style='mso-spacerun:yes'>  Diagnosis is by isolating the organism or through DNA tests.  Treatment is only effective if given during the catarrhal stage of the illness.  The drug of choice is erythromycin.  In Ohio, cases must be isolated for 3 weeks following the onset of paroxysms if they did not receive appropriate antibiotics.  Those who received therapy in time must be isolated for 5 days after therapy is started.  Contacts of cases should either be immunized or given a course of erythromycin if they are less than 1 year old.  Prevention involves receiving the recommended immunizations.” [32] 

 

Pneumococcal Disease

 

Streptococcus pneumoniae is a group of “strep” bacteria also known as pneumococci. Pneumococci live in the nose and throats of people of all ages. Pneumococci can infect many different sites, some common—like the middle ear and the sinuses—and some less common but more serious, including the lungs (pneumonia), central nervous system (meningitis), and blood stream (bacteremia).” http://www.immunizationinfo.org/vaccineInfo/vaccine_detail.cfv?id=9

 

Polio

 

“Polio is caused by poliovirus types 1, 2, and 3.  It has been eradicated in the Western hemisphere due to the massive immunization campaign over the past few decades.  Humans are the only source.  Poliovirus is passed by the fecal-oral route and can be found in contaminated water sources such as swimming pools.  Up to 90-95% of infections are asymptomatic, 4-8% of infections are mild and similar to a flu-like illness, 1-2% result in nonparalytic poliomyelitis characterized by aseptic meningitis, and only 0.1-2% of polio cases result in paralytic disease.  Paralytic polio manifests as flaccid paralysis of one or more limbs with loss of reflexes but maintained sensation.  In most cases, muscle function returns completely, but some cases have residual disability.  Diagnosis is confirmed by isolating the virus in spinal fluid, stool, or oral secretions.  Serologic tests are also available.  There is no specific treatment.  Immunization is the most important prevention.” [32] 

 

Rabies

 

“The rabies virus is transmitted from infected animals and affects the central nervous system.  It is fatal once symptoms occur.  Transmission is usually from a bite of a rabid animal.  Early symptoms are irritability, headache, anxiety, and fever.  These progress to paralysis, muscle spasms, seizures, delirium, and death.  Patients often have an intense fear of water.  Rabies can be prevented by immediate wound cleansing, the administration of rabies immune globulin, and 5 doses of the rabies vaccine.  Exposure from a rabid animal does not always result in disease.  Prevention on a community scale is accomplished by minimizing the number of stray animals, and avoiding contact with wild animals.” [32] 

 

Rotavirus

 

“Rotavirus is an intestinal virus that infects virtually all children by three years of age. It is the most common cause of diarrhea in children, including hospital-acquired diarrhea, and childcare center outbreaks are common. The disease usually lasts a week or longer and can cause persistent infection in immunocompromised people. Most rotavirus infections are mild, but about 1 in 50 cases develop severe dehydration. Each year in the U.S., rotavirus results in the hospitalization of 50,000 infants younger than two years of age. In developing countries, rotavirus leads to an estimated 480,000 to 640,000 deaths each year.”

http://www.immunizationinfo.org/vaccineInfo/vaccine_detail.cfv?id=17

 

Rubella

 

Rubella virus is an airborne infection that causes German measles.  The disease starts with a few days of fever, headache, malaise, conjunctivitis, runny nose, sore throat, cough, and swollen lymph nodes.  These symptoms then disappear with the appearance of the characteristic rash.  The rash consists of fine, pink bumps starting at the hair line and spreading downward.  It lasts only 48 hours.  The disease is especially dangerous in pregnant women since it can be devastating for the fetus.  Diagnosis depends on antibody tests.  There is no specific therapy.  Patients should be isolated for 7 days after the onset of rash in order to protect susceptible pregnant women.  The MMR vaccine has greatly reduced the incidence of rubella and is the best form of prevention.” [32] 

 

Smallpox

 

“Smallpox is caused by a virus known as Variola.  It was declared eliminated in 1980 due to worldwide vaccination, although stores of the virus are found in the US and Russia.  It is airborne and highly contagious.  Symptoms include sudden onset of fever, exhaustion, and malaise.  After several days the temperature drops and a rash appears on the face and arms, then spreading to the rest of the body.  The rash develops into vesicles filled with fluid or pus that eventually scab and leave scars.  These lesions are also highly infectiou.  Treatment is supportive, there is no cure.  The disease is fatal in 30% of cases.  Cases must be isolated as long as they are infectious.  Since the disease has been eradicated, the public is no longer immunized against it, thus making them susceptible to a biologic attack using this virus.” [32]

 

 

Tetanus

 

“Tetanus is caused by the bacteria Clostridium tetani.  Spores of the bacteria are found in the soil.  They can then be introduced into a puncture wound.  The bacteria do not need oxygen to grow.  Symptoms include excitability and generalized muscle spasms particularly of the neck.  Symptoms are due to a neurotoxin released by the bacteria.  Diagnosis can be made by culture but is usually clinical.  Treatment is with tetanus immune globulin or with an equine variety to counter the toxin.  Penicillin G or tetracycline is also given to kill the bacteria.  Prevention involves getting a booster tetanus shot every 10 years.” [32]

 

 

Tuberculosis

 

“TB is caused by the bacteria Mycobacterium tuberculosis that is spread through the air.  Many people are infected with TB, as seen by a positive PPD test on the skin but no bacteria in the sputum, but a far smaller number actually develop disease.  Those with weakened immune systems are much more likely to develop active disease.  Symptoms are fever, night sweats, weight loss, and cough.  Diagnosis is made by seeing the bacteria on sputum smear and by characteristic lesions on chest X-ray.  Several drugs are used to treat TB although resistance is developing.  The most common drugs are isoniazid, rifampin, ethambutol, and streptomycin.  Drugs must be taken for several months.  Those with evidence of disease even if it is not active should take several months of isoniazid.  Prevention involves using respiratory precautions among infected individuals.” [32] 

 

 

Typhoid Fever

 

“Typhoid is caused by the bacteria Salmonella typhi and occurs only in humans.  It is passed by the fecal-oral route.  Some people are carriers of the bacteria but do not suffer disease.  Symptoms include a high fever, loss of appetite, abdominal pain, and rash.  Severe cases can cause bowel obstruction.  Diagnosis is by stool culture.  Therapy includes ampicillin, trimethoprim-sulfamethoxazole, and ciprofloxacin.  There is a vaccine available for those traveling to endemic countries.  Prevention involves hygienic food preparation.” [32] 

 

Varicella (Chickenpox)

 

“Chicken pox are caused by varicella-zoster virus (VZV).  Humans are the only host.  Transmission is either airborne or through direct contact.  It is usually a disease of children.  Symptoms are a skin eruption of vesicles that are quite itchy.  Fever and malaise may also be present.   Complications include Reye syndrome, pneumonia, arthritis, and aseptic meningitis.  Those infected as older children or adults are more likely to develop complications.  Diagnosis can be made by isolating the virus from the lesions or by antibody tests.  Treatment is symptomatic.  Aspirin should not be used.  Immunity is conferred after one infection.  Cases should be isolated until the 6th day after the rash started or until all the lesions are dry.  There is now a vaccine available.” [32] 

 

Yellow Fever

 

“This disease is caused by a virus transmitted by mosquitoes.  It is only found in Africa and South America.  Many countries have regulations regarding yellow fever vaccination even though the illness is rare among travelers.  Symptoms are fever, jaundice (yellow skin and eyes), headache, myalgias, and light sensitivity.  More severe disease damages the liver, kidneys, and heart and may be accompanied by hemorrhage.  Diagnosis is by antibody tests.  Therapy is supportive.  Vector control is the best prevention.” [32] 

 

Vaccination Law

 

The Centers for Disease Control update the laws of vaccination on the website [5].   

 

Patients must be informed

“By law, parents, guardians, or patients must be given information in writing about the risks and benefits of vaccination before a vaccine is administered.”  This information typically comes in the form of Vaccination Information Statements (VIS).  These are one page, doubled-sided, documents prepared by the CDC that state the risks and benefits of vaccination. 

 

Some of these vaccines are covered by the National Childhood Vaccine Injury Act of 1986 (PL-99-660) [29]:

 

Tetanus

Measles

Haemophilus influenzae type B

Pertussis

Mumps

Hepatitis B

Polio

Rubella

Varicella

Rotavirus

 

Some of the vaccines are not covered by this act, but have a VIS that must be deseminated if the vaccine is purchased under CDC contract. The legal basis is the “Duty to Warn” clause in CDC’s vaccine contracts.

VIS’s in this category (as of January 2000) are [29]:

 

Influenza

Hepatitis A

Pneumococcal Polysaccharide

Lyme disease

 

When combination vaccines are given, all relevant VIS’s must be given.

 

You can obtain copies of these information sheets by calling the CDC National Immunization Program information hotline at 1-800-232-2522 (English) or 1-800-232-0233 (Spanish), or you can obtain copies online at http://www.cdc.gov/nip/publications/vis/.

 

For more general information about VIS’s and the National Childhood Vaccine Injury Act of 1986 (PL-99-660), you can see the CDC’s publication “What you need to know about Vaccine Information Statements” at http://www.immunizeseniors.org/website/downloads/instr00.pdf

 

National Childhood Vaccine Injury Act of 1986 (PL-99-660)

 

The National Childhood Vaccine Injury Act of 1986 (PL-99-660) is a vaccine safety and compensation system which (1) created a no-fault compensation alternative to suing vaccine manufacturers and providers on behalf of citizens injured or killed by vaccines; (2) helps prevent future vaccine injuries through education and an adverse reaction reporting system; and (3) creates incentives for the production of safer vaccines.” [30]

 

Below is an explanation of the compensation laws of this act from the National Vaccine Information Center Website [30]:

Compensation is divided into two parts:  

1)     Injuries or deaths prior to October 1, 1988 (no matter how long ago the injury occurred):

·         A citizen may choose to pursue a lawsuit unrestricted.

·         A citizen could have filed a claim in the compensation system by January 31, 1991

·         If the claim was not filed by 1/31/91, the statute of limitations has run out.

 2)     Injuries or deaths occurring after October 1, 1988:

·         A citizen is required to apply for federal compensation prior to pursuing a lawsuit.

·         The system will offer to pay up to $250,000 for a vaccine associated death.

·         The system will offer to pay for all past and future unreimbursed medical expenses, custodial and nursing home care; up to $250,000 pain and suffering; and loss of earned income.

·         If a citizen rejects the award or is turned down, a lawsuit may be filed.

·         Claims must be filed within 24 months of a death and 36 months of an injury.

·         Restrictions may apply to lawsuits.

·         The system is funded by a surcharge on each dose of vaccine sold.  

The NVIC publication, The Compensation System and How It Works, is available for a $5 donation and can be bought at https://www.nvic.org/ResourceCenter/Resource_Center.htm#Booklets

Immigration immunization laws

“Under new immigration laws passed in 1996 and in effect as of July 1, 1997, all individuals seeking permanent entry into the U.S. must prove that they have been inoculated against all vaccine-preventable diseases. This includes infants and children being brought into the country for international adoption.”

 

School immunization laws

            “Each state has immunization requirements, sometimes called ‘school laws,’ that must be met before a child may enter school... In most states, a parent must bring written proof of a child's immunizations from the health provider or clinic at the time of school registration.”  It is possible to obtain exemptions due to medical contraindications, or religious and philosophical beliefs.  “Religious exemptions are allowed in 48 states (West Virginia and Mississippi do not), and 15 states offer philosophical exemptions.  The requirements for documentation of medical, religious, or philosophical exemptions vary.”

            You can find out what the requirements for your state at            http://www.immunizationinfo.org/

            Select the state of interest from the list provided at the upper right hand corner of           the website.

Adult immunization laws


“There are no legally mandated vaccinations for adults, except for persons entering military service.  Some employers require certain immunizations for those employees who work with people who are sick or vulnerable to disease, or those who handle or are exposed to dangerous substances, such as certain bacteria or viruses. Hospitals, for example, may require some staff to have influenza or hepatitis B vaccine.” 

 

Travel immunization laws

“Immunizations were once required for persons traveling overseas. None are required at this time, but some vaccinations are recommended.”  Some diseases that are not common in the United States are still prevalent in other parts of the world.  Therefore, specific vaccinations are recommended when traveling to areas of possible exposure. For information about recommended vaccinations when traveling abroad, you can talk to your primary care physician or visit the following CDC website:  http://www.cdc.gov/travel/index.htm.

 

Current Federal and State Laws

 

To find out about current legislature, check out this National Vaccine Information Center Website: http://www.909shot.com/legs.htm

What Vaccines are Recommended?

 

            Below are the recommended vaccinations from the Centers for Disease Control (CDC).  Every year the vaccination schedule is revised.  It is important to check with the CDC or with a healthcare provider in order to make sure the proper vaccines are administered in a timely fashion.

 

Pediatrics

 

 

Adults

 

 

 

Pregnant Women

"Risk to a developing fetus from vaccination of the mother during pregnancy is primarily theoretical. No evidence exists for the risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. Benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm." Committee on Immunization Practices (ACIP) General Recommendations on Immunization, p. 18. [20]

In general, pregnant women should not be given live-virus vaccines.  If a woman is giving a vaccine within four weeks of pregnancy, the woman should be counseled about possible side-effects for the fetus. 

Below is a general chart delineating the proper treatment of pregnant woman [20]:

Vaccine

Should be considered if otherwise indicated

Contraindicated during pregnancy

Routine

Hepatitis A

 

 

Hepatitis B

X

 

Influenza (Inact.)

 Recommended

  

Influenza (LAIV)

 

X

Measles

  

 X

Mumps

  

 X

Pneumococcal

  

  

Polio (IPV)

  

  

Rubella

  

 X

Tetanus/
Diphtheria

 X

  

Varicella

  

 X

Travel & Other

Anthrax

 

 

BCG

 

X

Japanese Encephalitis

 

 

Meningococcal (MPSV4)

X

 

Meningococcal (MCV4)

 

 

Rabies

X

 

Typhoid (Parenteral & Ty21a)

 

 

Vaccinia

 

 

Yellow Fever

 

 

           

Current Technology Development and Research

 

            Currently, there are many clinical trials currently being conducted in order to determine the safety and efficacy of vaccination.  In addition, there many projects in search for new vaccines that can tackle diseases, such as AIDS.  One way vaccination can be improved, and new vaccines can be created is through the development of new technologies.

New Vaccine Biotechnology

"Recombinant" Vaccines

 Scientists are currently working on making vaccines by changing the genetic structure of infectious pathogens.  An important gene for organism survival can be removed thereby allowing the host to acquire immunity without acquiring disease.  Another method of this technology is to add a gene into an organism that will enode a protein of a pathogen.  Injection with this organism will lead to the mass production of this protein that will induce an immune response directed toward the pathogen protein.  One more method is to inject a naked fragment of a pathogen’s genetic material.  The body’s cells can use this DNA to make proteins.  These proteins can induce an immune response in the host.  These vaccines, in particular, could result in lifelong immunity.  This technology is currently being used to make vaccines for malaria, influenza, and HIV. [3]

Genome Sequencing

Many projects are being condected to determine the genetic sequence of pathogens.  These sequences could be used to create new vaccines, such recombinant vaccines.  Thus far, a complete sequence has been determined for the malaria parasite Plasmodium falciparum. [3]

Edible Vaccines

 “Researchers have found that edible vaccines can safely and effectively trigger an immune response against the Escherichia coli bacterium and the Norwalk virus. Scientists are now attempting to genetically engineer potatoes, bananas, and tomatoes that, when eaten, will initiate an immune response against harmful intestinal bacteria and viruses.” [3]

Slow Release Vaccines

 

 A consortium of British private companies and a university facility is working on producing a slow release vaccine  The group is working on nanotechnology that will help count down on the amount of booster shots needed, and can increase the amount of time for which a vaccine is effective.  “They stabilize the vaccine by embedding it in tiny microspheres, made of calcium phosphate glass, which dissolve in the body fluids after injection…Proprietary nanoparticles within the microsphere ensure the vaccine release will be slower and the vaccine continues to be released into the body over a longer time period.”[9]  In addition, MNLpharma is working to develop an imino sugar adjuvant for the new vaccines. [9]

Stable Liquid Vaccines

“Cambridge Biostability's stable liquid vaccines can be stored safely without the need for a cold chain and do not require reconstitution or bactericides, which are major causes of vaccine safety and wastage problems.”[9]

New Disease Targets

 

Current information about new vaccines can be obtained from the Red Book:

            http://aapredbook.aappublications.org/news/vaccstatus.shtml

 

AIDS

 

Acquired Immune Deficiency Syndrome (AIDS) is caused by the Human Immunodeficiency Virus (HIV).  HIV attacks the CD4 cells of the immune system thereby making it difficult for AIDS patients to fight off infections.  Currently there are more than 30 candidate AIDS vaccines.  Small trials are being conducted in 19 countries on six continents. [35]  For more information about the search for an AIDS vaccine, the International AIDS Vaccine Initiative is a good resource: http://www.iavi.org/

 

HPV (Human papillomavirus)

 

There are over 100 different types of Human papillomavirus (HPV).  About 30 of these viruses are sexual transmitted and infect the genital area of men and women.  10 of these 30 can lead to development of genital warts and cancer of the cervix, vulva, vagina, anus, or penis.  There have been many clinical trials testing the effectiveness and safety of HPV vaccines.  For example, a phase 3 trial called FUTURE II reported in October 2005 that a vaccine called Gardasil was an effective and safe method for preventing HPV infection. 
The researchers found that 90% of new infections were prevented, and that the vaccine protected against the number 6, 11, 16 and 18 strains of virus.  Future research is needed to design vaccines against the other strains of virus, to look at which vaccines may be useful for women who are already infected with HPV, and to know how long the vaccines can provide protection.  Merck is waiting to hear from the FDA about its application to sell Gardasil, and GlaxoSmithKline is planning to apply to the FDA for approval of their Cervarix vaccine by the end of the year. [37] For more information about HPV vaccine research go to http://www.cancerhelp.org.uk/help/default.asp?page=16024#vac

 

Avian Flu

“Avian influenza is an infection caused by avian (bird) influenza (flu) viruses. These influenza viruses occur naturally among birds... There are many different subtypes of type A influenza viruses. These subtypes differ because of changes in certain proteins on the surface of the influenza A virus (hemagglutinin [HA] and neuraminidase [NA] proteins). There are 16 known HA subtypes and 9 known NA subtypes of influenza A viruses… ‘Human influenza virus’ usually refers to those subtypes that spread widely among humans… Of the known viruses that affect humans, H5N1 is of the most concern since H5N1 has caused the largest number of detected cases of severe disease and death in humans. In the current outbreaks in Asia and Europe more than half of those infected with the virus have died… There currently is no commercially available vaccine to protect humans against H5N1. Research studies to test a vaccine to protect humans against H5N1 virus began in April 2005, and a series of clinical trials is under way.” [38] For more information about the H5N1 vaccine development process, visit the CDC’s Avian influenza Vaccine website at http://www.cdc.gov/flu/avian/gen-info/vaccines.htm

Dangers  of Vaccine Exemptions and Non-Compliance:

Vaccine Protection Beyond the Individual

 

            The ability for individuals to obtain exemption from vaccination is important for the protection of personal freedom and the protection of those with vaccine contraindications.  However, exemptions and non-compliance can put a population at risk for spreading disease.  There will always be a fraction of the population that is not immune, even if 100% of the population receives a vaccine because no vaccine is 100% effective.  Even if individual immunity is not perfect, a critical amount of people need to be immune in order to protect the whole population.  This phenomenon is called herd immunity, where “protection is achieved through obtaining a high enough level of immunity to a disease so as to make exposure to the organism that causes the disease extremely unlikely” [13].  The immunity necessary within a population depends on the disease and ranges from 83%-94%.  If too many people are exempted, than this percentage may not be reached.

            If vaccinations are ended prematurely, a large population can see the recurrence of a disease as the people who still contain the pathogen are able to renew the spread of infection.  Japan’s 1979 whooping cough epidemic serves as an example: “In 1974, Japan had a successful pertussis (whooping cough) vaccination program, with nearly 80% of Japanese children vaccinated. That year only 393 cases of pertussis were reported in the entire country, and there were no deaths from pertussis. But then rumors began to spread that pertussis vaccination was no longer needed and that the vaccine was not safe, and by 1976 only 10% of infants were getting vaccinated. In 1979 Japan suffered a major pertussis epidemic, with more than 13,000 cases of whooping cough and 41 deaths. In 1981 the government began vaccinating with acellular pertussis vaccine, and the number of pertussis cases dropped again.” [24] 

            In addition to preserving immunity, exemption also raises ethical problems within a society.  Those who receive vaccinations share in the risk of obtaining negative side effects, while those that are exempt can benefit from herd immunity without having to share these risks.  However, the price of exemption is not completely free.  Current research is exploring the consequences, and it had been found that exempted individuals have an increased risk of contracting measles, pertussis and tetanus. [14-16]

            Even when a country has eradicated a disease, recurrence can occur in this case because “the germs that cause the diseases still exist in other parts of the world.” [4]  When Nigeria took a hiatus from their polio vaccination program, the infection began to spread to other countries that were considered free from the disease. [7]  More recently, there is a Mumps outbreak in Iowa with at total number of “300 confirmed, probable, or suspected cases of mumps through April 3.” [33]  One theory of the source for the outbreak is that a college student may have brought back the pathogen from England, where mumps has been spreading over the previous two years. [34]

            In order to maintain herd immunity, it is important to regulate the amount of people obtaining exemptions.  In some states, gaining an exemption is actually easier than acquiring vaccinations for children.  For example, the state of California only requires parents to sign a prepared form. [11]  Under these circumstances, parents may be tempted to obtain exemption instead of going through the hassle of vaccination. 

            Exemptions can be limited by making the process more difficult.  Such provisions that make it harder to obtain exemption have been implemented in Arkansas and include a notarized statement, attendance at an educational session where the risks and benefits of vaccination are explained, and the signing of a statement acknowledging that a child can be removed from school during an outbreak. [11]  Perhaps a discussion specifically with a primary health care provider will further decrease the exemption rates, especially since they are a common source of vaccination. [10,11]

            Australia has used financial incentives to increase immunization rates.  In 1998, stipends were provided to practices with vaccination records of 90% children younger than 7.  The1999 Family Assistance Act awarded universal healthcare benefits and stipends to parents who either have proof of vaccination, or have prove from a healthcare provider that the risks and benefits of vaccination have been explained with the decision of exemption.

            Although the granting of exemption is an important practice in personal rights, it needs to be monitored in order to maintain communal immunity to life-threatening diseases.  It has been observed that the more difficult it is to obtain an exemption, the lower the number of people seeking exemption. [10, 11]  More efforts should be made to increase the difficulty for obtaining an exemption and to understand the affects of exemption and compulsory laws on the spread of disease. [10]

 

Barriers to Disease Eradication: Polio as an Example

 

            With over 200 years of vaccination, smallpox is the only disease that has been successfully eradicated.  There are many factors that make vaccination difficult.  The attempts to eradicate polio exemplify these barriers.  The Global Polio Eradication Initiative was started in 1988.  At this time in history, 125 countries reported cases of polio.  Although the number of cases and affected countries has decreased, eradication has not been possible. [4]  There are many barriers to finishing this initiative.  Besides the economics and logistics of getting the vaccine to everyone that needs it, there are political, educational, cultural, and motivational influences, as well as scientific limitations.

            Thus far $4 billion has been spent, and more will need to be spent until eradication is complete. [7].  What is the money being spent on?  Besides the purchasing of the vaccine, additional costs are needed for storage at cold temperature and vaccine delivery.  In addition, vaccination is not a “one shot” deal: “Here and elsewhere, eradicating polio means finding ways to get polio drops into the mouths of every child under 5 — over and over. Because it can take many doses to effectively immunize a child in parts of the world where the disease circulates intensely, eradication requires repeated sweeps.”[7]  In order to obtain immunity, it can possibly take up to 10 doses, and these doses need to be delivered months apart [7]. 

            Cultural requirements need to be worked around in order to provide enough workers to deliver the vaccinations.  According to Nigerian Muslim custom, only a woman can enter a household if the husband is not home.  In addition, mothers were the best at convincing other members of the community to accept the vaccines.  The combination of these cultural influences made mothers the best candidates for delivering vaccines.  However, many men prohibited their wives from leaving the household because they wanted the jobs for themselves. [7]  This catch 22 decreased the amount of the most effective workers. 

            Even if the vaccine reaches the door of every family, the family still needs to accept the vaccine.  Due to a lack of confidence in the program and other political set backs, the vaccine cannot always reach its target.  There is a general feeling of hostility towards the public health workers.  One woman Indian woman shouts “‘We have a lot of other problems, and you don't care about those…All you have is drops. My children get other diseases, and we don't get help.’"[7]  A skepticism has developed as public health workers drop by time and again to administer vaccinations without addressing day to day concerns.  This prolonged project wears on both the recipients and the workers.  The recipients are getting tired of hearing promises of eradication, and the public health workers get anxious as the numbers infected drop without the final goal of total eradication in site: “The closer a disease is to eradication, they say, the harder won the gains. Interest lags as the number of cases falls. Fatigue sets in among volunteers, donors and average people. “[7]

            Further set backs in the polio eradication program were caused by misconceptions about the vaccine.  For example, in 2003, the northern states of Nigeria stopped all vaccination due to rumors that the polio vaccine either contained the AIDS virus or was “part of a Western plot to sterilize Muslim girls. “ [7]  The vaccines were not reinstated for months until the safety of the vaccine could be assured.  In response to this lag, “18 once polio-free countries have had outbreaks traceable to Nigeria… In 2001, there were fewer than 500 confirmed cases of polio paralysis in the world. Last year (2005), the number jumped to more than 1,900…”[7].

            Limitations come from the vaccine itself.  The polio vaccine that started the eradication process is a modified live virus.  As explained in the safety section, these types of vaccines have the ability to mutate back into the wild type virus.  This occurs in about one in three million doses of the polio virus. [8]  These are the vaccines of choice because they are easy to administer and they provide a strong immunity by protecting against three strains of the virus.  However, the vaccine requires many injections as described above.  In order to address this issue, and to attempt to expedite the eradication process, other countries, such as India, are starting to use a faster acting vaccine that only vaccinates for the most common strain of the virus.  The use of this vaccine has not been successful as of now. [8]  Even after the infection is eradicated, vaccination is still required in order to sustain community-wide immunity.  A small number of people have an immune-system defect that allows them to produce and excrete virus without getting sick, thereby “creating a reservoir that could, theoretically, cause a new outbreak“ if the virus comes into contact with unvaccinated individuals [8].  This concerned was realized in the United States when five children from a Minnesotan Amish community contracted the polio virus from a carrier containing the immune system defect. [25]

            In addition to the scientific challenges, additional barriers to disease eradication have also been observed within the United States.  Just as the importance of polio vaccination was lost for a poor Indian woman in the economic and health disparities she faced daily, the importance of smallpox vaccination was lost in poor communities of Milwaukee in reaction to their health disparities: “In 1894, smallpox sparked a month of rioting in Milwaukee. The cause wasn't the disease itself, but the city's policy of seizing sick children in immigrant Polish and German neighborhoods and taking them to isolation hospitals, while leaving wealthy families alone, saying their larger houses and abundant servants would isolate them. With rioters flinging hot water and pepper in the eyes of the police and their horses, a vaccination drive collapsed and the epidemic spread.”[8]  When the city of Milwaukee ignored the differential treatment given to different classes, it risked the health of the city’s residents.

            Misinformation has also led to the inappropriate utilization of vaccination in the United States.  In Nigeria, the public linked the polio vaccine with AIDS, while the United States joined the global concern over a link between MMR vaccination and autism.[13, 21-23]  In this case, there was a decrease in MMR vaccination.  These misconceptions can lead to increases in exemptions and noncompliance, which can result in the revival of infectious disease.  On the other hand, increased demand for a vaccination has developed over misperceived risks and benefits of the flu vaccination during the 2004-2005 flu vaccine shortage [13]  During this shortage, there were cases of stolen vaccines and unreasonable price hikes in respond to the irrational demand.  These irrational demands for vaccine many prevent those who are within risk groups from obtaining vaccination.  Dr. May writes, “In many cases, the fears motivating irrational behavior are the result of media coverage that heighten a sense of risk” [13]  Frequently the media hyperbolizes the coverage of vaccination side effects in order to produce a more sensational story.  Although these views may help to sell papers, they leave the public with an incorrect perspective of the risks and benefits of vaccination. 

            The United States has become desensitized to the dangers of the infectious diseases due to their lack of first hand experience.  This lack of experience can result in a jaded attitude towards vaccination.  This is different from the Nigerian skepticism, which has formed from a decrease in polio prevalence in conjunction with an seemingly endless promise of eradication. [13]  The fear of vaccination side effects has overpowered the fear of contracting the actual disease: “The DTP vaccine results in adverse events such as convulsions or shock for 1 in 1,750; acute encephalopathy for 0-10.5 in 1,000,000; and the MMR vaccine results in encephalitis or severe allergic reaction for 1 in 1,000,000.  These risks are extremely low when compared to the adverse consequences from contracting vaccine-preventable disease (for pertussis, encephalitis for 1 in 20; death for 1 in 200; for measles, encephalitis for 1 in 2,000; death for 1 in 3,000” [13]  By better informing the public of the risks involved in not vaccinating in addition to the associated side effects, individuals will be able to make better decisions about their vaccination practices and their support of vaccination programs.

 

Conclusion

 

            The discovery of a vaccination does not necessarily result in the eradication of disease.  Public health efforts must be made to provide the public with accurate and balanced information about the benefits and risks of vaccination.  Continued research is necessary in order to uncover scientific barriers to eradication in addition to finding improved ways of producing effective and safe immune responses.  Finally, the overall health and quality of life of every individual must be considered in order to maintain trust in vaccination programs.  Less fortunate members of society can become skeptical of preventative measures when active efforts to improve current health and economic problems are absent.  Vaccination cannot be successful if it is viewed only as an effort to free society from infectious disease.  Vaccination needs to be part of an overall commitment to improve the health of the global community.

 

 

For More Information:

 

General Information:

 

National Immunization Program

            Sponsored by the Centers for Disease Control

            http://www.cdc.gov/nip/default.htm

 

National Vaccine Information Center

            http://www.909shot.com/Default.htm

                        NVIC Store Tab has a list of suggested books and resources

 

MedlinePlus

            Links to Many Sites about Vaccination

http://www.nlm.nih.gov/medlineplus/immunization.html

 

List of Websites recommended by the World Health Organization for vaccine safety

            http://www.who.int/immunization_safety/safety_quality/approved_vaccine_safety           _websites/en/

 

For articles in the news about vaccination

            http://www.vaccinationnews.com/

 

Information about the immune system and a good general overview

            http://www.niaid.nih.gov/publications/vaccine/pdf/undvacc.pdf

 

Vaccine Information Statements: Distribution is required by law when giving a vaccine

            http://www.cdc.gov/nip/publications/vis/

 

New Vaccine Information:

            http://aapredbook.aappublications.org/news/vaccstatus.shtml

 

Specific Questions:

 

CDC National Immunization Program information hotline

            1-800-232-2522 (English)

            1-800-232-0233 (Spanish)

 

Traveling Information

            http://www.cdc.gov/travel/index.htm

 

To Report Adverse Reactions:

Vaccine Adverse Event Reporting Service

            http://vaers.hhs.gov/

           

International Information:

 

World Health Organization Sites

            http://www.who.int/topics/vaccines/en/

            http://www.who.int/topics/immunization/en/

 

Global Polio Eradication Initiative

            http://www.polioeradication.org/

 

Global Alliance for Vaccines and Immunization

            http://www.vaccinealliance.org/

 

Global Immunizations and Vaccinations from the CDC

            http://www.cdc.gov/nip/global/default.htm

 

Resources

 

1)  State Government of Victoria Department of Human Services. November 2005

             “Vaccines Explained.” http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/

            pages/Vaccines_explained?OpenDocument

 

2)  Mayo Clinic. August 18, 2005. http://www.mayoclinic.com/health/vaccines/ID00023

3)  National Institute of Allergy and Infectious Diseases. November 20, 2003.             http://www.niaid.nih.gov/factsheets/evolution_vaccines.htm

4)  Mayo Clinic. August 18, 2005. http://www.mayoclinic.com/health/vaccines/CC00013

5)  Centers for Disease Control.“Immunization Laws.” March 26, 2006.

           http://www.hhs.gov/nvpo/law.htm#Globalization%20and%20international%20law

 

6)  National Network for Immunization Information.  http://www.immunizationinfo.org/

 

7)  Dugger, Celia W. and McNeil Jr., Donald G. “Rumor, Fear and Fatigue Hinder Final           Push to End Polio.” The New York Times. March 20, 2006.

 

8)  McNeil Jr., Donald G. “When a Disease Loses its most Potent Ally, Fear.” The New           York Times. March 26, 2006.

 

9) Roumeliotis, Gregory. “Researchers give 'one-off vaccines' a shot” March 20, 2006.             http://www.in-            pharmatechnologist.com/

 

10) Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA. (2006)        Compulsory Vaccination and Conscientious or Philosophical Exemptions: past,    present and future. The Lancet. 367: 436-442.

 

11)  Salmon DA, Sapsin JW, Teret S, Jacobs RF, Thompson JW, Ryan K, Halsey N. (2005)  Public Health and the Politics of School Immunization Requirements.   American Journal of Public Health. 95(5): 778-783.

 

12)  Offit PA, Jew RK. (2003) Addressing Parents’ Concerns: Do Vaccines Contain    Harmful Preservatives, Adjuvants, Additives, or Residuals?  Pediatrics. 112:         1394-1397.

 

13) May T. (2005) Public Communication, Risk Perception, and the Viability of            Preventative Vaccination Against Communicable Diseases Bioethics. 19(4): 407-            421.

 

14) Salmon DA, Haber M, Gangarosa EJ, Phillips L, Smith NJ, and Chen RT (1999).   Health Consequences of Religious and Philosophical Exemptions From      Immunization Laws: Individual and Societal Risk of Measles. JAMA 282:47-53

 

15)  Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, and Hoffman RE      (2000). Individual and Community Risks of Measles and Pertussis Associated        With Personal Exemptions to Immunization. JAMA 284:3145-3150.

 

16)  Fair E, Murphy TV, Golaz A, Wharton M. (2002) Philosophic Objection to           Vaccination as a Risk for Tetanus Among Children Younger Than 15 Years          Pediatrics 109(1): e2.

 

17)  Eldred BE, Dean AJ, McGuire TM, Nash AL. (2006) Vaccine components and    constituents: responding to consumer concerns. The Medical Journal of Australia.           184 (4): 170-175

 

18)  Murch SH, Anthony A, Casson DH, et al. (2004) Retraction of an interpretation.   Lancet. 363: 750.

 

19)  Parker SK, Schwartz B, Todd J, Pickering LK. (2004) Thimerosal-containing       vaccines and autistic spectrum disorder: a critical review of published original   data. Pediatrics 114: 793-804.

 

20)  Centers for Disease Control. July 2005. Guidelines for Vaccinating Pregnant Women             http://www.cdc.gov/nip/publications/preg_guide.htm

 

21)  "Deadly Immunity" Kennedy Jr., Robert F. Rolling Stone. June 20, 2005.   rollingstone.com

22)  Kennedy Jr., Robert F. "Autism, Mercury, and Politics" The Boston Globe. July 1,             2005.   boston.com

23)  Ropeik, David. "Commentary: Connection Between Vaccines and Autism." National          Public Radio, Morning Edition, 6/11/04, npr.org

 

24)  Centers for Disease Control. ”Why Immunize?” July 11, 2003.       http://www.cdc.gov/nip/publications/fs/gen/Why.htm

 

25)  Harris, Gardiner. “5 Cases of Polio in Amish Group Raise New Fears.” The           NewYork Times. November 8, 2005.

 

26) Smithsonian National Museum of American History. “What ever happened to Polio?”

            April 20, 2006. http://americanhistory.si.edu/polio/virusvaccine/history.htm

 

27) Harris, Fraser. “Edward Jenner and Vaccination.” April 20, 2006.              http://www.worldwideschool.org/library/books/tech/medicine/EdwardJennerAnd           Vaccination/Chap1.html

 

28)  “History of Immunology.” April 20, 2006.              http://blue.butler.edu/~jshellha/323/History.html

 

29) Centers for Disease Control. “What you need to know about Vaccine Information   Statements.” April 20, 2006.             http://www.immunizeseniors.org/website/downloads/instr00.pdf

 

30) National Vaccine Information Center. “The Vaccine Injury Compensation Program.”           April 20, 2006. http://www.909shot.com/Issues/Comp_Summary.htm

 

31) National Vaccine Information Center. “Federal Bills and State Bills” April 20, 2006.             http://www.909shot.com/legs.htm        

 

32) Stuebing, Beth “Reportable Infectious Diseases in the United States and Specifically            Ohio.” April 22, 2006.

             http://www.case.edu/med/epidbio/mphp439/Reportable_Diseases.htm


33) Hittt, Miranda. “Mumps Epidemic Hits Iowa : Iowa Notes 300 Confirmed or          Probable Cases of Mumps” WebMD Medical News. April 4, 2006

            http://www.webmd.com/content/article/120/113902.htm

 

34) Welte, Melanie S. “Mumps epidemic spreading across Iowa

            Star Tribune. March 31, 2006. http://www.startribune.com/484/story/343474.html

 

35) International AIDS Vaccine Initiative “Progress toward an AIDS vaccine since 2000”         April 21, 2006. http://www.iavi.org/viewpage.cfm?aid=13

 

36) Cancer Research UK. “Cervical Cancer Vaccine” March 20, 2006.

            http://www.cancerhelp.org.uk/help/default.asp?page=16024#vac

 

37)  Rubin, Rita.  “HPV vaccines show progress, but need for booster in question” USA           Today. April 4, 2006. http://www.usatoday.com/news/health/2006-04-05-hpv-          vaccines_x.htm

 

38) Centers for Disease Control “Key Facts About Avian Influenza (Bird Flu) and Avian           Influenza A (H5N1) Virus” February 7, 2006. http://www.cdc.gov/flu/avian/gen-     info/facts.htm