Safety of vaccinations. Miss America, the media, and public health

Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial

Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.

A comprehensive analysis of Italian web pages mentioning squalene-based influenza vaccine adjuvants reveals a high prevalence of misinformation

Squalene-based adjuvants have been included in influenza vaccines since 1997. Despite several advantages of adjuvanted seasonal and pandemic influenza vaccines, laypeople's perception of such formulations may be hesitant or even negative under certain circumstances. Moreover, in Italian, the term “squalene” has the same root as such common words as “shark” (squalo), “squalid” and “squalidness” that tend to have negative connotations. This study aimed to quantitatively and qualitatively analyze a representative sample of Italian web pages mentioning squalene-based adjuvants used in influenza vaccines. Every effort was made to limit the subjectivity of judgments. Eighty-four unique web pages were assessed. A high prevalence (47.6%) of pages with negative or ambiguous attitudes toward squalene-based adjuvants was established. Compared with web pages reporting balanced information on squalene-based adjuvants, those categorized as negative/ambiguous had significantly lower odds of belonging to a professional institution [adjusted odds ratio (aOR) = 0.12, p = .004], and significantly higher odds of containing pictures (aOR = 1.91, p = .034) and being more readable (aOR = 1.34, p = .006). Some differences in wording between positive/neutral and negative/ambiguous web pages were also observed. The most common scientifically unsound claims concerned safety issues and, in particular, claims linking squalene-based adjuvants to the Gulf War Syndrome and autoimmune disorders. Italian users searching the web for information on vaccine adjuvants have a high likelihood of finding unbalanced and misleading material. Information provided by institutional websites should be not only evidence-based but also carefully targeted towards laypeople. Conversely, authors writing for non-institutional websites should avoid sensationalism and provide their readers with more balanced information.

Safety assessment of adjuvanted vaccines: Methodological considerations

Adjuvants mainly interact with the innate immune response and are used to enhance the quantity and quality of the downstream adaptive immune response to vaccine antigens. Establishing the safety of a new adjuvant-antigen combination is achieved through rigorous evaluation that begins in the laboratory, and that continues throughout the vaccine life-cycle. The strategy for the evaluation of safety pre-licensure is guided by the disease profile, vaccine indication, and target population, and it is also influenced by available regulatory guidelines. In order to allow meaningful interpretation of clinical data, clinical program methodology should be optimized and standardized, making best use of all available data sources. Post-licensure safety activities are directed by field experience accumulated pre- and post-licensure clinical trial data and spontaneous adverse event reports. Continued evolution of safety evaluation processes that keep pace with advances in vaccine technology and updated communication of the benefit-risk profile is necessary to maintain public confidence in vaccines.

Vaccine policy and Arkansas childhood immunization exemptions: a multi-year review

BACKGROUND

An increase in total vaccine exemptions (medical, philosophic, and religious) occurred in Arkansas after a 2003 legislation added a philosophic category and used a new process for vaccine exemptions. By legislative requirement, the Arkansas Department of Health monitored exemptions through the 2009-2010 school year.

PURPOSE

The goal of the study was to determine the prevalence of vaccine exemption in 2003-2010 compared to the number of requests prior to the legislation enacted in 2003.

METHODS

Exemptions were calculated by school-age category using raw numbers of exemptions, total estimates of the population by age level, enrollment numbers for students in public and private schools, and in enrolled college students born after 1957. Exemptions also were analyzed by school district, grade level, type of exemption, and particular vaccine exemption requested.

RESULTS

Overall exemptions continued to rise each year, with an average increase of 23.1% annually. Medical exemptions declined from an average of 21.3% of all exemptions before to an average of 4.8% thereafter. The greatest increase in number of exemptions was observed among college students. The highest total rate of exemptions per precollegiate student population was <1.3%. When exemption requests were categorized, most (79%) were for exemptions from "all vaccines." The most common single exempted vaccine was MMR (measles, mumps, rubella).

CONCLUSIONS

Since philosophic exemptions were codified in 2003 in Arkansas, the number and rate of vaccine exemptions continue to progressively increase. However, vaccine-preventable disease clusters have not yet been linked to or identified in any population with a high rate of vaccine exemptions.

Lessons from across the pond: what the US can learn from European immunization programs

Childhood immunizations are the most effective clinical preventive services ever developed. Western European countries have a variety of governmental and non-governmental agencies involved in the development and operation of their immunization programs. Because of the range of programs in place across the European continent, various components of the US system parallel specific components of a variety of countries. Examining the experiences of other countries which have attempted to address issues now faced by the US can be valuable. However, such examinations are only of value if both the country and the policy itself to be examined are placed within the context of the US health care system and US policy constraints.

An innovative advance to increase the use of the vaccine information statement

Because many physicians do not use the Vaccine Information Statement (VIS), we created a revised statement that would alert the physician to the need to use the VIS. Even though the Centers for Disease Control (CDC) coordinated this evaluation, both the CDC and most of the State Board of Medical Examiners did not support this revision of the VIS. Despite the disinterest of the vast majority of the State Board of Medical Examiners, we would recommend that this updated VIS be implemented immediately to educate our society on the information in the VIS.

Vaccine shortages eliminate possibility for excess capacity in stockpiles

The ability to provide vaccines to the entire population stands as one of the greatest achievements of the past century. Many new antigens have been developed, and now more antigens are offered as part of combination vaccines, reducing the number of injections. Vaccines that are routinely administered protect against 11 common childhood diseases. In addition, through herd immunity, immunization even offers some benefit to those who are not immunized. Providing additional protection has come at some additional cost, however. Immunizing a child with the 20 doses of recommended vaccines increased in price from 200 dollars to 400 dollars, (at the discounted government price) between 1997 and 2001. In spite of this impressive record, vaccines shortages have occurred for eight of the routinely recommended vaccines, and the conjugate pneumococcal vaccine is still in short supply, mandating deferral of doses three and four. These shortages have resulted in some harm to the system. Several temporary changes to recommendations were made, and it is not at all clear to what extent children for whom doses were deferred have been called back. School immunization requirements have been modified in 48% of states. Concern has been raised that we may see a reversal in the trend toward improved vaccine coverage, and the possibility of outbreaks is seen as very real. Some, but not all, of the immediate factors that led to the vaccine shortages of 2 years ago have been resolved. Longstanding factors that contributed to the shortages remain. Undervaluation by society, inadequate communication between involved parties, attrition of manufacturers, and the threat of frivolous litigation have not been addressed and may once again threaten the vaccine supply. Currently, four manufacturers are responsible for almost all of the routinely recommended vaccines used in this country. Five vaccines are produced by a single manufacturer. Only one vaccine, conjugate Haemophilus influenzae type b, is produced by three. It will take between 4 and 5 years to improve vaccine stockpiles to the desired levels. With fewer manufacturers, there is no possibility for "excess" capacity that may provide a cushion to augment stockpiles or address any unanticipated shortfalls in supply. In short, the potential for additional shortages remains substantial, and the ability to respond to shortages may actually have worsened. We must hope the return of widespread shortages or even outbreaks will not be necessary before real solutions are implemented.

Childhood Vaccine Risk/Benefit Communication Among Public Health Clinics: A Time-Motion Study

United States law requires that immunization providers use Centers for Disease Control Vaccine Information Statements (VISs) and inform parents about vaccine risks and benefits prior to every childhood immunization. A recent national survey found that public health clinics (PHCs) reported high compliance with this law. To further investigate these findings, we conducted an immunization time-motion study in two PHCs in Kansas and Louisiana. Research assistants observed a convenience sample of 246 child immunization visits to record distribution of the VISs and content and time of vaccine communication. Thirty percent of parents read below a ninth grade level, 53% had Medicaid insurance, and 56% were Black. VISs were given with every dose of vaccine administered in 89% of visits. Public health nurses (PHNs) frequently discussed potential vaccine side effects (91%), treatment of side effects (91%), and the vaccine schedule (93%). Contraindications were screened in 71% of visits. Benefits were discussed in 48% of visits and severe risks in 29%. The national Vaccine Injury Compensation Program (VICP) was never discussed. The immunization visits lasted for a mean of 20 min. Vaccine communication of side effects, risks, benefits, screening for contraindications, and the next visit lasted for an average of 16 s for all vaccines. PHC compliance with mandated VIS distribution and practical vaccine communication was high. Room for improvement exists in discussion of benefits, serious risks, and the VICP.

Science writers' reactions to a medical "breakthrough" story

In numerous incidences, the news coverage of medical research has incited unjustified optimism or fear. The medical literature provides an archive of the scientific community's condemnation of these misleading reports, but little is known about how they are judged by newsmakers. This study explored science writers' reactions to a controversial New York Times story that inflated the hopes of thousands of cancer patients. More than 60 science writers in the US, Canada, and Great Britain participated in a 12-day email discussion triggered by the Times article. We analyzed 255 of these email postings and coded (1) positive and negative critiques of the Times story, (2) references to the article's repercussions including the creation of false hope, (3) attributions of responsibility for the resulting public misunderstanding, and (4) suggestions to improve the public's comprehension of medical research news. The participating science writers generally responded negatively to the controversial article: 83% of the critiques were unfavorable. In addition, the science writers in the sample were cognizant and concerned about the impact of their work on the public, and accepted the largest share of the responsibility for the false hope created by the news coverage of medical research. Finally, the suggestions offered by respondents to improve the public's understanding of medical research news were similar to those proposed by the scientific community. Thus, some commonality exists between how scientists and science writers believe the news coverage of medical research could be improved.

'The cold hard facts' immunisation and vaccine preventable diseases in Australia's newsprint media 1993-1998

The news media have the potential to influence public perceptions about childhood vaccination. Research has quantified the extent of positive news reportage on immunisation but no studies have explored the rhetorical nature and the core appeals that characterise positive reportage. To complement our previous research on the rhetorical nature of anti-immunisation reportage, this paper reviews positive coverage of immunisation in over four and a half years of Australian newsprint media. Three core topics dominated the reportage; the problem of vaccine preventable diseases and low immunisation rates, notions of who is responsible and the implied solutions. The threat of vaccine preventable diseases was conveyed using panic language, disease personification, quantification rhetoric, stories of personal tragedies and portentous tales from yesteryear. Attribution for low immunisation rates ranged from blaming parents to blaming lack of government coordination. However, most blame framed individuals as responsible. The most popular spokespersons were representatives of professional medical bodies who tended to be cast as voices of authority, castigating the ignorance and apathy of parents. Urging of compulsory vaccination, pleas for parents to immunise their children and the provision of information about vaccine preventable diseases were the most frequently occurring implied solutions. Immunisation was promoted as a modern medical miracle, health professionals were portrayed as soldiers in the fight against killer diseases and urges to immunise were usually conveyed through the use of stern directives. Understanding how immunisation messages are framed in the media and the core values to which those messages appeal highlights opportunities for media advocates to enhance desired messages and reframe those which are considered antipathetic to the goals of public health advocacy.

Philosophic objection to vaccination as a risk for tetanus among children younger than 15 years

OBJECTIVES

Although safe and effective vaccines are available to protect against tetanus in the United States and vaccination rates are high, cases of tetanus among children continue to occur. The objectives of this article are to describe reported cases of tetanus in children in the United States and to identify the reasons for lack of protection against tetanus.

METHODS

We reviewed all cases of tetanus in children <15 years of age that were reported to the National Notifiable Diseases Surveillance System from 1992 through 2000. Cases were defined by physician diagnosis. We verified the information in the case reports with state and local health departments.

RESULTS

From 1992 through 2000, 15 cases of tetanus in children <15 years of age were reported from 11 states. Twelve cases were in boys. Two cases were in neonates <10 days of age; the other 13 cases were in children who ranged in age from 3 to 14 years. The median length of hospitalization was 28 days; 8 children required mechanical ventilation. There were no deaths. Twelve (80%) children were unprotected because of lack of vaccination, including 1 neonate whose mother was not vaccinated. Among all unvaccinated cases, objection to vaccination, either religious or philosophic, was the reported reason for choosing not to vaccinate.

CONCLUSION

The majority of recent cases of tetanus among children in the United States were in unvaccinated children whose parents objected to vaccination. Parents who choose not to vaccinate their children should be advised of the seriousness of the disease and be informed that tetanus is not preventable by means other than vaccination.

Active immunization in the United States: developments over the past decade

The Centers for Disease Control and Prevention has identified immunization as the most important public health advance of the 20th century. The purpose of this article is to review the changes that have taken place in active immunization in the United States over the past decade. Since 1990, new vaccines have become available to prevent five infectious diseases: varicella, rotavirus, hepatitis A, Lyme disease, and Japanese encephalitis virus infection. Improved vaccines have been developed to prevent Haemophilus influenzae type b, pneumococcus, pertussis, rabies, and typhoid infections. Immunization strategies for the prevention of hepatitis B, measles, meningococcal infections, and poliomyelitis have changed as a result of the changing epidemiology of these diseases. Combination vaccines are being developed to facilitate the delivery of multiple antigens, and improved vaccines are under development for cholera, influenza, and meningococcal disease. Major advances in molecular biology have enabled scientists to devise new approaches to the development of vaccines against diseases ranging from respiratory viral to enteric bacterial infections that continue to plague the world's population.

How should physicians and nurses deal with people who do not want immunizations?

People who do not want immunizations represent a small fraction of the total population. However, they may have significant epidemiologic impact. Reasons for lack of support for immunization include ignorance, fear, contraindication, general opposition based on religion or philosophy, or "informed" opposition. The category of "informed" opposition includes those who have decided, based on reliable information, that the risks of immunization outweigh the benefits in their particular case. It also includes "misinformed" opposition arising from acceptance of unproven allegations about vaccine safety or efficacy. These views may be fostered by media accounts of adverse events alleged to be caused by vaccines. Carefully developed and forthright responses to these issues are needed to assure that people make truly informed immunization decisions.

Safety of routine childhood vaccinations. An epidemiological review

Immunisations have been one of the most cost-effective public health interventions in human history. Despite remarkable progress, several challenges face immunisation programs worldwide. Paradoxically, despite vaccines' clear effectiveness in reducing risks of diseases that were previously widely prevalent and caused substantial morbidity and mortality, current vaccination policies have become increasingly controversial due to concerns about vaccine safety. Vaccines, like other pharmaceutical products, are not entirely risk-free. While most known adverse effects are minor and self-limited, some vaccines have been associated with very rare but serious adverse effects. Because such rare effects are often not evident until vaccines come into widespread use, ongoing surveillance programs to monitor vaccine safety are needed. Such monitoring will be essential if the public is to accept the increasing number of new vaccines made possible by biotechnology. The interpretation of data from vaccine safety research is complex and is associated with some uncertainty. Effectively communicating this uncertainty and continuing to improve understanding of rare risks and risk factors are essential for "mature" immunisation programs to maintain public confidence in immunisations.