Vaccine Preventable Diseases: Vaccine Hesitancy & Infection Control Implications

1. Vaccine Preventable Diseases: Vaccine Hesitancy & Infection Control Implications • Monica Pierce-Charlton, MT (ASCP), MBA, CIC • Ankhi Dutta, MD MPH

2. Goals and Objectives • Discuss the epidemiology of vaccine preventable diseases • Discuss the infection control implications related to these diseases • Describe the resources available for vaccine education and addressing vaccine hesitancy

3. Case #1 • 6 week old male presented to WL Urgent Care with multiple vesicular lesions that are ruptured and crusting over. • He is afebrile and feeding well. • Mom’s prenatal labs were negative • Father has lesions on his neck and upper back that developed 2 weeks ago, likely spider bite, not treated • 5 year old brother and 2 year old sister: well and fully vaccinated

4. Case #1 • Well appearing child, all normal examination except for rash • EC course: blood, urine and CSF studies done in the EC.Labs otherwise normal. • Cultures and PCR sent from the lesion.

5. Case #1

6. Case #1 Decision was made to admit the patient. What is your differential diagnosis? What isolation would you place the infant on? • Contact • Contact and Droplet • Airborne • 1&3

7. Case #1 On admission to Acute Care • Patient is placed on Contact Isolation 7/8/2018 • That evening • HSV is negative • VZV is positive • Patient is placed on Airborne Isolation 7/10/2018

8. What does this rash look like?

9. Exposure Work-up

10. Exposure Work-up Emergency Room • Request list of patients that were in the EC • Total of 54 patients needing review • 19 needed further review • 5 needed further action Continued follow-up

11. Exposure Work-up Acute Care • Request list of patients that were on Acute Care • Total of 15 patients needing review • Of those 7 needed further action • Follow-up exposure workup required

12. Exposure Work-up Staff Exposure • Request a list staff and providers • Notify Occupational Health • 22 staff and providers

13. Case Study #2 • 2 wk old F presents with cough x 1 week and difficulty feeding. • When laying down, chokes, turns blue– multiple episodes. • Not always associated with feeds. • Afebrile, normal voids and stools. • No fast breathing as per mom. • Admitted for monitoring and further evaluation.

14. Case #2 • Respiratory viral panel sent • Pertussis PCR sent What isolation would you place the patient in? • Contact • Contact and Droplet • Airborne • Droplet

15. Case # 2 • Patient initially placed on Contact isolation only • Later, isolation changed to Droplet only • Pertussis PCR +

16. What would you recommend for the household contacts? • Vaccinate with Dtap or Tdap per age group • Start azithromycin • 1&2 • None of the above

17. Case #2 (continued) • Patient gets readmitted one week later with cough and “turning blue” again • Respiratory viral panel and Pertussis PCR sent What would your recommendation for isolation be this time? • Contact • Contact and Droplet • Airborne • Droplet

18. What would your recommendation be for the exposed staff? 1) Check vaccine status 2) Start azithromycin (Post exposure prophylaxis: PEP) 3) Monitor daily for 21 days 4) Excuse them from work if symptomatic 5) All of the above

19. Exposure in the unit • Check vaccination status • PEP is recommended for HCP who work in high-risk areas OR suctioned/intubated/performed close oral exam without a mask (even if immunized with Tdap) • If not taking PEP, monitor daily x 21 days • HCP with symptoms of pertussis or URI, should be excluded from work for at least the first 5 days of the recommended antimicrobial therapy.

20. Immunization Successes

24. Re-emerging Vaccine Preventable Diseases

29. Vaccination Coverage for MMR and Exemption Rates Among Children in Kindergarten — United States, 2017–18 School Year

30. The history behind it and some myths…

31. 1998: Wakefield reported 12 children with a new syndrome of enterocolitis and regressive autism with onset of days after receiving MMR • Hypothesized that combination MMR damaged the intestine allowing encephalopathic proteins to cross to the bloodstream and enter the brain • At a press conference Wakefield sensationally called for MMR to be separated into 3 monovalent vaccines

32. The other group believed thimersol in vaccines caused autism • The two groups came together • Since then a plethora of papers in well reputed journals showed that there was no link for either • In 2001: IOM reviewed data and announced there was no link • In 2004: Co-authors from Wakefield’s papers withdrew support from, Lancet withdrew paper • In 2007: Wakefield’s penalized for professional misconduct

33. Thimersol • Thimersol is ethyl mercury; Natural mercury is methyl mercury • Added to vials of vaccine that contain more than one dose to prevent contamination and growth of potentially harmful bacteria (currently only in multidose influenza vaccine. • Clinical features of mercury poisoning differs from autism

34. Aluminum • Enhances immune response • Present in tiny amounts: in the first 6 mo of life • 4mg in vaccines • 10mg in breast milk • 40mg in formula • Most is eliminated quickly

35. Some vaccines use fetal cells • Fetal cells are used to make 4 vaccines • rubella, varicella, hepatitis A, rabies • Isolated from two elective abortions in the 1960s • Used because • Viruses require cells to grow • Human cells better support growth of human viruses • Fetal cells are virtually immortal • The use of vaccines made in this way have been approved by major religions

36. Vaccines do not overload the immune system: • Immune system can respond to multiple antigens simultaneously • Immune system is not overwhelmed by vaccines • Mild or moderate illness does not interfere with the ability of immune system to respond to vaccines • Immunized children do not have a higher rate of other infections in the weeks after immunization • Fewer antigens are encountered in vaccines today than 40 years ago

37. Understanding “vaccine hesitancy”

38. Contributing Factors • Knowledge and Information sources • Experiences • Role of health care provider • Role of public health system • Social norm and Responsibility • Trust • Religious beliefs

40. Uninformed but Educable” • Influenced by skeptical friends/relatives • Unsure, looking for information • “Misinformed but Correctable” • Educated by TV, magazines, “University of Google” • Have only heard anti-vaccine messages • “Well-read and Open-minded” • Need help to assess merits of the arguments • “Convinced and Contented” • Convinced vaccines are bad but go to provider to “prove” they are open-minded • “Committed and Missionary” • Card-carrying anti-vaccine activists who try and convert you!

41. Who do parent’s trust?

42. Talking to parents about vaccines

44. DO NOTS: • Righting Reflex : Using too much information and persuasion • Missing cues • Using jargons • Discrediting information source • Overstating vaccine safety

45. TO DOs: • Listen, evaluate and categorize • Recognize legitimate concerns • Provide a context • Refute misinformation • Provide valid information

46. Recognize that it is the parent’s decision • Educate about potential consequences • Make a clear recommendation

48. Questions?