2. Talking about Vaccination: Addressing patient & parent concerns Jennifer Hamilton, MD, PhD July 2014

4. Courtesy Medical Journal of Australia We have NEVER seen this…

5. Courtesy Medical Journal of Australia We have NEVER seen this… (smallpox)

6. Images from AAP (left), CDC (right) Has anyone seen this?

7. Images from AAP (left), CDC (right) Has anyone seen this? (diphtheria – the picture above shows the pseudomembrane over the tonsils)

8. Image from CDC We don’t see this everyday…

9. Image from CDC We don’t see this everyday… (pertussis, AKA whooping cough – the sound file is more helpful than the picture)

10. Image from Britannica.com Some of us didn’t have this…

11. Image from Britannica.com Some of us didn’t have this… (varicella, AKA chicken pox)

12. Courtesy of University of Rochester Medical College we’re trying to get rid of this…

13. Courtesy of University of Rochester Medical College we’re trying to get rid of this… (meningococcal disease – this is a post-mortem picture)

14. …and we’re making progress against what killed her.

15. (photograph of Henrietta Lacks. Cells from the cervical cancer that killed her were developed as the HeLa cell line, without consent from her or her survivors.)

16. Why vaccinate?

18. Worries about vaccines “They cause autism.” “They have mercury, which poisons children.” “They don’t work.” “They’re not needed anymore.” “There are too many!” “They encourage bad behavior.” “They hurt.”

19. You’ll hear: “Vaccines cause autism” Claims started with article by Andrew Wakefield published in The Lancet in 1998 Study later discredited: data was fabricated Diagnosis of autism sometimes coincides with vaccinations around age 2-3… but no evidence of cause and effect

20. You’ll hear: “Mercury is a poison” Thimerosal (preservative) metabolized to ethylmercury Methylmercury is a potent toxin

21. Source: http://www.fda.gov/cber/vaccine/thimerosal.htm, July 6 2007 Thimerosal Content of Vaccines No Thimerosal DTap+HepB+IPV (Pediarix) Pneumococcus (Prevnar) IPV Varicella (Varivax) MMR (MMR-II) Influenza nasal (FluMist) Tdap Hep A Hib+HepB (Comvax) Hep B Recombivax Engerix B May Contain Thimerosal DTaP Infanrix – none Daptacel – none Tripedia – yes Influenza injected – depends on size Td – varies with brand Hep A + Hep B (Twinrix) Meningitis Menomune – depends on size Menactra – none

22. You’ll hear: “They don’t work”

23. You’ll hear: “They’re not needed”

26. Pertussis is back… and it’s killing infants.

28. Polio never went away completely – and now it’s spreading

29. You’ll hear: “There are too many!” Too many shots? Can use combination vaccines to limit number of injections Too many different germs? ▫Fewer proteins/epitopes now than in prior schedules (DTP vs. DTaP; smallpox vaccine) ▫Likely fewer germs than first year in day care

30. You’ll hear: “They encourage bad behavior.” (HPV vaccine) Protect now against problems later Will help prevent several forms of cancer

31. You’ll hear: “They hurt.” Yes, they can hurt. Other side effects: risk of fever and febrile seizure Can cuddle/soothe the child immediately afterwards Consider pain relievers like ibuprofen, acetaminophen

32. There have been problems OPV and polio Rotashield & intussusception Smallpox

33. There have been problems OPV and polio Rotashield & intussusception Oral polio vaccine contains weakened virus OPV highly effective OPV can transmit immunity – “contagious vaccine” Relative risks increase as wild polio declines OPV no longer used in US, but is used in endemic areas

34. There have been problems OPV and polio Rotashield & intussusception Rotashield was first rotavirus vaccine approved in US Found to increase risk of intussusception, especially in older infants Newer RotaTeq and Rotarix vaccines intensely studied for this possibility Current vaccines limited to first dose under age 15 weeks

36. To start school in Philadelphia

39. Talking with parents: Tips from the CDC Take time to listen Solicit and welcome questions Keep the conversation going – don’t shut it down early Get a sense of what sort of information the parents are looking for Acknowledge benefits and risks Respect parents’ authority Reduce the stress of shots From http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/talk-infants-bw-office.pdf

40. And if they say “no”? Some offices have parents sign something like an “informed un-consent” form Rarely, some physicians have refused to treat unvaccinated children. This approach is actively discouraged by the CDC.

41. Resources www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/talk-infants-bw-office.pdf Poland, Gregory A., and Robert M. Jacobson. “The Age-Old Struggle against the Antivaccinationists.” New England Journal of Medicine 364, no. 2 (2011): 97–99. doi:10.1056/NEJMp1010594. http://well.blogs.nytimes.com/2014/06/26/putting-us-all-at-risk-for- measles/?_php=true&_type=blogs&emc=eta1&_r=0 (editorial)http://well.blogs.nytimes.com/2014/06/26/putting-us-all-at-risk-for- measles/?_php=true&_type=blogs&emc=eta1&_r=0 Vaccination schedules: ▫http://www.immunizationed.org/ (SHOTS app)http://www.immunizationed.org/ ▫http://www.cdc.gov/vaccines/schedules/hcp/index.html