another limitation was the potential misclassification of patients with OM given clinician variability in diagnostic criteria, the researchers noted.

“Our results in this study, while not providing direct evidence of causality, nonetheless suggest a significant and positive impact of the PCV13 vaccination program on otitis media for children less than 5 years of age in the U.S., with further reductions in OM visits observed in PCV13 period following a decade of PCV7 use,” Dr. Zhou and associates said.

The investigators are employed by Pfizer, which funded the study.

SOURCE: Zhou X et al. Int J Pediatr Otorhinolaryngol. 2019 Apr. 119:96-102.

The mean number of office visits for otitis media in children younger than 5 years dropped significantly after the introduction of the 13-valent pneumococcal conjugate vaccine, according to findings published in the International Journal of Pediatric Otorhinolaryngology.

KatarzynaBialasiewicz/Thinkstock

Previous studies have shown that more than half of children with otitis media (OM) have serotypes included in the PCV7 vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F), wrote Xiaofeng Zhou, MD, of Pfizer, New York, and colleagues.

To assess the impact of PCV13, with the additional serotypes 1, 3, 5, 6A, 7F, and 19A, the researchers analyzed data from the U.S. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for three time periods: pre-PCV7 (1997-1999), after the introduction of PCV7 (2001-2009), and after the introduction of PCV13 (2011-2013).

Between the pre-PCV7 and PCV13 time periods, the researchers found significant reductions in the mean rates of OM visits of 48% and 41% among children younger than 2 years and younger than 5 years, respectively; reductions were 24% and 22%, respectively, when comparing PCV13 and PCV7. Ambulatory care visits for skin rash and trauma were not significantly different among the study periods.

Comparing the PCV7 and PCV13 time periods, the mean number of OM visits per 100 children declined from 84 to 64 per 100 children younger than 2 years, 41 to 34 per 100 children between ages 2 and 5 years, and from 59 to 46 per 100 children younger than 5 years.

The study findings were limited by several factors including the use of an ecologic study design, which was chosen to help reduce selection bias, but that did not show evidence of the field effectiveness of the PCV13 vaccine. Another limitation was the potential misclassification of patients with OM given clinician variability in diagnostic criteria, the researchers noted.

“Our results in this study, while not providing direct evidence of causality, nonetheless suggest a significant and positive impact of the PCV13 vaccination program on otitis media for children less than 5 years of age in the U.S., with further reductions in OM visits observed in PCV13 period following a decade of PCV7 use,” Dr. Zhou and associates said.

The investigators are employed by Pfizer, which funded the study.

SOURCE: Zhou X et al. Int J Pediatr Otorhinolaryngol. 2019 Apr. 119:96-102.

The number of U.S. measles cases in 2019 rose by 60 during the week ending May 3, which puts the new postelimination high at 764 cases for the year, according to the Centers for Disease Control and Prevention.

The CDC is currently tracking nine measles outbreaks in six states. The largest outbreak this year has been in New York City, mainly Brooklyn, which has almost half (367) of all cases in the country. An outbreak in New York’s Rockland County has resulted in another 109 cases so far this year. California is experiencing outbreaks in three counties – Butte, Los Angeles, and Sacramento – and the state was up to 40 confirmed cases as of May 1. The other states with outbreaks are Michigan, New Jersey, Georgia, and Maryland.

Twenty-three states now have reported measles cases in 2019, as officials in Pittsburgh reported Pennsylvania’s first case on April 30. Four additional cases in the area were reported on May 2 by the Allegheny County Health Department. A measles outbreak is “defined as three or more cases” by the CDC, but the situation in Pennsylvania is not yet being reported as such.

One Pennsylvania legislator in the state, Rep. Daryl Metcalfe (R) of Butler County, has authored a bill that would “bar health care practitioners and facilities and insurance companies from denying care if parents refuse or delay” recommended vaccinations, PennLive.com reported.

Pennsylvania Governor Tom Wolf (D) said that the “bill would put children, pregnant women, and vulnerable patients at risk of being exposed to horrific diseases – at the doctor’s office.”

[email protected]

The number of U.S. measles cases in 2019 rose by 60 during the week ending May 3, which puts the new postelimination high at 764 cases for the year, according to the Centers for Disease Control and Prevention.

The CDC is currently tracking nine measles outbreaks in six states. The largest outbreak this year has been in New York City, mainly Brooklyn, which has almost half (367) of all cases in the country. An outbreak in New York’s Rockland County has resulted in another 109 cases so far this year. California is experiencing outbreaks in three counties – Butte, Los Angeles, and Sacramento – and the state was up to 40 confirmed cases as of May 1. The other states with outbreaks are Michigan, New Jersey, Georgia, and Maryland.

Twenty-three states now have reported measles cases in 2019, as officials in Pittsburgh reported Pennsylvania’s first case on April 30. Four additional cases in the area were reported on May 2 by the Allegheny County Health Department. A measles outbreak is “defined as three or more cases” by the CDC, but the situation in Pennsylvania is not yet being reported as such.

One Pennsylvania legislator in the state, Rep. Daryl Metcalfe (R) of Butler County, has authored a bill that would “bar health care practitioners and facilities and insurance companies from denying care if parents refuse or delay” recommended vaccinations, PennLive.com reported.

Pennsylvania Governor Tom Wolf (D) said that the “bill would put children, pregnant women, and vulnerable patients at risk of being exposed to horrific diseases – at the doctor’s office.”

[email protected]

The number of U.S. measles cases in 2019 rose by 60 during the week ending May 3, which puts the new postelimination high at 764 cases for the year, according to the Centers for Disease Control and Prevention.

The CDC is currently tracking nine measles outbreaks in six states. The largest outbreak this year has been in New York City, mainly Brooklyn, which has almost half (367) of all cases in the country. An outbreak in New York’s Rockland County has resulted in another 109 cases so far this year. California is experiencing outbreaks in three counties – Butte, Los Angeles, and Sacramento – and the state was up to 40 confirmed cases as of May 1. The other states with outbreaks are Michigan, New Jersey, Georgia, and Maryland.

Twenty-three states now have reported measles cases in 2019, as officials in Pittsburgh reported Pennsylvania’s first case on April 30. Four additional cases in the area were reported on May 2 by the Allegheny County Health Department. A measles outbreak is “defined as three or more cases” by the CDC, but the situation in Pennsylvania is not yet being reported as such.

One Pennsylvania legislator in the state, Rep. Daryl Metcalfe (R) of Butler County, has authored a bill that would “bar health care practitioners and facilities and insurance companies from denying care if parents refuse or delay” recommended vaccinations, PennLive.com reported.

Pennsylvania Governor Tom Wolf (D) said that the “bill would put children, pregnant women, and vulnerable patients at risk of being exposed to horrific diseases – at the doctor’s office.”

[email protected]

The Food and Drug Administration has approved Dengvaxia, the first vaccine indicated for the prevention of dengue virus disease caused by all viral serotypes. The vaccine was approved for children aged 9-16 years who live in endemic areas and have previously had laboratory-confirmed dengue disease.

Dengue is endemic in the U.S. territories of American Samoa, Guam, Puerto Rico, and the U.S. Virgin Islands, according to an FDA statement announcing the approval.

While the first infection with dengue virus typically results in either no symptoms or a mild illness that can be mistaken for the flu, a second infection can lead to a more severe form of the disease, including dengue hemorrhagic fever, which can be fatal. About 95% of hospitalized patients with dengue disease have a second dengue virus infection.

FDA approval of Dengvaxia is based on results from three randomized, placebo-controlled studies of 35,000 individuals in dengue-endemic areas. The vaccine was about 76% effective in preventing symptomatic, laboratory-confirmed dengue disease in people aged 9-16 years with a previous dengue diagnosis. The most common adverse events were headache, muscle pain, joint pain, fatigue, injection site pain, and low-grade fever; the frequency of adverse events decreased after each subsequent dose.

“Infection by one type of dengue virus usually provides immunity against that specific serotype, but a subsequent infection by any of the other three serotypes of the virus increases the risk of developing severe dengue disease. ... The FDA’s approval of this vaccine will help protect people previously infected with dengue virus from subsequent development of dengue disease,” Peter Marks, MD, director of the FDA’s Center for Biologics Evaluation and Research, said in the FDA statement.

[email protected]

The Food and Drug Administration has approved Dengvaxia, the first vaccine indicated for the prevention of dengue virus disease caused by all viral serotypes. The vaccine was approved for children aged 9-16 years who live in endemic areas and have previously had laboratory-confirmed dengue disease.

Dengue is endemic in the U.S. territories of American Samoa, Guam, Puerto Rico, and the U.S. Virgin Islands, according to an FDA statement announcing the approval.

While the first infection with dengue virus typically results in either no symptoms or a mild illness that can be mistaken for the flu, a second infection can lead to a more severe form of the disease, including dengue hemorrhagic fever, which can be fatal. About 95% of hospitalized patients with dengue disease have a second dengue virus infection.

FDA approval of Dengvaxia is based on results from three randomized, placebo-controlled studies of 35,000 individuals in dengue-endemic areas. The vaccine was about 76% effective in preventing symptomatic, laboratory-confirmed dengue disease in people aged 9-16 years with a previous dengue diagnosis. The most common adverse events were headache, muscle pain, joint pain, fatigue, injection site pain, and low-grade fever; the frequency of adverse events decreased after each subsequent dose.

“Infection by one type of dengue virus usually provides immunity against that specific serotype, but a subsequent infection by any of the other three serotypes of the virus increases the risk of developing severe dengue disease. ... The FDA’s approval of this vaccine will help protect people previously infected with dengue virus from subsequent development of dengue disease,” Peter Marks, MD, director of the FDA’s Center for Biologics Evaluation and Research, said in the FDA statement.

[email protected]

The Food and Drug Administration has approved Dengvaxia, the first vaccine indicated for the prevention of dengue virus disease caused by all viral serotypes. The vaccine was approved for children aged 9-16 years who live in endemic areas and have previously had laboratory-confirmed dengue disease.

Dengue is endemic in the U.S. territories of American Samoa, Guam, Puerto Rico, and the U.S. Virgin Islands, according to an FDA statement announcing the approval.

While the first infection with dengue virus typically results in either no symptoms or a mild illness that can be mistaken for the flu, a second infection can lead to a more severe form of the disease, including dengue hemorrhagic fever, which can be fatal. About 95% of hospitalized patients with dengue disease have a second dengue virus infection.

FDA approval of Dengvaxia is based on results from three randomized, placebo-controlled studies of 35,000 individuals in dengue-endemic areas. The vaccine was about 76% effective in preventing symptomatic, laboratory-confirmed dengue disease in people aged 9-16 years with a previous dengue diagnosis. The most common adverse events were headache, muscle pain, joint pain, fatigue, injection site pain, and low-grade fever; the frequency of adverse events decreased after each subsequent dose.

“Infection by one type of dengue virus usually provides immunity against that specific serotype, but a subsequent infection by any of the other three serotypes of the virus increases the risk of developing severe dengue disease. ... The FDA’s approval of this vaccine will help protect people previously infected with dengue virus from subsequent development of dengue disease,” Peter Marks, MD, director of the FDA’s Center for Biologics Evaluation and Research, said in the FDA statement.

[email protected]

To the Editor: I am an active primary care provider. After reading the update on human papillomavirus (HPV) in the March 2019 issue by Zhang and Batur,¹ I was hoping for some clarification on a few points.

The statement is made that up to 70% of HPV-related cervical cancer cases can be prevented with vaccination. I have pulled the reference² but cannot find supporting data for this claim. Is this proven or optimistic thinking based on the decreased incidence of abnormal Papanicolaou (Pap) test results such as noted in the University of New Mexico HPV Pap registry database³? The authors do cite an additional reference⁴ documenting a decreased incidence of cervical cancer in the United States among 15- to 24-year-olds from 2003–2006 compared with 2011–2014. This study reported a 29% relative risk reduction in the group receiving the vaccine, with the absolute numbers 6 vs 8.4 cases per 1,000,000. Thus, can the authors provide further references to the statement that 70% of cervical cancers can be prevented by vaccination?

The authors also state that vaccine acceptance rates are highest when primary care providers announce that the vaccine is due rather than invite open-ended discussions. At first this shocked me, but then made me pause and wonder how often I do that—and when I do, why. I regularly do it with all the other vaccines recommended by the Advisory Committee on Immunization Practices. When the parent or patient asks for further information, I am armed to provide it. To date, I am struggling to provide data to educate the patient on the efficacy of the HPV vaccine, particularly the claim that it will prevent 70% of cervical cancers. Are there more data that I am missing?

Finally, let me state that I am a “vaccinator”—always have been, and always will be. I discuss the HPV vaccine with my patients and their parents and try to provide data to support my recommendation. However, I am concerned that this current practice regarding the HPV vaccine has been driven by scare tactics and has now turned to “just give it because I say so.” The University of New Mexico Center for HPV prevention reports up to a 50% reduction in cervical intraepithelial neoplasias (precancer lesions) in teens.³ This is exciting information and raises hope for the future successful battle against cervical cancer. I think it is also more accurate than stating to parents and patients that we have proof that we have prevented 70% of cervical cancers. When we explain it in this manner, the majority of parents and patients buy in and, I believe, enjoy and welcome this open-ended discussion.

To the Editor: I am an active primary care provider. After reading the update on human papillomavirus (HPV) in the March 2019 issue by Zhang and Batur,¹ I was hoping for some clarification on a few points.

The statement is made that up to 70% of HPV-related cervical cancer cases can be prevented with vaccination. I have pulled the reference² but cannot find supporting data for this claim. Is this proven or optimistic thinking based on the decreased incidence of abnormal Papanicolaou (Pap) test results such as noted in the University of New Mexico HPV Pap registry database³? The authors do cite an additional reference⁴ documenting a decreased incidence of cervical cancer in the United States among 15- to 24-year-olds from 2003–2006 compared with 2011–2014. This study reported a 29% relative risk reduction in the group receiving the vaccine, with the absolute numbers 6 vs 8.4 cases per 1,000,000. Thus, can the authors provide further references to the statement that 70% of cervical cancers can be prevented by vaccination?

The authors also state that vaccine acceptance rates are highest when primary care providers announce that the vaccine is due rather than invite open-ended discussions. At first this shocked me, but then made me pause and wonder how often I do that—and when I do, why. I regularly do it with all the other vaccines recommended by the Advisory Committee on Immunization Practices. When the parent or patient asks for further information, I am armed to provide it. To date, I am struggling to provide data to educate the patient on the efficacy of the HPV vaccine, particularly the claim that it will prevent 70% of cervical cancers. Are there more data that I am missing?

Finally, let me state that I am a “vaccinator”—always have been, and always will be. I discuss the HPV vaccine with my patients and their parents and try to provide data to support my recommendation. However, I am concerned that this current practice regarding the HPV vaccine has been driven by scare tactics and has now turned to “just give it because I say so.” The University of New Mexico Center for HPV prevention reports up to a 50% reduction in cervical intraepithelial neoplasias (precancer lesions) in teens.³ This is exciting information and raises hope for the future successful battle against cervical cancer. I think it is also more accurate than stating to parents and patients that we have proof that we have prevented 70% of cervical cancers. When we explain it in this manner, the majority of parents and patients buy in and, I believe, enjoy and welcome this open-ended discussion.

To the Editor: I am an active primary care provider. After reading the update on human papillomavirus (HPV) in the March 2019 issue by Zhang and Batur,¹ I was hoping for some clarification on a few points.

The statement is made that up to 70% of HPV-related cervical cancer cases can be prevented with vaccination. I have pulled the reference² but cannot find supporting data for this claim. Is this proven or optimistic thinking based on the decreased incidence of abnormal Papanicolaou (Pap) test results such as noted in the University of New Mexico HPV Pap registry database³? The authors do cite an additional reference⁴ documenting a decreased incidence of cervical cancer in the United States among 15- to 24-year-olds from 2003–2006 compared with 2011–2014. This study reported a 29% relative risk reduction in the group receiving the vaccine, with the absolute numbers 6 vs 8.4 cases per 1,000,000. Thus, can the authors provide further references to the statement that 70% of cervical cancers can be prevented by vaccination?

The authors also state that vaccine acceptance rates are highest when primary care providers announce that the vaccine is due rather than invite open-ended discussions. At first this shocked me, but then made me pause and wonder how often I do that—and when I do, why. I regularly do it with all the other vaccines recommended by the Advisory Committee on Immunization Practices. When the parent or patient asks for further information, I am armed to provide it. To date, I am struggling to provide data to educate the patient on the efficacy of the HPV vaccine, particularly the claim that it will prevent 70% of cervical cancers. Are there more data that I am missing?

Finally, let me state that I am a “vaccinator”—always have been, and always will be. I discuss the HPV vaccine with my patients and their parents and try to provide data to support my recommendation. However, I am concerned that this current practice regarding the HPV vaccine has been driven by scare tactics and has now turned to “just give it because I say so.” The University of New Mexico Center for HPV prevention reports up to a 50% reduction in cervical intraepithelial neoplasias (precancer lesions) in teens.³ This is exciting information and raises hope for the future successful battle against cervical cancer. I think it is also more accurate than stating to parents and patients that we have proof that we have prevented 70% of cervical cancers. When we explain it in this manner, the majority of parents and patients buy in and, I believe, enjoy and welcome this open-ended discussion.

In Reply: We would like to thank Dr. Lichtenberg for giving us the opportunity to clarify and expand on questions regarding HPV vaccine efficacy.

Our statement “HPV immunization can prevent up to 70% of cases of cervical cancer due to HPV as well as 90% of genital warts” was based on a statement by Thaxton and Waxman, ie, that immunization against HPV types 16 and 18 has the potential to prevent 70% of cancers of the cervix plus a large percentage of other lower anogenital tract cancers.¹ This was meant to describe the prevention potential of the quadrivalent vaccine. The currently available Gardasil 9 targets the HPV types that account for 90% of cervical cancers,² with projected effectiveness likely to vary based on geographic variation in HPV subtypes, ranging from 86.5% in Australia to 92% in North America.³ It is difficult to precisely calculate the effectiveness of HPV vaccination alone, given that cervical cancer prevention is twofold, with primary vaccination and secondary screening (with several notable updates to US national screening guidelines during the same time frame as vaccine development).⁴

It is true that the 29% decrease in US cervical cancer incidence rates during the years 2011–2014 compared with 2003–2006 is less than the predicted 70%.⁵ However, not all eligible US females are vaccinated; according to reports from the US Centers for Disease Control and Prevention, 49% of adolescents were appropriately immunized against HPV in 2017, an increase over the rate of only 35% in 2014.⁶ Low vaccination rates undoubtedly negatively impact any benefits from herd immunity, though the exact benefits of this population immunity are difficult to quantify.⁷

In Australia, a national school-based HPV vaccination program was initiated in 2007, making the vaccine available for free. Over 70% of girls ages 12 and 13 were vaccinated, and follow-up within the same decade showed a greater than 90% reduction in genital warts, as well as a reduction in high-grade cervical lesions.⁸ In addition, the incidence of genital warts in unvaccinated heterosexual males during the prevaccination vs the vaccination period decreased by up to 81% (a marker of herd immunity).⁹

In the US, the HPV subtypes found in the quadrivalent vaccine decreased by 71% in those ages 14 to 19, within 8 years of vaccine introduction.¹⁰ An analysis of US state cancer registries between 2009 and 2012 showed that in Michigan, the rates of high-grade, precancerous lesions declined by 37% each year for women ages 15 to 19, thought to be due to changes in screening and vaccination guidelines.¹¹ Similarly, an analysis of 9 million privately insured US females showed that the presence of high-grade precancerous lesions significantly decreased between the years 2007 and 2014 in those ages 15 to 24 (vaccinated individuals), but not in those ages 25 to 39 (unvaccinated individuals).¹² Most recently, a study of 10,206 women showed a 21.9% decrease in cervical intraepithelial neoplasia grade 2 or worse lesions due to HPV subtypes 16 or 18 in those who have received at least 1 dose of the vaccine; reduced rates in unvaccinated women were also seen, representing first evidence of herd immunity in the United States.¹³ In contrast, the rates of high-grade lesions due to nonvaccine HPV subtypes remained constant. Given that progression to cervical cancer can take 10 to 15 years or longer after HPV infection, true vaccine benefits will emerge once increased vaccination rates are achieved and after at least a decade of follow-up.

We applaud Dr. Lichtenberg’s efforts to clarify vaccine efficacy for appropriate counseling, as this is key to ensuring patient trust. Immunization fears have fueled the re-emergence of vaccine-preventable illnesses across the world. Given the wave of vaccine misinformation on the Internet, we all face patients and family members skeptical of vaccine efficacy and safety. Those requesting more information deserve an honest, informed discussion with their provider. Interestingly, however, among 955 unvaccinated women, the belief of not being at risk for HPV was the most common reason for not receiving the vaccine.¹⁴ Effective education can be achieved by focusing on the personal risks of HPV to the patient, as well as the overall favorable risk vs benefits of vaccination. Quoting an exact rate of cancer reduction is likely a less effective counseling strategy, and these efficacy estimates will change as vaccination rates and HPV prevalence within the population change over time.

In Reply: We would like to thank Dr. Lichtenberg for giving us the opportunity to clarify and expand on questions regarding HPV vaccine efficacy.

Our statement “HPV immunization can prevent up to 70% of cases of cervical cancer due to HPV as well as 90% of genital warts” was based on a statement by Thaxton and Waxman, ie, that immunization against HPV types 16 and 18 has the potential to prevent 70% of cancers of the cervix plus a large percentage of other lower anogenital tract cancers.¹ This was meant to describe the prevention potential of the quadrivalent vaccine. The currently available Gardasil 9 targets the HPV types that account for 90% of cervical cancers,² with projected effectiveness likely to vary based on geographic variation in HPV subtypes, ranging from 86.5% in Australia to 92% in North America.³ It is difficult to precisely calculate the effectiveness of HPV vaccination alone, given that cervical cancer prevention is twofold, with primary vaccination and secondary screening (with several notable updates to US national screening guidelines during the same time frame as vaccine development).⁴

It is true that the 29% decrease in US cervical cancer incidence rates during the years 2011–2014 compared with 2003–2006 is less than the predicted 70%.⁵ However, not all eligible US females are vaccinated; according to reports from the US Centers for Disease Control and Prevention, 49% of adolescents were appropriately immunized against HPV in 2017, an increase over the rate of only 35% in 2014.⁶ Low vaccination rates undoubtedly negatively impact any benefits from herd immunity, though the exact benefits of this population immunity are difficult to quantify.⁷

In Australia, a national school-based HPV vaccination program was initiated in 2007, making the vaccine available for free. Over 70% of girls ages 12 and 13 were vaccinated, and follow-up within the same decade showed a greater than 90% reduction in genital warts, as well as a reduction in high-grade cervical lesions.⁸ In addition, the incidence of genital warts in unvaccinated heterosexual males during the prevaccination vs the vaccination period decreased by up to 81% (a marker of herd immunity).⁹

In the US, the HPV subtypes found in the quadrivalent vaccine decreased by 71% in those ages 14 to 19, within 8 years of vaccine introduction.¹⁰ An analysis of US state cancer registries between 2009 and 2012 showed that in Michigan, the rates of high-grade, precancerous lesions declined by 37% each year for women ages 15 to 19, thought to be due to changes in screening and vaccination guidelines.¹¹ Similarly, an analysis of 9 million privately insured US females showed that the presence of high-grade precancerous lesions significantly decreased between the years 2007 and 2014 in those ages 15 to 24 (vaccinated individuals), but not in those ages 25 to 39 (unvaccinated individuals).¹² Most recently, a study of 10,206 women showed a 21.9% decrease in cervical intraepithelial neoplasia grade 2 or worse lesions due to HPV subtypes 16 or 18 in those who have received at least 1 dose of the vaccine; reduced rates in unvaccinated women were also seen, representing first evidence of herd immunity in the United States.¹³ In contrast, the rates of high-grade lesions due to nonvaccine HPV subtypes remained constant. Given that progression to cervical cancer can take 10 to 15 years or longer after HPV infection, true vaccine benefits will emerge once increased vaccination rates are achieved and after at least a decade of follow-up.

We applaud Dr. Lichtenberg’s efforts to clarify vaccine efficacy for appropriate counseling, as this is key to ensuring patient trust. Immunization fears have fueled the re-emergence of vaccine-preventable illnesses across the world. Given the wave of vaccine misinformation on the Internet, we all face patients and family members skeptical of vaccine efficacy and safety. Those requesting more information deserve an honest, informed discussion with their provider. Interestingly, however, among 955 unvaccinated women, the belief of not being at risk for HPV was the most common reason for not receiving the vaccine.¹⁴ Effective education can be achieved by focusing on the personal risks of HPV to the patient, as well as the overall favorable risk vs benefits of vaccination. Quoting an exact rate of cancer reduction is likely a less effective counseling strategy, and these efficacy estimates will change as vaccination rates and HPV prevalence within the population change over time.

In Reply: We would like to thank Dr. Lichtenberg for giving us the opportunity to clarify and expand on questions regarding HPV vaccine efficacy.

Our statement “HPV immunization can prevent up to 70% of cases of cervical cancer due to HPV as well as 90% of genital warts” was based on a statement by Thaxton and Waxman, ie, that immunization against HPV types 16 and 18 has the potential to prevent 70% of cancers of the cervix plus a large percentage of other lower anogenital tract cancers.¹ This was meant to describe the prevention potential of the quadrivalent vaccine. The currently available Gardasil 9 targets the HPV types that account for 90% of cervical cancers,² with projected effectiveness likely to vary based on geographic variation in HPV subtypes, ranging from 86.5% in Australia to 92% in North America.³ It is difficult to precisely calculate the effectiveness of HPV vaccination alone, given that cervical cancer prevention is twofold, with primary vaccination and secondary screening (with several notable updates to US national screening guidelines during the same time frame as vaccine development).⁴

It is true that the 29% decrease in US cervical cancer incidence rates during the years 2011–2014 compared with 2003–2006 is less than the predicted 70%.⁵ However, not all eligible US females are vaccinated; according to reports from the US Centers for Disease Control and Prevention, 49% of adolescents were appropriately immunized against HPV in 2017, an increase over the rate of only 35% in 2014.⁶ Low vaccination rates undoubtedly negatively impact any benefits from herd immunity, though the exact benefits of this population immunity are difficult to quantify.⁷

In Australia, a national school-based HPV vaccination program was initiated in 2007, making the vaccine available for free. Over 70% of girls ages 12 and 13 were vaccinated, and follow-up within the same decade showed a greater than 90% reduction in genital warts, as well as a reduction in high-grade cervical lesions.⁸ In addition, the incidence of genital warts in unvaccinated heterosexual males during the prevaccination vs the vaccination period decreased by up to 81% (a marker of herd immunity).⁹

In the US, the HPV subtypes found in the quadrivalent vaccine decreased by 71% in those ages 14 to 19, within 8 years of vaccine introduction.¹⁰ An analysis of US state cancer registries between 2009 and 2012 showed that in Michigan, the rates of high-grade, precancerous lesions declined by 37% each year for women ages 15 to 19, thought to be due to changes in screening and vaccination guidelines.¹¹ Similarly, an analysis of 9 million privately insured US females showed that the presence of high-grade precancerous lesions significantly decreased between the years 2007 and 2014 in those ages 15 to 24 (vaccinated individuals), but not in those ages 25 to 39 (unvaccinated individuals).¹² Most recently, a study of 10,206 women showed a 21.9% decrease in cervical intraepithelial neoplasia grade 2 or worse lesions due to HPV subtypes 16 or 18 in those who have received at least 1 dose of the vaccine; reduced rates in unvaccinated women were also seen, representing first evidence of herd immunity in the United States.¹³ In contrast, the rates of high-grade lesions due to nonvaccine HPV subtypes remained constant. Given that progression to cervical cancer can take 10 to 15 years or longer after HPV infection, true vaccine benefits will emerge once increased vaccination rates are achieved and after at least a decade of follow-up.

We applaud Dr. Lichtenberg’s efforts to clarify vaccine efficacy for appropriate counseling, as this is key to ensuring patient trust. Immunization fears have fueled the re-emergence of vaccine-preventable illnesses across the world. Given the wave of vaccine misinformation on the Internet, we all face patients and family members skeptical of vaccine efficacy and safety. Those requesting more information deserve an honest, informed discussion with their provider. Interestingly, however, among 955 unvaccinated women, the belief of not being at risk for HPV was the most common reason for not receiving the vaccine.¹⁴ Effective education can be achieved by focusing on the personal risks of HPV to the patient, as well as the overall favorable risk vs benefits of vaccination. Quoting an exact rate of cancer reduction is likely a less effective counseling strategy, and these efficacy estimates will change as vaccination rates and HPV prevalence within the population change over time.

Measles cases in the United States for this year have officially passed the postelimination high set in 2014, according to the Centers for Disease Control and Prevention.

As of Wednesday, April 24, the case count for measles is 695, which eclipses the mark of 667 cases that had been the highest since the disease was declared to be eliminated from this country in 2000, the CDC reported.

“The high number of cases in 2019 is primarily the result of a few large outbreaks – one in Washington State and two large outbreaks in New York that started in late 2018. The outbreaks in New York City and New York State are among the largest and longest lasting since measles elimination in 2000. The longer these outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States,” according to a written statement by the CDC.


Although these outbreaks began when the virus was brought into this country by unvaccinated travelers from other countries where there is widespread transmission, “a significant factor contributing to the outbreaks in New York is misinformation in the communities about the safety of the measles/mumps/rubella vaccine. Some organizations are deliberately targeting these communities with inaccurate and misleading information about vaccines,” according to the statement.

“Measles is not a harmless childhood illness, but a highly contagious, potentially life-threatening disease,” Health and Human Services Secretary Alex Azar said in a separate statement. “We have the ability to safely protect our children and our communities. Vaccines are a safe, highly effective public health solution that can prevent this disease. The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken. With a safe and effective vaccine that protects against measles, the suffering we are seeing is avoidable.”

[email protected]

Measles cases in the United States for this year have officially passed the postelimination high set in 2014, according to the Centers for Disease Control and Prevention.

As of Wednesday, April 24, the case count for measles is 695, which eclipses the mark of 667 cases that had been the highest since the disease was declared to be eliminated from this country in 2000, the CDC reported.

“The high number of cases in 2019 is primarily the result of a few large outbreaks – one in Washington State and two large outbreaks in New York that started in late 2018. The outbreaks in New York City and New York State are among the largest and longest lasting since measles elimination in 2000. The longer these outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States,” according to a written statement by the CDC.


Although these outbreaks began when the virus was brought into this country by unvaccinated travelers from other countries where there is widespread transmission, “a significant factor contributing to the outbreaks in New York is misinformation in the communities about the safety of the measles/mumps/rubella vaccine. Some organizations are deliberately targeting these communities with inaccurate and misleading information about vaccines,” according to the statement.

“Measles is not a harmless childhood illness, but a highly contagious, potentially life-threatening disease,” Health and Human Services Secretary Alex Azar said in a separate statement. “We have the ability to safely protect our children and our communities. Vaccines are a safe, highly effective public health solution that can prevent this disease. The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken. With a safe and effective vaccine that protects against measles, the suffering we are seeing is avoidable.”

[email protected]

Measles cases in the United States for this year have officially passed the postelimination high set in 2014, according to the Centers for Disease Control and Prevention.

As of Wednesday, April 24, the case count for measles is 695, which eclipses the mark of 667 cases that had been the highest since the disease was declared to be eliminated from this country in 2000, the CDC reported.

“The high number of cases in 2019 is primarily the result of a few large outbreaks – one in Washington State and two large outbreaks in New York that started in late 2018. The outbreaks in New York City and New York State are among the largest and longest lasting since measles elimination in 2000. The longer these outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States,” according to a written statement by the CDC.


Although these outbreaks began when the virus was brought into this country by unvaccinated travelers from other countries where there is widespread transmission, “a significant factor contributing to the outbreaks in New York is misinformation in the communities about the safety of the measles/mumps/rubella vaccine. Some organizations are deliberately targeting these communities with inaccurate and misleading information about vaccines,” according to the statement.

“Measles is not a harmless childhood illness, but a highly contagious, potentially life-threatening disease,” Health and Human Services Secretary Alex Azar said in a separate statement. “We have the ability to safely protect our children and our communities. Vaccines are a safe, highly effective public health solution that can prevent this disease. The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken. With a safe and effective vaccine that protects against measles, the suffering we are seeing is avoidable.”

[email protected]

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

The United States has topped 600 cases of measles for 2019 and is likely to pass the postelimination high set in 2014 “in the coming weeks,” according to the Centers for Disease Control and Prevention.

The 71 new measles cases reported during the week ending April 18 bring the total for the year to 626 in 22 states, the CDC reported April 22. Two states, Iowa and Tennessee, reported their first cases last week.

Outbreaks continue in five states: one in California (Butte County), one in Michigan (Oakland County/Wayne County/Detroit), one in New Jersey (Ocean County/Monmouth County), two in New York (New York City and Rockland County), and one in Washington (Clark County/King County), the CDC said.

The most active outbreak since mid-February has been the one occurring in New York City, mainly in Brooklyn, and last week was no exception as 50 of the 71 new U.S. cases were reported in the borough.

On April 18, a judge in Brooklyn “ruled against a group of parents who challenged New York City’s recently imposed mandatory measles vaccination order,” Reuters reported. That same day, the city issued a summons, subject to a fine of $1,000 each, to three people in Brooklyn who were still unvaccinated, according to NYC Health, which also said that four additional schools would be closed for not complying with an order to exclude unvaccinated students.

On April 15, the Iowa Department of Public Health confirmed the state’s first case of measles since 2011. The individual from Northeastern Iowa had not been vaccinated and had recently returned from Israel. The state’s second case of the year, a household contact of the first individual, was confirmed on April 18.

Also on April 18, the Tennessee Department of Health confirmed its first case of the year in a resident of the eastern part of the state. Meanwhile, media are reporting that state health officials in Mississippi are investigating possible exposures on April 9 and 10 in the Hattiesburg area by the infected Tennessee man.

Outside the United States, “many countries are in the midst of sizeable measles outbreaks, with all regions of the world experiencing sustained rises in cases,” the World Health Organization said. Current outbreaks include the Democratic Republic of the Congo, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand, and Ukraine.

Preliminary data for the first 3 months of 2019 show that cases worldwide were up by 300% over the first 3 months of 2018: 112,163 cases vs. 28,124. The actual numbers for 2019 are expected to be considerably higher than those reported so far, and WHO estimates that, globally, less than 1 in 10 cases are actually reported.

[email protected]

The United States has topped 600 cases of measles for 2019 and is likely to pass the postelimination high set in 2014 “in the coming weeks,” according to the Centers for Disease Control and Prevention.

The 71 new measles cases reported during the week ending April 18 bring the total for the year to 626 in 22 states, the CDC reported April 22. Two states, Iowa and Tennessee, reported their first cases last week.

Outbreaks continue in five states: one in California (Butte County), one in Michigan (Oakland County/Wayne County/Detroit), one in New Jersey (Ocean County/Monmouth County), two in New York (New York City and Rockland County), and one in Washington (Clark County/King County), the CDC said.

The most active outbreak since mid-February has been the one occurring in New York City, mainly in Brooklyn, and last week was no exception as 50 of the 71 new U.S. cases were reported in the borough.

On April 18, a judge in Brooklyn “ruled against a group of parents who challenged New York City’s recently imposed mandatory measles vaccination order,” Reuters reported. That same day, the city issued a summons, subject to a fine of $1,000 each, to three people in Brooklyn who were still unvaccinated, according to NYC Health, which also said that four additional schools would be closed for not complying with an order to exclude unvaccinated students.

On April 15, the Iowa Department of Public Health confirmed the state’s first case of measles since 2011. The individual from Northeastern Iowa had not been vaccinated and had recently returned from Israel. The state’s second case of the year, a household contact of the first individual, was confirmed on April 18.

Also on April 18, the Tennessee Department of Health confirmed its first case of the year in a resident of the eastern part of the state. Meanwhile, media are reporting that state health officials in Mississippi are investigating possible exposures on April 9 and 10 in the Hattiesburg area by the infected Tennessee man.

Outside the United States, “many countries are in the midst of sizeable measles outbreaks, with all regions of the world experiencing sustained rises in cases,” the World Health Organization said. Current outbreaks include the Democratic Republic of the Congo, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand, and Ukraine.

Preliminary data for the first 3 months of 2019 show that cases worldwide were up by 300% over the first 3 months of 2018: 112,163 cases vs. 28,124. The actual numbers for 2019 are expected to be considerably higher than those reported so far, and WHO estimates that, globally, less than 1 in 10 cases are actually reported.

[email protected]

The United States has topped 600 cases of measles for 2019 and is likely to pass the postelimination high set in 2014 “in the coming weeks,” according to the Centers for Disease Control and Prevention.

The 71 new measles cases reported during the week ending April 18 bring the total for the year to 626 in 22 states, the CDC reported April 22. Two states, Iowa and Tennessee, reported their first cases last week.

Outbreaks continue in five states: one in California (Butte County), one in Michigan (Oakland County/Wayne County/Detroit), one in New Jersey (Ocean County/Monmouth County), two in New York (New York City and Rockland County), and one in Washington (Clark County/King County), the CDC said.

The most active outbreak since mid-February has been the one occurring in New York City, mainly in Brooklyn, and last week was no exception as 50 of the 71 new U.S. cases were reported in the borough.

On April 18, a judge in Brooklyn “ruled against a group of parents who challenged New York City’s recently imposed mandatory measles vaccination order,” Reuters reported. That same day, the city issued a summons, subject to a fine of $1,000 each, to three people in Brooklyn who were still unvaccinated, according to NYC Health, which also said that four additional schools would be closed for not complying with an order to exclude unvaccinated students.

On April 15, the Iowa Department of Public Health confirmed the state’s first case of measles since 2011. The individual from Northeastern Iowa had not been vaccinated and had recently returned from Israel. The state’s second case of the year, a household contact of the first individual, was confirmed on April 18.

Also on April 18, the Tennessee Department of Health confirmed its first case of the year in a resident of the eastern part of the state. Meanwhile, media are reporting that state health officials in Mississippi are investigating possible exposures on April 9 and 10 in the Hattiesburg area by the infected Tennessee man.

Outside the United States, “many countries are in the midst of sizeable measles outbreaks, with all regions of the world experiencing sustained rises in cases,” the World Health Organization said. Current outbreaks include the Democratic Republic of the Congo, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand, and Ukraine.

Preliminary data for the first 3 months of 2019 show that cases worldwide were up by 300% over the first 3 months of 2018: 112,163 cases vs. 28,124. The actual numbers for 2019 are expected to be considerably higher than those reported so far, and WHO estimates that, globally, less than 1 in 10 cases are actually reported.

[email protected]

The severity and duration of vaccine-proximate febrile seizures (VP-FSs) are no worse than non–vaccine proximate febrile seizures (NVP-FSs), according to a study in Pediatrics.

KatarzynaBialasiewicz/Thinkstock

Lucy Deng, MBBS, of the University of Sydney and her colleagues investigated 1,022 index febrile seizures in children aged 6 years or less, of which 6% (n = 67) were VP-FSs and 94% (n = 955) were NVP-FSs. Both univariate and multivariate analyses showed no increased risk of severe seizure associated with VP-FSs, compared with NVP-FS. Most of the febrile seizures of either type were brief (15 minutes or less) and had a length of stay of 1 day or less; there also were no differences in 24-hour recurrence. The most common symptom was respiratory, and the rates were similar in each group (62.7% with VP-FS vs. 62.8% with NVP-FS). In keeping with a known 100% increased risk associated with measles vaccination, 84% of VP-FSs were associated with measles-containing vaccines. The majority of the remaining VP-FSs occurred after combination vaccines.

One limitation is that, because these cases were documented in sentinel tertiary pediatric hospitals, the case ascertainment may not be representative. Also, the small proportion of VP-FSs and limited cohort size means the study may not have been powered to detect true differences in prolonged seizures between the groups, Dr. Deng and her colleagues wrote.

“This study confirms that VP-FSs are clinically not any different from NVP-FSs and should be managed the same way,” the researchers concluded.

The authors reported no relevant financial disclosures, although Dr. Deng is supported by the University of Sydney Training Program scholarship, and two other study authors are supported by Australian National Health and Medical Research Council Career Development Fellowships. The study was funded by a grant from the Australian Government Department of Health and the National Health and Medical Research Council.

[email protected]

SOURCE: Deng L et al. Pediatrics. 2019 Apr 19. doi: 10.1542/peds.2018-2120.

The severity and duration of vaccine-proximate febrile seizures (VP-FSs) are no worse than non–vaccine proximate febrile seizures (NVP-FSs), according to a study in Pediatrics.

KatarzynaBialasiewicz/Thinkstock

Lucy Deng, MBBS, of the University of Sydney and her colleagues investigated 1,022 index febrile seizures in children aged 6 years or less, of which 6% (n = 67) were VP-FSs and 94% (n = 955) were NVP-FSs. Both univariate and multivariate analyses showed no increased risk of severe seizure associated with VP-FSs, compared with NVP-FS. Most of the febrile seizures of either type were brief (15 minutes or less) and had a length of stay of 1 day or less; there also were no differences in 24-hour recurrence. The most common symptom was respiratory, and the rates were similar in each group (62.7% with VP-FS vs. 62.8% with NVP-FS). In keeping with a known 100% increased risk associated with measles vaccination, 84% of VP-FSs were associated with measles-containing vaccines. The majority of the remaining VP-FSs occurred after combination vaccines.

One limitation is that, because these cases were documented in sentinel tertiary pediatric hospitals, the case ascertainment may not be representative. Also, the small proportion of VP-FSs and limited cohort size means the study may not have been powered to detect true differences in prolonged seizures between the groups, Dr. Deng and her colleagues wrote.

“This study confirms that VP-FSs are clinically not any different from NVP-FSs and should be managed the same way,” the researchers concluded.

The authors reported no relevant financial disclosures, although Dr. Deng is supported by the University of Sydney Training Program scholarship, and two other study authors are supported by Australian National Health and Medical Research Council Career Development Fellowships. The study was funded by a grant from the Australian Government Department of Health and the National Health and Medical Research Council.

[email protected]

SOURCE: Deng L et al. Pediatrics. 2019 Apr 19. doi: 10.1542/peds.2018-2120.

The severity and duration of vaccine-proximate febrile seizures (VP-FSs) are no worse than non–vaccine proximate febrile seizures (NVP-FSs), according to a study in Pediatrics.

KatarzynaBialasiewicz/Thinkstock

Lucy Deng, MBBS, of the University of Sydney and her colleagues investigated 1,022 index febrile seizures in children aged 6 years or less, of which 6% (n = 67) were VP-FSs and 94% (n = 955) were NVP-FSs. Both univariate and multivariate analyses showed no increased risk of severe seizure associated with VP-FSs, compared with NVP-FS. Most of the febrile seizures of either type were brief (15 minutes or less) and had a length of stay of 1 day or less; there also were no differences in 24-hour recurrence. The most common symptom was respiratory, and the rates were similar in each group (62.7% with VP-FS vs. 62.8% with NVP-FS). In keeping with a known 100% increased risk associated with measles vaccination, 84% of VP-FSs were associated with measles-containing vaccines. The majority of the remaining VP-FSs occurred after combination vaccines.

One limitation is that, because these cases were documented in sentinel tertiary pediatric hospitals, the case ascertainment may not be representative. Also, the small proportion of VP-FSs and limited cohort size means the study may not have been powered to detect true differences in prolonged seizures between the groups, Dr. Deng and her colleagues wrote.

“This study confirms that VP-FSs are clinically not any different from NVP-FSs and should be managed the same way,” the researchers concluded.

The authors reported no relevant financial disclosures, although Dr. Deng is supported by the University of Sydney Training Program scholarship, and two other study authors are supported by Australian National Health and Medical Research Council Career Development Fellowships. The study was funded by a grant from the Australian Government Department of Health and the National Health and Medical Research Council.

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SOURCE: Deng L et al. Pediatrics. 2019 Apr 19. doi: 10.1542/peds.2018-2120.