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LEARNING FROM THE PAST: VACCINE CHALLENGES

Catherine Lux, DNP, RN, CPNP-PC

DISCLOSURES:Nothing to disclose

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OBJECTIVES:

• Discuss the history of modern vaccine development, focusing on the social and physiologic details related to vaccine triumphs and tragedies, and subsequent public response.

• Trace the concurrent development of the anti-vaccine movement, and the theoretical underpinnings of anti-vaccine sentiment.

• Examine culturally sensitive ways to address vaccine resistance in practice.

• Explain the rationale for the AAP Refusal to Vaccinate policy and family statement, and how it can be applied in pediatric practice. “The greatest obstacle to knowledge is not ignorance--it is the illusion

of knowledge.” Daniel Boorstin

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ORIGINS-VARIOLATION

• Smallpox “inoculation”• Matter from infected sore put into a cut• From “in oculus”—to graft a bud• India and China from 10th century• Practiced in Ottoman Empire• Lady Mary Montague-wife of British

Ambassador—brought back to Britain• Smallpox epidemic 1721• Written up in British Royal Society

• https://upload.wikimedia.org/wikipedia/commons/5/5b/%D8%B1%D9%88%D8%AD_%DA%A9%DB%8C%D9%88%DA%91%D8%A7.jpg

AMERICAN BEGINNINGS

• Cotton Mather-Boston minister

• Learned of practice from Libyan slave Onesimus

• Read about it in Royal Society

• Began in 1721 during outbreak

• Opposition from doctors

• Opposition from city council

• Risks of variolation-3% died

• Variable acceptance in colonies

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JENNER AND VACCINIA

• first documented vaccination: Benjamin Jesty in 1774

• Jenner variolation at 8-traumatic

• First observed that variolation would not produce infection after cowpox.

• James Phipps-1796 vaccinated, then tested with smallpox

• vaca=cow

• Smallpox declared eradicated 1980https://commons.wikimedia.org/wiki/File:A_comparison_between_smallpox_and_cowpox_pustules_on_the_14t_Wellcome_V0016675.jpg

PROBLEMS WITH EARLY VACCINATION

• Medical• 3% fatality vs 30%

• efficacy

• Contamination-syphilis, sepsis, tetanus

• Social• Poorly enforced quarantine

• Quacks and medical “regimens”

• Forced vaccinations

• Animal cruelty issueshttps://upload.wikimedia.org/wikipedia/commons/d/d6/The_cow_pock.jpg

LOUIS PASTEUR

• Provided scientific explanation for vaccines

• Chicken cholera—discovered attenuation

• Rabies

• Anthraxhttps://fineartamerica.com/featured/10-louis-pasteur-1822-1895-granger.html

DIPTHERIA

• Loeffler-1884-guinea pigs

• Roux-1894-antiserum

• Horse antitoxin factories

• Allergies/anaphylaxis

• Theobald Smith 1908-toxin-antitoxin miz

• Origin of Iditarod 1925-Togo and Balto

• Lead to marketing of many useless “bacterins” and serum treatments

https://www.flickr.com/photos/perpetualplum/3796073312

EARLY 20TH CENTURY

• Public faith in science and technology

• World wars—techno-industrial complex and social authority

• Elevation of status of medical profession

• Increased life expectancy

• Heroism of pioneers/martyrs

• Socio-cultural appropriation of health care

• Flexner standardizing medical education

POLIO

• Public fear

• Frankiln D Roosevelt

• March of Dimes

• Sabin & Salk competition

• Cutter incident

https://www.texasobserver.org/lessons-unlearned/

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MMR AND HILLEMAN

• 1954-Enders isolates virus• 1958 first vaccine-side effects

• 1963-added gamma globulin• Hilleman-1968

• Merck

• Chicken embryos to attenuate

• “Moraten” strain

• Rubella 1969

• Mumps 1967

• 1971 MMR https://www.nytimes.com/2013/05/07/health/maurice-hilleman-mmr-vaccines-forgotten-hero.html

LATE 20TH CENTURY: RAPID EXPANSION

• Chickenpox 1995

• Hib 1985

• Hep B 1986

• Meningococcus 2005

• Rotvirus 2006

• HPV 2006

• Pneumococcus

• Prevnar P7 2007

• PCV 13-2010

https://vaxopedia.files.wordpress.com/2017/04/0-18yrs-child-combined-schedule.jpg?w=1108

VACCINE SAFETY CONCERNS

• Ralph Nader 1972-NIH whistleblowers forced switch to FDA

• ineffective flu vaccines

• licensing of 75 other ineffective products

• SV-40

• CDC-1978-”Monitoring System for Adverse Events Following Immunizations”

• Swine Flu fiasco 1976—Ford appropriations bill

• over 4000 claims, total over $1 million

• Guillain Barre cases probably from allergic reactions

• Late1970’s-Carter pushed universal vaccination

DTP CONTROVERSY

• DPT: Vaccine Roulette

• April 19, 1982, NBC

• Pertussis component-whole cell

• Convulsions, brain damage

• Pediatrics 1948 article-encephalitis

• “Dissatisfied Parents Together”

• Barbara Loe Fischer A Shot in the Dark

• National Childhood Vaccine Injury Act1986

• Vaccine Adverse Event Reporting System (VAERS)-FDA and CDC

dpt-roulette. Image credit Lea Thompson, WRC-TV, Washington D.C. 1982

AUTISM AND MMR

• Andrew Wakefield

• Lancet article1998

• Lionk between MMR and autism

• 2004 independent regulator found “fatal conflict of interest”

• Wakefield paid by litigators for parents suing vaccine manufacturer

• 2010 Lancet formally retracted article

• Wakefield’s medical licence revoked in Britain

• 2011—moves to Austin

THE ANTI-VAX MOVEMENT

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SAFETY CONCERNS

• Autism• Thimerosal-preservative

• Immunologic adjuvants

• Aluminum

• Squalene

• Local and systemic injury (SIRVA, serum sickness)

• Live vaccine causing infection (Cutter, Smallpox)

“IMMUNE SYSTEM OVERLOAD”

• Antigenic burden

• “Slow vax” vs “no vax”

RELIGIOUS OBJECTION

• Disease is “God’s will”

• Interfering with nature

• Only 3 states do not provide exemptions-• Mississippi,

• W. Virginia,

• California

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ALTERNATE MEDICAL THEORIES AND SOCIAL CONCERNS

• Chiropractic

• Homeopathy

• Suspicion over financial motivation

• Far Right and Far Left

• Patient and experimental subject rights

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PARENTAL RIGHTS

• Herd immunity

• Societal burden

• Political action

• Facebook activity

• “Mad moms in Minivans”

• Trolls and Malware link

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FEDERAL ANTI-VACCINE EFFORTS

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TEXAS ANTI-VACCINE POLITICS EFFECT IN U.S.

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EFFECT IN TEXAS

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AAP VACCINE REFUSAL STATEMENT

• “I have had the opportunity to discuss the recommendation and my refusal with my child’s doctor or nurse”

• “I understand the following:• The purpose of and the need for the recommended vaccine(s).

• The risks and benefits of the recommended vaccine(s).

• That some vaccine-preventable diseases are common in other countries and that my unvaccinated child could easily get one of these diseases while traveling or from a traveler.”

AAP VACCINE REFUSAL STATEMENT(CONT’D)

“If my child does not receive the vaccine(s) according to the medically accepted schedule, the consequences may include–Contracting the illness the vaccine is designed to prevent (the outcomes of these illnesses may include one or more of the following: certain types of cancer, pneumonia, illness requiring hospitalization, death, brain damage, paralysis, meningitis, seizures, and deafness; other severe and permanent effects from these vaccine-preventable diseases are possible as well).”

AAP VACCINE REFUSAL STATEMENT (CONT’D)

• “…Transmitting the disease to others (including those too young to be vaccinated or those with immune problems), possibly requiring my child to stay out of child care or school and requiring someone to miss work to stay home with my child during disease outbreaks.”

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AAP VACCINE REFUSAL STATEMENT(CONT’D)

• “I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others with whom my child might come into contact.”

• “I therefore agree to tell all health care professionals in all settings what vaccines my child has not received because he or she may need to be isolated or may require immediate medical evaluation and tests that might not be necessary if my child had been vaccinated.”

AAP VACCINE REFUSAL STATEMENT(CONT’D)

“I know that I may readdress this issue with my child’s doctor or nurse at any time and that I may change my mind and accept vaccination for my child any time in

the future.”

QUESTIONS?

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