Vaccines

WASHINGTON – Hospitalizations for shingles is twice as common among patients with inflammatory bowel disease than in the general U.S. population, based on analysis of data from the National Inpatient Sample.

Mitchel L. Zoler/MDedge News

This elevated risk for patients with inflammatory bowel disease (IBD) to develop a herpes zoster virus (HZV) reactivation severe enough to put them in the hospital makes it especially important for IBD patients to receive immunization against shingles, especially now that a more effective vaccine is available, Daniela G. Vinsard, MD, said at the annual Digestive Disease Week^®. Ideally, IBD patients should receive the full course of the adjuvanted, recombinant zoster vaccine Shingrix before starting an immunosuppressive regimen, said Dr. Vinsard, a physician at the University of Connecticut, Farmington.

This finding, which underscored the susceptibility of IBD patients to shingles because of their immunosuppressive treatments and the importance of vaccination, recently became even more relevant when the Food and Drug Administration approved tofacitinib (Xeljanz) to treat ulcerative colitis in late May, commented Gil Y. Melmed, MD, director of clinical inflammatory bowel disease at Cedars-Sinai Medical Center, Los Angeles. Tofacitinib, which may be an attractive option to some patients as an oral immunomodulator, carries a black box warning about the added risk for certain serious infections while taking the drug, including HZV. Recent recommendations from the American College of Gastroenterology said that IBD patients aged 51 years or older should “strongly consider” HZV vaccination, including immunosuppressed patients (Am J Gastroenterol. 2017 Feb; 112[2]:241-58). The introduction of a potentially popular drug for ulcerative colitis that’s known to pose a risk for shingles might lead to a stronger recommendation for vaccination in the near future, Dr. Melmed said in an interview.

The study Dr. Vinsard reported used data collected by the National Inpatient Sample from 2012 to September 2015, which represented, with weighting, more than 142 million hospitalized American patients. From this data set she and her associates identified 7,180 IBD patients hospitalized with a primary diagnosis of a vaccine-preventable disease, and about 589,000 weighted patients hospitalized for a vaccine-preventable disease but without IBD. The selection also focused on patients aged 18-65 years. Dr. Vinsard said that she excluded older patients to eliminate advanced age as a cause of immunosuppression.

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WASHINGTON – Hospitalizations for shingles is twice as common among patients with inflammatory bowel disease than in the general U.S. population, based on analysis of data from the National Inpatient Sample.

Mitchel L. Zoler/MDedge News

This elevated risk for patients with inflammatory bowel disease (IBD) to develop a herpes zoster virus (HZV) reactivation severe enough to put them in the hospital makes it especially important for IBD patients to receive immunization against shingles, especially now that a more effective vaccine is available, Daniela G. Vinsard, MD, said at the annual Digestive Disease Week^®. Ideally, IBD patients should receive the full course of the adjuvanted, recombinant zoster vaccine Shingrix before starting an immunosuppressive regimen, said Dr. Vinsard, a physician at the University of Connecticut, Farmington.

This finding, which underscored the susceptibility of IBD patients to shingles because of their immunosuppressive treatments and the importance of vaccination, recently became even more relevant when the Food and Drug Administration approved tofacitinib (Xeljanz) to treat ulcerative colitis in late May, commented Gil Y. Melmed, MD, director of clinical inflammatory bowel disease at Cedars-Sinai Medical Center, Los Angeles. Tofacitinib, which may be an attractive option to some patients as an oral immunomodulator, carries a black box warning about the added risk for certain serious infections while taking the drug, including HZV. Recent recommendations from the American College of Gastroenterology said that IBD patients aged 51 years or older should “strongly consider” HZV vaccination, including immunosuppressed patients (Am J Gastroenterol. 2017 Feb; 112[2]:241-58). The introduction of a potentially popular drug for ulcerative colitis that’s known to pose a risk for shingles might lead to a stronger recommendation for vaccination in the near future, Dr. Melmed said in an interview.

The study Dr. Vinsard reported used data collected by the National Inpatient Sample from 2012 to September 2015, which represented, with weighting, more than 142 million hospitalized American patients. From this data set she and her associates identified 7,180 IBD patients hospitalized with a primary diagnosis of a vaccine-preventable disease, and about 589,000 weighted patients hospitalized for a vaccine-preventable disease but without IBD. The selection also focused on patients aged 18-65 years. Dr. Vinsard said that she excluded older patients to eliminate advanced age as a cause of immunosuppression.

[email protected]

WASHINGTON – Hospitalizations for shingles is twice as common among patients with inflammatory bowel disease than in the general U.S. population, based on analysis of data from the National Inpatient Sample.

Mitchel L. Zoler/MDedge News

This elevated risk for patients with inflammatory bowel disease (IBD) to develop a herpes zoster virus (HZV) reactivation severe enough to put them in the hospital makes it especially important for IBD patients to receive immunization against shingles, especially now that a more effective vaccine is available, Daniela G. Vinsard, MD, said at the annual Digestive Disease Week^®. Ideally, IBD patients should receive the full course of the adjuvanted, recombinant zoster vaccine Shingrix before starting an immunosuppressive regimen, said Dr. Vinsard, a physician at the University of Connecticut, Farmington.

This finding, which underscored the susceptibility of IBD patients to shingles because of their immunosuppressive treatments and the importance of vaccination, recently became even more relevant when the Food and Drug Administration approved tofacitinib (Xeljanz) to treat ulcerative colitis in late May, commented Gil Y. Melmed, MD, director of clinical inflammatory bowel disease at Cedars-Sinai Medical Center, Los Angeles. Tofacitinib, which may be an attractive option to some patients as an oral immunomodulator, carries a black box warning about the added risk for certain serious infections while taking the drug, including HZV. Recent recommendations from the American College of Gastroenterology said that IBD patients aged 51 years or older should “strongly consider” HZV vaccination, including immunosuppressed patients (Am J Gastroenterol. 2017 Feb; 112[2]:241-58). The introduction of a potentially popular drug for ulcerative colitis that’s known to pose a risk for shingles might lead to a stronger recommendation for vaccination in the near future, Dr. Melmed said in an interview.

The study Dr. Vinsard reported used data collected by the National Inpatient Sample from 2012 to September 2015, which represented, with weighting, more than 142 million hospitalized American patients. From this data set she and her associates identified 7,180 IBD patients hospitalized with a primary diagnosis of a vaccine-preventable disease, and about 589,000 weighted patients hospitalized for a vaccine-preventable disease but without IBD. The selection also focused on patients aged 18-65 years. Dr. Vinsard said that she excluded older patients to eliminate advanced age as a cause of immunosuppression.

[email protected]

MALMO, SWEDEN – Children who experience a febrile seizure in conjunction with a vaccination have developmental outcomes comparable with those of children who have non–vaccine-related febrile seizures and healthy controls who’ve never had a febrile seizure, according to the first prospective case-control cohort study to examine the issue.

This finding has important implications for clinical practice, Lucy Deng, MD, observed at the annual meeting of the European Society for Paediatric Infectious Diseases.

“Febrile seizures associated with a vaccine can decrease parent and provider confidence in vaccine safety,” the pediatrician noted. Based upon her study results, however, physicians now can offer a truly evidence-based message of reassurance.

Bruce Jancin/MDedge News

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MALMO, SWEDEN – Children who experience a febrile seizure in conjunction with a vaccination have developmental outcomes comparable with those of children who have non–vaccine-related febrile seizures and healthy controls who’ve never had a febrile seizure, according to the first prospective case-control cohort study to examine the issue.

This finding has important implications for clinical practice, Lucy Deng, MD, observed at the annual meeting of the European Society for Paediatric Infectious Diseases.

“Febrile seizures associated with a vaccine can decrease parent and provider confidence in vaccine safety,” the pediatrician noted. Based upon her study results, however, physicians now can offer a truly evidence-based message of reassurance.

Bruce Jancin/MDedge News

[email protected]

MALMO, SWEDEN – Children who experience a febrile seizure in conjunction with a vaccination have developmental outcomes comparable with those of children who have non–vaccine-related febrile seizures and healthy controls who’ve never had a febrile seizure, according to the first prospective case-control cohort study to examine the issue.

This finding has important implications for clinical practice, Lucy Deng, MD, observed at the annual meeting of the European Society for Paediatric Infectious Diseases.

“Febrile seizures associated with a vaccine can decrease parent and provider confidence in vaccine safety,” the pediatrician noted. Based upon her study results, however, physicians now can offer a truly evidence-based message of reassurance.

Bruce Jancin/MDedge News

[email protected]

Many U.S. hospitals still did not have influenza vaccination requirements for health care personnel as of summer 2017, suggested the results of a national survey.

Nearly two-thirds of hospitals had mandatory influenza vaccination in place in 2017, up from just one-third in 2013, according to survey responses submitted by infection preventionists working at Veterans Affairs (VA) and non-VA hospitals.

Jovanmandic/Thinkstock

By contrast, the proportion of VA hospitals with such requirements increased only slightly, from 1.3% in 2013 to just 4.1% in 2017 (P = .29), the report showed.

Penalties for not complying with the policy were not universal in hospitals with mandates, they added. Only 74% said they had such penalties, and 13% allowed health care personnel to decline influenza vaccination without a specified reason.

After the survey responses were received, the VA issued a directive stating that all health care personnel should receive annual influenza vaccination and should wear masks during influenza season, Dr. Greene noted.

That directive is in line with recommendations from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices, which have stated that all health care personnel should receive influenza vaccination each year.

In addition, the U.S. Department of Health & Human Services has set a goal of 90% of health care personnel to be vaccinated by 2020, Dr. Green and his coauthors noted.

Mandating influenza vaccination is just one proven successful strategy for increasing coverage at hospitals, according to the study authors. Other approaches include influenza education, incentives, free and easy access to vaccination, and annual campaigns directed at health care personnel, as well as written policies describing the vaccination goal.

“Regardless of whether an organization has an official mandate for vaccinations, establishing a written policy that states the organizational commitment to increasing vaccination rates is among the recommended strategies for improving vaccination coverage among health care personnel,” they wrote.

Dr. Greene and his coauthors reported receiving grants from the Blue Cross Blue Shield of Michigan Foundation and the U.S. Department of Veterans Affairs Patient Safety Center of Inquiry during the conduct of the study. One study coauthor reported personal fees from Jvion and from Doximity outside the submitted work.

SOURCE: Greene MT et al. JAMA Network Open. 2018;1(2):e180143.

Many U.S. hospitals still did not have influenza vaccination requirements for health care personnel as of summer 2017, suggested the results of a national survey.

Nearly two-thirds of hospitals had mandatory influenza vaccination in place in 2017, up from just one-third in 2013, according to survey responses submitted by infection preventionists working at Veterans Affairs (VA) and non-VA hospitals.

Jovanmandic/Thinkstock

By contrast, the proportion of VA hospitals with such requirements increased only slightly, from 1.3% in 2013 to just 4.1% in 2017 (P = .29), the report showed.

Penalties for not complying with the policy were not universal in hospitals with mandates, they added. Only 74% said they had such penalties, and 13% allowed health care personnel to decline influenza vaccination without a specified reason.

After the survey responses were received, the VA issued a directive stating that all health care personnel should receive annual influenza vaccination and should wear masks during influenza season, Dr. Greene noted.

That directive is in line with recommendations from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices, which have stated that all health care personnel should receive influenza vaccination each year.

In addition, the U.S. Department of Health & Human Services has set a goal of 90% of health care personnel to be vaccinated by 2020, Dr. Green and his coauthors noted.

Mandating influenza vaccination is just one proven successful strategy for increasing coverage at hospitals, according to the study authors. Other approaches include influenza education, incentives, free and easy access to vaccination, and annual campaigns directed at health care personnel, as well as written policies describing the vaccination goal.

“Regardless of whether an organization has an official mandate for vaccinations, establishing a written policy that states the organizational commitment to increasing vaccination rates is among the recommended strategies for improving vaccination coverage among health care personnel,” they wrote.

Dr. Greene and his coauthors reported receiving grants from the Blue Cross Blue Shield of Michigan Foundation and the U.S. Department of Veterans Affairs Patient Safety Center of Inquiry during the conduct of the study. One study coauthor reported personal fees from Jvion and from Doximity outside the submitted work.

SOURCE: Greene MT et al. JAMA Network Open. 2018;1(2):e180143.

Many U.S. hospitals still did not have influenza vaccination requirements for health care personnel as of summer 2017, suggested the results of a national survey.

Nearly two-thirds of hospitals had mandatory influenza vaccination in place in 2017, up from just one-third in 2013, according to survey responses submitted by infection preventionists working at Veterans Affairs (VA) and non-VA hospitals.

Jovanmandic/Thinkstock

By contrast, the proportion of VA hospitals with such requirements increased only slightly, from 1.3% in 2013 to just 4.1% in 2017 (P = .29), the report showed.

Penalties for not complying with the policy were not universal in hospitals with mandates, they added. Only 74% said they had such penalties, and 13% allowed health care personnel to decline influenza vaccination without a specified reason.

After the survey responses were received, the VA issued a directive stating that all health care personnel should receive annual influenza vaccination and should wear masks during influenza season, Dr. Greene noted.

That directive is in line with recommendations from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices, which have stated that all health care personnel should receive influenza vaccination each year.

In addition, the U.S. Department of Health & Human Services has set a goal of 90% of health care personnel to be vaccinated by 2020, Dr. Green and his coauthors noted.

Mandating influenza vaccination is just one proven successful strategy for increasing coverage at hospitals, according to the study authors. Other approaches include influenza education, incentives, free and easy access to vaccination, and annual campaigns directed at health care personnel, as well as written policies describing the vaccination goal.

“Regardless of whether an organization has an official mandate for vaccinations, establishing a written policy that states the organizational commitment to increasing vaccination rates is among the recommended strategies for improving vaccination coverage among health care personnel,” they wrote.

Dr. Greene and his coauthors reported receiving grants from the Blue Cross Blue Shield of Michigan Foundation and the U.S. Department of Veterans Affairs Patient Safety Center of Inquiry during the conduct of the study. One study coauthor reported personal fees from Jvion and from Doximity outside the submitted work.

SOURCE: Greene MT et al. JAMA Network Open. 2018;1(2):e180143.

We all know how challenging and time-consuming it can be to convince vaccine-hesitant patients that vaccinations are what is best for them and their children. Patients are bombarded with misinformation through the news and social media that seeds or “confirms” their doubts about vaccines. And for our part, we have only a few minutes during an office visit to refute all of the false claims that are a mere click or scroll away.

To better prepare for this challenge, this article details a practical approach to discussing vaccines with your patients. Using the patient-friendly language and evidence described here, you will be well positioned to refute 13 common vaccine misconceptions and overcome the barriers that stand in the way of these lifesaving interventions.

A few important baseline concepts

In discussing vaccination with our patients, it is important to keep the following in mind:

Patients don’t refuse vaccinations just to make our lives difficult. They truly are trying to make the best decisions they can for themselves and their families. Recognizing this can significantly reduce frustration levels.

Time well spent. While educating patients about the value of vaccines takes time, the return is worth it. The more consistently we offer vaccines, along with the reasons they are important, the more likely patients are to give vaccines a second thought. In fact, studies show that provider recommendation is the most important factor in patients’ decisions to vaccinate.¹

Approach matters. In all other aspects of medicine, we attempt to use a participatory approach, involving our patients in decisions regarding their health care. When discussing vaccines, however, a participatory approach (eg, “What do you want to do about vaccines today?”) can introduce doubt into patients’ minds. Studies show that a presumptive approach (eg, “Today we are going to provide the tetanus, human papillomavirus [HPV], and meningitis vaccines”) is a much more effective way to get patients to vaccinate.²

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Continue to: Barriers to counseling

Barriers to counseling. Health care providers report a variety of barriers to effective vaccine counseling (limited time and resources, lack of confidence in addressing patients’ concerns, etc).³ In addition, providers sometimes worry that strong encouragement of vaccination will create an adversarial relationship with vaccine-hesitant patients. Developing a good rapport and trusting relationship, as well as using motivational interviewing approaches, can help communicate the importance of vaccines, while leaving patients with the sense that you have heard them and respect their intentions. (See “Facilitate vaccine discussions using these 2 approaches.” ^4-7)

Continue to: If at first you don't succeed...

If at first you don’t succeed, try again because patients often have an experience that changes their mind. Perhaps a friend died of throat cancer or a family member developed a complication of the flu that required hospitalization. You never know when something will influence patients’ choices.

Don’t wait for scheduled well visits. Use every patient encounter as a means to catch patients up on missing vaccinations.

Common misconceptions and concerns and how to counter them

1. I’ve heard that vaccines can actually make you sick.

When patients raise this concern, start with an explanation of how vaccines work. Explain that our bodies protect us from foreign invaders (such as viruses and bacteria) by mounting an immune response when we are exposed to these proteins. Vaccinations work by exploiting this immune response; they expose the body to killed or weakened viral or bacterial proteins in a safe and controlled manner. In this way, our immune system will have already developed antibodies to these invaders by the time we are exposed to an active infection.

To use an analogy to war, instead of being subjected to a surprise attack where we suffer large losses in the battle, vaccination prepares us with weapons (antibodies) to defend ourselves so that our bodies are now able to successfully fight off that attack.

Because the majority of vaccines are killed virus vaccines, they cannot cause the illness against which they are meant to protect. Triggering the immune system may make some recipients feel a little “under the weather” for a day or 2, but they do not make us “sick.”

Live attenuated vaccines are similarly safe for those with a healthy immune system. We don’t administer them, however, to people who have a weakened immune system (eg, pregnant women, newborns, people with acquired immunodeficiency virus, or patients receiving chemotherapy or other types of immunosuppression) because these patients could develop the illness that we are trying to protect against.

Continue to: 2. Don't vaccines cause autism? Aren't they toxic to the nervous system?

The largest setback to vaccination efforts in recent history was a 1998 study by Andrew Wakefield that suggested that vaccination (specifically the mercury [in the form of thimerosal] present in the measles, mumps, rubella [MMR] vaccine) was linked to the development of autism.⁸ This research was subsequently debunked,⁹ and the author of the 1998 study was stripped of his medical license for falsifying data. However, the damage to vaccination efforts had already been done.

Aluminum. Thimerosal is not the only agent that patients may find concerning. Some also worry about the aluminum content of vaccines. Aluminum works as an additive to boost the body’s immune response to a vaccine. It is used only in killed virus vaccines—not in live attenuated ones. The Agency for Toxic Substances and Disease Registry monitors minimum risk levels (MRLs) of aluminum and other compounds in potentially hazardous substances. The amount of aluminum in vaccines is far below the MRL for aluminum, which is 1 mg/kg/d.¹⁰ (See “The facts about thimerosal and aluminum in vaccines.”^11-16)

Contine to: 3. I'm healthy. I never get sick. Why do I need vaccinations?

A good way to counter this comment is to respond: “Saying you don’t need vaccinations because you never get sick is like saying you don’t need to wear a seat belt because you’ve never been in a car accident.” Advise patients that we seek to vaccinate all members of a community—not just those who are sick or at high risk—to protect ourselves and to provide “herd immunity.” It’s important to explain that herd immunity is resistance to the spread of a contagious disease that results if a sufficiently high number of people (depending on the illness, typically 80%-95%) are immune to the disease, especially through vaccination.^17,18 If vaccination levels fall, we see a rise in cases of vaccine-preventable illness (as was seen during the 2017 measles outbreak in a community in Minnesota).¹⁹

Studies show that provider recommendation is the most important factor in patients' decisions to vaccinate.

Even though many of us may not suffer severe consequences of an infection, we can still pass that infection to others. While the whooping cough that a healthy 35-year-old gets may cause only prolonged annoyance or time off from work, it can kill the baby that is sitting next to that adult on the plane or bus.

4. Isn’t it true that we see fewer serious illnesses because of improved hygiene and sanitation, rather than vaccines?

Our current US sanitation standards were established under the Safe Drinking Water Act of 1974.²⁰ While improvements in hygiene, sanitation, nutrition, and other public health measures have undoubtedly decreased the spread of disease and improved survival rates, there is no denying the significant drop in disease that occurs after the introduction of a vaccine for a particular illness or the increase in cases of that disease when vaccination rates drop off.

Saying you don't need vaccinations because you never get sick is like saying you don't need to wear a seat belt because you've never been in a car accident.

By the early 1990s, our current sanitation standards were already well established. Yet we didn’t see a significant decrease in the incidence of infections with Haemophilus influenzae type b (Hib) until after the conjugate Hib vaccines were introduced (dropping from about 20,000 cases/year to 1419 cases/year by 1993).²¹

In Britain, a drop in the rate of pertussis (whooping cough) vaccination in 1974 resulted in an epidemic of more than 100,000 cases and 36 deaths by 1978. There was no decrease in hygiene or sanitation standards to explain this rise.²¹

Continue to: 5. Vaccines are just another way for "big pharma" to make "big money."

Patients may benefit from knowing that in the earlier days of vaccines, pharmaceutical companies actually moved away from production of vaccines because they were not very profitable. These days, with worldwide distribution, drug companies are back in the swing of making vaccines and, as we would expect from all companies, are in business to make a profit.

That said, health care providers receive no payments from drug companies for offering vaccines or for offering one vaccine over another. The reason we recommend vaccination is because we know it is best for our patients’ health and the health of the community.

6. We don’t see polio anymore. Why do I need the vaccine?

One of the factors contributing to the rise in antivaccine sentiment is that we rarely see vaccine-preventable illnesses (such as polio, measles, and mumps). But the absence of these illnesses is precisely due to prior years’ vaccination efforts.

Smallpox, a deadly and disfiguring disease that killed many millions of people and contributed to the downfall of the Roman, Aztec, and Incan empires, was eradicated from the planet in 1979, thanks to focused vaccination efforts by the World Health Organization. Vaccination works, but we have to keep at it.

While we no longer see as many of these vaccine-preventable illnesses in the United States, they are still present in other parts of the world. Our world is much smaller than it used to be. International travel is common, and illnesses can be reintroduced into a community with relative ease. We must remain vigilant.

Continue to: 7. I heard that vaccines are made from aborted fetal tissue.

There are 5 vaccines (varicella, rubella, hepatitis A, shingles, and rabies vaccines) that were originally made using aborted fetal tissue. In 1960, tissue from 2 fetuses aborted by maternal choice (and not for the purpose of vaccine production) was used to propagate cell lines that are still used in vaccine development today.

Human cells provide advantages for vaccine production that other cells do not. Some viruses do not grow well in animal cells. Animal cells can introduce contamination by bacteria and viruses that are not carried in human cell lines. Vaccine production can be hindered or halted, resulting in a vaccine shortage, if animal products used in development are threatened (eg, if an illness strikes egg-producing chickens; eggs are used to make the influenza vaccine).²²

Some patients, particularly those who are Catholic, may have concerns about these vaccines. The National Catholic Bioethics Center has prepared a statement regarding the use of these vaccines that may help settle any moral dilemmas.²³ It reads:

“The cell lines under consideration were begun using cells taken from one or more fetuses aborted almost 40 years ago. Since that time, the cell lines have grown independently. It is important to note that descendent cells are not the cells of the aborted child.”

“One is morally free to use the vaccine regardless of its historical association with abortion. The reason is that the risk to public health, if one chooses not to vaccinate, outweighs the legitimate concern about the origins of the vaccine. This is especially important for parents, who have a moral obligation to protect the life and health of their children and those around them.”

Continue to: 8. Vaccines aren't studied—or monitored—thoroughly enough.

Patients would benefit from knowing that vaccines are some of the most thoroughly studied products brought to market. They undergo rigorous testing and oversight, from both public and private organizations, for 10 to 15 years before being released for distribution. Post-licensure monitoring is ongoing, and the manufacturer may voluntarily participate in Phase IV trials to continue to test the safety and efficacy of a vaccine after release to market.

Monitoring adverse effects. In addition, in 1990, the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration established the Vaccine Adverse Events Reporting System (VAERS) to “detect possible signals of adverse events associated with vaccines.”²⁴ Most events reported are coincidental, but some common mild adverse events (like redness and swelling at the injection site) are often underreported.

Serious events are always thoroughly investigated and are often found unrelated. However, rare associations have been found. For example, an intestinal problem called intussusception, related to the original rotavirus vaccine, was discovered, and the vaccine causing it was removed from the market.²⁵ A new, safer rotavirus vaccine option is now available. Patients need to know that we do have an effective system of checks and balances in which we can place our trust.

9. People can become paralyzed or stop breathing after receiving a vaccination. Why run those risks?

One of the most feared reactions to vaccination is Guillain-Barré syndrome (GBS), which can cause paralysis. The CDC estimates the risk for GBS associated with the flu vaccine, for example, to be 1 to 2 cases per 1 million people vaccinated.²⁶ Another potential concern is the rate of anaphylaxis following vaccination. However, in a 2016 study in the Journal of Allergy and Clinical Immunology, the rate of anaphylaxis for all vaccines combined was only 1.31 per 1 million vaccines.²⁷

In the United States, the 2013 annual cost of 4 major vaccine-preventable illnesses in adults ≥50 years was estimated at $26.5 billion.

The risk of developing severe complications from an illness is much greater than that of developing complications from the vaccine meant to protect a person against that illness. In the United States, the population-based risk for influenza-related hospitalization in children, for example, is as high as 150 in 100,000 with as many as 125 deaths annually.²⁶

Continue to: 10. Isn't vaccination a personal choice? How does my health/illness impact the community?

Patients may not realize that most viruses are contagious from 1 to 2 days before symptoms appear, which means we can spread an illness before we even know we have it. Protecting oneself also protects those around us.

While the whooping cough that a healthy 35-year-old gets may be a prolonged annoyance or prompt some time off from work, it can kill the baby sitting next to the adult on the plane or bus.

Economic concerns. There’s also the economic impact of these illnesses to consider. This includes the personal cost of being out of school or work for an extended period and the cost of a patient’s care, which can become astronomical if hospitalization is required and which can become the country’s problem if a person lacks sufficient health insurance coverage.

A study looking at the cost of 4 major adult vaccine-preventable illnesses (influenza, pneumococcal disease, shingles, and whooping cough) in the United States in 2013 estimated the annual cost for these illnesses in adults ≥50 years to be $26.5 billion.²⁸ And that doesn’t include the cost of childhood vaccine-preventable diseases.

Countering 3 concerns about childhood vaccinations

1. I can’t afford vaccines for my child.

The Vaccines for Children program is a federally-funded program that covers the cost of all vaccines for children younger than 19 years of age who are Medicaid-eligible, American Indian, Alaskan Native, uninsured, or underinsured.²⁹ Although there may be a small administration fee charged by the provider’s office, the vaccine is free.

2. Don’t all of the vaccines recommended for children overwhelm their immune systems?

Children are exposed to so many more proteins on a daily basis (by crawling around on the floor, putting their hands in their mouths, attending school or day care, etc) than they are ever exposed to in a series of vaccines.³⁰ Exposure to these proteins in their environment and to those in vaccines only serves to boost their immunity and keep them healthier in the long run.

And thanks to advances in vaccine production, the immunologic load in vaccines is far less than it used to be. The 14 vaccines given today contain <200 bacterial and viral proteins or polysaccharides, compared with the >3000 of these immunologic components in the 7 vaccines administered in 1980.³¹

Continue to: Influenza vaccine: Patient-friendly talking points

Continue to: 3. Why don't we adhere to Dr. Sears' vaccine schedule?

There are multiple ways in which Dr. Robert Sears’ book, The Vaccine Book: Making the Right Decision for your Child, published in 2007, misrepresents vaccine science and leads patients astray in making decisions regarding vaccinations.³² Most important to note is that Dr. Sears’ Alternative Vaccine Schedule, which seeks to make it so that children do not receive more than 2 vaccinations per office visit, would require visits to a health care provider at 2, 3, 4, 5, 6, 7, 9, 12, 15, 18, and 21 months, and at 2, 2.5, 3, 3.5, 4, 5, and 6 years of age. This significantly increases the number of office visits and needle sticks, and raises the age at which vaccines are given, increasing the risk of illness outbreaks and decreasing the likelihood that parents would return to the office to complete the full series.

Acceptance of influenza and HPV vaccines remains a challenge

We are significantly less successful at getting parents and patients to agree to influenza and HPV vaccines than to the other vaccines we offer. The influenza vaccine success rate in 2016 was 59% in children and 43.3% in adults.³³ Compared to the Tdap vaccine (88%) and the meningococcal vaccine (82%), which are offered at the same age as the HPV vaccine, success rates for HPV vaccine are significantly lower. In 2016, only 60.4% of boys and girls were current on their first HPV injection and only 43.3% were up to date with the full series.³⁴

Newness of vaccines a factor?

Perhaps it is because the recommendations for these 2 vaccines are relatively new, and people don’t yet grasp the seriousness and scope of the diseases. Until 2010, the flu shot was recommended only for the very young, the elderly, and the medically high risk.

Similarly, the HPV vaccine was originally introduced for girls in 2006 and wasn’t recommended for boys until 2011.

Continue to: Human papillomavirus vaccine: Patient-friendly talking points

Continue to: A sensitive subject

A sensitive subject. Discussion of a vaccine related to a child’s sexual health makes some parents uncomfortable. Studies show that focusing on the cancer prevention aspects of the vaccine, rather than on sexual transmission of HPV, results in greater vaccine acceptance.³⁵

In 2016, only 60.4% of boys and girls were current on their first HPV vaccination and only 43.3% were up to date with the full series.

However, if discussion of sexual transmission is unavoidable, remind parents to consider their own adolescence and whether they chose to share everything with their parents. Point out that there were probably things they did that they later looked back on and thought, “What was I thinking?” Their children, no matter how wonderful and levelheaded they are, will be no different. And, as much as parents don’t want to think about it, some kids will suffer unwanted sexual contact. Shouldn’t parents protect their children as best as they can?

A teen’s right to choose? Some states have passed a Mature Minor Doctrine, which provides for mature, unemancipated teens to make their own medical decisions regarding such issues as sexuality, mental health, and drug and alcohol use without their parents’ consent. In these states, teens may elect to receive the HPV vaccine without parental permission. (Check your state’s laws for specifics, and see the 2 boxes with patient-friendly talking points for influenza vaccine^7,36-39 and human papillomavirus vaccine.^40-47)

CORRESPONDENCE
Gretchen LaSalle, MD, MultiCare Rockwood Clinic, 2214 East 29th Avenue, Spokane, WA 99203; [email protected].

We all know how challenging and time-consuming it can be to convince vaccine-hesitant patients that vaccinations are what is best for them and their children. Patients are bombarded with misinformation through the news and social media that seeds or “confirms” their doubts about vaccines. And for our part, we have only a few minutes during an office visit to refute all of the false claims that are a mere click or scroll away.

To better prepare for this challenge, this article details a practical approach to discussing vaccines with your patients. Using the patient-friendly language and evidence described here, you will be well positioned to refute 13 common vaccine misconceptions and overcome the barriers that stand in the way of these lifesaving interventions.

A few important baseline concepts

In discussing vaccination with our patients, it is important to keep the following in mind:

Patients don’t refuse vaccinations just to make our lives difficult. They truly are trying to make the best decisions they can for themselves and their families. Recognizing this can significantly reduce frustration levels.

Time well spent. While educating patients about the value of vaccines takes time, the return is worth it. The more consistently we offer vaccines, along with the reasons they are important, the more likely patients are to give vaccines a second thought. In fact, studies show that provider recommendation is the most important factor in patients’ decisions to vaccinate.¹

Approach matters. In all other aspects of medicine, we attempt to use a participatory approach, involving our patients in decisions regarding their health care. When discussing vaccines, however, a participatory approach (eg, “What do you want to do about vaccines today?”) can introduce doubt into patients’ minds. Studies show that a presumptive approach (eg, “Today we are going to provide the tetanus, human papillomavirus [HPV], and meningitis vaccines”) is a much more effective way to get patients to vaccinate.²

[polldaddy:10018427]

Continue to: Barriers to counseling

Barriers to counseling. Health care providers report a variety of barriers to effective vaccine counseling (limited time and resources, lack of confidence in addressing patients’ concerns, etc).³ In addition, providers sometimes worry that strong encouragement of vaccination will create an adversarial relationship with vaccine-hesitant patients. Developing a good rapport and trusting relationship, as well as using motivational interviewing approaches, can help communicate the importance of vaccines, while leaving patients with the sense that you have heard them and respect their intentions. (See “Facilitate vaccine discussions using these 2 approaches.” ^4-7)

Continue to: If at first you don't succeed...

If at first you don’t succeed, try again because patients often have an experience that changes their mind. Perhaps a friend died of throat cancer or a family member developed a complication of the flu that required hospitalization. You never know when something will influence patients’ choices.

Don’t wait for scheduled well visits. Use every patient encounter as a means to catch patients up on missing vaccinations.

Common misconceptions and concerns and how to counter them

1. I’ve heard that vaccines can actually make you sick.

When patients raise this concern, start with an explanation of how vaccines work. Explain that our bodies protect us from foreign invaders (such as viruses and bacteria) by mounting an immune response when we are exposed to these proteins. Vaccinations work by exploiting this immune response; they expose the body to killed or weakened viral or bacterial proteins in a safe and controlled manner. In this way, our immune system will have already developed antibodies to these invaders by the time we are exposed to an active infection.

To use an analogy to war, instead of being subjected to a surprise attack where we suffer large losses in the battle, vaccination prepares us with weapons (antibodies) to defend ourselves so that our bodies are now able to successfully fight off that attack.

Because the majority of vaccines are killed virus vaccines, they cannot cause the illness against which they are meant to protect. Triggering the immune system may make some recipients feel a little “under the weather” for a day or 2, but they do not make us “sick.”

Live attenuated vaccines are similarly safe for those with a healthy immune system. We don’t administer them, however, to people who have a weakened immune system (eg, pregnant women, newborns, people with acquired immunodeficiency virus, or patients receiving chemotherapy or other types of immunosuppression) because these patients could develop the illness that we are trying to protect against.

Continue to: 2. Don't vaccines cause autism? Aren't they toxic to the nervous system?

The largest setback to vaccination efforts in recent history was a 1998 study by Andrew Wakefield that suggested that vaccination (specifically the mercury [in the form of thimerosal] present in the measles, mumps, rubella [MMR] vaccine) was linked to the development of autism.⁸ This research was subsequently debunked,⁹ and the author of the 1998 study was stripped of his medical license for falsifying data. However, the damage to vaccination efforts had already been done.

Aluminum. Thimerosal is not the only agent that patients may find concerning. Some also worry about the aluminum content of vaccines. Aluminum works as an additive to boost the body’s immune response to a vaccine. It is used only in killed virus vaccines—not in live attenuated ones. The Agency for Toxic Substances and Disease Registry monitors minimum risk levels (MRLs) of aluminum and other compounds in potentially hazardous substances. The amount of aluminum in vaccines is far below the MRL for aluminum, which is 1 mg/kg/d.¹⁰ (See “The facts about thimerosal and aluminum in vaccines.”^11-16)

Contine to: 3. I'm healthy. I never get sick. Why do I need vaccinations?

A good way to counter this comment is to respond: “Saying you don’t need vaccinations because you never get sick is like saying you don’t need to wear a seat belt because you’ve never been in a car accident.” Advise patients that we seek to vaccinate all members of a community—not just those who are sick or at high risk—to protect ourselves and to provide “herd immunity.” It’s important to explain that herd immunity is resistance to the spread of a contagious disease that results if a sufficiently high number of people (depending on the illness, typically 80%-95%) are immune to the disease, especially through vaccination.^17,18 If vaccination levels fall, we see a rise in cases of vaccine-preventable illness (as was seen during the 2017 measles outbreak in a community in Minnesota).¹⁹

Studies show that provider recommendation is the most important factor in patients' decisions to vaccinate.

Even though many of us may not suffer severe consequences of an infection, we can still pass that infection to others. While the whooping cough that a healthy 35-year-old gets may cause only prolonged annoyance or time off from work, it can kill the baby that is sitting next to that adult on the plane or bus.

4. Isn’t it true that we see fewer serious illnesses because of improved hygiene and sanitation, rather than vaccines?

Our current US sanitation standards were established under the Safe Drinking Water Act of 1974.²⁰ While improvements in hygiene, sanitation, nutrition, and other public health measures have undoubtedly decreased the spread of disease and improved survival rates, there is no denying the significant drop in disease that occurs after the introduction of a vaccine for a particular illness or the increase in cases of that disease when vaccination rates drop off.

Saying you don't need vaccinations because you never get sick is like saying you don't need to wear a seat belt because you've never been in a car accident.

By the early 1990s, our current sanitation standards were already well established. Yet we didn’t see a significant decrease in the incidence of infections with Haemophilus influenzae type b (Hib) until after the conjugate Hib vaccines were introduced (dropping from about 20,000 cases/year to 1419 cases/year by 1993).²¹

In Britain, a drop in the rate of pertussis (whooping cough) vaccination in 1974 resulted in an epidemic of more than 100,000 cases and 36 deaths by 1978. There was no decrease in hygiene or sanitation standards to explain this rise.²¹

Continue to: 5. Vaccines are just another way for "big pharma" to make "big money."

Patients may benefit from knowing that in the earlier days of vaccines, pharmaceutical companies actually moved away from production of vaccines because they were not very profitable. These days, with worldwide distribution, drug companies are back in the swing of making vaccines and, as we would expect from all companies, are in business to make a profit.

That said, health care providers receive no payments from drug companies for offering vaccines or for offering one vaccine over another. The reason we recommend vaccination is because we know it is best for our patients’ health and the health of the community.

6. We don’t see polio anymore. Why do I need the vaccine?

One of the factors contributing to the rise in antivaccine sentiment is that we rarely see vaccine-preventable illnesses (such as polio, measles, and mumps). But the absence of these illnesses is precisely due to prior years’ vaccination efforts.

Smallpox, a deadly and disfiguring disease that killed many millions of people and contributed to the downfall of the Roman, Aztec, and Incan empires, was eradicated from the planet in 1979, thanks to focused vaccination efforts by the World Health Organization. Vaccination works, but we have to keep at it.

While we no longer see as many of these vaccine-preventable illnesses in the United States, they are still present in other parts of the world. Our world is much smaller than it used to be. International travel is common, and illnesses can be reintroduced into a community with relative ease. We must remain vigilant.

Continue to: 7. I heard that vaccines are made from aborted fetal tissue.

There are 5 vaccines (varicella, rubella, hepatitis A, shingles, and rabies vaccines) that were originally made using aborted fetal tissue. In 1960, tissue from 2 fetuses aborted by maternal choice (and not for the purpose of vaccine production) was used to propagate cell lines that are still used in vaccine development today.

Human cells provide advantages for vaccine production that other cells do not. Some viruses do not grow well in animal cells. Animal cells can introduce contamination by bacteria and viruses that are not carried in human cell lines. Vaccine production can be hindered or halted, resulting in a vaccine shortage, if animal products used in development are threatened (eg, if an illness strikes egg-producing chickens; eggs are used to make the influenza vaccine).²²

Some patients, particularly those who are Catholic, may have concerns about these vaccines. The National Catholic Bioethics Center has prepared a statement regarding the use of these vaccines that may help settle any moral dilemmas.²³ It reads:

“The cell lines under consideration were begun using cells taken from one or more fetuses aborted almost 40 years ago. Since that time, the cell lines have grown independently. It is important to note that descendent cells are not the cells of the aborted child.”

“One is morally free to use the vaccine regardless of its historical association with abortion. The reason is that the risk to public health, if one chooses not to vaccinate, outweighs the legitimate concern about the origins of the vaccine. This is especially important for parents, who have a moral obligation to protect the life and health of their children and those around them.”

Continue to: 8. Vaccines aren't studied—or monitored—thoroughly enough.

Patients would benefit from knowing that vaccines are some of the most thoroughly studied products brought to market. They undergo rigorous testing and oversight, from both public and private organizations, for 10 to 15 years before being released for distribution. Post-licensure monitoring is ongoing, and the manufacturer may voluntarily participate in Phase IV trials to continue to test the safety and efficacy of a vaccine after release to market.

Monitoring adverse effects. In addition, in 1990, the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration established the Vaccine Adverse Events Reporting System (VAERS) to “detect possible signals of adverse events associated with vaccines.”²⁴ Most events reported are coincidental, but some common mild adverse events (like redness and swelling at the injection site) are often underreported.

Serious events are always thoroughly investigated and are often found unrelated. However, rare associations have been found. For example, an intestinal problem called intussusception, related to the original rotavirus vaccine, was discovered, and the vaccine causing it was removed from the market.²⁵ A new, safer rotavirus vaccine option is now available. Patients need to know that we do have an effective system of checks and balances in which we can place our trust.

9. People can become paralyzed or stop breathing after receiving a vaccination. Why run those risks?

One of the most feared reactions to vaccination is Guillain-Barré syndrome (GBS), which can cause paralysis. The CDC estimates the risk for GBS associated with the flu vaccine, for example, to be 1 to 2 cases per 1 million people vaccinated.²⁶ Another potential concern is the rate of anaphylaxis following vaccination. However, in a 2016 study in the Journal of Allergy and Clinical Immunology, the rate of anaphylaxis for all vaccines combined was only 1.31 per 1 million vaccines.²⁷

In the United States, the 2013 annual cost of 4 major vaccine-preventable illnesses in adults ≥50 years was estimated at $26.5 billion.

The risk of developing severe complications from an illness is much greater than that of developing complications from the vaccine meant to protect a person against that illness. In the United States, the population-based risk for influenza-related hospitalization in children, for example, is as high as 150 in 100,000 with as many as 125 deaths annually.²⁶

Continue to: 10. Isn't vaccination a personal choice? How does my health/illness impact the community?

Patients may not realize that most viruses are contagious from 1 to 2 days before symptoms appear, which means we can spread an illness before we even know we have it. Protecting oneself also protects those around us.

While the whooping cough that a healthy 35-year-old gets may be a prolonged annoyance or prompt some time off from work, it can kill the baby sitting next to the adult on the plane or bus.

Economic concerns. There’s also the economic impact of these illnesses to consider. This includes the personal cost of being out of school or work for an extended period and the cost of a patient’s care, which can become astronomical if hospitalization is required and which can become the country’s problem if a person lacks sufficient health insurance coverage.

A study looking at the cost of 4 major adult vaccine-preventable illnesses (influenza, pneumococcal disease, shingles, and whooping cough) in the United States in 2013 estimated the annual cost for these illnesses in adults ≥50 years to be $26.5 billion.²⁸ And that doesn’t include the cost of childhood vaccine-preventable diseases.

Countering 3 concerns about childhood vaccinations

1. I can’t afford vaccines for my child.

The Vaccines for Children program is a federally-funded program that covers the cost of all vaccines for children younger than 19 years of age who are Medicaid-eligible, American Indian, Alaskan Native, uninsured, or underinsured.²⁹ Although there may be a small administration fee charged by the provider’s office, the vaccine is free.

2. Don’t all of the vaccines recommended for children overwhelm their immune systems?

Children are exposed to so many more proteins on a daily basis (by crawling around on the floor, putting their hands in their mouths, attending school or day care, etc) than they are ever exposed to in a series of vaccines.³⁰ Exposure to these proteins in their environment and to those in vaccines only serves to boost their immunity and keep them healthier in the long run.

And thanks to advances in vaccine production, the immunologic load in vaccines is far less than it used to be. The 14 vaccines given today contain <200 bacterial and viral proteins or polysaccharides, compared with the >3000 of these immunologic components in the 7 vaccines administered in 1980.³¹

Continue to: Influenza vaccine: Patient-friendly talking points

Continue to: 3. Why don't we adhere to Dr. Sears' vaccine schedule?

There are multiple ways in which Dr. Robert Sears’ book, The Vaccine Book: Making the Right Decision for your Child, published in 2007, misrepresents vaccine science and leads patients astray in making decisions regarding vaccinations.³² Most important to note is that Dr. Sears’ Alternative Vaccine Schedule, which seeks to make it so that children do not receive more than 2 vaccinations per office visit, would require visits to a health care provider at 2, 3, 4, 5, 6, 7, 9, 12, 15, 18, and 21 months, and at 2, 2.5, 3, 3.5, 4, 5, and 6 years of age. This significantly increases the number of office visits and needle sticks, and raises the age at which vaccines are given, increasing the risk of illness outbreaks and decreasing the likelihood that parents would return to the office to complete the full series.

Acceptance of influenza and HPV vaccines remains a challenge

We are significantly less successful at getting parents and patients to agree to influenza and HPV vaccines than to the other vaccines we offer. The influenza vaccine success rate in 2016 was 59% in children and 43.3% in adults.³³ Compared to the Tdap vaccine (88%) and the meningococcal vaccine (82%), which are offered at the same age as the HPV vaccine, success rates for HPV vaccine are significantly lower. In 2016, only 60.4% of boys and girls were current on their first HPV injection and only 43.3% were up to date with the full series.³⁴

Newness of vaccines a factor?

Perhaps it is because the recommendations for these 2 vaccines are relatively new, and people don’t yet grasp the seriousness and scope of the diseases. Until 2010, the flu shot was recommended only for the very young, the elderly, and the medically high risk.

Similarly, the HPV vaccine was originally introduced for girls in 2006 and wasn’t recommended for boys until 2011.

Continue to: Human papillomavirus vaccine: Patient-friendly talking points

Continue to: A sensitive subject

A sensitive subject. Discussion of a vaccine related to a child’s sexual health makes some parents uncomfortable. Studies show that focusing on the cancer prevention aspects of the vaccine, rather than on sexual transmission of HPV, results in greater vaccine acceptance.³⁵

In 2016, only 60.4% of boys and girls were current on their first HPV vaccination and only 43.3% were up to date with the full series.

However, if discussion of sexual transmission is unavoidable, remind parents to consider their own adolescence and whether they chose to share everything with their parents. Point out that there were probably things they did that they later looked back on and thought, “What was I thinking?” Their children, no matter how wonderful and levelheaded they are, will be no different. And, as much as parents don’t want to think about it, some kids will suffer unwanted sexual contact. Shouldn’t parents protect their children as best as they can?

A teen’s right to choose? Some states have passed a Mature Minor Doctrine, which provides for mature, unemancipated teens to make their own medical decisions regarding such issues as sexuality, mental health, and drug and alcohol use without their parents’ consent. In these states, teens may elect to receive the HPV vaccine without parental permission. (Check your state’s laws for specifics, and see the 2 boxes with patient-friendly talking points for influenza vaccine^7,36-39 and human papillomavirus vaccine.^40-47)

CORRESPONDENCE
Gretchen LaSalle, MD, MultiCare Rockwood Clinic, 2214 East 29th Avenue, Spokane, WA 99203; [email protected].

We all know how challenging and time-consuming it can be to convince vaccine-hesitant patients that vaccinations are what is best for them and their children. Patients are bombarded with misinformation through the news and social media that seeds or “confirms” their doubts about vaccines. And for our part, we have only a few minutes during an office visit to refute all of the false claims that are a mere click or scroll away.

To better prepare for this challenge, this article details a practical approach to discussing vaccines with your patients. Using the patient-friendly language and evidence described here, you will be well positioned to refute 13 common vaccine misconceptions and overcome the barriers that stand in the way of these lifesaving interventions.

A few important baseline concepts

In discussing vaccination with our patients, it is important to keep the following in mind:

Patients don’t refuse vaccinations just to make our lives difficult. They truly are trying to make the best decisions they can for themselves and their families. Recognizing this can significantly reduce frustration levels.

Time well spent. While educating patients about the value of vaccines takes time, the return is worth it. The more consistently we offer vaccines, along with the reasons they are important, the more likely patients are to give vaccines a second thought. In fact, studies show that provider recommendation is the most important factor in patients’ decisions to vaccinate.¹

Approach matters. In all other aspects of medicine, we attempt to use a participatory approach, involving our patients in decisions regarding their health care. When discussing vaccines, however, a participatory approach (eg, “What do you want to do about vaccines today?”) can introduce doubt into patients’ minds. Studies show that a presumptive approach (eg, “Today we are going to provide the tetanus, human papillomavirus [HPV], and meningitis vaccines”) is a much more effective way to get patients to vaccinate.²

[polldaddy:10018427]

Continue to: Barriers to counseling

Barriers to counseling. Health care providers report a variety of barriers to effective vaccine counseling (limited time and resources, lack of confidence in addressing patients’ concerns, etc).³ In addition, providers sometimes worry that strong encouragement of vaccination will create an adversarial relationship with vaccine-hesitant patients. Developing a good rapport and trusting relationship, as well as using motivational interviewing approaches, can help communicate the importance of vaccines, while leaving patients with the sense that you have heard them and respect their intentions. (See “Facilitate vaccine discussions using these 2 approaches.” ^4-7)

Continue to: If at first you don't succeed...

If at first you don’t succeed, try again because patients often have an experience that changes their mind. Perhaps a friend died of throat cancer or a family member developed a complication of the flu that required hospitalization. You never know when something will influence patients’ choices.

Don’t wait for scheduled well visits. Use every patient encounter as a means to catch patients up on missing vaccinations.

Common misconceptions and concerns and how to counter them

1. I’ve heard that vaccines can actually make you sick.

When patients raise this concern, start with an explanation of how vaccines work. Explain that our bodies protect us from foreign invaders (such as viruses and bacteria) by mounting an immune response when we are exposed to these proteins. Vaccinations work by exploiting this immune response; they expose the body to killed or weakened viral or bacterial proteins in a safe and controlled manner. In this way, our immune system will have already developed antibodies to these invaders by the time we are exposed to an active infection.

To use an analogy to war, instead of being subjected to a surprise attack where we suffer large losses in the battle, vaccination prepares us with weapons (antibodies) to defend ourselves so that our bodies are now able to successfully fight off that attack.

Because the majority of vaccines are killed virus vaccines, they cannot cause the illness against which they are meant to protect. Triggering the immune system may make some recipients feel a little “under the weather” for a day or 2, but they do not make us “sick.”

Live attenuated vaccines are similarly safe for those with a healthy immune system. We don’t administer them, however, to people who have a weakened immune system (eg, pregnant women, newborns, people with acquired immunodeficiency virus, or patients receiving chemotherapy or other types of immunosuppression) because these patients could develop the illness that we are trying to protect against.

Continue to: 2. Don't vaccines cause autism? Aren't they toxic to the nervous system?

The largest setback to vaccination efforts in recent history was a 1998 study by Andrew Wakefield that suggested that vaccination (specifically the mercury [in the form of thimerosal] present in the measles, mumps, rubella [MMR] vaccine) was linked to the development of autism.⁸ This research was subsequently debunked,⁹ and the author of the 1998 study was stripped of his medical license for falsifying data. However, the damage to vaccination efforts had already been done.

Aluminum. Thimerosal is not the only agent that patients may find concerning. Some also worry about the aluminum content of vaccines. Aluminum works as an additive to boost the body’s immune response to a vaccine. It is used only in killed virus vaccines—not in live attenuated ones. The Agency for Toxic Substances and Disease Registry monitors minimum risk levels (MRLs) of aluminum and other compounds in potentially hazardous substances. The amount of aluminum in vaccines is far below the MRL for aluminum, which is 1 mg/kg/d.¹⁰ (See “The facts about thimerosal and aluminum in vaccines.”^11-16)

Contine to: 3. I'm healthy. I never get sick. Why do I need vaccinations?

A good way to counter this comment is to respond: “Saying you don’t need vaccinations because you never get sick is like saying you don’t need to wear a seat belt because you’ve never been in a car accident.” Advise patients that we seek to vaccinate all members of a community—not just those who are sick or at high risk—to protect ourselves and to provide “herd immunity.” It’s important to explain that herd immunity is resistance to the spread of a contagious disease that results if a sufficiently high number of people (depending on the illness, typically 80%-95%) are immune to the disease, especially through vaccination.^17,18 If vaccination levels fall, we see a rise in cases of vaccine-preventable illness (as was seen during the 2017 measles outbreak in a community in Minnesota).¹⁹

Studies show that provider recommendation is the most important factor in patients' decisions to vaccinate.

Even though many of us may not suffer severe consequences of an infection, we can still pass that infection to others. While the whooping cough that a healthy 35-year-old gets may cause only prolonged annoyance or time off from work, it can kill the baby that is sitting next to that adult on the plane or bus.

4. Isn’t it true that we see fewer serious illnesses because of improved hygiene and sanitation, rather than vaccines?

Our current US sanitation standards were established under the Safe Drinking Water Act of 1974.²⁰ While improvements in hygiene, sanitation, nutrition, and other public health measures have undoubtedly decreased the spread of disease and improved survival rates, there is no denying the significant drop in disease that occurs after the introduction of a vaccine for a particular illness or the increase in cases of that disease when vaccination rates drop off.

Saying you don't need vaccinations because you never get sick is like saying you don't need to wear a seat belt because you've never been in a car accident.

By the early 1990s, our current sanitation standards were already well established. Yet we didn’t see a significant decrease in the incidence of infections with Haemophilus influenzae type b (Hib) until after the conjugate Hib vaccines were introduced (dropping from about 20,000 cases/year to 1419 cases/year by 1993).²¹

In Britain, a drop in the rate of pertussis (whooping cough) vaccination in 1974 resulted in an epidemic of more than 100,000 cases and 36 deaths by 1978. There was no decrease in hygiene or sanitation standards to explain this rise.²¹

Continue to: 5. Vaccines are just another way for "big pharma" to make "big money."

Patients may benefit from knowing that in the earlier days of vaccines, pharmaceutical companies actually moved away from production of vaccines because they were not very profitable. These days, with worldwide distribution, drug companies are back in the swing of making vaccines and, as we would expect from all companies, are in business to make a profit.

That said, health care providers receive no payments from drug companies for offering vaccines or for offering one vaccine over another. The reason we recommend vaccination is because we know it is best for our patients’ health and the health of the community.

6. We don’t see polio anymore. Why do I need the vaccine?

One of the factors contributing to the rise in antivaccine sentiment is that we rarely see vaccine-preventable illnesses (such as polio, measles, and mumps). But the absence of these illnesses is precisely due to prior years’ vaccination efforts.

Smallpox, a deadly and disfiguring disease that killed many millions of people and contributed to the downfall of the Roman, Aztec, and Incan empires, was eradicated from the planet in 1979, thanks to focused vaccination efforts by the World Health Organization. Vaccination works, but we have to keep at it.

While we no longer see as many of these vaccine-preventable illnesses in the United States, they are still present in other parts of the world. Our world is much smaller than it used to be. International travel is common, and illnesses can be reintroduced into a community with relative ease. We must remain vigilant.

Continue to: 7. I heard that vaccines are made from aborted fetal tissue.

There are 5 vaccines (varicella, rubella, hepatitis A, shingles, and rabies vaccines) that were originally made using aborted fetal tissue. In 1960, tissue from 2 fetuses aborted by maternal choice (and not for the purpose of vaccine production) was used to propagate cell lines that are still used in vaccine development today.

Human cells provide advantages for vaccine production that other cells do not. Some viruses do not grow well in animal cells. Animal cells can introduce contamination by bacteria and viruses that are not carried in human cell lines. Vaccine production can be hindered or halted, resulting in a vaccine shortage, if animal products used in development are threatened (eg, if an illness strikes egg-producing chickens; eggs are used to make the influenza vaccine).²²

Some patients, particularly those who are Catholic, may have concerns about these vaccines. The National Catholic Bioethics Center has prepared a statement regarding the use of these vaccines that may help settle any moral dilemmas.²³ It reads:

“The cell lines under consideration were begun using cells taken from one or more fetuses aborted almost 40 years ago. Since that time, the cell lines have grown independently. It is important to note that descendent cells are not the cells of the aborted child.”

“One is morally free to use the vaccine regardless of its historical association with abortion. The reason is that the risk to public health, if one chooses not to vaccinate, outweighs the legitimate concern about the origins of the vaccine. This is especially important for parents, who have a moral obligation to protect the life and health of their children and those around them.”

Continue to: 8. Vaccines aren't studied—or monitored—thoroughly enough.

Patients would benefit from knowing that vaccines are some of the most thoroughly studied products brought to market. They undergo rigorous testing and oversight, from both public and private organizations, for 10 to 15 years before being released for distribution. Post-licensure monitoring is ongoing, and the manufacturer may voluntarily participate in Phase IV trials to continue to test the safety and efficacy of a vaccine after release to market.

Monitoring adverse effects. In addition, in 1990, the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration established the Vaccine Adverse Events Reporting System (VAERS) to “detect possible signals of adverse events associated with vaccines.”²⁴ Most events reported are coincidental, but some common mild adverse events (like redness and swelling at the injection site) are often underreported.

Serious events are always thoroughly investigated and are often found unrelated. However, rare associations have been found. For example, an intestinal problem called intussusception, related to the original rotavirus vaccine, was discovered, and the vaccine causing it was removed from the market.²⁵ A new, safer rotavirus vaccine option is now available. Patients need to know that we do have an effective system of checks and balances in which we can place our trust.

9. People can become paralyzed or stop breathing after receiving a vaccination. Why run those risks?

One of the most feared reactions to vaccination is Guillain-Barré syndrome (GBS), which can cause paralysis. The CDC estimates the risk for GBS associated with the flu vaccine, for example, to be 1 to 2 cases per 1 million people vaccinated.²⁶ Another potential concern is the rate of anaphylaxis following vaccination. However, in a 2016 study in the Journal of Allergy and Clinical Immunology, the rate of anaphylaxis for all vaccines combined was only 1.31 per 1 million vaccines.²⁷

In the United States, the 2013 annual cost of 4 major vaccine-preventable illnesses in adults ≥50 years was estimated at $26.5 billion.

The risk of developing severe complications from an illness is much greater than that of developing complications from the vaccine meant to protect a person against that illness. In the United States, the population-based risk for influenza-related hospitalization in children, for example, is as high as 150 in 100,000 with as many as 125 deaths annually.²⁶

Continue to: 10. Isn't vaccination a personal choice? How does my health/illness impact the community?

Patients may not realize that most viruses are contagious from 1 to 2 days before symptoms appear, which means we can spread an illness before we even know we have it. Protecting oneself also protects those around us.

While the whooping cough that a healthy 35-year-old gets may be a prolonged annoyance or prompt some time off from work, it can kill the baby sitting next to the adult on the plane or bus.

Economic concerns. There’s also the economic impact of these illnesses to consider. This includes the personal cost of being out of school or work for an extended period and the cost of a patient’s care, which can become astronomical if hospitalization is required and which can become the country’s problem if a person lacks sufficient health insurance coverage.

A study looking at the cost of 4 major adult vaccine-preventable illnesses (influenza, pneumococcal disease, shingles, and whooping cough) in the United States in 2013 estimated the annual cost for these illnesses in adults ≥50 years to be $26.5 billion.²⁸ And that doesn’t include the cost of childhood vaccine-preventable diseases.

Countering 3 concerns about childhood vaccinations

1. I can’t afford vaccines for my child.

The Vaccines for Children program is a federally-funded program that covers the cost of all vaccines for children younger than 19 years of age who are Medicaid-eligible, American Indian, Alaskan Native, uninsured, or underinsured.²⁹ Although there may be a small administration fee charged by the provider’s office, the vaccine is free.

2. Don’t all of the vaccines recommended for children overwhelm their immune systems?

Children are exposed to so many more proteins on a daily basis (by crawling around on the floor, putting their hands in their mouths, attending school or day care, etc) than they are ever exposed to in a series of vaccines.³⁰ Exposure to these proteins in their environment and to those in vaccines only serves to boost their immunity and keep them healthier in the long run.

And thanks to advances in vaccine production, the immunologic load in vaccines is far less than it used to be. The 14 vaccines given today contain <200 bacterial and viral proteins or polysaccharides, compared with the >3000 of these immunologic components in the 7 vaccines administered in 1980.³¹

Continue to: Influenza vaccine: Patient-friendly talking points

Continue to: 3. Why don't we adhere to Dr. Sears' vaccine schedule?

There are multiple ways in which Dr. Robert Sears’ book, The Vaccine Book: Making the Right Decision for your Child, published in 2007, misrepresents vaccine science and leads patients astray in making decisions regarding vaccinations.³² Most important to note is that Dr. Sears’ Alternative Vaccine Schedule, which seeks to make it so that children do not receive more than 2 vaccinations per office visit, would require visits to a health care provider at 2, 3, 4, 5, 6, 7, 9, 12, 15, 18, and 21 months, and at 2, 2.5, 3, 3.5, 4, 5, and 6 years of age. This significantly increases the number of office visits and needle sticks, and raises the age at which vaccines are given, increasing the risk of illness outbreaks and decreasing the likelihood that parents would return to the office to complete the full series.

Acceptance of influenza and HPV vaccines remains a challenge

We are significantly less successful at getting parents and patients to agree to influenza and HPV vaccines than to the other vaccines we offer. The influenza vaccine success rate in 2016 was 59% in children and 43.3% in adults.³³ Compared to the Tdap vaccine (88%) and the meningococcal vaccine (82%), which are offered at the same age as the HPV vaccine, success rates for HPV vaccine are significantly lower. In 2016, only 60.4% of boys and girls were current on their first HPV injection and only 43.3% were up to date with the full series.³⁴

Newness of vaccines a factor?

Perhaps it is because the recommendations for these 2 vaccines are relatively new, and people don’t yet grasp the seriousness and scope of the diseases. Until 2010, the flu shot was recommended only for the very young, the elderly, and the medically high risk.

Similarly, the HPV vaccine was originally introduced for girls in 2006 and wasn’t recommended for boys until 2011.

Continue to: Human papillomavirus vaccine: Patient-friendly talking points

Continue to: A sensitive subject

A sensitive subject. Discussion of a vaccine related to a child’s sexual health makes some parents uncomfortable. Studies show that focusing on the cancer prevention aspects of the vaccine, rather than on sexual transmission of HPV, results in greater vaccine acceptance.³⁵

In 2016, only 60.4% of boys and girls were current on their first HPV vaccination and only 43.3% were up to date with the full series.

However, if discussion of sexual transmission is unavoidable, remind parents to consider their own adolescence and whether they chose to share everything with their parents. Point out that there were probably things they did that they later looked back on and thought, “What was I thinking?” Their children, no matter how wonderful and levelheaded they are, will be no different. And, as much as parents don’t want to think about it, some kids will suffer unwanted sexual contact. Shouldn’t parents protect their children as best as they can?

A teen’s right to choose? Some states have passed a Mature Minor Doctrine, which provides for mature, unemancipated teens to make their own medical decisions regarding such issues as sexuality, mental health, and drug and alcohol use without their parents’ consent. In these states, teens may elect to receive the HPV vaccine without parental permission. (Check your state’s laws for specifics, and see the 2 boxes with patient-friendly talking points for influenza vaccine^7,36-39 and human papillomavirus vaccine.^40-47)

CORRESPONDENCE
Gretchen LaSalle, MD, MultiCare Rockwood Clinic, 2214 East 29th Avenue, Spokane, WA 99203; [email protected].

MALMO, SWEDEN – The neonatal intensive care unit often represents a lost opportunity to bring an infant fully up to date for recommended age-appropriate immunizations – but it needn’t be that way, Raymond C. Stetson, MD, declared at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

copyright Metin Kiyak/Thinkstock

[email protected]

SOURCE: Stetson R. E-Poster Discussion Session 04.

MALMO, SWEDEN – The neonatal intensive care unit often represents a lost opportunity to bring an infant fully up to date for recommended age-appropriate immunizations – but it needn’t be that way, Raymond C. Stetson, MD, declared at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

copyright Metin Kiyak/Thinkstock

[email protected]

SOURCE: Stetson R. E-Poster Discussion Session 04.

MALMO, SWEDEN – The neonatal intensive care unit often represents a lost opportunity to bring an infant fully up to date for recommended age-appropriate immunizations – but it needn’t be that way, Raymond C. Stetson, MD, declared at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

copyright Metin Kiyak/Thinkstock

[email protected]

SOURCE: Stetson R. E-Poster Discussion Session 04.

TORONTO – Implementation of a simple screening tool improved the influenza vaccination status of hospitalized children, results from a single-center study showed.

“When we looked at the immunization status of children in New York City, we found that one of the vaccines most commonly missed was influenza vaccine, especially from 2011 through 2014,” one of the study authors, Anmol Goyal, MD, of SUNY Downstate Medical Center, Brooklyn, N.Y., said in an interview at the Pediatric Academic Societies meeting.

Doug Brunk/MDedge News

“Given this year’s epidemic of influenza and the increasing deaths, we decided to look back on interventions we had done in the past to see if any can be reimplemented to help improve the vaccination status for these children,” he said. “The national goal is 80%, but if we look at the recent trend, even though we have been able to improve vaccination status, it is still below the national goal.” For example, he said, according to New York Department of Health data, the 2012-2013 influenza vaccination rates in New York City were 65% among children 6 months to 5 years old, 47% among those 5-8 years old, and 31% among those 9-18 years old, which were well below the national goal.

In an effort to improve influenza vaccine access, lead author Stephan Kohlhoff, MD, a pediatric infectious disease specialist at the medical center, and his associates, implemented a simple vaccine screening tool to use in the inpatient setting as an opportunity to improve vaccination rates among children in New York City. It consisted of nursing staff assessing the patient’s influenza immunization status on admission and conducting source verification using the citywide immunization registry, or with vaccine cards brought by parents or guardians during admission. Influenza vaccine was administered as a standing order before discharge, unless refused by the parents or guardians. The study population comprised 602 patients between the ages of 6 months and 21 years who were admitted to the inpatient unit during 2 months of the influenza season (November and December) from 2011 to 2013.

Dr. Goyal, a second-year pediatric resident at the medical center, reported that the influenza vaccination status on admission was positive in only 31% of children in 2011, 30% in 2012, and 34% in 2013. The vaccine screening tool was implemented in 64% of admitted children in 2012 and 70% in 2013. Following implementation, the researchers observed a 5% increase in immunization rates in 2012 and an 11% increase in 2013, with an overall increase of 8% over 2 years (P less than .001). He was quick to point out that the influenza rate could have been improved by an additional 22% had 77% of patients not refused vaccination.

“Unfortunately, as our primary objective was to assess the utility of our screening tool in improving inpatient immunization status, we had very limited data points toward refusal of vaccine,” Dr. Goyal said. “Some of the reasons for refusal that were gathered during screening included preferred vaccination by their primary care provider after discharge. Or, maybe they don’t want the vaccine because they feel that the vaccine will make their kids sick. We don’t have enough data to point to any particular reason. This study provides information on acceptance rate of inpatient immunization, which may be useful for implementing additional educational initiatives to overcome potential barriers and help us reach our national goal.”

The researchers reported having no financial disclosures.

[email protected]

TORONTO – Implementation of a simple screening tool improved the influenza vaccination status of hospitalized children, results from a single-center study showed.

“When we looked at the immunization status of children in New York City, we found that one of the vaccines most commonly missed was influenza vaccine, especially from 2011 through 2014,” one of the study authors, Anmol Goyal, MD, of SUNY Downstate Medical Center, Brooklyn, N.Y., said in an interview at the Pediatric Academic Societies meeting.

Doug Brunk/MDedge News

“Given this year’s epidemic of influenza and the increasing deaths, we decided to look back on interventions we had done in the past to see if any can be reimplemented to help improve the vaccination status for these children,” he said. “The national goal is 80%, but if we look at the recent trend, even though we have been able to improve vaccination status, it is still below the national goal.” For example, he said, according to New York Department of Health data, the 2012-2013 influenza vaccination rates in New York City were 65% among children 6 months to 5 years old, 47% among those 5-8 years old, and 31% among those 9-18 years old, which were well below the national goal.

In an effort to improve influenza vaccine access, lead author Stephan Kohlhoff, MD, a pediatric infectious disease specialist at the medical center, and his associates, implemented a simple vaccine screening tool to use in the inpatient setting as an opportunity to improve vaccination rates among children in New York City. It consisted of nursing staff assessing the patient’s influenza immunization status on admission and conducting source verification using the citywide immunization registry, or with vaccine cards brought by parents or guardians during admission. Influenza vaccine was administered as a standing order before discharge, unless refused by the parents or guardians. The study population comprised 602 patients between the ages of 6 months and 21 years who were admitted to the inpatient unit during 2 months of the influenza season (November and December) from 2011 to 2013.

Dr. Goyal, a second-year pediatric resident at the medical center, reported that the influenza vaccination status on admission was positive in only 31% of children in 2011, 30% in 2012, and 34% in 2013. The vaccine screening tool was implemented in 64% of admitted children in 2012 and 70% in 2013. Following implementation, the researchers observed a 5% increase in immunization rates in 2012 and an 11% increase in 2013, with an overall increase of 8% over 2 years (P less than .001). He was quick to point out that the influenza rate could have been improved by an additional 22% had 77% of patients not refused vaccination.

“Unfortunately, as our primary objective was to assess the utility of our screening tool in improving inpatient immunization status, we had very limited data points toward refusal of vaccine,” Dr. Goyal said. “Some of the reasons for refusal that were gathered during screening included preferred vaccination by their primary care provider after discharge. Or, maybe they don’t want the vaccine because they feel that the vaccine will make their kids sick. We don’t have enough data to point to any particular reason. This study provides information on acceptance rate of inpatient immunization, which may be useful for implementing additional educational initiatives to overcome potential barriers and help us reach our national goal.”

The researchers reported having no financial disclosures.

[email protected]

TORONTO – Implementation of a simple screening tool improved the influenza vaccination status of hospitalized children, results from a single-center study showed.

“When we looked at the immunization status of children in New York City, we found that one of the vaccines most commonly missed was influenza vaccine, especially from 2011 through 2014,” one of the study authors, Anmol Goyal, MD, of SUNY Downstate Medical Center, Brooklyn, N.Y., said in an interview at the Pediatric Academic Societies meeting.

Doug Brunk/MDedge News

“Given this year’s epidemic of influenza and the increasing deaths, we decided to look back on interventions we had done in the past to see if any can be reimplemented to help improve the vaccination status for these children,” he said. “The national goal is 80%, but if we look at the recent trend, even though we have been able to improve vaccination status, it is still below the national goal.” For example, he said, according to New York Department of Health data, the 2012-2013 influenza vaccination rates in New York City were 65% among children 6 months to 5 years old, 47% among those 5-8 years old, and 31% among those 9-18 years old, which were well below the national goal.

In an effort to improve influenza vaccine access, lead author Stephan Kohlhoff, MD, a pediatric infectious disease specialist at the medical center, and his associates, implemented a simple vaccine screening tool to use in the inpatient setting as an opportunity to improve vaccination rates among children in New York City. It consisted of nursing staff assessing the patient’s influenza immunization status on admission and conducting source verification using the citywide immunization registry, or with vaccine cards brought by parents or guardians during admission. Influenza vaccine was administered as a standing order before discharge, unless refused by the parents or guardians. The study population comprised 602 patients between the ages of 6 months and 21 years who were admitted to the inpatient unit during 2 months of the influenza season (November and December) from 2011 to 2013.

Dr. Goyal, a second-year pediatric resident at the medical center, reported that the influenza vaccination status on admission was positive in only 31% of children in 2011, 30% in 2012, and 34% in 2013. The vaccine screening tool was implemented in 64% of admitted children in 2012 and 70% in 2013. Following implementation, the researchers observed a 5% increase in immunization rates in 2012 and an 11% increase in 2013, with an overall increase of 8% over 2 years (P less than .001). He was quick to point out that the influenza rate could have been improved by an additional 22% had 77% of patients not refused vaccination.

“Unfortunately, as our primary objective was to assess the utility of our screening tool in improving inpatient immunization status, we had very limited data points toward refusal of vaccine,” Dr. Goyal said. “Some of the reasons for refusal that were gathered during screening included preferred vaccination by their primary care provider after discharge. Or, maybe they don’t want the vaccine because they feel that the vaccine will make their kids sick. We don’t have enough data to point to any particular reason. This study provides information on acceptance rate of inpatient immunization, which may be useful for implementing additional educational initiatives to overcome potential barriers and help us reach our national goal.”

The researchers reported having no financial disclosures.

[email protected]

Seasonal flu vaccines mainly target an influenza surface protein called hemagglutinin (HA). But new research from National Institute of Health (NIH) studies suggest that it might be better to target a surface protein called neuraminidase (NA) for broader protection.

Researchers analyzed blood samples from people vaccinated against influenza and people who were diagnosed with the 2009 H1N1 virus or H3N2 viruses. The analyses indicated that influenza vaccines rarely induce NA-reactive antibodies, whereas natural influenza infection induces these types of antibodies at least as often as it induces HA-reactive antibodies, the researchers say.

Additional laboratory experiments showed the NA-reactive antibodies induced during natural flu infection were “broadly reactive,” meaning they could potentially protect against diverse strains. To test that theory, the researchers isolated NA-reactive monoclonal antibodies from the patients  with H3N2 and H1N1, then administered 13 N2-reactive antibodies to mice and infected the mice with a different H3N2 virus strain. Eleven of the N2-reactive antibodies partially or fully protected the mice. In a similar test of N1-reactive antibodies versus H1N1 virus and H5N1-like virus, 4 of 8 antibodies completely protected against both strains.

Seasonal flu vaccines mainly target an influenza surface protein called hemagglutinin (HA). But new research from National Institute of Health (NIH) studies suggest that it might be better to target a surface protein called neuraminidase (NA) for broader protection.

Researchers analyzed blood samples from people vaccinated against influenza and people who were diagnosed with the 2009 H1N1 virus or H3N2 viruses. The analyses indicated that influenza vaccines rarely induce NA-reactive antibodies, whereas natural influenza infection induces these types of antibodies at least as often as it induces HA-reactive antibodies, the researchers say.

Additional laboratory experiments showed the NA-reactive antibodies induced during natural flu infection were “broadly reactive,” meaning they could potentially protect against diverse strains. To test that theory, the researchers isolated NA-reactive monoclonal antibodies from the patients  with H3N2 and H1N1, then administered 13 N2-reactive antibodies to mice and infected the mice with a different H3N2 virus strain. Eleven of the N2-reactive antibodies partially or fully protected the mice. In a similar test of N1-reactive antibodies versus H1N1 virus and H5N1-like virus, 4 of 8 antibodies completely protected against both strains.

Seasonal flu vaccines mainly target an influenza surface protein called hemagglutinin (HA). But new research from National Institute of Health (NIH) studies suggest that it might be better to target a surface protein called neuraminidase (NA) for broader protection.

Researchers analyzed blood samples from people vaccinated against influenza and people who were diagnosed with the 2009 H1N1 virus or H3N2 viruses. The analyses indicated that influenza vaccines rarely induce NA-reactive antibodies, whereas natural influenza infection induces these types of antibodies at least as often as it induces HA-reactive antibodies, the researchers say.

Additional laboratory experiments showed the NA-reactive antibodies induced during natural flu infection were “broadly reactive,” meaning they could potentially protect against diverse strains. To test that theory, the researchers isolated NA-reactive monoclonal antibodies from the patients  with H3N2 and H1N1, then administered 13 N2-reactive antibodies to mice and infected the mice with a different H3N2 virus strain. Eleven of the N2-reactive antibodies partially or fully protected the mice. In a similar test of N1-reactive antibodies versus H1N1 virus and H5N1-like virus, 4 of 8 antibodies completely protected against both strains.

A study of a potential new Ebola treatment has begun at the National Institutes of Health Clinical Center in Bethesda, Md. The small phase 1 clinical trial will examine the safety and tolerability of a single monoclonal antibody (mAb114), which was developed by scientists at the National Institute of Allergy and Infectious Diseases (NIAID) and their collaborators. Investigators plan to enroll between 18 and 30 healthy volunteers aged 18-60. The trial will not expose participants to Ebola virus, according to the NIH announcement.

©CDC/Cynthia Goldsmith

MAb114 is a monoclonal antibody – a protein that binds to a single target on a pathogen — isolated from a human survivor of the 1995 Ebola outbreak in Kikwit, Democratic Republic of the Congo. Nancy Sullivan, PhD, chief of the Biodefense Research Section in NIAID’s Vaccine Research Center, and her team, in collaboration with researchers from the National Institute of Biomedical Research in the Democratic Republic of the Congo and the Institute for Biomedical Research in Switzerland, discovered that the survivor retained antibodies against Ebola 11 years after infection. They isolated and tested the antibodies and selected mAb114 as the most promising.

Although rVSV-ZEBOV, an experimental vaccine, is now available and in use in Africa during the current outbreak, specific treatment modalities are lacking.

More information can be found at www.clinicaltrials.gov, trial # NCT03478891.

A study of a potential new Ebola treatment has begun at the National Institutes of Health Clinical Center in Bethesda, Md. The small phase 1 clinical trial will examine the safety and tolerability of a single monoclonal antibody (mAb114), which was developed by scientists at the National Institute of Allergy and Infectious Diseases (NIAID) and their collaborators. Investigators plan to enroll between 18 and 30 healthy volunteers aged 18-60. The trial will not expose participants to Ebola virus, according to the NIH announcement.

©CDC/Cynthia Goldsmith

MAb114 is a monoclonal antibody – a protein that binds to a single target on a pathogen — isolated from a human survivor of the 1995 Ebola outbreak in Kikwit, Democratic Republic of the Congo. Nancy Sullivan, PhD, chief of the Biodefense Research Section in NIAID’s Vaccine Research Center, and her team, in collaboration with researchers from the National Institute of Biomedical Research in the Democratic Republic of the Congo and the Institute for Biomedical Research in Switzerland, discovered that the survivor retained antibodies against Ebola 11 years after infection. They isolated and tested the antibodies and selected mAb114 as the most promising.

Although rVSV-ZEBOV, an experimental vaccine, is now available and in use in Africa during the current outbreak, specific treatment modalities are lacking.

More information can be found at www.clinicaltrials.gov, trial # NCT03478891.

A study of a potential new Ebola treatment has begun at the National Institutes of Health Clinical Center in Bethesda, Md. The small phase 1 clinical trial will examine the safety and tolerability of a single monoclonal antibody (mAb114), which was developed by scientists at the National Institute of Allergy and Infectious Diseases (NIAID) and their collaborators. Investigators plan to enroll between 18 and 30 healthy volunteers aged 18-60. The trial will not expose participants to Ebola virus, according to the NIH announcement.

©CDC/Cynthia Goldsmith

MAb114 is a monoclonal antibody – a protein that binds to a single target on a pathogen — isolated from a human survivor of the 1995 Ebola outbreak in Kikwit, Democratic Republic of the Congo. Nancy Sullivan, PhD, chief of the Biodefense Research Section in NIAID’s Vaccine Research Center, and her team, in collaboration with researchers from the National Institute of Biomedical Research in the Democratic Republic of the Congo and the Institute for Biomedical Research in Switzerland, discovered that the survivor retained antibodies against Ebola 11 years after infection. They isolated and tested the antibodies and selected mAb114 as the most promising.

Although rVSV-ZEBOV, an experimental vaccine, is now available and in use in Africa during the current outbreak, specific treatment modalities are lacking.

More information can be found at www.clinicaltrials.gov, trial # NCT03478891.

TORONTO – Infants who do not receive the hepatitis B vaccine birth dose are less likely to be up-to-date recipients of recommended vaccines by 19 months, based on results from a retrospective study of more than 9,000 infants.

“As pediatricians, we should be mindful of that when we are meeting families after the birth hospitalization and start a conversation at that point around vaccines,” one of the study authors, Annika M. Hofstetter, MD, PhD, said in an interview at the Pediatric Academic Societies meeting.

Doug Brunk/MDedge News

[email protected]

TORONTO – Infants who do not receive the hepatitis B vaccine birth dose are less likely to be up-to-date recipients of recommended vaccines by 19 months, based on results from a retrospective study of more than 9,000 infants.

“As pediatricians, we should be mindful of that when we are meeting families after the birth hospitalization and start a conversation at that point around vaccines,” one of the study authors, Annika M. Hofstetter, MD, PhD, said in an interview at the Pediatric Academic Societies meeting.

Doug Brunk/MDedge News

[email protected]

TORONTO – Infants who do not receive the hepatitis B vaccine birth dose are less likely to be up-to-date recipients of recommended vaccines by 19 months, based on results from a retrospective study of more than 9,000 infants.

“As pediatricians, we should be mindful of that when we are meeting families after the birth hospitalization and start a conversation at that point around vaccines,” one of the study authors, Annika M. Hofstetter, MD, PhD, said in an interview at the Pediatric Academic Societies meeting.

Doug Brunk/MDedge News

[email protected]

Veterinarians and farmers have known it for decades. If you give a herd or flock antibiotics, its members grow better and have a better survival rate than an equivalent group of unmedicated animals. The economic benefits of administering antibiotics are so great that until very recently the practice has been the norm. However, the “everything organic” movement has begun to turn the tide as more consumers have become aware of the hazards inherent in the agricultural use of antibiotics.

Grigorev_Vladimir/iStock Editorial/Getty Images

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Veterinarians and farmers have known it for decades. If you give a herd or flock antibiotics, its members grow better and have a better survival rate than an equivalent group of unmedicated animals. The economic benefits of administering antibiotics are so great that until very recently the practice has been the norm. However, the “everything organic” movement has begun to turn the tide as more consumers have become aware of the hazards inherent in the agricultural use of antibiotics.

Grigorev_Vladimir/iStock Editorial/Getty Images

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Veterinarians and farmers have known it for decades. If you give a herd or flock antibiotics, its members grow better and have a better survival rate than an equivalent group of unmedicated animals. The economic benefits of administering antibiotics are so great that until very recently the practice has been the norm. However, the “everything organic” movement has begun to turn the tide as more consumers have become aware of the hazards inherent in the agricultural use of antibiotics.

Grigorev_Vladimir/iStock Editorial/Getty Images

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].