It takes a planet: global implications/consequences of local vaccine refusal

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1 It takes a planet: global implications/consequences of local vaccine refusal Meg Fisher, MD Medical Director Disclosures I have no disclosures. I may be mentioning off label uses of vaccines.

2 Objectives/Outcomes Following this presentation, you will be able to: Discuss vaccine safety Discuss the logic behind mandates Explain the impacts of global problems on vaccine preventable diseases Public Concerns Are vaccines safe? The vaccine schedule: are there too many, too soon? Is natural disease better? Why are vaccines mandated in the US?

3 Global issues Vaccine preventable diseases in travelers Pockets of unimmunized patients allow for local transmission What impact will Ebola virus disease have on global immunization efforts Can we eliminate polio forever? Immunization Safety Starts during development Animal studies before human studies Safety and efficacy Investigational New Drug Application Phase 1, 2 and 3 clinical trials

4 Post-licensure Safety Vaccine adverse events reporting system Vaccine Safety datalink Clinical immunization safety assessment Manufacturer University, interested investigators Are Vaccines Safe Yes All medicines have side effects Adverse events following immunization must be reported and are being studied Safety is a priority in public health

5 Vaccine Schedule Why so soon?: Early infection often more dangerous Delaying doesn t decrease adverse events Delaying leaves children unprotected Vaccine Schedule Why so many?: Prevention is better than trying to cure More in this case is better The immune system is designed to handle multiple antigens at once

6 Vaccine Schedule Too many: no, we could use some more Too soon: no, based on optimal protection One size fits all: no, rather it is the best schedule to protect children as soon as possible Is Natural Disease Better? Very risky approach No way! An ounce of prevention makes more sense Not true for many of the diseases Not an approach that protects children

7 Why Mandate Vaccines? Prior to mandates, rates were low and disparities abounded Look at adult rates for influenza and pneumococcal vaccines Why mandate education: children=our future Why immunizations: Ounce of prevention will always be superior to pounds of cure Vaccine Preventable Diseases Hepatitis B, rotavirus, diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, Streptococcus pneumoniae, influenza, measles, mumps, rubella, varicella, hepatitis A, Neisseria meningitidis, human papillomavirus

8 Travelers Vaccine preventable diseases: measles and polio, also hepatitis B, hepatitis A, mumps, rubella, varicella, influenza, diphtheria, pertussis, rotaviruses, pneumococcus, meningcoccus, and human papillomaviruses Can be contagious before symptoms appear Carrier states for some infections Measles Outbreaks US declared measles free in 2000 Imported cases continue to occur Local spread increased when there are unimmunized contacts Measles outbreak in Brooklyn

9 Protecting Travelers Immunizations prior to travel: usual, especially measles and hepatitis A plus select vaccines depending on the travel Measles: all children over 6 months Adoption: hepatitis A and hepatitis B for family members See War Famine Global Threats Government instability Other outbreaks: Ebola virus disease Interfere with immunization efforts and health systems in general

10 Polioviruses Three types: type 2 gone, type 3 almost gone Virus circulates in the spring, summer, fall Spread by fecal oral route; once infected a child sheds the virus for weeks Most have no illness, some fever, less than 1% will become paralyzed

11 Status of Polio Worldwide Polio is still a life-threatening disease Global polio eradication initiative: 1988 Dramatic progress but milestones missed; current hope for elimination by 2018 Polio decreased by 99% From 125 endemic countries to 3 (Nigeria, Pakistan and Afghanistan) Polio Then and Now But polio travels

12 Polio Vaccine for Travelers Single lifetime booster for some travelers: countries with recent polio virus circulation WHO declared public health emergency Proof of vaccine to depart after prolonged stay (> 4 wk): Afghanistan, Cameroon, Guinea, Ethiopia, Iraq, Israel, Nigeria, Pakistan, Somalia, and Syria Endgame: Detect + interrupt all virus transmission 2. Strengthen immunization systems and withdraw oral polio vaccine 3. Contain poliovirus and certify interruption of transmission 4. Plan polio s legacy work

13 Endgame Introduce IPV into routine vaccination in all 145 countries using OPV now Stop using OPV: bivalent, monovalent, none Remove type 2 first since it is gone BUT vaccine derived type 2 strains persist Monitor progress Timeline Stop Last wild polio Outbreak response Routine Strengthen IPV in all; no OPV2 Certify Planning Certification IPV and OPV for all Legacy Develop plan Plan implementation

14 Challenges Introduction of IPV requires funding, education, training, waste disposal Vaccine safety rumors Violence to immunization workers Difficult to reach areas Difficult to reach children Imagine a World Without Polio

15 Ebola, AKA Ebola virus disease Ebola hemorrhagic fever Filoviridae, genus Ebolavirus 5 subspecies: Zaire, Sudan, Tai Forest, Bundibugyo, Reston Humans, primates, bats Discovered 1976, Ebola river, DRC Ebola Epidemiology

16 2014 Ebola West Africa: Guinea, Liberia, Sierra Leone, Nigeria and Senegal now free of disease 10/20/14 11/5/14 10/25/14 Ebola Epidemiology Sporadic outbreaks in Africa Spread by direct contact with blood or body fluids of symptomatic person In Africa, contact with bushmeat, bats 11/5/14: West Africa 13,268 cases, 8168 confirmed, 4,960 deaths 11/5/14: US 4 cases, 1 death

17 Ebola Clinical illness Incubation 8-10 days (range 2-21) All ages Asymptomatic to rapidly fatal Fever, headache, myalgia, weakness, diarrhea, vomiting, abdominal pain Tissue necrosis, bleeding, organ failure, death in 50 to 80% Ebola Diagnosis No evidence of virus outside of Africa Consider in returning traveler, especially health care volunteer, with fever and flulike illness Notify health department Studies: virus isolation, PCR, serology

18 Ebola Treatment Supportive care No antiviral yet ZMapp: mixture of monoclonal antibodies - experimental Isolation and infection control Ebola Prevention For travelers and people in Africa, avoid contact with bats, sick animals, and the meat of wild animals Avoid contact with the blood and body fluids of Ebola patients Avoid funeral practices which allow contact with blood or body fluids

19 Ebola Vaccines Phase 1 tests began in September Several candidate vaccines have been developed or are being developed No product has been licensed Ebola Virus Disease Cost enormous: lives and morbidity Interrupts all other programs Affected countries Surrounding countries Exported cases Nigeria, Senegal, Mali, Spain, USA

20 References wwwnc.cdc.gov/travel/ Smiling is a contagious condition!

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