Pharmacy & Therapeutics - September 2008 - (Page 542)

HEALTH CARE AND LAW Vaccine Declinations Present New Challenges for Public Health Robert I. Field, JD, MPH, PhD Dr. Field chairs the Department of Health Policy and Public Health and is Professor of Health Policy at University of the Sciences in Philadelphia, Pennsylvania. autism link in 2004.2 Several of the most prestigious medical organizations in world, including the Institute of Medicine, the World Health Organization, the Food and Drug Administration, and the American Academy of Pediatrics, have explicitly rejected the possibility of a link. Vaccine advocates also note that the use of thimerosal in vaccines was almost entirely discontinued in 2001, yet autism rates have remained unchanged. Nevertheless, concern that vaccines can cause autism remains widespread. Skeptics of vaccines point out that rates of autism have been rising for several years while at the same time the list of recommended childhood immunizations has continued to grow. Autism often first appears in children who are about the same age at which several recommended vaccines are administered. Many parents find this set of facts too suggestive to ignore, even in the absence of actual scientific support of a causal connection. Some conjecture that if thimerosal is not the culprit, then it is the multiple vaccinations that overload the immune system; however, corroborating data are lacking to support this conclusion as well. nized individuals can fall below the threshold for herd immunity, which gives the infectious organism a chance to reestablish itself. Children are not the only ones avoiding recommended vaccinations. Studies indicate that many health care workers are declining routine immunization against seasonal influenza.4 This group includes many hospital-based nurses, who can transmit the disease to susceptible patients, often with lethal con sequences. Although these vaccine decliners are clearly not motivated by concerns about developing autism, they often express more general qualms about vaccine risks. Over the past century, it would be safe to say that vaccines have saved more lives than any other medical technology. The first vaccine was developed more than 200 years ago to prevent smallpox. Since then, dozens of new vaccines have enabled millions of people to avoid devastating diseases and have prevented untold amounts of human suffering. Public health officials consider increased rates of immunization and the development of new vaccines as keys to safeguarding the health of populations in the future. Recently, however, a contrary trend has arisen. Reports of risks associated with vaccines have led a growing number of people to decline inoculations, both for themselves and on behalf of their children. These changing attitudes may have profound consequences for public health efforts going forward. Recent Legal Actions May Embolden Vaccine Decliners A decision in the fall of 2007 by the National Vaccine Injury Compensation Program, a federal fund that reimburses families for vaccine-related harm, may accelerate the trend toward vaccine declinations.5 The program awarded compensation to a nine-year-old girl, Hannah Poling, for symptoms of autism related to a rare mitochondrial disorder based on the possibility that her condition had been exacerbated by a series of routine immunizations. Vaccine skeptics consider this award a concession by the government that vaccines can cause autism, and they have promised to rely on this decision in future cases. However, government officials, including Dr. Julie L. Gerberding, Director of the Centers for Disease Control and Prevention (CDC), have vehemently rejected that interpretation. The fund is structured on a no-fault basis and deliberately resolves scientific uncertainties in favor of claimants. Because the course of Hannah’s condition is extremely variable and unpredictable, the program refused to rule out the possibility that her condition was worsened by vaccinations, but it did not affirmatively endorse the conclusion that the vaccines were an underlying cause. In other legal actions, the U.S. Federal Court of Claims is considering three Vaccines and Autism: Is There a Relationship? Like all pharmaceutical products, vaccines present some level of unavoidable risk. For example, eggs are used in the production of many vaccines, and this can create a hazard for patients with egg allergies. A more far-reaching concern followed publication of an article in The Lancet in 1998 suggesting a link between the vaccine for measles, mumps, and rubella (MMR) and the development of autism in children.1 The link was based on the hypothesized effect of thimerosal, a mercury-based preservative used in that vaccine and in others. The weight of subsequent scientific opinion against this suggestion has been considerable, with numerous research studies having failed to produce any evidence to confirm it. Moreover, 10 of the 13 authors of the Lancet article published a retraction of the suggested vaccine– Vaccine Declinations And Community Risk Concerns about the safety of vaccines have led many parents to decline recommended inoculations for their children. As isolated cases, such declinations pose little risk to the children involved or to the communities in which they live. This is because widespread vaccination can produce a phenomenon known as “herd immunity,” which protects everyone, even unvaccinated persons.3 Most infectious agents require a sufficient number of susceptible hosts to maintain their presence in a population. After a threshold of immunized individuals is achieved, generally in the range of 90%, the infectious agent disappears entirely, and even those without immunity are safe. However, when a sufficient number of members of a community forgo vaccination, the percentage of immu- 542 P&T® • September 2008 • Vol. 33 No. 9

Table of Contents Feed for the Digital Edition of Pharmacy & Therapeutics - September 2008

Pharmacy & Therapeutics - September 2008 Contents Editorial Medication Errors Prescription: Washington New Drugs/Drug News/New Medical Devices Drug Forecast Effect of Prescription Copays on Adherence and Treatment Failure with Oral Antidiabetic Medications Vaccine Declinations Present New Challenges for Public Health Universal Health Care in America Digestive Disease Week and American Diabetes Association Pharmaceutical Approval Update

Pharmacy & Therapeutics - September 2008

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