Dr. Buttery's Public Health BLOG

A wonderful example of how to confuse people. .Food and Drug Administration (FDA) has approved six influenza vaccines intended to target strains that "are likely to cause flu in the United States" during the 2008-09 season. Agency officials explained that every year, the "vaccines are modified to reflect the virus strains most likely to be circulating," and the "closer the match between the circulating strains and the strains in the vaccines, the better the protection." Last year's flu vaccine didn't match two of three main types of flu that sickened people. Still, the "vaccination remains the cornerstone of preventing influenza. Comment: The problem is that the flu virus mutates so rapidly, and dispersion is so simple (with air travel) that it is very difficult to predict what strain will be dominant in the US each fall. It still takes so long to identify and prepare a new targeted vaccine that we will have to wait for improved technology before a real annual match tor currently circulating strains can be developed..

Posted by at 9:39 AM | Permalink | Comments (2)

Vaccinating infants and toddlers is an almost universal practice in the United States. Vaccines to prevent flu are a regular part of medical care for senior citizens and at-risk patients. But, according to a study published in the August 2008 issue of the American Journal of Preventive Medicine, the US healthcare system is not very effective in getting vaccines to the adolescent population. The traditional role of the primary care physician to administer vaccines may not be effective for adolescents, who tend to enter the healthcare system only for acute problems. Additional healthcare settings that can provide additional access include pharmacies, family planning and sexually transmitted infection clinics, obstetrician–gynecologist offices, emergency departments, teen clinics and health departments.

Posted by at 11:06 AM | Permalink | Comments (0)

Since Mumps vaccine was introduced there has been a significant drop in new cases, as seen in this graph.

However in 2006 a resurgence of mumps ocurred in the upper central USA. There was only moderate uptake of a second dose of mumps vaccine putting adolescents and young adults at risk. This shows a similar pattern to the Measles outbreak in South Texas twenty years ago which lead to recommendation of a second dose of vaccine in middle school. The difference was that 98%+ of the Texas students had received their vaccine dose as recommended. This was not the case with the mumps vaccine. Part of the problem is anxiety anong parents about supposed ill effects from vaccines, grossly overestimated but pushed by the media for its value as a scary story. Future studies will help to evaluate the national vaccine policy, including whether the administration of a second dose of MMR vaccine at a later age or the administration of a third dose would provide higher or more durable immunity.
N Engl J Med 2008;358:1580-9.

Posted by at 11:02 AM | Permalink | Comments (0)

With all the concern about autism and John McCain injecting himself into the debate, politics takes another low road. Politicians will do anything to get a few extra votes. The problem occurs when a rare incident is used as representing a common occurrence. Clinical investigation and analysis is a difficult enough task to perform properly. My belief is that less than 10%, probably a lot less, of published articles meet good scientific evidence. If this is the case among careful educated scientists, how on earth can we expect laymen to understand all the ins and outs of such research. Then we have the lawyers and activists who rush in and say "You haven't proved nothing happened". There is no way to prove the absence of an effect, only its presence. Study after study, performed at great effort and with great cost has failed to prove that immunization has any common bad outcomes. When any action is performed millions of times injury may occur concurrently, just by chance. This is not to say that 'A" causes "B", although activists, politicians and lawyers rush to judgement. We should be very concerned that the current belief of many people that no one should be harmed by anything", or that "the individual is more important than the population" may lead us down the road to the point where we can do nothing to prevent a disease in case the preventive intervention might harm one person in one million.

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Endemic cholera, a potentially fatal diarrheal disease found in the world's most impoverished countries, could be effectively controlled by orally vaccinating half of the affected populations once every two years for only pennies per dose, according to new findings by an international team of researchers led by Ira M. Longini Jr., Ph.D., a biostatistician in the Vaccine and Infectious Disease Institute at Fred Hutchinson Cancer Research Center in Seattle.

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From JAMA today: A greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 were shown for diphtheria, mumps, pertussis, and tetanus. Endemic transmission of poliovirus and measles and rubella viruses has been eliminated in the United States; smallpox has been eradicated worldwide. Declines were 80% or greater for cases and deaths of most vaccine-preventable diseases targeted since 1980 including hepatitis A, acute hepatitis B, Hib, and varicella. Declines in cases and deaths of invasive S pneumoniae were 34% and 25%, respectively.
[Sandra W. Roush, MT, MPH; Trudy V. Murphy, MD; and the Vaccine-Preventable Disease Table Working Group-JAMA. 2007;298(18):2155-2163.]

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According to the latest report from the WHO Recent scientific advances and increased vaccine manufacturing capacity have prompted experts to increase their projections of how many pandemic influenza vaccine courses can be made available in the coming years. Dr Marie-Paule Kieny, Director of the Initiative for Vaccine Research at WHO, said today. "However, although this is significant progress, it is still far from the 6.7 billion immunization courses that would be needed in a six month period to protect the whole world."
If we have to wait until six months after a pandemic is declared the majority of susceptible people will have had the flu.

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The new study, led by Scripps Research scientists was recently published in PLoS Pathogens*. "The new anti-anthrax agent that we developed is an important and potentially critical development for anyone who works with the bacterium or those who might be exposed to it in a bioterrorism attack," Schneemann said. "While other strategies are being pursued to develop improved anthrax vaccines, none of these offer the distinct advantage of combining the function of a vaccine with a potent antitoxin."

Posted by at 10:07 AM | Permalink | Comments (0)

In Today's JAMA there are articles and editorials about access to immunization. Among the snippets is the following: "New vaccines recommended for children have doubled in the past five years and the cost to fully vaccinate a child -- about $1,170 -- is 7.5-times higher in 2007 than it was in 1995." The research was based a survey of "state immunization program managers in 48 states from January to June 2006."

Posted by at 10:14 AM | Permalink | Comments (0)

The American Academy of Pediatrics (AAP) is alarmed that the soaring costs of vaccines. Often payments are below the cost of the vaccine. Gardasil, the new cervical cancer vaccine, costs physicians $360 for the recommended series of three doses per person. RotaTeq, the vaccine against diarrhea-causing rotavirus, costs $190 for the recommended three doses. Even the routine measles, mumps and rubella (MMR) vaccine costs $86 for the recommended two doses. In addition to the cost of the vaccine, additional costs of ordering, storing, inventory control, insurance and spoilage expenses need to be considered. Once more the long term effects of law suits are interferring with good medical care.

Posted by at 11:40 AM | Permalink | Comments (0)

From Imperial College. London a new monovalent vaccine against type 1 polio has been developed. Type1 is the most prevalent polio virus in India. To get 80% protection against this virus needs 14 doses of the current vaccine. The new vaccine will give the same results with 3 shots!

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IS HPV really worth the current furore. The article this week in the BMJ [Coombes R:2007;334:721-723] is worth reading for highlighting unanswered questions in the international rush to immunize. Has Merck had too much influence? Is the science clear enough for a vaccine that has only had a 5 year trial but is proprosed for all females?

Posted by at 10:17 AM | Permalink | Comments (0)

From this week's NEJM [Volume 356:1338-1343 March 29, 2007 Number 13] is a recommendation for that a single dose of the Zoster vaccine be universally administered to persons over 60, provided there is no contraindication.

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From the LA Times yesterday: In response to a series of hepatitis A outbreaks at restaurants and catered events across L.A., county officials said Tuesday they might require food-service workers in all 25,000 eateries to be vaccinated for the virus. Dr. Jonathan E. Fielding, the county's director of public health, said workers who prepare uncooked food such as salads are most likely to pass on the disease, especially if they do not wear gloves. Nevertheless, he cautioned that the risk of infection even then was very low. At $200 a per person and more than 100,000 food handlers, a workforce moblity of 100% a year, it might cost half a billion dollars to protect against 200 people a year reportedly infected. This is assuming that all foodhandlers become immunized. Maybe handwashing enforcement is simpler.

Posted by at 10:46 AM | Permalink | Comments (0)

Issued – Thursday 1st March 2007, London, UK & Rixensart, Belgium - A new candidate vaccine against hepatitis E, developed collaboratively by GlaxoSmithKline (GSK) and the Walter Reed Army Institute of Research (WRAIR), was found to be 95.5% effective in a Phase Two trial, according to a study to be published in the New England Journal of Medicine. [Volume 356:895-903]
Hepatitis E, a waterborne strain of hepatitis that occurs almost exclusively in the developing world, is currently without cure or medical prophylaxis. Three doses were administered over six months. After the third dose and over a follow-up period of approximately 20 months, there was a 7% attack rate in those in the placebo group and a 0.3% rate in those who had received the vaccine. The trial’s results also show that the vaccine was well-tolerated, with a safety profile similar to placebo, except for increased pain at the injection site; the most common adverse reaction besides injection site pain was mild to moderate headache after vaccination.

Posted by at 11:13 AM | Permalink | Comments (2)

This opinion piece by Arthur Allen in today's NY Times is worth reading as he describes the pitfalls of trying to vaccinate populations when the media sensationalize rare events. Tha fear of one or less deaths (among 20,000 or more recipients, depending oin the vaccine) may doom many thousands to death and disability from prevetable disease. As Spock would dsay, "the value of one must be weighed against the worth of many".

Posted by at 11:39 AM | Permalink | Comments (0)

From UNICEF, NEW YORK, USA, 18 January 2007- There has been an unprecedented decline in the number of child deaths from measles, thanks to a worldwide initiative to combat the disease, the Measles Initiative partnership announced today. “Reducing measles deaths by 60 per cent in just five years is an incredible achievement,� said UNICEF Executive Director Ann M. Veneman. “Immunizing children is clearly saving lives and contributing to the achievement of the Millennium Development Goals. "

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CDC published the Recommended Immunization Schedules for Persons Aged 0-18 Years -- United States, 2007 on January 5th. The Rotavirus vaccine is added, while modifications are made to Flu, Varicella and HPV vaccines. The schedule has been divided into two parta; one for those less than 7 years of age, and one for those over 6 years of age. The second part highlights needs for the 11-12 year olds. It keeps getting more complex. It is time for computer based reminder schedules which can be integrated into developing Medical Records Systems.

Posted by at 10:34 AM | Permalink | Comments (0)

Reported by many media outlets today the Centers for Disease Control and Prevention said that "the biggest U.S. measles outbreak in a decade...was traced back to a 17-year-old girl who had traveled to Romania without first getting vaccinated." The other patients "became infected after they attended a church gathering with her the day after her return," and "only two of the 34 people had been vaccinated against measles." Again, we see how hard it is to get everyone vaccinated against a virus that spreads so easily. Herd immunity for measles requires near 100% immunization of he population.

Posted by at 11:04 AM | Permalink | Comments (0)

Researchers from Imperial College London and international partners, explains the persistence of the disease in northern India, one of the few remaining places in the world where endemic polio has not yet been eradicated. They argue that the simple measure of using a ‘monovalent’ form of the polio vaccine alongside the standard ‘trivalent’ form in these areas could sufficiently increase the effectiveness of vaccination programmes to wipe out the poliovirus where it persists.

Posted by at 10:26 AM | Permalink | Comments (0)

From the Karolinska Institute today: A Swedish HIV vaccine study conducted by researchers at Karolinska Institutet (KI), Karolinska University Hospital and the Swedish Institute for Infectious Disease Control (SMI) has produced surprisingly good results. Over 90 per cent of the subjects in the phase 1 trials developed an immune response to HIV.

"Never has such a good result been seen with a vaccine of this type," says Professor Eric Sandström, Chief Physician at Karolinska University Hospital.

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One more vaccine added to the complex system. Today, the MMWR (Vol 55/No RR-12) published the recommendations of the Advisory Committee on Immunization Practices for use of rotavirus vaccine to prevent disease in infants and children less than 5 years of age.

Posted by at 3:11 PM | Permalink | Comments (0)

One more 'last' study on the topic Measles Mumps Rubella and mercury-based immunizations cleared as causes of autism from McGill UNiversity in Montreal.
"There is no relationship between the level of exposure to MMR vaccines and thimerosal-containing vaccines and rates of autism," says Dr. Eric Fombonne, Director of Pediatric Psychiatry at the Montreal Children's Hospital of the MUHC and lead investigator of the new study. Thimerosal was used to prevent bacterial and fungal contamination in the manufacture of various vaccines until its elimination from vaccine formulas in 1996 in Quebec. "According to our data, the incidence of autism was higher in children who were vaccinated after thimerosal was eliminated from vaccines," says Dr. Fombonne.

Posted by at 12:02 PM | Permalink | Comments (0)

Immunization is among the most successful and cost-effective public health interventions. Immunization programs have led to eradication of smallpox, elimination of measles and poliomyelitis in regions of the world, and substantial reductions in the morbidity and mortality attributed to diphtheria, tetanus, and pertussis. The World Health Organization (WHO) estimates that 2 million child deaths were prevented by vaccinations in 2003. Nonetheless, more deaths can be prevented through optimal use of currently existing vaccines. This report summarizes estimates of deaths attributed to vaccine-preventable diseases (VPDs) and vaccination coverage by WHO region and outlines the Global Immunization Vision and Strategy developed by WHO and the United Nations Children's Fund (UNICEF) and partners for implementation during 2006-2015.
Ref: MMWR. 2006;55:511-515

Posted by at 11:47 AM | Permalink | Comments (0)

From U. Rochester Medical Center In one approach taking place at Rochester and several other sites, 1,200 people are taking part in a study of the vaccine together with an adjuvant, a substance designed to enhance the response of the immune system. The vaccine will be given with alum, a vaccine additive that has been used in commercial vaccines for decades to make them more effective, in two studies involving 600 participants each. If alum is effective, researchers ultimately would be able to reduce the amount of vaccine given to each person, thus making the vaccine available to more people.
"These findings represent an important step forward in the nation’s efforts to prepare for the possible emergence of a human pandemic of H5N1 avian influenza," noted NIAID Director Anthony S. Fauci, M.D. "We are working hard to address the many challenges that remain with regard to the development of an H5N1 vaccine."

Posted by at 10:45 AM | Permalink | Comments (1)

From Rice Univsedrsity a new study on Dengue, A mosquito-born disease, which kills tens of thousands of people per year and sickens 100 million more. Known as “bone-break disease,� Dengue is characterized by excruciating pain and was “the most important mosquito-borne viral disease affecting humans� in 2005 according to the U.S. Centers for Disease Control.

The study, from bioengineers and physicists at Rice University, appears in the March 24 issue of the journal Vaccine. The study suggests that the multi-site vaccination strategy, termed polytopic vaccination, may be effective against other diseases as well, including HIV and cancer.

Posted by at 10:40 AM | Permalink | Comments (0)

This book (Yale University Press ISBN 0 300 10864 8) by Paul Offit, an infectious disease physician traced the origins of today's "vaccine crisis" to an incident during the 1950s in which thousands of people received polio vaccine containing live polio virus. Offit describes the development of polio vaccine, from trials of early vaccines through to the appearance on the scene of Jonas Salk.
The vaccine was highly effective and safe. It was licensed the next day thanks to political pressure, and during the next two weeks, five companies distributed about five million doses. Thirteen days after the first doses were administered, there were reports of cases of polio in immunised children. All of these initial cases had received vaccine manufactured by one company—Cutter Laboratories (although vaccine made by Wyeth also caused some cases of polio). In the end, at least 220 000 people were infected with live polio virus in Cutter's vaccine (including 100 000 contacts of immunised children), 70 000 developed muscle weakness, 164 were severely paralysed, and 10 died.
We are used to the effectiveness and safety of current immunogens. Most of us have never been told, or read, about this incident and the subsequent lawsuits that finally lead to the 1986 Vaccine Injury Compensation Program.

Posted by at 11:54 AM | Permalink | Comments (0)

From this month's Health Affairs (Health Affairs, 25, no. 2 (2006): 348-356) we learn that "VACCINES ARE AMONG THE MOST EFFECTIVE and cost-effective interventions to improve child survival in low- and middle-income countries. Nevertheless, millions of children fail to receive the routine traditional six vaccines against diphtheria, pertussis, and tetanus (DPT); polio; bacillus Calmette-Guérin (BCG); and measles. The World Health Organization (WHO) estimates that in 2003 there were 528,400 cases of measles, 106,135 cases of pertussis, 13,831 cases of tetanus, and 6,654 cases of diphtheria

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Every Tuesday and Thursday afternoon you can hear the pitiful cries. Mothers enter the doctor's surgery ashen-faced to queue up for the next round of injections. They leave half an hour later, cramming chocolate into their babies' mouths to stop their sobbing. When my husband took our five-year-old for his 20th injection since he was born, the doctor missed and jabbed my husband's leg instead. Parents watched in horror as he limped out of the surgery. (The Telegraph - Jan 30.2005)

There has to be a better way!!

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