MEASLES OUTBREAK FUELS VACCINE DEBATE
Research has shown that benefits of vaccination are demonstrated by eradication or significant decline in the incidence of many vaccine preventable diseases, including measles and influenza. Yet, measles has re-emerged in the United States after it was declared eliminated in 2000 after years of intensive childhood vaccine efforts. In addition, the influenza vaccine for the 2014-2015 flu season, was found to be largely ineffective in the older population.
Measles Outbreak
Substandard vaccination compliance appears to be the cause for the 2015 measles outbreak linked to the Disneyland Resort in California, according to a recent study that analyzed the data, which was published in JAMA Pediatrics [2015; DOI:10.1001/jamapediatrics.2015.0384]. As of press time, the latest Centers for Disease Control and Prevention (CDC) data indicated that between January 1 and April 3, 159 individuals in 18 states including the District of Columbia were reported to have measles. The majority of cases (74%) had been tied to the Disneyland outbreak.
Without the measles, mumps, and rubella (MMR) vaccination, measles is highly contagious. The findings showed that substandard vaccination compliance is likely to blame for the 2015 outbreak, meaning that less than 96% to 99% of the population exposed to measles during the course of the outbreak were vaccinated. Furthermore, the researchers noted that MMR vaccination rates “among the exposed population in which secondary cases have occurred might be as low as 50% and likely no higher than 86%.”
This latest study continues to spot- light the antivaccination movement in the United States and the prevalence of vaccination-hesitant parents. Prior to published findings, states were con- sidering tightening their immunization requirements. As of press time, at least 14 states have introduced bills that would make it harder for parents to gain certain types of vaccination requirements.
Ineffective Flu Vaccine
This flu season also garnered a lot of media attention. The FDA’s Vaccines and Related Biological Products Advisory Committee has recommended an overhaul for the influenza vaccine for 2015-2016 flu season. The influenza vaccine has included the exact same strains for the last 2 flu seasons; however, data from this year’s flu vaccine has proven ineffective, particularly among the older population.
The CDC reported that this flu season the influenza A (H3N2) virus was the predominant strain and that adults ≥65 years of age have been the most seri- ously affected. Furthermore, this age group also accounted for the majority of deaths attributed to pneumonia and influenza. The most recent CDC data (as of March 14) indicated that hospitalization rates for seniors were the highest at 284.3 per 100,000 people, followed by children 0 to 4 years of age at 50.8 per 100,000 people. Among all hospitalizations, 92.5% were associated with influenza A. The agency recommends early treatment with antiviral drugs for any patient with confirmed or suspected influenza who is hospitalized, has severe, complicated, or progressive illness, or is at high risk for influenza-associated complications, including children <2 years of age and adults ≥65 years of age.
To provide perspective on the influenza vaccine and the measles outbreak, First Report Managed Care conducted an interview with 2 of our Editorial Advisory Board members—William J. Cardarelli, PharmD, and Barney S. Spivack, MD, FACP.
Q: What are some of the overall benefits of vaccination and, in particular, the influenza vaccine?
Dr. Cardarelli: I think there are many benefits to vaccinating patients, especially the childhood vaccines. They protect the child against some the most [potentially] deadly diseases. They provide protection [via herd immunity] to others around them, [which is] especially important to immune-compromised patients; and they also lower the risk of death.
Dr. Spivack: The benefits of flu vaccination are well-known, although the effectiveness of a given year’s flu vaccine varies year to year. Flu vaccination not only provides protection for the vaccinated individual, but also protects those who may be more vulnerable. Older adults, those with chronic health conditions, and those <6 months of age are at greatest risk of serious illness from the flu, and adequate herd vaccination protects these more vulnerable individuals. Serious outcomes such as hospitalizations and deaths are reduced, and the illness is made milder by vaccination. Reduced duration and severity of illness, a reduced need for hospitalization, reduced event rates for complications of chronic diseases, reduced work-related absence and productivity losses, reduced caregiver illness, and adherence with this impor- tant preventive health intervention will benefit patients, providers, and payers, including Medicare.
Q: What are some of the barriers of vac- cination and, in particular, the influenza vaccine?
Dr. Cardarelli: My practice setting is in a universal supply state [Massachusetts], so vaccine cost is not an issue. However, accessing a physician may be in some communities. There are also religious and cultural issues. For payers in a universal supply state, the only adjudicated cost is the administration fee, which is quite low.
Dr. Spivack: Concerns about safety of the [flu] vaccine and misunderstanding and beliefs regarding risk of vaccine-related illness unfortunately exist, and physicians and payers need to stress the safety and effectiveness overall of the vaccine. Patients may have been confused by the variety of flu vaccine options available. Some physicians may not have gotten a supply of vaccines until late in the season or may have decided that they will no longer offer the convenience of vaccination in their offices, referring patients to other centers. Cost may be a barrier for some, despite coverage of this and other recommended preventive health measures by payers for those at risk.
Q: While the flu season is winding down, the senior population was hit particularly hard this flu season. What do you attribute to this increased risk among the older population?
Dr. Cardarelli: The elderly are much more susceptible to the flu than other populations. In a year where it appears that the strains included in the flu vaccine were not a good match for the strain that emerged, it stands to reason that the elderly would be the most impacted. What I would really like to know is if the high-dose vaccine made a difference, in other words, would the flu outbreak in seniors have been much worse without it? The product was approved based on 2 very small, company-funded studies. There are plenty of people who believe that high dose is the victory of market- ing over medicine. It would be nice to answer that question once and for all.
Dr. Spivack: This year’s flu vaccine was less effective than in previous years, due to the lack of inclusion in the vaccine of a strain (A/Switzerland/9715293/2013-like virus), that unfortunately later became predominant in this year’s flu. The FDA advised vaccine recommendations in February at a time when this strain was not recognized as a major agent that would cause illness. Consequently, the level of effectiveness was estimated as 19% by the CDC instead of 60% or more in recent years, and those more vulnerable, such as older adults, had more flu-related illness this season.
Despite the fact that flu vaccines can work less well in people who are ≥65 years of age, there are many reasons why people in that age group should be vaccinated each year. For example, people ≥65 years of age are at high risk of getting seriously ill, being hospitalized, and dying from the flu. In frail elderly adults, hospitalizations can mark the beginning of a significant decline in overall health and mobility, potentially resulting in loss of the ability to live independently or to complete basic activities of daily living. While the protection elderly adults obtain from flu vaccination can vary significantly, a yearly flu vaccination is still the best protection currently available against the flu.
Q: In the wake of the measles outbreak, what advice do you have for physicians who encounter parents who do not want to vaccinate against measles or “spread out” the recommended vaccine schedule for their children?
Dr. Cardarelli: It is really up to the physicians to carefully outline both the risks and benefits of vaccines, to dispel the many myths surrounding the use of vaccines and overcome the parents fears. This is not a very easy or short conversation, but it is an important one.
Q: More states are introducing bills to toughen vaccination laws. Do you agree that there needs to be tougher laws that would make it harder for parents to gain certain types of vaccination exemptions?
Dr. Cardarelli: I think that when craft- ing legislation to mandate vaccinations, especially those that might interfere with a child attending school, the lawmakers must be sensitive to religious beliefs and focus their attention on those parents whose only objections might be based on unsupported information. Unfortunately, these patients not only expose their children to risk but also unsuspecting other children whose only mistake was being in the wrong place at the wrong time. We have seen this in Chicago and California this year already.—Eileen Koutnik-Fotopoulos
