Safety of vaccines used for routine immunization of U.S. children: a systematic review

Rubella Virus Infection, the Congenital Rubella Syndrome, and the Link to Autism

Rubella is a systemic virus infection that is usually mild. It can, however, cause severe birth defects known as the congenital rubella syndrome (CRS) when infection occurs early in pregnancy. As many as 8%-13% of children with CRS developed autism during the rubella epidemic of the 1960s compared to the background rate of about 1 new case per 5000 children. Rubella infection and CRS are now rare in the U.S. and in Europe due to widespread vaccination. However, autism rates have risen dramatically in recent decades to about 3% of children today, with many cases appearing after a period of normal development ('regressive autism'). Evidence is reviewed here suggesting that the signs and symptoms of rubella may be due to alterations in the hepatic metabolism of vitamin A (retinoids), precipitated by the acute phase of the infection. The infection causes mild liver dysfunction and the spillage of stored vitamin A compounds into the circulation, resulting in an endogenous form of hypervitaminosis A. Given that vitamin A is a known teratogen, it is suggested that rubella infection occurring in the early weeks of pregnancy causes CRS through maternal liver dysfunction and exposure of the developing fetus to excessive vitamin A. On this view, the multiple manifestations of CRS and associated autism represent endogenous forms of hypervitaminosis A. It is further proposed that regressive autism results primarily from post-natal influences of a liver-damaging nature and exposure to excess vitamin A, inducing CRS-like features as a function of vitamin A toxicity, but without the associated dysmorphogenesis. A number of environmental factors are discussed that may plausibly be candidates for this role, and suggestions are offered for testing the model. The model also suggests a number of measures that may be effective both in reducing the risk of fetal CRS in women who acquire rubella in their first trimester and in reversing or minimizing regressive autism among children in whom the diagnosis is suspected or confirmed.

[Distrust of vaccination: Why?]

Vaccines have saved millions of lives and reduced the severity of many infections. A reduction in vaccination coverage is now reflected in the re-emergence of epidemics of mumps, pertussis, measles and chickenpox. Many people do not recognize the effectiveness of vaccination and fear the side effects. The main concern is the safety of vaccines. Lack of information weighs less than lack of trust in health authorities. The greater responsibility of the individual and the respect for his free will, may lead the authorities to a less vigourous promotion of the "vaccination duty" which is also a social duty. The attitude of individuals is guided by their health beliefs which are often supported by an erroneous perception of risk. In addition, insidious anti-vaccine lobbying plays on fears and uses biased reasoning that the media help to amplify. Thus the analysis of the brakes to vaccination both in the general population and among health professionals, the dismantling of the arguments developed by the anti-vaccine leagues and vigilance with regard to "fake news" should allow a concerted communication, transparent, clear and effective, in order to limit the occurrence of preventable deaths.

Characteristics of stakeholder involvement in systematic and rapid reviews: a methodological review in the area of health services research

OBJECTIVE

Engaging stakeholders in reviews is considered to generate more relevant evidence and to facilitate dissemination and use. As little is known about stakeholder involvement, we assessed the characteristics of their engagement in systematic and rapid reviews and the methodological quality of included studies. Stakeholders were people with a particular interest in the research topic.

DESIGN

Methodological review.

SEARCH STRATEGY

Four databases (Medline, Embase, Cochrane database of systematic reviews, databases of the University of York, Center for Reviews and Dissemination (CRD)) were searched based on an a priori protocol. Four types of reviews (Cochrane and non-Cochrane systematic reviews, rapid and CRD rapid reviews) were retrieved between January 2011 and October 2015, pooled by potential review type and duplicates excluded. Articles were randomly ordered and screened for inclusion and exclusion criteria until 30 reviews per group were reached. Their methodological quality was assessed using AMSTAR and stakeholder characteristics were collected.

RESULTS

In total, 57 822 deduplicated citations were detected with potential non-Cochrane systematic reviews being the biggest group (56 986 records). We found stakeholder involvement in 13% (4/30) of Cochrane, 20% (6/30) of non-Cochrane, 43% (13/30) of rapid and 93% (28/30) of CRD reviews. Overall, 33% (17/51) of the responding contact authors mentioned positive effects of stakeholder involvement. A conflict of interest statement remained unmentioned in 40% (12/30) of non-Cochrane and in 27% (8/30) of rapid reviews, but not in Cochrane or CRD reviews. At most, half of non-Cochrane and rapid reviews mentioned an a priori study protocol in contrast to all Cochrane reviews.

CONCLUSION

Stakeholder engagement was not general practice, except for CRD reviews, although it was more common in rapid reviews. Reporting factors, such as including an a priori study protocol and a conflict of interest statement should be considered in conjunction with involving stakeholders.

Measles Status-Barriers to Vaccination and Strategies for Overcoming Them

BACKGROUND

The World Health Organization (WHO) set the year 2020 as a target date for the eradication of measles in Europe, yet Germany is still far away from this goal. In this article, we provide an overview of current vaccination gaps and barriers to vaccination among children and adults in Germany, as well as potential strategies for overcoming them.

METHODS

This review is based on pertinent publications identified by a selective literature search in PubMed (Medline).

RESULTS

Measles vaccinations are not carried out in the appropriate timely fashion in Germany. Moreover, current vaccination rates among both children and adults are too low to achieve the goal of measles eradication. For example, among children born in 2014, the recommended vaccination rate of more than 95% was only reached when these children were 24 months old. Primary care physicians bear the responsibility for this situation, as they have the greatest influence on the decision to vaccinate. The main causes of vaccination gaps are safety worries and complacen- cy on the patients' part, and partial skepticism regarding vaccination on the part of the caregivers. We identified promising strategies for overcoming these problems: an instructive talk to provide evidence-based information to patients in an atmos- phere of mutual trust, reminder systems, multifactorial interventions, and facilitated access to vaccination, or, as a last resort, the reintroduction of compulsory vacci- nation.

CONCLUSION

Primary care physicians play a key role in vaccination. The focus of further strategies should lie above all in improved patient education and in targeted reminders for patients who neglect to vaccinate themselves and/or their children.

Measles outbreaks in Italy: A paradigm of the re-emergence of vaccine-preventable diseases in developed countries

Over the last decade, outbreaks of vaccine-preventable diseases have been reported in developed countries around the world. In particular, measles outbreaks have been ongoing in the European Union since 2017, with the majority of cases concentrated in Romania and Italy. Measles has been identified as a powerful indicator of the status of vaccination programs in a region, as outbreaks have been reported to quickly emerge as a result of underlying problems in the immunisation routine. This paper aims to report and critically comment on the factors underpinning the recent measles outbreaks in Italy, considering the psychological, cultural, social and political causes of vaccine hesitancy and refusal amongst the population. Data from government agencies including the Italian National Institute of Statistics (ISTAT) and the Italian National Institute of Health (ISS) are analysed to describe incidence and mortality trends from 1887 to the present day, including regional variations and the impact of measles vaccination coverage. The topic of compulsory vaccination is currently the object of heated debate in the Italian social and political panorama; this paper discusses the current state of the vaccination controversy in the Italian political discourse and its potential impact on immunisation policies and measles vaccine coverage amongst the population. A burgeoning body of evidence indicates that every effort should be made to bolster the existing legislation on mandatory vaccination through widespread health education campaigns aimed at improving scientific literacy amongst the Italian population with regards to the topic of immunisation.

Vaccine Hesitancy, History, and Human Nature: The 2018 Stanley A. Plotkin Lecture

Navigating the waters of vaccine hesitancy requires a view towards history and a deep understanding of how humans think. Getting children vaccinated is as much, or more, about connecting with people as it is about communicating scientific information.

Vaccination Status of Children With Epilepsy or Cerebral Palsy in Hunan Rural Area and a Relative KAP Survey of Vaccinators

Background: In China, the vaccination of children with epilepsy (EP) and cerebral palsy (CP) has no specific protocol. Parents are often concerned that vaccination of their children may cause complications due to negative recommendations from vaccinators, resulting in a decline in vaccination. It is therefore is essential to investigate the vaccination status of these specific populations, and the knowledge, attitudes, and practices (KAP) of vaccinators. Methods: This study contains two parts. For the vaccination status survey, residency- and age-matched children whose medical expenditure were covered by the New Rural Cooperative Medical System in Hunan Province were enrolled. Children who were diagnosed with EP or CP were included as the case group, while children without any chronic disease were enrolled as the control group. The vaccination rates of the two groups were compared. For the KAP survey, vaccinators who registered in Hunan CDC were recruited as respondents, and questions were asked related to their experience and attitudes toward vaccinating children with EP or CP. Results: The vaccination rates of the case group were significantly lower than the control group (P < 0.001), with the exception of BCG and Hep B1. Nine measles and two mumps cases were diagnosed in the case group, while there were no Vaccine Preventable Disease (VPD) cases in the control group. The vaccinators' knowledge of the issues related to the vaccination of children with EP or CP was weaker than their knowledge of general vaccination issues. Furthermore, when making a vaccination decision, seizure-free periods and EEG status were their main concerns. Conclusion: The vaccination status of rural children with EP and CP is in jeopardy in Hunan, China, and there are several misunderstandings regarding the contraindications of vaccines among vaccinators. We suggest that measures are taken to improve this situation.

Current landscape of nonmedical vaccination exemptions in the United States: impact of policy changes

INTRODUCTION

In the United States, high childhood vaccination coverage has reduced the morbidity and mortality due to vaccine-preventable diseases. The success of vaccination programs in achieving this high coverage is due, in part, to vaccination mandates for school entry. All states have such mandates, but there is heterogeneity across the states in the allowance of non-medical exemptions (e.g. religious or personal belief exemptions) to these mandates.

AREAS COVERED

We examine historical trends in non-medical exemption prevalence in the US, discuss recent state-level policy changes that may impact non-medical exemption prevalence, and review recent studies on the association between non-medical exemptions and infectious disease outbreaks.

EXPERT COMMENTARY

State-level implementation of mandates, and related allowances for medical and non-medical exemptions, varies greatly across the United States. Non-medical exemption rates have increased over the last two decades, with an increased risk of disease outbreaks in clusters of children with non-medical exemptions due to differences in state laws. Recent efforts to address non-medical exemption rates range from incorporating additional administrative requirements for exemptions and disallowance of any non-medical exemptions. Continued monitoring is needed to evaluate the impact of these changes on exemption rates, to develop optimal childhood vaccination policy across the United States.

Immunization and Vaccination

Vaccines have been recognized as one of the most successful public health measures. In this chapter, we provide a historical overview of immunization measures and discuss the basics of immunization and vaccination in the context of a pandemic outbreak. We will also discuss vaccine hesitancy, the factors that lead to vaccine acceptance and refusal, the determinants of individual decision-making about vaccination, and strategies of how to approach it on an individual, community, and global level.

Vaccination policy in Italy: An update

The effective control of vaccine-preventable diseases generally requires indefinite maintenance of extremely high rates of timely vaccination. Therefore, vaccine hesitancy is of paramount importance and needs to be addressed. In Italy, regulations about vaccinations are controversial and, to some extent, inconsistent. Even though the childhood vaccinations are mandatory by law (Italian Law n. 891/1939, n. 292/1963, n.51/1966 and n. 165/1991), the limited deterrent effectiveness of the sanctioning system, and the changes introduced by the Italian Constitutional Law n. 3/2001 (devolution of almost all the competences and responsibilities in health matters to the Regions and the Autonomous Provinces), were the fertile ground in which new vaccine policies were generated and developed, radically different from the existing ones: many Regions, based on what was decided in 2005 - on an experimental basis - by the State-Regions Conference, decided to abolish the vaccination obligation and/or to stop the imposition of administrative sanctions on non-compliant parents. In addition, since then, there is a worrying tendency to decline vaccinations due to the parents’ mistrust in pharmaceutical companies and health policies. Therefore, recently, the Italian government decided to deploy an emergency ordinance (Italian Decree Law n. 73/2017). In this article, the authors are going to illustrate the current situation in Italy concerning vaccination policy, from a legislative and social point of view.

Perspectives on the Measles, Mumps and Rubella Vaccination among Somali Mothers in Stockholm

Background: Vaccination hesitancy and skepticism among parents hinders progress in achieving full vaccination coverage. Swedish measles, mumps and rubella (MMR) vaccine coverage is high however some areas with low vaccination coverage risk outbreaks. This study aimed to explore factors influencing the decision of Somali parents living in the Rinkeby and Tensta districts of Stockholm, Sweden, on whether or not to vaccinate their children with the measles, mumps and rubella (MMR) vaccine. Method: Participants were 13 mothers of at least one child aged 18 months to 5 years, who were recruited using snowball sampling. In-depth interviews were conducted in Somali and Swedish languages and the data generated was analysed using qualitative content analysis. Both written and verbal informed consent were obtained from participants. Results: Seven of the mothers had not vaccinated their youngest child at the time of the study and decided to postpone the vaccination until their child became older (delayers). The other six mothers had vaccinated their child for MMR at the appointed time (timely vaccinators). The analysis of the data revealed two main themes: (1) barriers to vaccinate on time, included issues surrounding fear of the child not speaking and unpleasant encounters with nurses and (2) facilitating factors to vaccinate on time, included heeding vaccinating parents’ advice, trust in nurses and trust in God. The mothers who had vaccinated their children had a positive impact in influencing other mothers to also vaccinate. Conclusions: Fear, based on the perceived risk that vaccination will lead to autism, among Somali mothers in Tensta and Rinkeby is evident and influenced by the opinions of friends and relatives. Child Healthcare Center nurses are important in the decision-making process regarding acceptance of MMR vaccination. There is a need to address mothers’ concerns regarding vaccine safety while improving the approach of nurses as they address these concerns.

Vaccinating donors for hematopoietic cell transplantation: A systematic review and future perspectives

Allogeneic hematopoietic cell transplantation (Allo-HCT) recipients are at an increased risk of infectious complications, which is a major cause of morbidity and mortality post-transplant. Vaccination of donors is one of the strategies that has been studied to improve immune reconstitution post-transplant, however the efficacy and safety of this strategy is not well reviewed in the literature. In this systematic review we sought to evaluate the current strategies of donor vaccination along with their immunogenicity, effectiveness and safety. Utilizing strict selection criteria with defined MeSH terminology, an electronic search was conducted from the following databases: Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Scopus. Abstracts of various professional society meetings were also screened and hand searching of various reviews and guideline articles was carried out. The full text of 52 articles were reviewed, from which 5 articles satisfied the inclusion/exclusion criteria for effectiveness and immunogenicity trials and 1 article was included for safety data. Jadad score was used to assess the quality of included studies. The results of the included studies were inconsistent, and the studies were generally of suboptimal methodological quality. Most of the included studies (n = 3) investigated the use of more than one vaccine, however not all commonly used vaccines in HCT were investigated. None of the studies reported any long-term benefits for HCT recipients of vaccinated donors. Only one study reported safety data of using vaccination in donors. Given the suboptimal quality of the studies, and questionable effectiveness, donor vaccination cannot be recommended for all. Prospective high-quality vaccine trials in HCT donors are needed.

Vaccination as a cause of autism-myths and controversies

Despite significant progress in the study of the epidemiology and genetics of autism, the etiology and patho-physiology of this condition is far from being elucidated and no curative treatment currently exists. Although solid scientific research continues, in an attempt to find explanations and solutions, a number of nonscientific and pure myths about autism have emerged. Myths that vaccines or mercury are associated with autism have been amplified by misguided scientists; frustrated, but effective parent groups; and politicians. Preventing the protection provided by vaccination or administration of mercury-chelating agents may cause real damage to autistic individuals and to innocent bystanders who as a result may be exposed to resurgent diseases that had already been “extinguished. ” That such myths flourish is a consequence of the authority of scientific evidence obtained by scientific methodology losing ground to alternative truths and alternative science. This article presents a narrative of the origin of the myths around autism.

Measles in Children

Measles, which until recently had been a rare disease in the United States, is re-emerging in our communities due to a combination of increased global mobility and decreased vaccinations across the country. As providers, we need to reacquaint ourselves with this disease so that we may diagnose it as well as educate our patients on how to prevent it. With public resistance to vaccinations on the rise, it is also important to be prepared to answer questions about the measles vaccine, its efficacy, and its side effects. By being educated ourselves, we will be able to educate our communities and help keep illnesses like measles at bay. [Pediatr Ann. 2018;47(9):e340-e344.].

Addressing Vaccine Hesitancy in Clinical Practice

Vaccines have had a profound impact on public health; however, parents are increasingly refusing or delaying vaccines for their children. Population-based studies have demonstrated the safety and efficacy of vaccines. Pediatricians should be well informed about vaccine development, safety, and efficacy to inspire parental confidence in vaccines. Systemic challenges in discussing and providing immunizations exist. Discussions about immunizations may be lengthy and time spent discussing immunizations is not routinely reimbursed. Adolescents may be inadequately immunized because they do not routinely present for preventive health visits. Routine immunizations should be offered and discussed at sick visits, particularly for adolescents. Improving immunization rates requires a multifaceted approach. [Pediatr Ann. 2018;47(9):e366-e370.].

HPV vaccine and autoimmune diseases: systematic review and meta-analysis of the literature

BACKGROUND

In the literature conflicting opinions are detectable on the onset of adverse events as autoimmune disease post HPV vaccine and often case reports describes the onset of one of these events, but don't emerge a clear relationship and we don't have data to support it.

METHODS

We carried out a systematic review to identify all scientific publications dealing with the correlation between vaccine anti-papillomavirus and new onset of autoimmune diseases. We searched the main scientific databases (PubMed, Sciverse Scopus, Web of knowledge and Cochrane Central Register of Controlled Clinical Trials) for the following search terms: "vaccine"; "anti-papillomavirus"; "autoimmune"; "disease"; "disorder". To evaluate the safety of HPV vaccines, the dichotomous data on the number of subjects experiencing an autoimmune disorder in the study vaccine group and the placebo group were extracted from each study with subsequent determination of the risk ratios and their 95% confidence intervals. We combined data statistically using a random effects model.

RESULTS

We conduct a meta-analysis on six studies on bivalent and quadrivalent HPV vaccine. The total number of subjects included in the meta-analysis comprised 243,289 in the vaccine group and 248,820 in control groups. Four of the six trials had a Jadad score of 3 or 4 indicating an adequate trial quality. The most frequent autoimmune disease observed across the six studies were musculoskeletal,CNS conditions and endocrinological conditions . The results of the meta-analysis demonstrated no correlation between autoimmune disorders and HPV vaccines (pooled OR 1.038, 95% CI 0.689-1.562).

CONCLUSIONS

No correlation was identified for bivalent and quadrivalent HPV vaccines. It's therefore essential to correctly inform the general population in order to try to increase both Italian and international vaccination coverage.

Legal approaches to promoting parental compliance with childhood immunization recommendations

Rates of vaccine-preventable diseases have increased in the United States in recent years, largely due to parental refusals of recommended childhood immunizations. Empirical studies have demonstrated a relationship between nonvaccination rates and permissive state vaccine exemption policies, indicating that legal reforms may promote higher immunization rates. This article reviews relevant data and considers the legal landscape. It analyzes federal and state Constitutional law, concluding that religious and personal belief exemptions to school-entry vaccine mandates are not constitutionally required. It identifies public health, bioethical, and policy considerations relevant to the choice among legal approaches employed by states to promote parental compliance. The article describes a range of legal tools that may help promote parental cooperation with immunization recommendations.

T-cell receptor excision circle levels and safety of paediatric immunization: A population-based self-controlled case series analysis

T-cell receptor excision circle levels are a surrogate marker of T-cell production and immune system function. We sought to determine whether non-pathological levels of infant T-cell receptor excision circles were associated with adverse events following immunization. A self-controlled case series design was applied on a sample of 231,693 children who completed newborn screening for severe combined immunodeficiency in Ontario, Canada between August 2013 and December 2015. Exposures included routinely administered pediatric vaccines up to 15 months of age. Main outcomes were combined health services utilization for recognized adverse events following immunization. 1,406,981 vaccination events were included in the final dataset. 103,007 children received the Pneu-C-13 or Men-C-C vaccine and 97,998 received the MMR vaccine at 12 months of age. 67,725 children received the varicella immunization at 15 months. Our analysis identified no association between newborn T-cell receptor excision circle levels and subsequent health services utilization events following DTa-IPV-Hib, Pneu-C-13, and Men-C-C vaccinations at 2-month (RI 0.94[95%CI 0.87-1.02]), 4-month (RI 0.82[95%CI 0.75-0.9]), 6-month (RI 0.63[95%CI 0.57-0.7]) and 12-month (RI 0.49[95%CI 0.44-0.55]). We also found no trends in health services utilization following MMR (RI 1.43[95%1.34-1.52]) or varicella (RI 1.14[95%CI 1.05-1.23]) vaccination. Our findings provide further support for the safety of pediatric vaccinations.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Varicella Virus Vaccination in the United States

Varicella zoster virus (VZV) is the cause of chickenpox (varicella) and shingles (zoster), and was once responsible for over 4 million infections in the United States annually. The development of a live attenuated VZV vaccine was initially viewed with extreme skepticism. Nonetheless, a VZV vaccine was developed in the 1970s by Takahashi and his colleagues in Japan and was eventually licensed in the US. It is now known to be one of the safest and most effective vaccines available and is administered worldwide. Here are described important factors that contributed to the successful research and licensure of the highly successful VZV vaccine.

Use of electronic immunization registry in the surveillance of adverse events following immunization

OBJECTIVE

To describe adverse events following vaccination (AEFV) of children under two years old and analyze trend of this events from 2000 to 2013, in the city of Araraquara (SP), Brazil.

METHODS

This is a descriptive study conducted with data of the passive surveillance system of AEFV that is available in the electronic immunization registry (EIR) of the computerized medical record of the municipal health service (Juarez System). The study variables were: age, gender, vaccine, dose, clinical manifestations and hospitalization. We estimated rates using AEFV as numerator and administered doses of vaccines as denominator. The surveillance sensitivity was estimated by applying the method proposed by the Centers for Disease Control and Prevention. We used Prais-Winsten regression with a significance level of 5.0%.

RESULTS

The average annual rate of AEFV was 11.3/10,000 administered doses, however without a trend in the study period (p=0.491). Most cases occurred after the first dose (41.7%) and among children under one year of age (72.6%). Vaccines with pertussis component, yellow fever and measles-mumps-rubella were the most reactogenic. We highlighted the rates of hypotonic-hyporesponsive episodes and convulsion that were 4.1/10,000 and 1.5/10,000 doses of vaccines with pertussis component, respectively, most frequently in the first dose; 60,0% of cases presented symptoms in the first 24 hours after vaccination, however, 18.6% showed after 96 hours. The sensitivity of surveillance was 71.9% and 78.9% for hypotonic-hyporesponsive episodes and convulsion, respectively.

CONCLUSIONS

The EIR-based AEFV surveillance system proved to be useful and highly sensitive to describe the safety profile of vaccines in a medium-sized city. It was also shown that the significant increase of the vaccines included in the basic vaccination schedule in childhood in the last decade did not alter the high safety standard of the National Immunization Program.

The effect of antipyretics on immune response and fever following receipt of inactivated influenza vaccine in young children

BACKGROUND

Antipyretics reduce fever following childhood vaccinations; after inactivated influenza vaccine (IIV) they might ameliorate fever and thereby decrease febrile seizure risk, but also possibly blunt the immune response. We assessed the effect of antipyretics on immune responses and fever following IIV in children ages 6 through 47 months.

METHODS

Over the course of three seasons, one hundred forty-two children, receiving either a single or the first of 2 recommended doses of IIV, were randomized to receive either oral acetaminophen suspension (n = 59) or placebo (n = 59) (double-blinded) or ibuprofen (n = 24) (open-label) immediately following IIV and every 4-8 h thereafter for 24 h. Blood samples were obtained at enrollment and 4 weeks following the last recommended IIV dose. Responses to IIV were assessed by hemagglutination inhibition assay (HAI). Seroprotection was defined as an HAI titer ≥1:40 and seroconversion as a titer ≥1:40 if baseline titer <1:10 or four-fold rise if baseline titer ≥1:10. Participants were monitored for fever and other solicited symptoms on the day of and day following IIV.

RESULTS

Significant differences in seroconversion and post-vaccination seroprotection were not observed between children included in the different antipyretic groups and the placebo group for the vaccine antigens included in IIV over the course of the studies. Frequencies of solicited symptoms, including fever, were similar between treatment groups and the placebo group.

CONCLUSIONS

Significant blunting of the immune response was not observed when antipyretics were administered to young children receiving IIV. Studies with larger sample sizes are needed to definitively establish the effect of antipyretics on IIV immunogenicity.

Illness Representations of Pertussis and Predictors of Child Vaccination Among Mothers in a Strict Vaccination Exemption State

Background Vaccine preventable diseases are making a comeback in the US. However, research is lacking on illness representations of vaccine preventable diseases and their application in improving childhood immunization. Objective We utilized the common sense model of self-regulation to examine illness representations of pertussis and their associations with child's receipt of any vaccine, up-to-date vaccination status, and mothers' intentions to follow the recommended vaccination schedule in the future. Methods We developed vaccine worry and vaccine hassles scales to assess mothers' worries and hassles for child vaccination, and used an open ended question to assess mother's illness representations of pertussis. We surveyed mothers with children <3 years old (N = 160) in the Appalachian state of West Virginia, which only allows medical vaccine exemptions. Results Some children (5.0%) had received no vaccination, 15.0% were not up-to-date with the recommended vaccination schedule, and 13.8% mothers reported no intention to follow the recommended schedule in future (future intention). Illness representations included identity (17.8%), timeline (61.8%), consequences (58.6%), cause (35.0%), and cure/control (56.7%). Higher vaccine worry was associated with child receiving no vaccine. Not using daycare, higher vaccine worry, and difficulty breathing (identity) were associated with child not being up-to-date. Higher vaccine worry, cough (identity), and belief that vaccines are ineffective (cure/control) were associated with no future intention. Conclusions Vaccination interventions need to address mothers' worry regarding vaccine safety. 'Common Sense' beliefs regarding vaccines need to be reconciled with scientific data about vaccine safety and effectiveness, even among those with high socio-economic status in a strict vaccination state.

The importance of immunization in cancer prevention, treatment, and survivorship

Answer questions and earn CME/CNE A measles outbreak originating in California during 2014 and 2015 called attention to the potential for infectious disease outbreaks related to underimmunized populations in the United States and the potential risk to pediatric patients with cancer attending school when such outbreaks occur. Compliance with vaccine recommendations is important for the prevention of hepatitis B-related and human papillomavirus-related cancers and for protecting immunocompromised patients with cancer, and these points are often overlooked, resulting in the continued occurrence of vaccine-preventable neoplastic and infectious diseases and complications. This article provides an overview of the importance of vaccines in the context of cancer and encourages clinician, health system, and public policy efforts to promote adherence to immunization recommendations in the United States. CA Cancer J Clin 2017;67:398-410. © 2017 American Cancer Society.

A self-affirmation exercise does not improve intentions to vaccinate among parents with negative vaccine attitudes (and may decrease intentions to vaccinate)

Two studies investigated the effectiveness of a self-affirmation exercise on vaccine safety beliefs and intent to vaccinate future children. In Study 1, a sample of 585 parents with at least one child under the age of 18 in the home participated through Amazon’s MTurk. Participants were randomly assigned to one of four conditions in a 2 x 2 design. Participants read either correcting information refuting a link between the measles, mumps, and rubella (MMR) vaccine and autism or a control passage about bird feeding. Additionally, participants either completed a self-affirmation exercise where they reflected on their personal values or in a control condition in which they reflected on least-personally-important values that might be important to others. Participants exposed to the correcting information were less likely to believe that vaccines cause serious side effects, but no less likely to believe that the MMR vaccine causes autism. For parents with initially positive vaccine attitudes, there was no effect of condition on intent to vaccinate a future child. For parents with initially negative vaccine attitudes, self-affirmation was ineffective in the presence of correcting information and resulted in less intention to vaccinate in the absence of correcting information. This effect was partially replicated in Study 2 (N = 576), which provided no correcting information but otherwise followed the same procedure as Study 1.

Parents' concerns about vaccine scheduling in Shanghai, China

BACKGROUND

Several new vaccines have been introduced into China in recent years, but some parents in China have shown concerns about the scheduling of vaccinations for young infants. This study explores caregiver concerns about children receiving multiple vaccines during a single visit and about vaccine administration in infants <6months, and assesses the degree to which these concerns are associated with ratings of the importance of different sources of vaccine information in Shanghai.

METHODS

Caregivers of children 8months to 7years presenting at immunization clinics in Shanghai completed a survey about vaccine co-administration and vaccine administration <6months of age. Respondents provided ratings of information from different sources (Internet, family/friends, other parents) and trust in doctors. We analyzed vaccine concerns using linear regression analyses that included these information sources after adjusting for socioeconomic variables.

RESULTS

Among 618 caregivers, 64% were concerned about vaccine co-administration and 31% were concerned about vaccine administration to infants <6months of age. Higher ratings of Internet as an important source of information were associated with greater concern about co-administration (β=0.11, 95% CI: 0.00, 0.22) and concern about administration at <6months of age (β=0.17, 95% CI: 0.05, 0.28). Higher ratings given to information from other parents corresponded to 0.24 points greater concern about vaccine co-administration (95% CI: 0.04, 0.44). More trust in doctors and ratings of information from friends and family were not associated with vaccine concerns.

CONCLUSIONS

Caregiver concerns about vaccine scheduling may limit China's flexibility to add vaccines to its official immunization schedule. Reporting information about vaccine safety on the Internet and bringing groups of parents together to discuss vaccines might help to ameliorate concerns about vaccine scheduling.

Immunological considerations regarding parental concerns on pediatric immunizations

Despite the fundamental role of vaccines in the decline of infant mortality, parents may decide to decline vaccination for their own children. Many factors may influence this decision, such as the belief that the infant immune system is weakened by vaccines, and concerns have been raised about the number of vaccines and the early age at which they are administered. Studies focused on the infant immune system and its reaction to immunizations, summarized in this review, show that vaccines can overcome those suboptimal features of infant immune system that render them more at risk of infections and of their severe manifestations. In addition, many vaccines have been shown to improve heterologous innate and adaptive immunity resulting in lower mortality rates for fully vaccinated children. Thus, multiple vaccinations are necessary and not dangerous, as infants can respond to several antigens as well as when responding to single stimuli. Current immunization schedules have been developed and tested to avoid vaccine interference, improve benefits and reduce side effects compared to single administrations. The infant immune system is therefore capable, early after birth, of managing several antigenic challenges and exploits them to prompt its development.

On religious and secular exemptions: A case study of childhood vaccination waivers

This paper analyses exemptions to general law through the prism of vaccine waivers in the United States. All US states legally require the vaccination of children prior to school or daycare entry; however, this obligation is accompanied with a system of medical, religious, and/or philosophical exemptions. Nonmedical exemptions became subject of discussion after the 2015 Disneyland measles outbreak in California, which unequivocally brought to light what had been brewing below the surface for a while: a slow but steady decline in vaccination rates in Western societies, resulting in the reoccurrence of measles outbreaks. This can be traced back to an increasing public questioning of vaccines by a growing anti-vaccination movement. In reaction to the outbreak and the public outrage it generated, several states proposed-and some already passed-bills to eliminate nonmedical exemptions. I analyze two questions. First, can legal exemptions from mandatory childhood vaccination schemes for parents who are opposed to vaccination (still) be justified? Second, should legal exemptions be limited to religious objections to vaccination, or should they also be granted to secular objections? Although the argument in the paper starts from the example of the US, it seeks to provide a more general philosophical reflection on the question of exemptions from mandatory childhood vaccination.

The Changing Epidemiology of Autism Spectrum Disorders

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition with lifelong impacts. Genetic and environmental factors contribute to ASD etiology, which remains incompletely understood. Research on ASD epidemiology has made significant advances in the past decade. Current prevalence is estimated to be at least 1.5% in developed countries, with recent increases primarily among those without comorbid intellectual disability. Genetic studies have identified a number of rare de novo mutations and gained footing in the areas of polygenic risk, epigenetics, and gene-by-environment interaction. Epidemiologic investigations focused on nongenetic factors have established advanced parental age and preterm birth as ASD risk factors, indicated that prenatal exposure to air pollution and short interpregnancy interval are potential risk factors, and suggested the need for further exploration of certain prenatal nutrients, metabolic conditions, and exposure to endocrine-disrupting chemicals. We discuss future challenges and goals for ASD epidemiology as well as public health implications.

Rectal Bleeding and Abdominal Pain Following Vaccination in a 4-Month-Old Infant

Intussusception is one of the most frequent causes of intestinal obstruction in infants. Rotavirus vaccination has been associated with intussusception in the medical literature. We report a case of a 4-month-old female with intussusception requiring hemicolectomy one week following rotavirus vaccination. We review the pathophysiology, presentation, and management of intussusception with a distinct focus on the history of rotavirus vaccination and risks of intussusception associated with timing of rotavirus vaccine administration. The discussion makes a strong case for rotavirus vaccine counseling regarding signs of intestinal obstruction and the importance of early recognition.

Active surveillance study of adverse events following immunisation of children in the Czech Republic

Background

Despite the undisputed public health benefits of routine vaccination, adverse events following immunisation (AEFI) remain a concern. As most adverse events are mild, they may be under-reported; this may underlie the wide range of AEFI rates reported in the literature. We investigated the rates of AEFI related to routine vaccination of children 0–10 years old in the Czech Republic.

Methods

The study reviewed patients’ records in a sample of 49 paediatric GP practices covering all 12 administrative regions of the Czech Republic between 2011 and 2013. Adverse events following routine immunisation of children aged 0–10 years were identified and recorded.

Results

The overall rate of AEFI was 209/100,000 doses; this was 6 times higher than the rate reported to the Czech State Institute for Drug Control (34/100,000 doses). Over two fifths (44%) of all AEFI occurred after the booster dose of the combined diphteria, tetanus and pertussis vaccine in 5-year old children. The vast majority of AEFI were non-serious local events (e.g. redness) and fever. Most AEFI occurred the second day after the immunisation, lasted 4 days on average, and were treated by cold therapy, antipyretics and analgesics.

Conclusions

The rate of AEFI identified in this study was considerably higher than the officially reported rate. Although the vast majority of AEFI were non-serious, health care providers and the public should be educated and encouraged to report AEFI to address the issue of underreporting, to increase the safety profile of vaccines, and to improve public confidence in immunisation programmes.

The impact of a vaccine scare on parental views, trust and information needs: a qualitative study in Sydney, Australia

BACKGROUND

Vaccine safety scares can undermine public confidence in vaccines and decrease immunisation rates. Understanding and addressing parental concerns arising during such scares can assist in lessening their impact. In Australia in April 2010 there was a temporary suspension of influenza vaccine for children under 5 years of age after reports of an increase in the rate of adverse events following vaccination. This qualitative study aimed to explore the impact of the vaccine suspension on parental knowledge, attitudes, trust, information needs, and intent related to influenza vaccination and broader immunisation programs.

METHODS

Semi-structured interviews were conducted with 25 parents of children attending childcare centres in Sydney, Australia, between June 2010 and May 2011. Centres were selected to include parents from a range of socioeconomic backgrounds. Interview transcripts were coded and analysed using an approach informed by grounded theory.

RESULTS

Findings indicated that, for those who recalled the vaccine suspension, there was a lasting sense of uncertainty and confusion and a perceived lack of information. Parents had distinct information needs following the vaccine suspension, especially in regards to vaccine safety, testing and recommendations. For many, influenza vaccination intent was conditional on receipt of information from a trusted, authoritative source allaying safety concerns. Importantly, the impact of the scare was contained to influenza vaccines only, and not other vaccine programs.

CONCLUSIONS

Parental concerns and information gaps following a vaccine safety scare need to be actively addressed. We provide policy and practice suggestions for proactively managing such incidents, particularly in relation to communication of timely, targeted information to parents and immunisation providers.

Is It Time for Vaccination to "Go Viral"?

To promote and sustain excellent vaccination coverage, while preserving the key core values of ethics, truth, transparency and trust, the vaccine community should adopt modern digital communication strategies. This article summarizes our views-as experts in multidisciplinary field of vaccinology (consisting of an anthropologist, a public health policy advisor, a vaccine industry expert, a health care journalist and a practicing physician)-which were presented at a satellite symposium held at the 33rd European Society of Paediatric Infectious Disease conference in Leipzig, Germany, in May 2015. This article aims to suggest and recommend strategies to promote vaccination awareness, and highlight proactive measures for building, maintaining and enhancing trust in vaccination through innovative communication and evidence-based interaction with the end user. We believe that converting the results of vaccine research into a successful vaccination program, and replacing misinformation with evidence-based communication, will require a multidisciplinary approach that embraces modern digital and tailored applications to reach out to all populations.

International Consensus (ICON): allergic reactions to vaccines

BACKGROUND

Routine immunization, one of the most effective public health interventions, has effectively reduced death and morbidity due to a variety of infectious diseases. However, allergic reactions to vaccines occur very rarely and can be life threatening. Given the large numbers of vaccines administered worldwide, there is a need for an international consensus regarding the evaluation and management of allergic reactions to vaccines.

METHODS

Following a review of the literature, and with the active participation of representatives from the World Allergy Organization (WAO), the European Academy of Allergy and Clinical Immunology (EAACI), the American Academy of Allergy, Asthma, and Immunology (AAAAI), and the American College of Allergy, Asthma, and Immunology (ACAAI), the final committee was formed with the purpose of having members who represented a wide-range of countries, had previously worked on vaccine safety, and included both allergist/immunologists as well as vaccinologists.

RESULTS

Consensus was reached on a variety of topics, including: definition of immediate allergic reactions, including anaphylaxis, approaches to distinguish association from causality, approaches to patients with a history of an allergic reaction to a previous vaccine, and approaches to patients with a history of an allergic reaction to components of vaccines.

CONCLUSIONS

This document provides comprehensive and internationally accepted guidelines and access to on-line documents to help practitioners around the world identify allergic reactions following immunization. It also provides a framework for the evaluation and further management of patients who present either following an allergic reaction to a vaccine or with a history of allergy to a component of vaccines.

Vaccine hesitancy: More than a movement

Vaccines are some of if not the most successful public health endeavors ever put into practice. Countless lives have been saved and the occurrences of vaccine preventable diseases are at a fraction of the rate experienced before vaccines. Vaccines and the realization of their compulsory scheduling are highly studied, safe, and purposeful. Despite these realities, there are an alarming number of parents who do not permit the vaccination of their children as scheduled. This is known in the health community as vaccine hesitancy and commonly portrayed in popular media as anti-vaccination sediment. This analysis opens with the topic as it was addressed during a September 2015 debate for the Republic Party's 2016 presidential nomination. Some key historical aspects of vaccine hesitancy are presented. This history leads to a description of the 2014-2015 measles outbreak in California. The factors that aide in the recruitment of under vaccination are then explored. Finally, select strategies to control, combat, and potentially attenuate vaccine hesitancy are presented.

Countering Vaccine Hesitancy

Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.

Immune status of representative infectious diseases among Japanese female university students

OBJECTIVE

To elucidate the immune status of representative infectious diseases among Japanese youth, we retrospectively investigated serum antibody levels in university students, partly comparing these to immunization records and infectious disease histories confirmed by the maternal and child health (MCH) handbooks.

MATERIALS AND METHODS

In total, 168 Japanese female university students, aged 20-21 years, were included. Data were collected from examinations of antibody titers against measles, rubella, varicella-zoster (VZ), mumps, and hepatitis B (HB) and C (HC) viruses, and from QuantiFERON®-TB Gold tests, between 2011 and 2015. Records of immunization and infectious disease histories were available from MCH handbooks for students who agreed with the use of their data for this study (n=23).

RESULTS

All students had positive antibodies, detected by enzyme immunoassay (EIA), against measles, rubella, VZ, and mumps; however, seroprevalences within the range of seroprotective antibody levels were 38.1% (64/168), 67.9% (114/168), 95.9% (141/147), and 89.8% (132/147), respectively. The students had probably not been infected with HB, HC, or tuberculosis at the time of the examinations.

DISCUSSION

The study indicated that a two-dose vaccine for measles and rubella (MR) might not be sufficient to produce antibodies at seroprotective levels. Therefore, we propose that health care workers, including students, should receive an additional MR vaccine, even if they have received two doses of MR vaccine or if they have unknown histories of immunizations or infectious diseases. Further investigations in these areas will be needed.

Mast cell activation disease and the modern epidemic of chronic inflammatory disease

A large and growing portion of the human population, especially in developed countries, suffers 1 or more chronic, often quite burdensome ailments which either are overtly inflammatory in nature or are suspected to be of inflammatory origin, but for which investigations to date have failed to identify specific causes, let alone unifying mechanisms underlying the multiple such ailments that often afflict such patients. Relatively recently described as a non-neoplastic cousin of the rare hematologic disease mastocytosis, mast cell (MC) activation syndrome-suspected to be of greatly heterogeneous, complex acquired clonality in many cases-is a potential underlying/unifying explanation for a diverse assortment of inflammatory ailments. A brief review of MC biology and how aberrant primary MC activation might lead to such a vast range of illness is presented.

Risk is for the rich? Childhood vaccination resistance and a Culture of Health

Childhood vaccination resistance has given rise to outbreaks of diseases, which had been virtually eliminated in the developed world. A parent's decision to forego vaccination for their child is a private choice that can have collective outcomes. This article takes a two-pronged approach to unraveling the puzzle of perceiving vaccines as dangerous in view of evidence that testifies to their effectiveness and relative safety. First, it draws on fifty-seven years of newspaper articles on vaccines to outline the public narratives. Second, it uses school-level data from New York and California to explore how these public narratives shape a geography of vaccination rates. We have two main findings. First, we find that while risk has always been a feature of vaccine narratives, the perception that the risks of vaccines out-weigh the benefits has grown. By the millennium, some began to view medical treatments as sources of risk rather than cure. Second, our geography of childhood vaccination reveals two distinct vaccine worlds. Affluence governs one world. Poverty governs the other. The geographic locales where vaccination rates are low enable us to contrast the difference between imagining risk, the prerogative of the affluent, and being at risk, the fate of the poor. Vaccination resistance speaks directly to a Culture of Health as it poses questions about the collective perception of risk and its relation to social inequality and solidarity.

What do homeopathic doctors think of vaccines? An international online survey

BACKGROUND AND OBJECTIVES

Parental refusal to vaccinate is a cause of serious concern. Use of homeopathy is believed to be a relevant reason for parents to refuse to vaccinate. However, vaccination is one of the main gaps dividing between medically qualified or not homeopathic practitioners. The present study sought to investigate the attitude of homeopathic doctors towards vaccination and associated variables.

METHODS

An international online survey was conducted with homeopathic doctors by means of an anonymous self-reported questionnaire in Portuguese or Spanish. Questions investigated sociodemographic and professional characteristics, overall opinion on vaccination and on some specific vaccines.

RESULTS

A total of 512 responses were obtained, 77.5% of respondents were from Latin American countries, 16.8% from Spain, with small numbers from several other countries. About 75.6% of the respondents considered vaccination safe, effective and necessary, while 12.5% stated they would not recommend vaccination under any circumstance. The variables significantly correlated with positive attitude towards vaccination were: working in the public health system (p=0.04) and homeopathy not the main medical activity (p=0.005). Homeopaths from Brazil, where homeopathy is officially accredited, were more favorable to vaccination compared to respondents from countries where homeopathy has inferior status (p<0.001).

CONCLUSION

The results show that there is no contradiction between homeopathy and primary prevention by means of vaccination.

Vaccine hesitancy: More than a movement

Vaccines are some of if not the most successful public health endeavors ever put into practice. Countless lives have been saved and the occurrences of vaccine preventable diseases are at a fraction of the rate experienced before vaccines. Vaccines and the realization of their compulsory scheduling are highly studied, safe, and purposeful. Despite these realities, there are an alarming number of parents who do not permit the vaccination of their children as scheduled. This is known in the health community as vaccine hesitancy and commonly portrayed in popular media as anti-vaccination sediment. This analysis opens with the topic as it was addressed during a September 2015 debate for the Republic Party's 2016 presidential nomination. Some key historical aspects of vaccine hesitancy are presented. This history leads to a description of the 2014-2015 measles outbreak in California. The factors that aide in the recruitment of under vaccination are then explored. Finally, select strategies to control, combat, and potentially attenuate vaccine hesitancy are presented.

Adverse events following immunization: real causality and myths

INTRODUCTION

To assure the highest safety of immunization programs, detect adverse events following immunization (AEFIs), eliminate concerns, and reduce the risk of low vaccination coverage, authorities in industrialized countries have collected years of reports of suspected AEFIs and have systematically assessed their clinical importance.

AREAS COVERED

In this paper, the methods used to assess vaccine safety and the results obtained by the analysis of reports, studies, and meta-analyses are discussed.

EXPERT OPINION

Severe AEFIs are rare, and all evaluations of safety of vaccines recommended for both children and adults have demonstrated that the advantages of vaccines are always significantly higher than the problems that they cause, and there is no need to modify recommendations. However, the definition of AEFI is dependent on the vaccines themselves, complicating the definition of an AEFI and explaining why doubts and concerns have been raised. Presently, disease epidemiology data collected in healthy people and in subjects with underlying disease, general vaccine coverage, and the vaccination status of subjects with AEFIs are managed by many independent institutions. Only strict co-operation between these institutions will lead to the successful identification of AEFIs and to a reduction of the weight of anti-vaccine arguments.

Autoimmune disease and vaccination: impact on infectious disease prevention and a look at future applications

Vaccines hold promise both for the prevention of infections and as potential immunologic therapy for patients with autoimmune disease (AD). These patients are at high risk for both common and opportunistic infections, but this risk can be significantly reduced and even obviated with the use of recommended available vaccines. Unfortunately, patients with ADs are not routinely offered or provided indicated vaccinations and have higher rates of complications from vaccine-preventable illnesses than patients without ADs. In addition, vaccine therapy is currently under study for the treatment of autoimmune disorders, with early studies demonstrating immunomodulatory effects that may counter undesired immune activation and alleviate disease activity.