Vaccine-Preventable Disease Prevention and Control in the Era of

the Anti-Vaccination Movement

Payton Revolt, Vaccine-Preventable Disease EpidemiologistEpidemiology Resource Center

Jill King, Immunizations Deputy DirectorImmunizations Division

Overview• Vaccine controversies• Vaccine hesitancy• Impact of vaccine hesitancy• Vaccine communication• Immunization Series Completion and

County Rate Assessments• School Requirements

Vaccine Controversies

MMR and Autism

• In 1998, Lancet published a small study of 12 children by Andrew Wakefield and colleagues asserting a link between bowel disease, autism and MMR vaccine based on parental report alone

• Wakefield then implicated MMR vaccine during a subsequent press conference about the article, stating it should not be used until its safety could be further investigated

• Fraudulent ClaimsoNo objective link between MMR vaccine and

regressive autismo Lab reports failing to find a link were buried

• Conflict of Interesto Attorney representing children with autismo Application filed to patent single antigen vaccineoNot revealed to Lancet or co-authors

Other Vaccine Concerns• Harmful chemicals (e.g.

thimerosal/mercury, aluminum, etc.)• Too many, too soon (immune system

overload)• Money source for pharmaceutical

companies• Diseases no longer common• Egg and embryo cells

Vaccine Information?

• National Vaccine Information Center• Think Twice Global Vaccine Institute• Parents Requesting Information on

Vaccines• Vaccine Information Network

About ½ of all websites pulled up during a routine Internet search are anti-vaccine

Vaccine Hesitancy• Delay in acceptance or refusal

of vaccination despite availability of vaccination services

• Variety of factors

Image by iStock

Impact of Vaccine Hesitancy

0

200

400

600

800

1000

1200

1400

2010 2012 2014 2016 2018

NU

MBE

R O

F CA

SES

YEAR

Measles Cases

63

220

55

187

667

188

86 120

1250

372

Source: Centers for Disease Control and Prevention

Number of Measles Cases Reported by Year2010-2019** (as of October 3, 2019)

Measles Outbreaks Nationwide

2014667 Cases

2015188 Cases

201686 Cases

2017120 Cases

2018372 Cases

23 outbreaks nationwide;large outbreak among Ohio

Amish population (383 cases)

Multistate outbreak linked to California amusement park

Large outbreak among Minnesota Somali community

(75 cases)

Large outbreak among NY and NJ Orthodox Jewish community

(over 200 cases)

Source: CDC. Data are preliminary and subject to change.

Real-world Consequences

Source: Hall V, Banerjee E, Kenyon C, et al. Measles Outbreak – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep 2017; 66:713-717.

Declining Vaccination Rates

Source: Hall V, Banerjee E, Kenyon C, et al. Measles Outbreak – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep 2017; 66:713-717.

“MMWR vaccination coverage rates declined among Minnesota’s Somali-American community members starting with the 2008 birth-year cohort. The decline in vaccination coverage was in response to concerns about autism, the perceived increased rates of autism in the Somali-American community, and the misunderstanding that autism was related to the MMR vaccine.”

Real-world Consequences of Vaccine Misinformation

Source: Hall V, Banerjee E, Kenyon C, et al. Measles Outbreak – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep 2017; 66:713-717.

• From January 1 to October 3, 1,250 individual cases of measles have been confirmed in 31 states.

• Orthodox Jewish communities• Low vaccination coverage• Tight-knit communities

• Linked to travel to Israel, Ukraine, and the Philippines

• Vaccine hesitancies

2019 Measles Outbreak

Image Source: The New York Times. Jan. 17, 2019. https://www.nytimes.com/2019/01/17/nyregion/measles-outbreak-jews-nyc.html

Vaccine Communication

“Good” Messaging• People respond better to messages that:

• Are short and to the point• Give concrete answers• Are relatable• Give actions the reader can take• Are easy to read and understand• Do not attack or shame them for a belief they

hold

What’s Gone Wrong with Vaccine Messaging?

• Problems in patient-provider communication• Lack of strong provider recommendation• Lack of preparation in responding to common

questions• Public demonization of particular views• Social media messaging• Too much jargon and data

What to Do?• Utilize most trusted sources of information• Change the focus of messaging• Make health literacy accessible:

• Use plain language• Start early

• Train providers on how to have successful vaccine conversations with all types of patients

CDC Provider Vaccination Communication Guidance

Image source: Centers for Disease Control and Prevention (CDC).

CDC Parent Resources

Image source: Centers for Disease Control and Prevention (CDC).

Immunization Series Completion and County Rate Assessments

Immunization Schedules• Advisory Committee for Immunization Practices

(ACIP) publishes the schedule annually

Immunization Series Completion• The ACIP recommends children 19 to 35 months to

complete the 4:3:1:3:3:1:4 series. This consists of the following vaccines:• at least four doses of diphtheria-tetanus-acellular pertussis

(DTaP)• at least three doses of polio• at least one dose of measles-mumps-rubella (MMR)• at least three of Haemophilus influenzae B (Hib)• at least three doses of hepatitis B• at least one dose of varicella antigens• at least 4 doses of pneumococcal conjugate vaccine

(PCV)

Heathy People 2020• Healthy People 2020 objectives include:

• Targets for reducing vaccine-preventable disease rates

• Increase vaccine coverage• To reach these objectives, the Immunization

Division annually reports the immunization rates both statewide and on a county basis

County Rate Assessments• The immunization rate for Indiana is 70%

for completion of the 4:3:1:3:3:1:4 series at 19-35 months • Nearly 64% of our counties were at or above

the rate of 70%.

Recommendations• Ensure that health-care providers administer

recommended vaccinations and use each visit as an opportunity to ensure each child is fully vaccinated on time with every recommended vaccine

• Implement targeted provider education to confirm kids are vaccinated before they fall within 19-35 months of age

• Reducing the number of missed opportunities, and vaccinating at the 15 month appointment would greatly improve vaccination rates as well as number of children who are behind

County Rate Assessment Dashboard

• https://www.in.gov/isdh/26722.htm

School Requirements

School Entry Vaccine Requirements

• Vaccine requirements for school entry are a best-practice and help school communities achieve high levels of protection against vaccine-preventable diseases

• Indiana State Law requires schools to report student immunization coverage data to ISDH every February for kindergarten, sixth grade, and twelfth grade

School Entry Vaccine Requirements

Required Vaccines for School Attendance

Required vs Recommended Vaccines for School Attendance

School Entry Vaccine Requirements

• This year, the ISDH Immunization Division, the Fairbanks School of Public Health at IUPUI, and the Indiana Immunization Coalition (IIC) collaborated to produce school vaccination coverage reports for each public school to demonstrate their compliance with state requirements

• This effort is intended to help schools define their under-vaccinated populations and develop targeted interventions to improve compliance

School Entry Vaccine Requirements

Questions

Indiana State Department of Health 4110/10/2019

Thank you!Jill King, Immunizations Deputy Director

Immunization Divisionjiking@isdh.in.gov

317-233-8460

Payton Revolt, Vaccine-Preventable Disease EpidemiologistEpidemiology Resource Center

prevolt@isdh.in.gov317-233-7277