A recent MMWR (11/1/13, 62(43);858-61) highlighted global vaccination coverage. While it may seem as though these data are unimportant in the scheme of things, some attention may be warranted. We have all heard and many of us have probably even said, “Continuing to get vaccines is important because vaccine-preventable diseases are only a plane ride away.” Indeed, the data in this report provide evidence for that statement:
Indeed, 83 percent of children having had three doses of diphtheria, tetanus, pertussis-containing vaccine may seem pretty good; however, this means almost 23 million children throughout the world did not receive three doses.
Importantly, the communication discusses the caveats associated with data collection methods and highlights the goals for global vaccination coverage. The report also briefly discusses geographic differences among regions.
Reports such as this may be useful to share with your patients, particularly those who are preparing to travel.
As the country recovers from the recent government shutdown, due in part to Congressional disagreements related to the Affordable Care Act, it seems a good time to discuss the most recently implemented aspect of the system – the requirement for health insurance.
According to the Affordable Care Act, virtually everyone must have health insurance coverage by January 1, 2014. The Kaiser Family Foundation offers an infographic that helps individuals determine their requirements for purchasing insurance. The IRS also has a question and answer page on its website regarding who needs to get coverage. Individuals and their families covered by employer packages are likely to meet the minimum essential requirements of the law. In some cases individuals are exempt from the law, such as undocumented immigrants, members of an Indian tribe, those with religious beliefs opposed to acceptance of benefits from a health insurance policy, individuals or families below the income threshold for filing taxes, and those who would have to pay more than eight percent of their income on health insurance (after contributions by employer or tax credits). People who receive Medicare, Medicaid, CHIP, TRICARE, or veteran’s health programs are considered to have satisfied the requirement with these coverage types. Those who do not have coverage will be fined beginning in 2014.
Despite claims that Americans do not want the Affordable Care Act, the day the insurance exchange opened, so many people visited the website that it was overloaded and slow to respond. For consumers the health exchange will help them through the determination of eligibility and enrollment process, offer customer support to get questions answered, and help with management of both the insurance plans and the finances related to each. Because plans are standardized by levels of co-pays and deductibles, consumers should be able to easily compare pricing and choose coverage appropriate for their needs. Plans with higher co-pays and deductibles will be less expensive, and those with lower co-pays and deductibles will cost more.
The Immunization Partnership is hosting a 90-minute webinar on the Affordable Care Act and immunization on November 7 at 10 a.m. Central time. Expert speakers will discuss major changes to immunization access through healthcare reform and challenges facing states without Medicaid expansion. Resources to help reinforce the preventive role of immunization will also be presented.
Speakers will include Patricia Gray, JD, LLM, Director of Research at the Health Law & Policy Institute, University of Houston Law Center; Litjen (LJ) Tan, MS, PhD, Chief Strategy Officer, Immunization Action Coalition; and Robyn Correll Carlyle, MPH, The Immunization Partnership.
In his regular program, Health Commentary, posted on October 2, 2013, the day after the insurance exchange opened, Mike McGee reviewed the functions of the health exchanges, the new rules for insurers and additional powers of the exchanges.
The Shot of Prevention blog posted an article, The Affordable Care Act and Its Impact on Immunizations, on October 1, 2013. The article not only reviews the aspects of the Act related to immunizations, it also has multiple links to additional information.
If you are interested in further reading on this subject, the following resources are suggested:
Dorit Rubenstein Reiss recently published a paper in the Cornell Journal of Law and Public Policy (Vol. 23, No. 3, 2014; UC Hastings Research Paper No. 61) titled, “Compensating the victims of failure to vaccinate: What are the options?” The central premise of this piece is that parents who choose not to vaccinate may be liable through a tort system when their choice compromises the health of others in the community.
Likening the dangers of infectious diseases to drunken driving and unshoveled sidewalks, Reiss suggests that families should similarly be compensated for the costs incurred from an illness transmitted by someone who was not vaccinated. With that backdrop, the reader is provided with background information highlighting the known risks of infectious diseases and the proven success and safety of vaccines.
The essence of the article is contained in the second section, which outlines the requirements needed to win a case of negligence, such as duty to act, lack of action, proof of harm and probable link between the inaction and the harm, and concludes with a discussion of the potential for compensation.
Two additional sections of the article offer a proposal for the text of such a law and additional concerns that might arise, such as religious beliefs and situations that might be used to argue against this approach.
Editor’s Note: We’d love to hear your thoughts on this concept. Do you agree or disagree with the approach? Do you think it would strengthen or weaken the vaccine program? Do you think it would make your job of giving vaccines easier or more difficult?
Please email us at email@example.com after you’ve considered the approach suggested by the author. Feedback may be shared with the author, but identifying information will be removed unless otherwise indicated by the author of the email.
Recent issues of MMWR reported vaccination coverage rates for children entering kindergarten and adolescent girls receiving HPV vaccine:
The August 2, 2013 MMWR (Volume 62, Number 30, pages 607-12) reported both vaccine coverage and exemption rates for children entering kindergarten during the 2012-13 school year.
Key findings or considerations included:
Editorial note: Parents should be educated according to the recommended immunization schedule. Explanations regarding the difference between recommendations and requirements are important, so that parents realize protecting their children may mean getting more vaccines than the school requires. The VEC offers a brief explanation of these differences on its Parents PACK website.
Editorial note: The VEC offers a description of the types of exemptions and what the choice not to get a vaccine means in terms of taking a different risk as well as putting others in the community at risk in the “Schools and Vaccines” article on its Parents PACK website.
In summary, given the above-mentioned variables, the most helpful way to interpret these data is on a local level. Understanding the communities in which you practice will afford the best information about the work that needs to be done and the likelihood of an outbreak.
Note: Some respondents have posted local data online; links to these data are footnoted in the article (page 610).
The July 26, 2013 MMWR (Volume 62, Number 29, pages 591-5) reported HPV vaccine coverage among adolescents between 2007 and 2012 as well as results of post-licensure safety monitoring between 2006 and 2013. Key findings or considerations included:
Merck recently recalled a single lot of the Recombivax HB® hepatitis B vaccine; this version is the adult formulation in a 10 microgram per milliliter concentration. Here’s what you should know:
For additional information, consult the related Medscape article.
The Middle East Respiratory Syndrome Coronavirus (MERS-CoV), previously known as novel coronavirus, continues to infect people in and around the Arabian Peninsula. In addition, cases further removed from this geographic locale suggest transmission is occurring via travel. Nosocomial outbreaks, particularly with infection of healthcare personnel, have also been identified. A recent MMWR update (June 14, 2013) indicated that no cases have been reported in the U.S. and no travel restrictions have been announced at this point.
To review cases and locations and see the current CDC guidance, read the June 14, 2013 MMWR article.
The influenza story is always a bit confusing, but the current outbreaks of H3N2v in the U.S. and H7N9 in Asia make things even more difficult. Here’s what you should know:
The Centers for Disease Control and Prevention (CDC) recently released guidance related to current vaccine shortages. Here’s what you should know:
Expected length of shortage: through summer, 2013
Possible scheduling scenarios and additional information can be found on the CDC’s “Current Vaccine Shortages and Delays” Web page.
If you have watched the news lately, you have probably heard about disease outbreaks in other parts of the world. The United Kingdom (UK) continues to grapple with measles outbreaks and the latest strain of influenza, H7N9, sickening people in China continues to worry public health officials. These examples are making international headlines; however, the Centers for Disease Control and Prevention (CDC) has recently updated other travel notices as well. Here’s what you should know:
The UK continues efforts to reach the large number of unvaccinated adolescents and teens in an effort to protect them and curb the current spread of measles in that country. While immunization rates in younger children are at sufficient levels, gaps in the immunization coverage of adolescents and young teens, resulting from unfounded concerns about the safety of the MMR vaccine in the late 1990s and early 2000s, have fueled the spread of measles. While the CDC has not posted any travel updates related to this outbreak, several news outlets have carried stories, particularly as that country publicly debates whether mandates should be employed.
Even as this outbreak continues, the Measles & Rubella Initiative Annual Report was released and cited progress in the strategic priorities related to the global efforts to immunize every child against measles and rubella. Containing photos by Sophie Blackwell, the report highlights successes and outlines necessary efforts that must continue, pointing out that approximately 430 deaths occur each day as a result of measles infections and more than 100,000 children are still born each year affected by congenital rubella syndrome. Read more about the Measles and Rubella Initiative»
Public health officials continue to monitor the cases of influenza caused by H7N9 in China. To date, travel restrictions have not been made; however, travelers are recommended to practice good hand hygiene and food safety practices as well as avoid contact with animals.
The Vaccine Education Center has posted information on the Vaccine-related news section of its website.
Cholera – Updates regarding cholera outbreaks in Haiti and the Dominican Republic were posted in mid-April. In addition to information about how travelers can protect themselves, the Haiti notice also includes information for healthcare providers regarding travelers arriving to this country from Haiti.
Malaria – Information for travelers to Greece has been updated due to the emergence of malaria in areas not previously reporting cases. Information about decreasing risk for travelers and clinician information for suspected infections is provided in the update.
Novel coronavirus - A novel strain of coronavirus has been identified as the cause of respiratory illness in Saudi Arabia, Qatar, Jordan and the UK. As of May, 27 people were infected, 16 of whom subsequently died. Limited evidence of person-to-person transmission has been suggested by a cluster of cases in a family in the UK. Travelers are recommended to practice precautions such as frequent hand washing, avoiding touching eyes, nose and mouth, covering coughs and sneezes and avoiding close contact with people who are ill. Guidance for healthcare providers is also included in the travel notice.
Polio – Travelers to several countries are recommended to be up to date on the polio vaccine. The list includes common travel destinations such as India, China and several African nations.
The March 29, 2013 issue of Morbidity and Mortality Weekly Report (MMWR) contained articles related to cases of vaccine-preventable diseases in the United States:
Despite the fact that many vaccine-preventable diseases (VPD) are no longer common in the U.S., considering the possibility that a patient with symptoms suggestive of a VPD may be infected is of the utmost importance. In addition, because many of these diseases can easily spread in communities, handling of suspected cases should include conversations with local public health officials.
The looming deadline for the sequestration has come and gone and it may seem as though not much has changed. In fact, in the short term, it is likely that not much will change, but without any congressional votes to undo the required budget cuts, change will come. The sequestration means that almost all federally funded agencies and programs will need to implement spending cuts to the tune of 5.3 to 7.9 percent. While some programs are shielded from these cuts, most are not. Agencies such as the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) will be required to adhere to these measures. Because the cuts are discretionary within programs, we cannot know for sure what each agency will decide to cut in order to meet the requirements. However, we have gotten a chance to see what they could mean with the White House’s state-by-state analysis.
Public health stands to take a severe hit with these cuts because for the most part, public health agencies are already operating on tight budgets. While health departments operate at the state level, most of them receive a significant amount of federal funding. For example federal funds from the 317 program often help provide immunizations and program support in areas that Vaccines for Children (VFC) programs do not cover; both programs are expected to endure cuts. Other areas such as disease surveillance, emergency preparedness and food safety are also supported by federal funds, so while cuts hopefully will not end these programs, they may alter the number of staff who can attend to them. In terms of community health, these types of cuts — lower vaccine coverage, less surveillance and decreased emergency preparedness — could set the stage for disease outbreaks and widespread transmission. For healthcare providers, it means less of a safety net in the community and a need for greater vigilance when it comes to diagnosis and treatment of infectious diseases.
To review areas of public health expected to be affected, see the FY2014 Programmatic Funding Priorities document prepared by the National Association of County & City Health Officials (NACCHO).
Additional information can be found on the website of the Association of State and Territorial Health Officials (ASTHO).
Read Shot of Prevention’s blog “Sequestration and its impact on public health.”
Families that rely on programs such as Head Start, military tuition assistance, nutrition assistance, and unemployment benefits may lose access to these and other programs. Jobs are expected to be lost in areas such as the military, education and law enforcement. In some cases, these losses will make already fragile living situations virtually unmanageable. A logical assumption is that these developments are likely to lead to stress-induced illnesses and mental health-related conditions in a setting in which support programs are less available.
Read more about projected cuts related to the following:
Federally funded agencies including the NIH, National Science Foundation (NSF), National Aeronautics and Space Administration (NASA), National Oceanic and Atmospheric Agency (NOAA), Environmental Protection Agency (EPA) and U.S. Geological Survey will all experience cuts. These agencies will be forced to trim in areas of grants, programs, staff and facilities. Unfortunately, the effects are not likely to be seen before the damage to scientific progress is irreversible. Grants often fund research at institutions such as universities, hospitals and other research centers, so ripple effects are expected.
To hear more about the expected effects on the sciences, listen to Science Friday on NPR, aired on March 1, 2013.
To stay abreast of budget developments related to the sciences, visit the American Academy for the Advancement of Science (AAAS) budget page.
Historically, the Institute of Medicine (IOM) has convened groups to review a variety of vaccine-related issues, including vaccine safety concerns. In each case a committee of experts was charged with offering “independent, objective, evidence-based advice” meant to inform the direction of policy and provide a viewpoint based on the compendium of existing information for the public and private sectors. Most recently, the IOM turned its attention to concerns about the safety of the childhood immunization schedule. The resulting report, “The Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies,” was released on January 16, 2013.
The 14-member committee was charged with:
To compile the report, committee members participated in three information-gathering sessions and five committee meetings, completed an extensive literature review, commissioned a paper about study designs, and reviewed approximately 900 public comments.
The resulting approximately 200-page report provides background information about both the study and the immunization schedule (chapters 1 and 2), reviews existing systems for data collection and existing literature (chapters 3 and 5), discusses stakeholder concerns (chapter 4), and reviews methodological approach options as well as feasibility, ethical issues, and priorities as they relate to questions about the current schedule (chapter 6). The final chapter (chapter 7), a report summary and an abstract outline the conclusions of the committee.
Conclusions were based on three primary sources of information including the current scientific literature, online comments and public testimony. A subset of parents was found to be the stakeholder group with the most concerns about the safety of the immunization schedule. Their concerns focused on overloading the child’s immune system, lack of data in the literature, specifically regarding individual susceptibilities that may make a child more likely to experience negative outcomes, and communication of existing data in response to these fears. Outside influences were also identified, particularly in the online comments and the public testimony, suggesting that parental decisions are also affected by skepticism relating to the quality of research and untoward influence by pharmaceutical companies and governmental groups that oversee research.
Concerns related to effectively communicating vaccine safety among stakeholders were indicated by a larger subgroup that included not only parents, but also providers and public health officials. In addition, while the latter groups did not indicate concerns about the safety of the immunization schedule, providers did indicate a need for more information related to vaccine delivery and communication surrounding the schedule.
The committee determined the scientific literature to be lacking in three areas:
The committee felt that standardizing definitions related to these areas would improve the quality of future studies.
Four broad research questions relating to concerns about the safety of the immunization schedule were defined:
A variety of methodological approaches were reviewed for the appropriateness of answering these questions including randomized controlled trials, observational studies, secondary analysis of existing databases, and animal models. While randomized controlled trials were considered the gold standard, the report discussed reasons they were not an appropriate approach for the aforementioned questions. The Vaccine Safety Datalink (VSD) was described as one of the current best systems for gathering information via a secondary analysis, and enhancements were suggested to make this a more robust option.
After review of presentations, sources of data, the commissioned report and the literature, the committee suggested an approach in which concerns of stakeholders are identified and decisions to begin studies are then based upon the following:
The committee also commented on the oft-suggested “vaccinated versus unvaccinated” study recommending against such a study based on factors that included:
The conclusions of the report described a lack of evidence to support the safety concerns purported by stakeholders, but a realization that perceptions must also be addressed. In this light, the committee called for future studies to address the full scope of the schedule as well as the commencement of studies to better understand perceptions and how they are formed. Further, while concerns of stakeholders should be acknowledged and serve as a potential source for scientific questions, existing evidence and biological plausibility should inform the decision to begin scientific studies. The committee further concluded that evidence does not suggest that the current immunization schedule is unsafe.
The IOM report can serve as evidence that parents’ concerns related to the immunization schedule are being addressed, and that when an extensive review was completed, the conclusion was that the current schedule is safe. Further, while the committee pointed to the fact that evidence looking at the elements of the schedule is not as plentiful as we may wish, the reality is that this indicates even less knowledge about the effects of altering the schedule.
The framework suggested by the committee can also provide a basis for discussions about how the scientific community addresses parental concerns about vaccine safety. That is to say, if a concern is brought about, the existing evidence and biological plausibility should be assessed and if appropriate, sound scientific studies should follow.
Finally, the discussion of the “vaccinated versus unvaccinated” study provided in this report should provide support when discussing this notion with parents who deem such a study plausible.
If you’ve heard renewed interest related to thimerosal in vaccines, it is likely because of the United Nations Environment Program’s (UNEP) recent investigation of exposure to mercury. Much human exposure is through the consumption of the more harmful form of mercury, known as methylmercury, commonly found in fish and other marine organisms. Despite vocal activists who believe that thimerosal, the more efficiently degraded ethylmercury found in some vaccines, is harmful the UNEP ruled that the mercury in vaccines was exempt from the proposed ban on mercury.
Although thimerosal at preservative levels is not contained in childhood vaccines used in the United States, with the exception of multi-dose vials of some influenza vaccines, many other countries continue to use vaccines that contain thimerosal and a ban would have been detrimental to the immunization programs and the children they aim to protect. The important points include:
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