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U.S. measles cases up to 159 for the year
Reported measles cases are now up to 159 for the year in the United States, according to the Centers for Disease Control and Prevention.
The most recent reporting week, which ended Feb. 21, brought another 32 cases of measles and one new outbreak of 4 cases in Illinois. The total number of outbreaks – an outbreak is defined as three or more cases – is now six, and cases have been reported in 10 states, the CDC said Feb. 25.
The majority (17) of those 32 new cases occurred in Brooklyn, one of New York state’s three outbreaks this year. The largest of the 2019 outbreaks is in Washington state, primarily in Clark County, and is up to 66 cases after 4 more were reported in the last week by the state’s department of health. The outbreaks are linked to travelers who brought the disease to the United States.
There are now two measures “advancing through the [Washington] state legislature that would bar parents from using personal or philosophical exemptions to avoid immunizing their school-age children. Both have bipartisan support despite strong antivaccination sentiment in parts of the state,” the Washington Post said on Feb. 25.
Reported measles cases are now up to 159 for the year in the United States, according to the Centers for Disease Control and Prevention.
The most recent reporting week, which ended Feb. 21, brought another 32 cases of measles and one new outbreak of 4 cases in Illinois. The total number of outbreaks – an outbreak is defined as three or more cases – is now six, and cases have been reported in 10 states, the CDC said Feb. 25.
The majority (17) of those 32 new cases occurred in Brooklyn, one of New York state’s three outbreaks this year. The largest of the 2019 outbreaks is in Washington state, primarily in Clark County, and is up to 66 cases after 4 more were reported in the last week by the state’s department of health. The outbreaks are linked to travelers who brought the disease to the United States.
There are now two measures “advancing through the [Washington] state legislature that would bar parents from using personal or philosophical exemptions to avoid immunizing their school-age children. Both have bipartisan support despite strong antivaccination sentiment in parts of the state,” the Washington Post said on Feb. 25.
Reported measles cases are now up to 159 for the year in the United States, according to the Centers for Disease Control and Prevention.
The most recent reporting week, which ended Feb. 21, brought another 32 cases of measles and one new outbreak of 4 cases in Illinois. The total number of outbreaks – an outbreak is defined as three or more cases – is now six, and cases have been reported in 10 states, the CDC said Feb. 25.
The majority (17) of those 32 new cases occurred in Brooklyn, one of New York state’s three outbreaks this year. The largest of the 2019 outbreaks is in Washington state, primarily in Clark County, and is up to 66 cases after 4 more were reported in the last week by the state’s department of health. The outbreaks are linked to travelers who brought the disease to the United States.
There are now two measures “advancing through the [Washington] state legislature that would bar parents from using personal or philosophical exemptions to avoid immunizing their school-age children. Both have bipartisan support despite strong antivaccination sentiment in parts of the state,” the Washington Post said on Feb. 25.
Pseudoscience redux
My most recent column discussed the problem of pseudoscience that pervades some corners of the Internet. Personally, I respond to pseudoscience primarily by trying to provide accurate and less-biased information. I recognize that not everyone approaches decision making by seeking more information. When dealing a diverse public, a medical professional needs to have other approaches in the armamentarium.1 When dealing with other physicians, I am less flexible. Either the profession of medicine believes in science or it doesn’t.
Since that column was published, there have been major developments. There are measles outbreaks in the states of Washington and New York, and more than 100 deaths from a measles epidemic in the Philippines. The World Health Organization has made vaccine hesitancy one of its ten threats to global health in 2019.
Facebook has indicated that it might demote the priority and frequency with which it recommends articles that promulgate anti-vax information and conspiracy theories.2 Facebook isn’t doing this because it has had an epiphany; it has come under pressure for its role in the spread of misinformation. Current legislation was written before the rise of social media, when Internet Service Providers were primarily conduits to transfer bits and bytes between computers. Those ISPs were not liable for the content of the transmitted Web pages. Facebook, by producing what it called a newsfeed and by making personalized suggestions for other websites to browse, doesn’t fit the passive model of an ISP.
For alleged violations of user’s privacy, Facebook might be subject to billion dollar fines, according to a Washington Post article.3 Still, for a company whose revenue is $4 billion per month and whose stock market value is $400 billion, paying a billion dollar fine for years of alleged misbehaviors that have enabled it to become a giant empire is, “in the scheme of things ... a speeding ticket” in the parlance of the penultimate scene of the movie The Social Network. The real financial risk is people deciding they can’t trust the platform and going elsewhere.
Authorities in the United Kingdom in February 2019 released a highly critical, 108-page report about fake news, which said, “Facebook should not be allowed to behave like ‘digital gangsters’ in the online world.”4 The U.K. report urges new regulations to deal with privacy breaches and with fake news. It endeavors to create a duty for social media companies to combat the spread of misinformation.
Then the Wall Street Journal reported that Pinterest has stopped returning results for searches related to vaccination.5 Pinterest realized that most of the shared images on its platform cautioned against vaccination, which contradicts the recommendations of medical experts. Unable to otherwise combat the flow of misinformation, the company apparently has decided to eliminate returning results, pro or con, for any search terms related to vaccines.
While lamenting the public’s inability to distinguish misinformation on the Internet, I’ve also been observing the factors that lead physicians astray. I expect physicians, as trained scientists and as professionals, to be able to assimilate new information and change their practices accordingly. Those who do research on the translation of technology find that, this doesn’t happen with any regularity.
The February 2019 issue of Hospital Pediatrics has four items on the topic of treating bronchiolitis, including two research articles, a brief report, and a commentary. That is obviously a relevant topic this time of year. The impression after reading those four items is that hospitalists don’t really know how to best treat the most common illness they encounter. And even when they “know” how to do it, many factors distort the science. Those factors are highlighted in the article on barriers to minimizing viral testing.6
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. “Discussing immunization with vaccine-hesitant parents requires caring, individualized approach,” by Jeff Craven, Pediatric News, Nov. 7, 2018; “How do you get anti-vaxxers to vaccinate their kids? Talk to them – for hours,” by Nadine Gartner, Washington Post, Feb. 19, 2019.
2. “Facebook will consider removing or demoting anti-vaccination recommendations amid backlash,” by Taylor Telford, Washington Post, Feb. 15, 2019.
3. “U.S. regulators have met to discuss imposing a record-setting fine against Facebook for privacy violations,” by Tony Romm and Elizabeth Dwoskin, Washington Post, Jan. 18, 2019; “Report: Facebook, FTC discussing ‘multibillion dollar’ fine,” by Associated Press.
4. “Disinformation and ‘fake news’: Final Report,” House of Commons, Feb. 18, 2019, p. 42, item 139.
5. “Pinterest blocks vaccination searches in move to control the conversation,” by Robert McMillan and Daniela Hernandez, The Wall Street Journal, Feb. 20, 2019.
6. “Barriers to minimizing respiratory viral testing in bronchiolitis: Physician perceptions on testing practices,” by MZ Huang et al. Hospital Pediatrics 2019 Feb. doi: 10.1542/hpeds.2018-0108.
My most recent column discussed the problem of pseudoscience that pervades some corners of the Internet. Personally, I respond to pseudoscience primarily by trying to provide accurate and less-biased information. I recognize that not everyone approaches decision making by seeking more information. When dealing a diverse public, a medical professional needs to have other approaches in the armamentarium.1 When dealing with other physicians, I am less flexible. Either the profession of medicine believes in science or it doesn’t.
Since that column was published, there have been major developments. There are measles outbreaks in the states of Washington and New York, and more than 100 deaths from a measles epidemic in the Philippines. The World Health Organization has made vaccine hesitancy one of its ten threats to global health in 2019.
Facebook has indicated that it might demote the priority and frequency with which it recommends articles that promulgate anti-vax information and conspiracy theories.2 Facebook isn’t doing this because it has had an epiphany; it has come under pressure for its role in the spread of misinformation. Current legislation was written before the rise of social media, when Internet Service Providers were primarily conduits to transfer bits and bytes between computers. Those ISPs were not liable for the content of the transmitted Web pages. Facebook, by producing what it called a newsfeed and by making personalized suggestions for other websites to browse, doesn’t fit the passive model of an ISP.
For alleged violations of user’s privacy, Facebook might be subject to billion dollar fines, according to a Washington Post article.3 Still, for a company whose revenue is $4 billion per month and whose stock market value is $400 billion, paying a billion dollar fine for years of alleged misbehaviors that have enabled it to become a giant empire is, “in the scheme of things ... a speeding ticket” in the parlance of the penultimate scene of the movie The Social Network. The real financial risk is people deciding they can’t trust the platform and going elsewhere.
Authorities in the United Kingdom in February 2019 released a highly critical, 108-page report about fake news, which said, “Facebook should not be allowed to behave like ‘digital gangsters’ in the online world.”4 The U.K. report urges new regulations to deal with privacy breaches and with fake news. It endeavors to create a duty for social media companies to combat the spread of misinformation.
Then the Wall Street Journal reported that Pinterest has stopped returning results for searches related to vaccination.5 Pinterest realized that most of the shared images on its platform cautioned against vaccination, which contradicts the recommendations of medical experts. Unable to otherwise combat the flow of misinformation, the company apparently has decided to eliminate returning results, pro or con, for any search terms related to vaccines.
While lamenting the public’s inability to distinguish misinformation on the Internet, I’ve also been observing the factors that lead physicians astray. I expect physicians, as trained scientists and as professionals, to be able to assimilate new information and change their practices accordingly. Those who do research on the translation of technology find that, this doesn’t happen with any regularity.
The February 2019 issue of Hospital Pediatrics has four items on the topic of treating bronchiolitis, including two research articles, a brief report, and a commentary. That is obviously a relevant topic this time of year. The impression after reading those four items is that hospitalists don’t really know how to best treat the most common illness they encounter. And even when they “know” how to do it, many factors distort the science. Those factors are highlighted in the article on barriers to minimizing viral testing.6
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. “Discussing immunization with vaccine-hesitant parents requires caring, individualized approach,” by Jeff Craven, Pediatric News, Nov. 7, 2018; “How do you get anti-vaxxers to vaccinate their kids? Talk to them – for hours,” by Nadine Gartner, Washington Post, Feb. 19, 2019.
2. “Facebook will consider removing or demoting anti-vaccination recommendations amid backlash,” by Taylor Telford, Washington Post, Feb. 15, 2019.
3. “U.S. regulators have met to discuss imposing a record-setting fine against Facebook for privacy violations,” by Tony Romm and Elizabeth Dwoskin, Washington Post, Jan. 18, 2019; “Report: Facebook, FTC discussing ‘multibillion dollar’ fine,” by Associated Press.
4. “Disinformation and ‘fake news’: Final Report,” House of Commons, Feb. 18, 2019, p. 42, item 139.
5. “Pinterest blocks vaccination searches in move to control the conversation,” by Robert McMillan and Daniela Hernandez, The Wall Street Journal, Feb. 20, 2019.
6. “Barriers to minimizing respiratory viral testing in bronchiolitis: Physician perceptions on testing practices,” by MZ Huang et al. Hospital Pediatrics 2019 Feb. doi: 10.1542/hpeds.2018-0108.
My most recent column discussed the problem of pseudoscience that pervades some corners of the Internet. Personally, I respond to pseudoscience primarily by trying to provide accurate and less-biased information. I recognize that not everyone approaches decision making by seeking more information. When dealing a diverse public, a medical professional needs to have other approaches in the armamentarium.1 When dealing with other physicians, I am less flexible. Either the profession of medicine believes in science or it doesn’t.
Since that column was published, there have been major developments. There are measles outbreaks in the states of Washington and New York, and more than 100 deaths from a measles epidemic in the Philippines. The World Health Organization has made vaccine hesitancy one of its ten threats to global health in 2019.
Facebook has indicated that it might demote the priority and frequency with which it recommends articles that promulgate anti-vax information and conspiracy theories.2 Facebook isn’t doing this because it has had an epiphany; it has come under pressure for its role in the spread of misinformation. Current legislation was written before the rise of social media, when Internet Service Providers were primarily conduits to transfer bits and bytes between computers. Those ISPs were not liable for the content of the transmitted Web pages. Facebook, by producing what it called a newsfeed and by making personalized suggestions for other websites to browse, doesn’t fit the passive model of an ISP.
For alleged violations of user’s privacy, Facebook might be subject to billion dollar fines, according to a Washington Post article.3 Still, for a company whose revenue is $4 billion per month and whose stock market value is $400 billion, paying a billion dollar fine for years of alleged misbehaviors that have enabled it to become a giant empire is, “in the scheme of things ... a speeding ticket” in the parlance of the penultimate scene of the movie The Social Network. The real financial risk is people deciding they can’t trust the platform and going elsewhere.
Authorities in the United Kingdom in February 2019 released a highly critical, 108-page report about fake news, which said, “Facebook should not be allowed to behave like ‘digital gangsters’ in the online world.”4 The U.K. report urges new regulations to deal with privacy breaches and with fake news. It endeavors to create a duty for social media companies to combat the spread of misinformation.
Then the Wall Street Journal reported that Pinterest has stopped returning results for searches related to vaccination.5 Pinterest realized that most of the shared images on its platform cautioned against vaccination, which contradicts the recommendations of medical experts. Unable to otherwise combat the flow of misinformation, the company apparently has decided to eliminate returning results, pro or con, for any search terms related to vaccines.
While lamenting the public’s inability to distinguish misinformation on the Internet, I’ve also been observing the factors that lead physicians astray. I expect physicians, as trained scientists and as professionals, to be able to assimilate new information and change their practices accordingly. Those who do research on the translation of technology find that, this doesn’t happen with any regularity.
The February 2019 issue of Hospital Pediatrics has four items on the topic of treating bronchiolitis, including two research articles, a brief report, and a commentary. That is obviously a relevant topic this time of year. The impression after reading those four items is that hospitalists don’t really know how to best treat the most common illness they encounter. And even when they “know” how to do it, many factors distort the science. Those factors are highlighted in the article on barriers to minimizing viral testing.6
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. “Discussing immunization with vaccine-hesitant parents requires caring, individualized approach,” by Jeff Craven, Pediatric News, Nov. 7, 2018; “How do you get anti-vaxxers to vaccinate their kids? Talk to them – for hours,” by Nadine Gartner, Washington Post, Feb. 19, 2019.
2. “Facebook will consider removing or demoting anti-vaccination recommendations amid backlash,” by Taylor Telford, Washington Post, Feb. 15, 2019.
3. “U.S. regulators have met to discuss imposing a record-setting fine against Facebook for privacy violations,” by Tony Romm and Elizabeth Dwoskin, Washington Post, Jan. 18, 2019; “Report: Facebook, FTC discussing ‘multibillion dollar’ fine,” by Associated Press.
4. “Disinformation and ‘fake news’: Final Report,” House of Commons, Feb. 18, 2019, p. 42, item 139.
5. “Pinterest blocks vaccination searches in move to control the conversation,” by Robert McMillan and Daniela Hernandez, The Wall Street Journal, Feb. 20, 2019.
6. “Barriers to minimizing respiratory viral testing in bronchiolitis: Physician perceptions on testing practices,” by MZ Huang et al. Hospital Pediatrics 2019 Feb. doi: 10.1542/hpeds.2018-0108.
Working With Parents to Vaccinate Children
Global outbreaks of infectious diseases—such as smallpox, pertussis, dysentery, and scarlet fever—seem like fodder for the history books. It was centuries ago that epidemics wiped out large swathes of the world population. Many people living and raising children today have never witnessed the devastating effects of measles, mumps, polio, and influenza—diseases that have been substantially reduced or even eradicated.1 Why? Because since the early 1900s, we have had scientifically developed and widely distributed vaccines at our disposal.
In context, it is incredible to realize that we are still in the beginning stages of vaccine research and development. From that perspective, it is perhaps not as surprising that some parents are hesitant to vaccinate their children—after all, do we really know everything we can and should know about inoculation? Parental resistance to or refusal of vaccination is further fueled by tainted research (Andrew Wakefield was forced to retract his findings that “validated” a link between thimerosal in vaccines and autism) and misinformation propagated on the Internet.2
But what has long been a source of frustration to those who support routine vaccination has, in recent years, started to become a public health issue. Measles outbreaks are no longer historical artifacts—they are real, as evidenced by the current rise in cases centered in Clark County, Washington. Through the first full week of February 2019, there were 101 confirmed cases of measles in the US, half of which occurred in Washington State—leading the governor to declare a public health emergency.3
This has, of course, reinvigorated the ongoing discussion about parental refusal to vaccinate. Enough has been said on this topic, by both public officials and private individuals, in a variety of venues over the years. So I’d like to focus instead on the role that individual health care providers can play in this situation.
Over the years, many of my colleagues have shared stories about parents who have refused to vaccinate their children. We know many things: These parents often fear complications from vaccination more than complications of disease. Many have religious or philosophical reasons for their reluctance or refusal to vaccinate their children. Some have concerns about vaccine safety or effectiveness. We know these things … but we don’t always know how to speak with parents about these issues.
It is somewhat ironic that the core motivation for hesitant parents and well-meaning clinicians is the same: care and protection of the child. The difficulty lies in the disparate view of what that entails. As NPs and PAs, though, our duty is to seek health benefits for and minimize harm to the patients in our care. Part of our role, when those patients are children, is to provide parents with the necessary risk-benefit information to help them make informed decisions. When the subject is vaccination, we must listen carefully and be respectful of parents’ concerns; we must recognize that their decision-making criteria may differ from ours.
So how can we bridge the gap with parents who “don’t see it the way we do”? We start by being honest with them about what is and isn’t known as far as the risks and benefits of vaccination in general or a vaccine in particular. This means acknowledging that although vaccines are very safe, they are not risk-free or 100% effective. But this also gives us the opportunity to provide them with validated data and to emphasize that the risks of any vaccine should not be considered in a silo but rather in comparison with the risks of the disease in question or of the lack of immunization.
Continue to: Helpfully, Leask and colleagues...
Helpfully, Leask and colleagues have classified parental positions on vaccination, which also provided the groundwork to offer strategies for communicating with each group.4 They identified five classes:
Unquestioning acceptors (30% to 40% of parents), who vaccinate their children and typically have no specific questions about the need for or safety of vaccines. Since this group tends to have a good relationship with their health care team but less detailed knowledge about vaccination, clinicians should continue to build rapport while providing scientific information about the vaccine being recommended or administered.4
Cautious acceptors (25% to 35%), who vaccinate their children despite having minor concerns. They tend to recognize the risk for adverse effects and hope their child will not be affected. In addition to building rapport, clinicians should provide verbal and numeric descriptions of relevant vaccine data and explain common adverse effects and disease risks.4
Hesitant vaccinators (20% to 30%), who are on the fence about the benefits and safety of vaccination. Their focus is more on the negative aspects, and they may not feel particularly trusting of their health care provider. Therefore, gaining trust is vital—parents in this group are eager to discuss their concerns with their clinician and have their questions answered satisfactorily. Motivational interviewing using a guiding style may be a helpful tool.4
Late or selective vaccinators (2% to 27%), who have significant doubts about the safety and necessity of vaccines, resulting in their choice to delay vaccination or select only some of the recommended vaccines for their child. These parents may require additional time—possibly a second appointment—in which to fully discuss their concerns. Be sure to provide up-to-date information on the risks and benefits of a vaccine, and use decision aids as appropriate.4
Continue to: Refusers...
Refusers (<2%), who have concerns about the number of vaccines children receive and conflicting feelings about whom to trust and how best to get answers to their questions. This group tends to demonstrate high knowledge levels about vaccination but may be the most argumentative when presented with information. Emphasize the importance of protecting the child from an infectious disease and reinforce the effectiveness of the vaccine. Use statistics rather than anecdotes. But above all, spend the time needed to provide refusers with a thorough understanding of the risks of not immunizing their child.4
Although it is not a universal sentiment, many parents confer trust on their health care providers. We can use this trust in a respectful, noncoercive, and non-condescending manner by providing research-supported facts about vaccines. Clinicians who listen with a compassionate ear will be in the best position to lead the hesitant, late or selective, or refusing parents to confidently make an informed decision that immunization is the best way to protect their children from vaccine-preventable diseases.4
Rather than yet again focusing on the negative, I’d like to ask: Have you had a success story of helping parents to choose vaccination for their children? How did you overcome their concerns? Share your experience with me at [email protected].
1. CDC. Achievements in public health, 1900-1999 impact of vaccines universally recommended for children—United States, 1990-1998. MMWR Morb Mortal Wkly Rep. 1999;48(12):243-248.
2. Wakefield AJ, Murch SH, Anthony A, et al. RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351(9103):637-641.
3. Franki R. United States now over 100 measles cases for the year. MDEdge Family Practice. February 11, 2019.
4. Leask J, Kinnersley P, Jackson C, et al. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatrics. 2012;12:154.
Global outbreaks of infectious diseases—such as smallpox, pertussis, dysentery, and scarlet fever—seem like fodder for the history books. It was centuries ago that epidemics wiped out large swathes of the world population. Many people living and raising children today have never witnessed the devastating effects of measles, mumps, polio, and influenza—diseases that have been substantially reduced or even eradicated.1 Why? Because since the early 1900s, we have had scientifically developed and widely distributed vaccines at our disposal.
In context, it is incredible to realize that we are still in the beginning stages of vaccine research and development. From that perspective, it is perhaps not as surprising that some parents are hesitant to vaccinate their children—after all, do we really know everything we can and should know about inoculation? Parental resistance to or refusal of vaccination is further fueled by tainted research (Andrew Wakefield was forced to retract his findings that “validated” a link between thimerosal in vaccines and autism) and misinformation propagated on the Internet.2
But what has long been a source of frustration to those who support routine vaccination has, in recent years, started to become a public health issue. Measles outbreaks are no longer historical artifacts—they are real, as evidenced by the current rise in cases centered in Clark County, Washington. Through the first full week of February 2019, there were 101 confirmed cases of measles in the US, half of which occurred in Washington State—leading the governor to declare a public health emergency.3
This has, of course, reinvigorated the ongoing discussion about parental refusal to vaccinate. Enough has been said on this topic, by both public officials and private individuals, in a variety of venues over the years. So I’d like to focus instead on the role that individual health care providers can play in this situation.
Over the years, many of my colleagues have shared stories about parents who have refused to vaccinate their children. We know many things: These parents often fear complications from vaccination more than complications of disease. Many have religious or philosophical reasons for their reluctance or refusal to vaccinate their children. Some have concerns about vaccine safety or effectiveness. We know these things … but we don’t always know how to speak with parents about these issues.
It is somewhat ironic that the core motivation for hesitant parents and well-meaning clinicians is the same: care and protection of the child. The difficulty lies in the disparate view of what that entails. As NPs and PAs, though, our duty is to seek health benefits for and minimize harm to the patients in our care. Part of our role, when those patients are children, is to provide parents with the necessary risk-benefit information to help them make informed decisions. When the subject is vaccination, we must listen carefully and be respectful of parents’ concerns; we must recognize that their decision-making criteria may differ from ours.
So how can we bridge the gap with parents who “don’t see it the way we do”? We start by being honest with them about what is and isn’t known as far as the risks and benefits of vaccination in general or a vaccine in particular. This means acknowledging that although vaccines are very safe, they are not risk-free or 100% effective. But this also gives us the opportunity to provide them with validated data and to emphasize that the risks of any vaccine should not be considered in a silo but rather in comparison with the risks of the disease in question or of the lack of immunization.
Continue to: Helpfully, Leask and colleagues...
Helpfully, Leask and colleagues have classified parental positions on vaccination, which also provided the groundwork to offer strategies for communicating with each group.4 They identified five classes:
Unquestioning acceptors (30% to 40% of parents), who vaccinate their children and typically have no specific questions about the need for or safety of vaccines. Since this group tends to have a good relationship with their health care team but less detailed knowledge about vaccination, clinicians should continue to build rapport while providing scientific information about the vaccine being recommended or administered.4
Cautious acceptors (25% to 35%), who vaccinate their children despite having minor concerns. They tend to recognize the risk for adverse effects and hope their child will not be affected. In addition to building rapport, clinicians should provide verbal and numeric descriptions of relevant vaccine data and explain common adverse effects and disease risks.4
Hesitant vaccinators (20% to 30%), who are on the fence about the benefits and safety of vaccination. Their focus is more on the negative aspects, and they may not feel particularly trusting of their health care provider. Therefore, gaining trust is vital—parents in this group are eager to discuss their concerns with their clinician and have their questions answered satisfactorily. Motivational interviewing using a guiding style may be a helpful tool.4
Late or selective vaccinators (2% to 27%), who have significant doubts about the safety and necessity of vaccines, resulting in their choice to delay vaccination or select only some of the recommended vaccines for their child. These parents may require additional time—possibly a second appointment—in which to fully discuss their concerns. Be sure to provide up-to-date information on the risks and benefits of a vaccine, and use decision aids as appropriate.4
Continue to: Refusers...
Refusers (<2%), who have concerns about the number of vaccines children receive and conflicting feelings about whom to trust and how best to get answers to their questions. This group tends to demonstrate high knowledge levels about vaccination but may be the most argumentative when presented with information. Emphasize the importance of protecting the child from an infectious disease and reinforce the effectiveness of the vaccine. Use statistics rather than anecdotes. But above all, spend the time needed to provide refusers with a thorough understanding of the risks of not immunizing their child.4
Although it is not a universal sentiment, many parents confer trust on their health care providers. We can use this trust in a respectful, noncoercive, and non-condescending manner by providing research-supported facts about vaccines. Clinicians who listen with a compassionate ear will be in the best position to lead the hesitant, late or selective, or refusing parents to confidently make an informed decision that immunization is the best way to protect their children from vaccine-preventable diseases.4
Rather than yet again focusing on the negative, I’d like to ask: Have you had a success story of helping parents to choose vaccination for their children? How did you overcome their concerns? Share your experience with me at [email protected].
Global outbreaks of infectious diseases—such as smallpox, pertussis, dysentery, and scarlet fever—seem like fodder for the history books. It was centuries ago that epidemics wiped out large swathes of the world population. Many people living and raising children today have never witnessed the devastating effects of measles, mumps, polio, and influenza—diseases that have been substantially reduced or even eradicated.1 Why? Because since the early 1900s, we have had scientifically developed and widely distributed vaccines at our disposal.
In context, it is incredible to realize that we are still in the beginning stages of vaccine research and development. From that perspective, it is perhaps not as surprising that some parents are hesitant to vaccinate their children—after all, do we really know everything we can and should know about inoculation? Parental resistance to or refusal of vaccination is further fueled by tainted research (Andrew Wakefield was forced to retract his findings that “validated” a link between thimerosal in vaccines and autism) and misinformation propagated on the Internet.2
But what has long been a source of frustration to those who support routine vaccination has, in recent years, started to become a public health issue. Measles outbreaks are no longer historical artifacts—they are real, as evidenced by the current rise in cases centered in Clark County, Washington. Through the first full week of February 2019, there were 101 confirmed cases of measles in the US, half of which occurred in Washington State—leading the governor to declare a public health emergency.3
This has, of course, reinvigorated the ongoing discussion about parental refusal to vaccinate. Enough has been said on this topic, by both public officials and private individuals, in a variety of venues over the years. So I’d like to focus instead on the role that individual health care providers can play in this situation.
Over the years, many of my colleagues have shared stories about parents who have refused to vaccinate their children. We know many things: These parents often fear complications from vaccination more than complications of disease. Many have religious or philosophical reasons for their reluctance or refusal to vaccinate their children. Some have concerns about vaccine safety or effectiveness. We know these things … but we don’t always know how to speak with parents about these issues.
It is somewhat ironic that the core motivation for hesitant parents and well-meaning clinicians is the same: care and protection of the child. The difficulty lies in the disparate view of what that entails. As NPs and PAs, though, our duty is to seek health benefits for and minimize harm to the patients in our care. Part of our role, when those patients are children, is to provide parents with the necessary risk-benefit information to help them make informed decisions. When the subject is vaccination, we must listen carefully and be respectful of parents’ concerns; we must recognize that their decision-making criteria may differ from ours.
So how can we bridge the gap with parents who “don’t see it the way we do”? We start by being honest with them about what is and isn’t known as far as the risks and benefits of vaccination in general or a vaccine in particular. This means acknowledging that although vaccines are very safe, they are not risk-free or 100% effective. But this also gives us the opportunity to provide them with validated data and to emphasize that the risks of any vaccine should not be considered in a silo but rather in comparison with the risks of the disease in question or of the lack of immunization.
Continue to: Helpfully, Leask and colleagues...
Helpfully, Leask and colleagues have classified parental positions on vaccination, which also provided the groundwork to offer strategies for communicating with each group.4 They identified five classes:
Unquestioning acceptors (30% to 40% of parents), who vaccinate their children and typically have no specific questions about the need for or safety of vaccines. Since this group tends to have a good relationship with their health care team but less detailed knowledge about vaccination, clinicians should continue to build rapport while providing scientific information about the vaccine being recommended or administered.4
Cautious acceptors (25% to 35%), who vaccinate their children despite having minor concerns. They tend to recognize the risk for adverse effects and hope their child will not be affected. In addition to building rapport, clinicians should provide verbal and numeric descriptions of relevant vaccine data and explain common adverse effects and disease risks.4
Hesitant vaccinators (20% to 30%), who are on the fence about the benefits and safety of vaccination. Their focus is more on the negative aspects, and they may not feel particularly trusting of their health care provider. Therefore, gaining trust is vital—parents in this group are eager to discuss their concerns with their clinician and have their questions answered satisfactorily. Motivational interviewing using a guiding style may be a helpful tool.4
Late or selective vaccinators (2% to 27%), who have significant doubts about the safety and necessity of vaccines, resulting in their choice to delay vaccination or select only some of the recommended vaccines for their child. These parents may require additional time—possibly a second appointment—in which to fully discuss their concerns. Be sure to provide up-to-date information on the risks and benefits of a vaccine, and use decision aids as appropriate.4
Continue to: Refusers...
Refusers (<2%), who have concerns about the number of vaccines children receive and conflicting feelings about whom to trust and how best to get answers to their questions. This group tends to demonstrate high knowledge levels about vaccination but may be the most argumentative when presented with information. Emphasize the importance of protecting the child from an infectious disease and reinforce the effectiveness of the vaccine. Use statistics rather than anecdotes. But above all, spend the time needed to provide refusers with a thorough understanding of the risks of not immunizing their child.4
Although it is not a universal sentiment, many parents confer trust on their health care providers. We can use this trust in a respectful, noncoercive, and non-condescending manner by providing research-supported facts about vaccines. Clinicians who listen with a compassionate ear will be in the best position to lead the hesitant, late or selective, or refusing parents to confidently make an informed decision that immunization is the best way to protect their children from vaccine-preventable diseases.4
Rather than yet again focusing on the negative, I’d like to ask: Have you had a success story of helping parents to choose vaccination for their children? How did you overcome their concerns? Share your experience with me at [email protected].
1. CDC. Achievements in public health, 1900-1999 impact of vaccines universally recommended for children—United States, 1990-1998. MMWR Morb Mortal Wkly Rep. 1999;48(12):243-248.
2. Wakefield AJ, Murch SH, Anthony A, et al. RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351(9103):637-641.
3. Franki R. United States now over 100 measles cases for the year. MDEdge Family Practice. February 11, 2019.
4. Leask J, Kinnersley P, Jackson C, et al. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatrics. 2012;12:154.
1. CDC. Achievements in public health, 1900-1999 impact of vaccines universally recommended for children—United States, 1990-1998. MMWR Morb Mortal Wkly Rep. 1999;48(12):243-248.
2. Wakefield AJ, Murch SH, Anthony A, et al. RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351(9103):637-641.
3. Franki R. United States now over 100 measles cases for the year. MDEdge Family Practice. February 11, 2019.
4. Leask J, Kinnersley P, Jackson C, et al. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatrics. 2012;12:154.
Measles: 26 new cases reported last week
according to the Centers for Disease Control and Prevention.
On Jan. 31, total measles cases stood at 79, which means that the number of individuals with measles has risen by 61% in just the last 2 weeks. Of the five outbreaks (defined as three or more cases) so far in 2019, three have occurred in New York (57 cases in three counties), one in Texas (8 cases in five counties), and one in Washington (62 cases in two counties), the CDC reported Feb. 18.
The majority of the Washington cases (61 of the 62) have occurred in Clark County, which is located just across the Columbia River from Portland, Ore. Oregon, in turn, has a higher percentage of kindergartners with nonmedical exemptions from vaccination (7.5%) than any other state, the CDC reported in October 2018. Washington’s rate of 3.9% was nearly double the national median of 2.0% for the 2017-2018 school year, while Texas (1.8%) and New York (1.0%) were below it, the CDC said.
In the Pacific Northwest, however, some parents may be changing their minds about vaccinations, according to the New York Times, which reported that “about triple the number of children have been vaccinated this year, compared with the same period in 2018,” in Oregon and southwest Washington.
Individual cases of measles have been reported to the CDC by seven other states: California, Colorado, Connecticut, Georgia, Illinois, Kentucky, and Oregon.
according to the Centers for Disease Control and Prevention.
On Jan. 31, total measles cases stood at 79, which means that the number of individuals with measles has risen by 61% in just the last 2 weeks. Of the five outbreaks (defined as three or more cases) so far in 2019, three have occurred in New York (57 cases in three counties), one in Texas (8 cases in five counties), and one in Washington (62 cases in two counties), the CDC reported Feb. 18.
The majority of the Washington cases (61 of the 62) have occurred in Clark County, which is located just across the Columbia River from Portland, Ore. Oregon, in turn, has a higher percentage of kindergartners with nonmedical exemptions from vaccination (7.5%) than any other state, the CDC reported in October 2018. Washington’s rate of 3.9% was nearly double the national median of 2.0% for the 2017-2018 school year, while Texas (1.8%) and New York (1.0%) were below it, the CDC said.
In the Pacific Northwest, however, some parents may be changing their minds about vaccinations, according to the New York Times, which reported that “about triple the number of children have been vaccinated this year, compared with the same period in 2018,” in Oregon and southwest Washington.
Individual cases of measles have been reported to the CDC by seven other states: California, Colorado, Connecticut, Georgia, Illinois, Kentucky, and Oregon.
according to the Centers for Disease Control and Prevention.
On Jan. 31, total measles cases stood at 79, which means that the number of individuals with measles has risen by 61% in just the last 2 weeks. Of the five outbreaks (defined as three or more cases) so far in 2019, three have occurred in New York (57 cases in three counties), one in Texas (8 cases in five counties), and one in Washington (62 cases in two counties), the CDC reported Feb. 18.
The majority of the Washington cases (61 of the 62) have occurred in Clark County, which is located just across the Columbia River from Portland, Ore. Oregon, in turn, has a higher percentage of kindergartners with nonmedical exemptions from vaccination (7.5%) than any other state, the CDC reported in October 2018. Washington’s rate of 3.9% was nearly double the national median of 2.0% for the 2017-2018 school year, while Texas (1.8%) and New York (1.0%) were below it, the CDC said.
In the Pacific Northwest, however, some parents may be changing their minds about vaccinations, according to the New York Times, which reported that “about triple the number of children have been vaccinated this year, compared with the same period in 2018,” in Oregon and southwest Washington.
Individual cases of measles have been reported to the CDC by seven other states: California, Colorado, Connecticut, Georgia, Illinois, Kentucky, and Oregon.
Conservatism spreads in prostate cancer
, the United States now has more than 100 measles cases for the year, e-cigarette use reverses progress in reducing teens’ tobacco use, and consider adopting the MESA 10-year coronary heart disease risk calculator.
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, the United States now has more than 100 measles cases for the year, e-cigarette use reverses progress in reducing teens’ tobacco use, and consider adopting the MESA 10-year coronary heart disease risk calculator.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
, the United States now has more than 100 measles cases for the year, e-cigarette use reverses progress in reducing teens’ tobacco use, and consider adopting the MESA 10-year coronary heart disease risk calculator.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Vaccination and antiviral treatment do not affect stroke risk following shingles
HONOLULU – according to findings from a retrospective study of Medicare beneficiaries with shingles and ischemic stroke.
The findings suggest that primary prevention of shingles through vaccination might be the most effective approach to prevent shingles-associated acute ischemic stroke, said the researchers, who presented the study at the International Stroke Conference sponsored by the American Heart Association.
Almost one in three people in the United States will develop shingles, also known as herpes zoster, in their lifetime, according to the Centers for Disease Control and Prevention. Previous research has not simultaneously examined the effect of shingles vaccination and antiviral treatment following shingles onset on the risk of acute ischemic stroke.
Quanhe Yang, PhD, a senior scientist at the CDC, and his colleagues examined data for 35,186 Medicare fee-for-service beneficiaries who were 66 years or older, diagnosed with shingles during 2008-2014, and diagnosed with acute ischemic stroke within a year of shingles diagnosis. Using a self-controlled case series design, the investigators analyzed the association between shingles and stroke. Dr. Yang and his colleagues estimated the incident rate ratio (IRR) by comparing the incidence of stroke during risk periods (i.e., periods following shingles), compared with control periods. To minimize confounding by age, they restricted their analyses to approximately 365 days from the shingles index date.
To investigate how vaccination against shingles with Zostavax and antiviral treatment following shingles affected stroke risk, the researchers classified beneficiaries into the following four groups: Group 1 had no vaccination and no antiviral treatment (49% of beneficiaries), Group 2 had vaccination only (9%), Group 3 had antiviral treatment only (34%), and Group 4 had vaccination and antiviral treatment (8%). The researchers tested for interaction to examine the changes in IRRs across the four groups.
IRRs for stroke progressively declined as time passed from the index shingles date, from 1.61 at 0-14 days following shingles to 1.35 at 15-30 days, 1.16 at 31-90 days, and 1.05 at 91-180 days. The researchers found no evidence that shingles vaccination and antiviral treatment modified the risk of acute ischemic stroke. The association between shingles and risk for acute ischemic stroke was consistent across age groups (i.e., 66-74 years, 75-84 years, and 85 years or older), sex, and race (i.e., non-Hispanic white, non-Hispanic black, and Hispanic, other).
One of the study’s strengths was that its sample was a large national cohort of Medicare fee-for-service beneficiaries, Dr. Yang said. In addition, the study design eliminated all fixed confounding effects. Potential weaknesses, however, included the fact that herpes zoster diagnosis was based on administrative data and that the vaccine’s efficacy declines over time.
The findings suggest that the importance of following the recommended shingles vaccination protocol in the prevention of shingles, Dr. Yang said. Shingrix, a vaccine that the Food and Drug Administration approved in 2017, prevents shingles with an efficacy greater than 90%, he added.
The investigators reported no funding source or disclosures for this study.
SOURCE: Yang Q et al. Circulation. 2019;50(Suppl_1): Abstract 39
HONOLULU – according to findings from a retrospective study of Medicare beneficiaries with shingles and ischemic stroke.
The findings suggest that primary prevention of shingles through vaccination might be the most effective approach to prevent shingles-associated acute ischemic stroke, said the researchers, who presented the study at the International Stroke Conference sponsored by the American Heart Association.
Almost one in three people in the United States will develop shingles, also known as herpes zoster, in their lifetime, according to the Centers for Disease Control and Prevention. Previous research has not simultaneously examined the effect of shingles vaccination and antiviral treatment following shingles onset on the risk of acute ischemic stroke.
Quanhe Yang, PhD, a senior scientist at the CDC, and his colleagues examined data for 35,186 Medicare fee-for-service beneficiaries who were 66 years or older, diagnosed with shingles during 2008-2014, and diagnosed with acute ischemic stroke within a year of shingles diagnosis. Using a self-controlled case series design, the investigators analyzed the association between shingles and stroke. Dr. Yang and his colleagues estimated the incident rate ratio (IRR) by comparing the incidence of stroke during risk periods (i.e., periods following shingles), compared with control periods. To minimize confounding by age, they restricted their analyses to approximately 365 days from the shingles index date.
To investigate how vaccination against shingles with Zostavax and antiviral treatment following shingles affected stroke risk, the researchers classified beneficiaries into the following four groups: Group 1 had no vaccination and no antiviral treatment (49% of beneficiaries), Group 2 had vaccination only (9%), Group 3 had antiviral treatment only (34%), and Group 4 had vaccination and antiviral treatment (8%). The researchers tested for interaction to examine the changes in IRRs across the four groups.
IRRs for stroke progressively declined as time passed from the index shingles date, from 1.61 at 0-14 days following shingles to 1.35 at 15-30 days, 1.16 at 31-90 days, and 1.05 at 91-180 days. The researchers found no evidence that shingles vaccination and antiviral treatment modified the risk of acute ischemic stroke. The association between shingles and risk for acute ischemic stroke was consistent across age groups (i.e., 66-74 years, 75-84 years, and 85 years or older), sex, and race (i.e., non-Hispanic white, non-Hispanic black, and Hispanic, other).
One of the study’s strengths was that its sample was a large national cohort of Medicare fee-for-service beneficiaries, Dr. Yang said. In addition, the study design eliminated all fixed confounding effects. Potential weaknesses, however, included the fact that herpes zoster diagnosis was based on administrative data and that the vaccine’s efficacy declines over time.
The findings suggest that the importance of following the recommended shingles vaccination protocol in the prevention of shingles, Dr. Yang said. Shingrix, a vaccine that the Food and Drug Administration approved in 2017, prevents shingles with an efficacy greater than 90%, he added.
The investigators reported no funding source or disclosures for this study.
SOURCE: Yang Q et al. Circulation. 2019;50(Suppl_1): Abstract 39
HONOLULU – according to findings from a retrospective study of Medicare beneficiaries with shingles and ischemic stroke.
The findings suggest that primary prevention of shingles through vaccination might be the most effective approach to prevent shingles-associated acute ischemic stroke, said the researchers, who presented the study at the International Stroke Conference sponsored by the American Heart Association.
Almost one in three people in the United States will develop shingles, also known as herpes zoster, in their lifetime, according to the Centers for Disease Control and Prevention. Previous research has not simultaneously examined the effect of shingles vaccination and antiviral treatment following shingles onset on the risk of acute ischemic stroke.
Quanhe Yang, PhD, a senior scientist at the CDC, and his colleagues examined data for 35,186 Medicare fee-for-service beneficiaries who were 66 years or older, diagnosed with shingles during 2008-2014, and diagnosed with acute ischemic stroke within a year of shingles diagnosis. Using a self-controlled case series design, the investigators analyzed the association between shingles and stroke. Dr. Yang and his colleagues estimated the incident rate ratio (IRR) by comparing the incidence of stroke during risk periods (i.e., periods following shingles), compared with control periods. To minimize confounding by age, they restricted their analyses to approximately 365 days from the shingles index date.
To investigate how vaccination against shingles with Zostavax and antiviral treatment following shingles affected stroke risk, the researchers classified beneficiaries into the following four groups: Group 1 had no vaccination and no antiviral treatment (49% of beneficiaries), Group 2 had vaccination only (9%), Group 3 had antiviral treatment only (34%), and Group 4 had vaccination and antiviral treatment (8%). The researchers tested for interaction to examine the changes in IRRs across the four groups.
IRRs for stroke progressively declined as time passed from the index shingles date, from 1.61 at 0-14 days following shingles to 1.35 at 15-30 days, 1.16 at 31-90 days, and 1.05 at 91-180 days. The researchers found no evidence that shingles vaccination and antiviral treatment modified the risk of acute ischemic stroke. The association between shingles and risk for acute ischemic stroke was consistent across age groups (i.e., 66-74 years, 75-84 years, and 85 years or older), sex, and race (i.e., non-Hispanic white, non-Hispanic black, and Hispanic, other).
One of the study’s strengths was that its sample was a large national cohort of Medicare fee-for-service beneficiaries, Dr. Yang said. In addition, the study design eliminated all fixed confounding effects. Potential weaknesses, however, included the fact that herpes zoster diagnosis was based on administrative data and that the vaccine’s efficacy declines over time.
The findings suggest that the importance of following the recommended shingles vaccination protocol in the prevention of shingles, Dr. Yang said. Shingrix, a vaccine that the Food and Drug Administration approved in 2017, prevents shingles with an efficacy greater than 90%, he added.
The investigators reported no funding source or disclosures for this study.
SOURCE: Yang Q et al. Circulation. 2019;50(Suppl_1): Abstract 39
REPORTING FROM ISC 2019
Key clinical point: After a patient develops shingles, prior vaccination or treatment with antiviral medication does not change the risk of acute ischemic stroke.
Major finding: Stroke incidence increased by 61% within 14 days after shingles onset.
Study details: A self-controlled case series of 35,186 Medicare beneficiaries with shingles and acute ischemic stroke.
Disclosures: The authors reported no funding source or disclosures for this study.
Source: Yang Q et al. Circulation. 2019;50(Suppl_1), Abstract 39
Adult HIV patients should receive standard vaccinations, with caveats
Patients infected with HIV have an increased risk of mortality and morbidity from diseases that are preventable with vaccines. Undervaccination of these patients poses a major concern, according to a literature review of the vaccine response in the adult patient with HIV published in The American Journal of Medicine.
Despite the fact that data are limited, patients infected with HIV are advised to receive their age-specific and risk group−based vaccines, according to Firas El Chaer, MD, of the University of Maryland, Baltimore, and his colleague.
HIV patients are of particular concern regarding vaccination, because, despite the use of retroviral therapy, CD4+ T-lymphocytes in individuals infected with HIV remain lower than in those without HIV. In addition, HIV causes an inappropriate response to B-cell stimulation, which results in suboptimal primary and secondary response to vaccination, according to Dr. El Chaer and his colleague. Despite this and initial concerns about vaccine safety in this population, it is now recommended that adult patients infected with HIV receive their age-specific and risk group−based vaccines, they stated.
Inactivated or subunit vaccines
Haemophilus influenzae type b vaccine is not recommended under current guidelines for individuals older than age 18 with HIV infection, unless they have a clinical indication.
Vaccination against hepatitis A virus is recommended for HIV-infected patients who are hepatitis A virus seronegative and have chronic liver disease, men who have sex with men, intravenous drug users, and travelers to endemic regions. However, research has shown that the immunogenicity of the vaccine is lower in patients with HIV than in uninfected individuals. It was found that the CD4 count at the time of vaccination, not the CD4 low point, was the major predictor of the immune response.
Patients coinfected with HIV and hepatitis B virus have an 8-fold and 19-fold increase in mortality, respectively, compared with either virus monoinfection. Although vaccination is recommended, the optimal hepatitis B virus vaccination schedule in patients with HIV remains controversial, according to the authors. They indicated that new strategies to improve hepatitis B virus vaccine immunogenicity for those infected with HIV are needed.
Individuals infected with HIV have been found to have a higher risk of human papillomavirus (HPV) infection. The safety and immunogenicity results and prospect of benefits has led to a consensus on the benefit of vaccinating HIV-infected patients who meet the HPV vaccine age criteria, the authors indicated.
With regard to standard flu vaccinations: “An annual inactivated influenza vaccine is recommended during the influenza season for all adult individuals with HIV; however, a live attenuated influenza vaccine is contraindicated in this population,” according to the review.
Patients with HIV have a more than 10-fold increased risk of invasive meningococcal disease, compared with the general population, with the risk being particularly higher in those individuals with CD4 counts less than 200 cells/mm3 and in men who have sex with men in cities with meningococcal outbreaks. For these reasons, the “quadrivalent meningococcal vaccine is recommended for all patients with HIV regardless of their CD4 count, with 2-dose primary series at least 2 months apart and with a booster every 5 years.”
Pneumonia is known to be especially dangerous in the HIV-infected population. With regard to pneumonia vaccination, the 13-valent pneumococcal conjugate vaccine is recommended for all patients with HIV, regardless of their CD4 cell counts. According to Dr. El Chaer and his colleague, it should be followed by the 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later as a prime-boost regimen, preferably when CD4 counts are greater than 200 cells/mm3 and in patients receiving ART.
“Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines are recommended once for all individuals infected with HIV, regardless of the CD4 count, with a tetanus toxoid and diphtheria toxoid booster every 10 years,” according to the review.
Live vaccines
Live vaccines are a concerning issue for HIV-infected adults and recommendations for use are generally tied to the CD4 T-cell count. The measles, mumps, and rubella vaccine seems to be safe in patients infected with HIV with a CD4 count greater than 200 cells/mm3, according to Dr. El Chaer and his colleague. Similarly, patients with HIV with CD4 counts greater than 200 cells/mm3 and no evidence of documented immunity to varicella should receive the varicella vaccine.
In contrast, the live, attenuated varicella zoster virus vaccine is not recommended for patients infected with HIV, and it is contraindicated if CD4 count is less than 200 cells/mm3. Recently, a herpes zoster subunit vaccine (HZ/su) was tested in a phase 1/2a randomized, placebo-controlled study and was found to be safe and immunogenic regardless of CD4 count, although it has not yet been given a specific recommendation for immunocompromised patients.
“With the widespread use of ART resulting in better HIV control, ,” the authors concluded.
The study was not sponsored. Dr. El Chaer and his colleague reported that they had no conflicts.
SOURCE: El Chaer F et al. Am J Med. 2019. doi: 10.1016/j.amjmed.2018.12.011.
Patients infected with HIV have an increased risk of mortality and morbidity from diseases that are preventable with vaccines. Undervaccination of these patients poses a major concern, according to a literature review of the vaccine response in the adult patient with HIV published in The American Journal of Medicine.
Despite the fact that data are limited, patients infected with HIV are advised to receive their age-specific and risk group−based vaccines, according to Firas El Chaer, MD, of the University of Maryland, Baltimore, and his colleague.
HIV patients are of particular concern regarding vaccination, because, despite the use of retroviral therapy, CD4+ T-lymphocytes in individuals infected with HIV remain lower than in those without HIV. In addition, HIV causes an inappropriate response to B-cell stimulation, which results in suboptimal primary and secondary response to vaccination, according to Dr. El Chaer and his colleague. Despite this and initial concerns about vaccine safety in this population, it is now recommended that adult patients infected with HIV receive their age-specific and risk group−based vaccines, they stated.
Inactivated or subunit vaccines
Haemophilus influenzae type b vaccine is not recommended under current guidelines for individuals older than age 18 with HIV infection, unless they have a clinical indication.
Vaccination against hepatitis A virus is recommended for HIV-infected patients who are hepatitis A virus seronegative and have chronic liver disease, men who have sex with men, intravenous drug users, and travelers to endemic regions. However, research has shown that the immunogenicity of the vaccine is lower in patients with HIV than in uninfected individuals. It was found that the CD4 count at the time of vaccination, not the CD4 low point, was the major predictor of the immune response.
Patients coinfected with HIV and hepatitis B virus have an 8-fold and 19-fold increase in mortality, respectively, compared with either virus monoinfection. Although vaccination is recommended, the optimal hepatitis B virus vaccination schedule in patients with HIV remains controversial, according to the authors. They indicated that new strategies to improve hepatitis B virus vaccine immunogenicity for those infected with HIV are needed.
Individuals infected with HIV have been found to have a higher risk of human papillomavirus (HPV) infection. The safety and immunogenicity results and prospect of benefits has led to a consensus on the benefit of vaccinating HIV-infected patients who meet the HPV vaccine age criteria, the authors indicated.
With regard to standard flu vaccinations: “An annual inactivated influenza vaccine is recommended during the influenza season for all adult individuals with HIV; however, a live attenuated influenza vaccine is contraindicated in this population,” according to the review.
Patients with HIV have a more than 10-fold increased risk of invasive meningococcal disease, compared with the general population, with the risk being particularly higher in those individuals with CD4 counts less than 200 cells/mm3 and in men who have sex with men in cities with meningococcal outbreaks. For these reasons, the “quadrivalent meningococcal vaccine is recommended for all patients with HIV regardless of their CD4 count, with 2-dose primary series at least 2 months apart and with a booster every 5 years.”
Pneumonia is known to be especially dangerous in the HIV-infected population. With regard to pneumonia vaccination, the 13-valent pneumococcal conjugate vaccine is recommended for all patients with HIV, regardless of their CD4 cell counts. According to Dr. El Chaer and his colleague, it should be followed by the 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later as a prime-boost regimen, preferably when CD4 counts are greater than 200 cells/mm3 and in patients receiving ART.
“Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines are recommended once for all individuals infected with HIV, regardless of the CD4 count, with a tetanus toxoid and diphtheria toxoid booster every 10 years,” according to the review.
Live vaccines
Live vaccines are a concerning issue for HIV-infected adults and recommendations for use are generally tied to the CD4 T-cell count. The measles, mumps, and rubella vaccine seems to be safe in patients infected with HIV with a CD4 count greater than 200 cells/mm3, according to Dr. El Chaer and his colleague. Similarly, patients with HIV with CD4 counts greater than 200 cells/mm3 and no evidence of documented immunity to varicella should receive the varicella vaccine.
In contrast, the live, attenuated varicella zoster virus vaccine is not recommended for patients infected with HIV, and it is contraindicated if CD4 count is less than 200 cells/mm3. Recently, a herpes zoster subunit vaccine (HZ/su) was tested in a phase 1/2a randomized, placebo-controlled study and was found to be safe and immunogenic regardless of CD4 count, although it has not yet been given a specific recommendation for immunocompromised patients.
“With the widespread use of ART resulting in better HIV control, ,” the authors concluded.
The study was not sponsored. Dr. El Chaer and his colleague reported that they had no conflicts.
SOURCE: El Chaer F et al. Am J Med. 2019. doi: 10.1016/j.amjmed.2018.12.011.
Patients infected with HIV have an increased risk of mortality and morbidity from diseases that are preventable with vaccines. Undervaccination of these patients poses a major concern, according to a literature review of the vaccine response in the adult patient with HIV published in The American Journal of Medicine.
Despite the fact that data are limited, patients infected with HIV are advised to receive their age-specific and risk group−based vaccines, according to Firas El Chaer, MD, of the University of Maryland, Baltimore, and his colleague.
HIV patients are of particular concern regarding vaccination, because, despite the use of retroviral therapy, CD4+ T-lymphocytes in individuals infected with HIV remain lower than in those without HIV. In addition, HIV causes an inappropriate response to B-cell stimulation, which results in suboptimal primary and secondary response to vaccination, according to Dr. El Chaer and his colleague. Despite this and initial concerns about vaccine safety in this population, it is now recommended that adult patients infected with HIV receive their age-specific and risk group−based vaccines, they stated.
Inactivated or subunit vaccines
Haemophilus influenzae type b vaccine is not recommended under current guidelines for individuals older than age 18 with HIV infection, unless they have a clinical indication.
Vaccination against hepatitis A virus is recommended for HIV-infected patients who are hepatitis A virus seronegative and have chronic liver disease, men who have sex with men, intravenous drug users, and travelers to endemic regions. However, research has shown that the immunogenicity of the vaccine is lower in patients with HIV than in uninfected individuals. It was found that the CD4 count at the time of vaccination, not the CD4 low point, was the major predictor of the immune response.
Patients coinfected with HIV and hepatitis B virus have an 8-fold and 19-fold increase in mortality, respectively, compared with either virus monoinfection. Although vaccination is recommended, the optimal hepatitis B virus vaccination schedule in patients with HIV remains controversial, according to the authors. They indicated that new strategies to improve hepatitis B virus vaccine immunogenicity for those infected with HIV are needed.
Individuals infected with HIV have been found to have a higher risk of human papillomavirus (HPV) infection. The safety and immunogenicity results and prospect of benefits has led to a consensus on the benefit of vaccinating HIV-infected patients who meet the HPV vaccine age criteria, the authors indicated.
With regard to standard flu vaccinations: “An annual inactivated influenza vaccine is recommended during the influenza season for all adult individuals with HIV; however, a live attenuated influenza vaccine is contraindicated in this population,” according to the review.
Patients with HIV have a more than 10-fold increased risk of invasive meningococcal disease, compared with the general population, with the risk being particularly higher in those individuals with CD4 counts less than 200 cells/mm3 and in men who have sex with men in cities with meningococcal outbreaks. For these reasons, the “quadrivalent meningococcal vaccine is recommended for all patients with HIV regardless of their CD4 count, with 2-dose primary series at least 2 months apart and with a booster every 5 years.”
Pneumonia is known to be especially dangerous in the HIV-infected population. With regard to pneumonia vaccination, the 13-valent pneumococcal conjugate vaccine is recommended for all patients with HIV, regardless of their CD4 cell counts. According to Dr. El Chaer and his colleague, it should be followed by the 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later as a prime-boost regimen, preferably when CD4 counts are greater than 200 cells/mm3 and in patients receiving ART.
“Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines are recommended once for all individuals infected with HIV, regardless of the CD4 count, with a tetanus toxoid and diphtheria toxoid booster every 10 years,” according to the review.
Live vaccines
Live vaccines are a concerning issue for HIV-infected adults and recommendations for use are generally tied to the CD4 T-cell count. The measles, mumps, and rubella vaccine seems to be safe in patients infected with HIV with a CD4 count greater than 200 cells/mm3, according to Dr. El Chaer and his colleague. Similarly, patients with HIV with CD4 counts greater than 200 cells/mm3 and no evidence of documented immunity to varicella should receive the varicella vaccine.
In contrast, the live, attenuated varicella zoster virus vaccine is not recommended for patients infected with HIV, and it is contraindicated if CD4 count is less than 200 cells/mm3. Recently, a herpes zoster subunit vaccine (HZ/su) was tested in a phase 1/2a randomized, placebo-controlled study and was found to be safe and immunogenic regardless of CD4 count, although it has not yet been given a specific recommendation for immunocompromised patients.
“With the widespread use of ART resulting in better HIV control, ,” the authors concluded.
The study was not sponsored. Dr. El Chaer and his colleague reported that they had no conflicts.
SOURCE: El Chaer F et al. Am J Med. 2019. doi: 10.1016/j.amjmed.2018.12.011.
FROM THE AMERICAN JOURNAL OF MEDICINE
Key clinical point: Undervaccination is too common among HIV-infected patients.
Major finding: Data on vaccine effectiveness in HIV patients are limited, but do not contraindicate the need for vaccination.
Study details: Literature review of immunogenicity and vaccine efficacy in HIV-infected adults.
Disclosures: The study was unsponsored and the authors reported they had no conflicts.
Source: El Chaer F et al. Am J Med. 2019. doi: 10.1016/j.amjmed.2018.12.011.
Measles outbreak sends vaccine demand soaring, even among the hesitant
Demand for measles vaccine has surged in the Washington county in which the highly contagious virus is linked to more than 50 confirmed illnesses this year – including among people who had previously shunned the shots.
Orders for two types of measles vaccines in Clark County were up nearly 500% in January, compared with the same month last year, jumping from 530 doses to 3,150, according to state health department figures.
Area health clinics are scrambling to keep up with sudden demand, mostly among parents of children who had not been inoculated.
“During an outbreak is when you see an influx of patients who would otherwise be vaccine hesitant,” said Virginia Ramos, infection control nurse with Sea Mar Community Health Center, which runs six sites that offer vaccines in Clark County.
“We’re just happy that we’re prepared and that there is vaccine available.”
The Vancouver Clinic, which operates medical offices and urgent care centers in the area, reported that shots administered jumped from 263 in January 2018 to 1,444 last month, a nearly 450% increase.
That’s a huge rise in a county in which vaccination rates lag – only 76.5% of kindergartners had all the required immunizations for the 2017-2018 school year. Health officials have long worried about the potential for an outbreak in the region.
Statewide in Washington, orders for measles vaccine jumped about 30% in January, compared with the same month last year, climbing from 12,140 doses to 15,780 doses, figures showed. The vaccines include MMR, which protects against measles, mumps and rubella, and MMR-V, which also protects against the varicella-zoster virus, which causes chickenpox. The vaccine takes effect within 72 hours, health officials said.
The orders represent only state-supplied vaccines requested through the federal Vaccines for Children program, which provides free immunizations to children who otherwise couldn’t afford them.
But it’s a snapshot of the scare an outbreak can cause, said Alan Melnick, MD, the health officer and public health director for Clark County overseeing the response.
“I would rather it not take an outbreak for this to happen,” he said.
Since Jan. 1, 2019, 50 cases of measles have been confirmed in Clark County, with 11 more cases suspected, officials said. The Pacific Northwest outbreak includes one confirmed case in King County, where Seattle is located, and four in Multnomah County, which includes Portland, Ore.
On Feb. 6, officials sent letters to families of 5,000 children in Multnomah County telling them they’ll be excluded from school if they don’t have up-to-date immunizations or valid exemptions by Feb. 20.
Most of the infections have occurred in children, under age 18 years, who were unvaccinated. The outbreak includes 43 cases among those who were not immunized, 6 cases in which immunization has not been verified, and 1 case in which the person had received only a single dose of vaccine.
The Centers for Disease Control and Prevention recommends two doses of measles vaccine, one given at between 12 and 15 months of age and one between ages 4 and 6. Health officials say the shots are safe and effective, providing about 93% protection with one dose and 97% with two doses.
The Northwest cases are among three ongoing measles outbreaks in the United States that sickened 79 people in January, according to the CDC. Last year, 372 measles cases were confirmed nationwide, the most since an outbreak in 2014 sickened 667 people.
Washington and Oregon are among 17 states that allow nonmedical exemptions from vaccination requirements for school entry, according to the National Conference of State Legislatures.
Washington state Rep. Paul Harris (R-Vancouver) has introduced a measure that would remove personal belief exemptions for the MMR vaccine.
Research has confirmed that vaccines don’t cause autism, a common reason cited by parents who reject vaccinations. Others object to the timing and combinations of the vaccines and to being forced to inoculate their children.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Demand for measles vaccine has surged in the Washington county in which the highly contagious virus is linked to more than 50 confirmed illnesses this year – including among people who had previously shunned the shots.
Orders for two types of measles vaccines in Clark County were up nearly 500% in January, compared with the same month last year, jumping from 530 doses to 3,150, according to state health department figures.
Area health clinics are scrambling to keep up with sudden demand, mostly among parents of children who had not been inoculated.
“During an outbreak is when you see an influx of patients who would otherwise be vaccine hesitant,” said Virginia Ramos, infection control nurse with Sea Mar Community Health Center, which runs six sites that offer vaccines in Clark County.
“We’re just happy that we’re prepared and that there is vaccine available.”
The Vancouver Clinic, which operates medical offices and urgent care centers in the area, reported that shots administered jumped from 263 in January 2018 to 1,444 last month, a nearly 450% increase.
That’s a huge rise in a county in which vaccination rates lag – only 76.5% of kindergartners had all the required immunizations for the 2017-2018 school year. Health officials have long worried about the potential for an outbreak in the region.
Statewide in Washington, orders for measles vaccine jumped about 30% in January, compared with the same month last year, climbing from 12,140 doses to 15,780 doses, figures showed. The vaccines include MMR, which protects against measles, mumps and rubella, and MMR-V, which also protects against the varicella-zoster virus, which causes chickenpox. The vaccine takes effect within 72 hours, health officials said.
The orders represent only state-supplied vaccines requested through the federal Vaccines for Children program, which provides free immunizations to children who otherwise couldn’t afford them.
But it’s a snapshot of the scare an outbreak can cause, said Alan Melnick, MD, the health officer and public health director for Clark County overseeing the response.
“I would rather it not take an outbreak for this to happen,” he said.
Since Jan. 1, 2019, 50 cases of measles have been confirmed in Clark County, with 11 more cases suspected, officials said. The Pacific Northwest outbreak includes one confirmed case in King County, where Seattle is located, and four in Multnomah County, which includes Portland, Ore.
On Feb. 6, officials sent letters to families of 5,000 children in Multnomah County telling them they’ll be excluded from school if they don’t have up-to-date immunizations or valid exemptions by Feb. 20.
Most of the infections have occurred in children, under age 18 years, who were unvaccinated. The outbreak includes 43 cases among those who were not immunized, 6 cases in which immunization has not been verified, and 1 case in which the person had received only a single dose of vaccine.
The Centers for Disease Control and Prevention recommends two doses of measles vaccine, one given at between 12 and 15 months of age and one between ages 4 and 6. Health officials say the shots are safe and effective, providing about 93% protection with one dose and 97% with two doses.
The Northwest cases are among three ongoing measles outbreaks in the United States that sickened 79 people in January, according to the CDC. Last year, 372 measles cases were confirmed nationwide, the most since an outbreak in 2014 sickened 667 people.
Washington and Oregon are among 17 states that allow nonmedical exemptions from vaccination requirements for school entry, according to the National Conference of State Legislatures.
Washington state Rep. Paul Harris (R-Vancouver) has introduced a measure that would remove personal belief exemptions for the MMR vaccine.
Research has confirmed that vaccines don’t cause autism, a common reason cited by parents who reject vaccinations. Others object to the timing and combinations of the vaccines and to being forced to inoculate their children.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Demand for measles vaccine has surged in the Washington county in which the highly contagious virus is linked to more than 50 confirmed illnesses this year – including among people who had previously shunned the shots.
Orders for two types of measles vaccines in Clark County were up nearly 500% in January, compared with the same month last year, jumping from 530 doses to 3,150, according to state health department figures.
Area health clinics are scrambling to keep up with sudden demand, mostly among parents of children who had not been inoculated.
“During an outbreak is when you see an influx of patients who would otherwise be vaccine hesitant,” said Virginia Ramos, infection control nurse with Sea Mar Community Health Center, which runs six sites that offer vaccines in Clark County.
“We’re just happy that we’re prepared and that there is vaccine available.”
The Vancouver Clinic, which operates medical offices and urgent care centers in the area, reported that shots administered jumped from 263 in January 2018 to 1,444 last month, a nearly 450% increase.
That’s a huge rise in a county in which vaccination rates lag – only 76.5% of kindergartners had all the required immunizations for the 2017-2018 school year. Health officials have long worried about the potential for an outbreak in the region.
Statewide in Washington, orders for measles vaccine jumped about 30% in January, compared with the same month last year, climbing from 12,140 doses to 15,780 doses, figures showed. The vaccines include MMR, which protects against measles, mumps and rubella, and MMR-V, which also protects against the varicella-zoster virus, which causes chickenpox. The vaccine takes effect within 72 hours, health officials said.
The orders represent only state-supplied vaccines requested through the federal Vaccines for Children program, which provides free immunizations to children who otherwise couldn’t afford them.
But it’s a snapshot of the scare an outbreak can cause, said Alan Melnick, MD, the health officer and public health director for Clark County overseeing the response.
“I would rather it not take an outbreak for this to happen,” he said.
Since Jan. 1, 2019, 50 cases of measles have been confirmed in Clark County, with 11 more cases suspected, officials said. The Pacific Northwest outbreak includes one confirmed case in King County, where Seattle is located, and four in Multnomah County, which includes Portland, Ore.
On Feb. 6, officials sent letters to families of 5,000 children in Multnomah County telling them they’ll be excluded from school if they don’t have up-to-date immunizations or valid exemptions by Feb. 20.
Most of the infections have occurred in children, under age 18 years, who were unvaccinated. The outbreak includes 43 cases among those who were not immunized, 6 cases in which immunization has not been verified, and 1 case in which the person had received only a single dose of vaccine.
The Centers for Disease Control and Prevention recommends two doses of measles vaccine, one given at between 12 and 15 months of age and one between ages 4 and 6. Health officials say the shots are safe and effective, providing about 93% protection with one dose and 97% with two doses.
The Northwest cases are among three ongoing measles outbreaks in the United States that sickened 79 people in January, according to the CDC. Last year, 372 measles cases were confirmed nationwide, the most since an outbreak in 2014 sickened 667 people.
Washington and Oregon are among 17 states that allow nonmedical exemptions from vaccination requirements for school entry, according to the National Conference of State Legislatures.
Washington state Rep. Paul Harris (R-Vancouver) has introduced a measure that would remove personal belief exemptions for the MMR vaccine.
Research has confirmed that vaccines don’t cause autism, a common reason cited by parents who reject vaccinations. Others object to the timing and combinations of the vaccines and to being forced to inoculate their children.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
No increase in severe community-acquired pneumonia after PCV13
Despite concern about the rise of nonvaccine serotypes following widespread PCV13 immunization, cases of community-acquired pneumonia (CAP) remain nearly as low as after initial implementation of the vaccine and severe cases have not risen at all.
This was the finding of a prospective time-series analysis study from eight French pediatric emergency departments between June 2009 and May 2017.
The 12,587 children with CAP enrolled in the study between June 2009 and May 2017 were all aged 15 years or younger and came from one of eight French pediatric EDs.
Pediatric pneumonia cases per 1,000 ED visits dropped 44% after PCV13 was implemented, a decrease from 6.3 to 3.5 cases of CAP per 1,000 pediatric visits from June 2011 to May 2014, with a slight but statistically significant increase to 3.8 cases of CAP per 1,000 pediatric visits from June 2014 to May 2017. However, there was no statistically significant increase in cases with pleural effusion, hospitalization, or high inflammatory biomarkers.
“These results contrast with the recent increase in frequency of invasive pneumococcal disease observed in several countries during the same period linked to serotype replacement beyond 5 years after PCV13 implementation,” reported Naïm Ouldali, MD, of the Association Clinique et Thérapeutique Infantile du Val-de-Marne in France, and associates. The report is in JAMA Pediatrics.
“This difference in the trends suggests different consequences of serotype replacement on pneumococcal CAP vs invasive pneumococcal disease,” they wrote. “The recent slight increase in the number of all CAP cases and virus involvement may reflect changes in the epidemiology of other pathogens and/or serotype replacement with less pathogenic serotypes.”
This latter point arose from discovering no dominant serotype during the study period. Of the 11 serotypes not covered by PCV13, none appeared in more than four cases.
“The implementation of PCV13 has led to the quasi-disappearance of the more invasive serotypes and increase in others in nasopharyngeal flora, which greatly reduces the frequency of the more severe forms of CAP, but could also play a role in the slight increase in frequency of the more benign forms,” the authors reported.
Among the study’s limitations was lack of a control group, precluding the ability to attribute findings to any changes in case reporting. And “participating physicians were encouraged to not change their practice, including test use, and no other potential interfering intervention.”
Funding sources for this study included the Pediatric Infectious Diseases Group of the French Pediatrics Society, Association Clinique et Thérapeutique Infantile du Val-de-Marne, the Foundation for Medical Research and a Pfizer Investigator Initiated Research grant.
Dr Ouldali has received grants from GlaxoSmithKline, and many of the authors have financial ties and/or have received non-financial support from AstraZeneca, Biocodex, GlaxoSmithKline, Merck, Novartis, Pfizer and/or Sanofi Pasteur.
SOURCE: Ouldali N et al. JAMA Pediatrics. 2019 Feb 4. doi: 10.1001/jamapediatrics.2018.5273.
Despite concern about the rise of nonvaccine serotypes following widespread PCV13 immunization, cases of community-acquired pneumonia (CAP) remain nearly as low as after initial implementation of the vaccine and severe cases have not risen at all.
This was the finding of a prospective time-series analysis study from eight French pediatric emergency departments between June 2009 and May 2017.
The 12,587 children with CAP enrolled in the study between June 2009 and May 2017 were all aged 15 years or younger and came from one of eight French pediatric EDs.
Pediatric pneumonia cases per 1,000 ED visits dropped 44% after PCV13 was implemented, a decrease from 6.3 to 3.5 cases of CAP per 1,000 pediatric visits from June 2011 to May 2014, with a slight but statistically significant increase to 3.8 cases of CAP per 1,000 pediatric visits from June 2014 to May 2017. However, there was no statistically significant increase in cases with pleural effusion, hospitalization, or high inflammatory biomarkers.
“These results contrast with the recent increase in frequency of invasive pneumococcal disease observed in several countries during the same period linked to serotype replacement beyond 5 years after PCV13 implementation,” reported Naïm Ouldali, MD, of the Association Clinique et Thérapeutique Infantile du Val-de-Marne in France, and associates. The report is in JAMA Pediatrics.
“This difference in the trends suggests different consequences of serotype replacement on pneumococcal CAP vs invasive pneumococcal disease,” they wrote. “The recent slight increase in the number of all CAP cases and virus involvement may reflect changes in the epidemiology of other pathogens and/or serotype replacement with less pathogenic serotypes.”
This latter point arose from discovering no dominant serotype during the study period. Of the 11 serotypes not covered by PCV13, none appeared in more than four cases.
“The implementation of PCV13 has led to the quasi-disappearance of the more invasive serotypes and increase in others in nasopharyngeal flora, which greatly reduces the frequency of the more severe forms of CAP, but could also play a role in the slight increase in frequency of the more benign forms,” the authors reported.
Among the study’s limitations was lack of a control group, precluding the ability to attribute findings to any changes in case reporting. And “participating physicians were encouraged to not change their practice, including test use, and no other potential interfering intervention.”
Funding sources for this study included the Pediatric Infectious Diseases Group of the French Pediatrics Society, Association Clinique et Thérapeutique Infantile du Val-de-Marne, the Foundation for Medical Research and a Pfizer Investigator Initiated Research grant.
Dr Ouldali has received grants from GlaxoSmithKline, and many of the authors have financial ties and/or have received non-financial support from AstraZeneca, Biocodex, GlaxoSmithKline, Merck, Novartis, Pfizer and/or Sanofi Pasteur.
SOURCE: Ouldali N et al. JAMA Pediatrics. 2019 Feb 4. doi: 10.1001/jamapediatrics.2018.5273.
Despite concern about the rise of nonvaccine serotypes following widespread PCV13 immunization, cases of community-acquired pneumonia (CAP) remain nearly as low as after initial implementation of the vaccine and severe cases have not risen at all.
This was the finding of a prospective time-series analysis study from eight French pediatric emergency departments between June 2009 and May 2017.
The 12,587 children with CAP enrolled in the study between June 2009 and May 2017 were all aged 15 years or younger and came from one of eight French pediatric EDs.
Pediatric pneumonia cases per 1,000 ED visits dropped 44% after PCV13 was implemented, a decrease from 6.3 to 3.5 cases of CAP per 1,000 pediatric visits from June 2011 to May 2014, with a slight but statistically significant increase to 3.8 cases of CAP per 1,000 pediatric visits from June 2014 to May 2017. However, there was no statistically significant increase in cases with pleural effusion, hospitalization, or high inflammatory biomarkers.
“These results contrast with the recent increase in frequency of invasive pneumococcal disease observed in several countries during the same period linked to serotype replacement beyond 5 years after PCV13 implementation,” reported Naïm Ouldali, MD, of the Association Clinique et Thérapeutique Infantile du Val-de-Marne in France, and associates. The report is in JAMA Pediatrics.
“This difference in the trends suggests different consequences of serotype replacement on pneumococcal CAP vs invasive pneumococcal disease,” they wrote. “The recent slight increase in the number of all CAP cases and virus involvement may reflect changes in the epidemiology of other pathogens and/or serotype replacement with less pathogenic serotypes.”
This latter point arose from discovering no dominant serotype during the study period. Of the 11 serotypes not covered by PCV13, none appeared in more than four cases.
“The implementation of PCV13 has led to the quasi-disappearance of the more invasive serotypes and increase in others in nasopharyngeal flora, which greatly reduces the frequency of the more severe forms of CAP, but could also play a role in the slight increase in frequency of the more benign forms,” the authors reported.
Among the study’s limitations was lack of a control group, precluding the ability to attribute findings to any changes in case reporting. And “participating physicians were encouraged to not change their practice, including test use, and no other potential interfering intervention.”
Funding sources for this study included the Pediatric Infectious Diseases Group of the French Pediatrics Society, Association Clinique et Thérapeutique Infantile du Val-de-Marne, the Foundation for Medical Research and a Pfizer Investigator Initiated Research grant.
Dr Ouldali has received grants from GlaxoSmithKline, and many of the authors have financial ties and/or have received non-financial support from AstraZeneca, Biocodex, GlaxoSmithKline, Merck, Novartis, Pfizer and/or Sanofi Pasteur.
SOURCE: Ouldali N et al. JAMA Pediatrics. 2019 Feb 4. doi: 10.1001/jamapediatrics.2018.5273.
FROM JAMA PEDIATRICS
Key clinical point:
Major finding: Pediatric community-acquired pneumonia cases dropped from 6.3 to 3.5 cases per 1,000 visits from 2010 to 2014 and increased to 3.8 cases per 1,000 visits in May 2017.
Study details: The findings are based on a prospective time series analysis of 12,587 pediatric pneumonia cases (under 15 years old) in eight French emergency departments from June 2009 to May 2017.
Disclosures: Funding sources for this study included the Pediatric Infectious Diseases Group of the French Pediatrics Society, Association Clinique et Thérapeutique Infantile du Val-de-Marne, the Foundation for Medical Research, and a Pfizer Investigator Initiated Research grant. Dr. Ouldali has received grants from GlaxoSmithKline, and many of the authors have financial ties and/or have received nonfinancial support from AstraZeneca, Biocodex, GlaxoSmithKline, Merck, Novartis, Pfizer, and/or Sanofi Pasteur.
Source: Ouldali N et al. JAMA Pediatrics. 2019 Feb 4. doi: 10.1001/jamapediatrics.2018.5273.
FDA approves 0.5-mL Fluzone Quadrivalent vaccine in young children
according to Sanofi Pasteur, the vaccine’s manufacturer.
FDA approval was based on results of a phase 4 safety and immunogenicity study of nearly 2,000 children. Children aged 6-35 months who received one or two doses of Fluzone at 0.50 mL had a safety profile similar to that of children who received one or two doses of Fluzone at 0.25 mL. Results from the study were presented at the Pediatric Academic Societies annual meeting in April 2018.
This flu vaccine should not be given to anyone with a severe allergic reaction (anaphylaxis) to egg or egg products, according to the press release.
In children, the most common adverse events are injection site reactions, muscle aches, fatigue, and headache; in young children, irritability, abnormal crying, drowsiness, appetite loss, vomiting, and fever are common.
“Offering pediatricians the convenience of the same 0.5-mL dose option for children may help streamline immunization efforts. The potentially life-threatening effects of influenza in children reported during the 2017-18 season, especially among those who were not vaccinated, is sobering,” David P. Greenberg, MD, regional medical head of Sanofi Pasteur of North America, said in the press release.
Find the full press release on the Sanofi website.
according to Sanofi Pasteur, the vaccine’s manufacturer.
FDA approval was based on results of a phase 4 safety and immunogenicity study of nearly 2,000 children. Children aged 6-35 months who received one or two doses of Fluzone at 0.50 mL had a safety profile similar to that of children who received one or two doses of Fluzone at 0.25 mL. Results from the study were presented at the Pediatric Academic Societies annual meeting in April 2018.
This flu vaccine should not be given to anyone with a severe allergic reaction (anaphylaxis) to egg or egg products, according to the press release.
In children, the most common adverse events are injection site reactions, muscle aches, fatigue, and headache; in young children, irritability, abnormal crying, drowsiness, appetite loss, vomiting, and fever are common.
“Offering pediatricians the convenience of the same 0.5-mL dose option for children may help streamline immunization efforts. The potentially life-threatening effects of influenza in children reported during the 2017-18 season, especially among those who were not vaccinated, is sobering,” David P. Greenberg, MD, regional medical head of Sanofi Pasteur of North America, said in the press release.
Find the full press release on the Sanofi website.
according to Sanofi Pasteur, the vaccine’s manufacturer.
FDA approval was based on results of a phase 4 safety and immunogenicity study of nearly 2,000 children. Children aged 6-35 months who received one or two doses of Fluzone at 0.50 mL had a safety profile similar to that of children who received one or two doses of Fluzone at 0.25 mL. Results from the study were presented at the Pediatric Academic Societies annual meeting in April 2018.
This flu vaccine should not be given to anyone with a severe allergic reaction (anaphylaxis) to egg or egg products, according to the press release.
In children, the most common adverse events are injection site reactions, muscle aches, fatigue, and headache; in young children, irritability, abnormal crying, drowsiness, appetite loss, vomiting, and fever are common.
“Offering pediatricians the convenience of the same 0.5-mL dose option for children may help streamline immunization efforts. The potentially life-threatening effects of influenza in children reported during the 2017-18 season, especially among those who were not vaccinated, is sobering,” David P. Greenberg, MD, regional medical head of Sanofi Pasteur of North America, said in the press release.
Find the full press release on the Sanofi website.