Vaccination has greatly reduced the burden of infectious diseases. Only clean water, also considered to be a basic human right, performs better. Paradoxically, a vociferous anti-vaccine lobby thrives today in spite of the undeniable success of vaccination programs against formerly fearsome diseases that are now rare in developed countries. Understandably, vaccine safety gets more public attention than vaccination effectiveness, but independent experts and WHO have shown that vaccines are far safer than therapeutic medicines. Modern research has spurred the development of less reactogenic products, such as acellular pertussis vaccines and rabies vaccines produced in cell culture.
Today, vaccines have an excellent safety record and most “vaccine scares” have been shown to be false alarms. Misguided safety concerns in some developing countries have led to a fall in vaccination coverage, causing the re-emergence of pertussis and measles. However, on the global scale, health organizations continue to distribute vaccines to poorer countries. Thanks to increased access to the measles vaccine internationally, the annual death toll from the disease has fallen from almost 600,000 in 2000 to just 122,000 in 2012, a reduction of 79%. Moreover, 86% of the world’s children received the required 3 doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) in 2015, a coverage level that has been sustained above 85% since 2010. As a result, the number of children who did not receive routine life-saving vaccinations has dropped to an estimated 19.4 million, down from 33.8 million in 2000. However, this progress falls short of global immunization targets. In 2012, all 194 WHO Member States endorsed the Global Vaccine Action Plan (GVAP) and committed to ensuring no one misses out on vital immunizations, with a target of achieving 90% DTP3 vaccination coverage in all countries by 2015 (UNICEF, 2015).
Immunization System in the US
Since 1995, five new vaccines were added to the children’s immunization schedule in the U.S., which the CDC estimated saved thousands of lives. The pneumococcal conjugate vaccine, added in 2001, likely saved 13,000 U.S. lives from 2001 to 2008. And the rotavirus vaccination, added in 2006, is now estimated to prevent 40,000 – 60,000 hospitalizations yearly. The Advisory Committee on Immunization Practices makes scientific recommendations which are generally followed by the federal government, state governments, and private health insurance companies. The public sector still vaccinates many children, including disenfranchised and hard-to-reach patients, and is now also assuming newer functions including assessment of local vaccination rates, policy development, and assurance of immunization delivery.
States in the U.S. mandate immunization, or obtaining exemption, before children enroll in public school. Exemptions are typically for people who have compromised immune systems, allergies to the components used in vaccinations, or strongly held objections. A widespread and growing number of parents claim religious and philosophical beliefs to get vaccination exemptions: researchers have cited these exemptions as contributing to loss of herd immunity within these communities, and hence an increasing number of disease outbreaks.
The American Academy of Pediatrics (AAP) advises physicians to respect the refusal of parents to vaccinate their child after adequate discussion, unless the child is put at significant risk of harm (e.g., during an epidemic, or after a deep and contaminated puncture wound). Under such circumstances, the AAP states that parental refusal of immunization constitutes a form of medical neglect and should be reported to state child protective services agencies.
Developing sound policy now will help to reduce the severity of or altogether stop future outbreaks in the US. There are a myriad of ethical issues regarding such topics as vaccination development, administration, communication, and safety monitoring. We focus on a few key ethical issues concerning childhood immunization in the United States—what we refer to as a “vaccine ethics” approach—and describe how such an approach affects policy development and clinical immunization practice (Hendrix, Sturm, Zimet, & Meslin, 2016).
· Concern About Side Effects. Some parents question the safety of vaccines, think their children are more likely to acquire infectious diseases if vaccinated, and even consider vaccines to cause attention-deficit/hyperactivity disorder and/or autism. Some parents believe that vaccines will weaken their child’s immune system or cause chronic illnesses, such as asthma or multiple sclerosis. Others parents assert that infants and young children should not be vaccinated because their bodies are still immature and fragile (Ventola, 2016).
· Lack of Access Due to Cost and Other Reasons. lack of access to health care due to socioeconomic and other factors (Ventola, 2016).
· Lack of Information. Language barriers and insufficient knowledge about immunizations contribute to reduced immunization adherence (Ventola, 2016).
· Moral or Religious Grounds. Objection to vaccination on the basis of moral or religious grounds is particularly relevant to the Human Papillomavirus (HPV) vaccine. Apparently, there are some misconceptions regarding the HPV vaccine, such as believing that it’s not safe or that it’s only necessary for sexually active teens (Ventola, 2016).
· Parental Refusal of Vaccines. In an effort to reduce childhood morbidity and mortality, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) issues annual recommendations and guidelines for childhood and adolescent immunizations. However, some parents decline or delay vaccinating their children or follow alternative immunization schedules because of medical, religious, philosophical, or socioeconomic reasons. Health care provider-based interventions have been suggested to overcome such vaccine noncompliance, including patient counseling; improving access to vaccinations; maximizing patient office visits; offering combination vaccines; and using electronic medical records (EMRs) and practice alerts. Community- and government-based interventions to improve parent and patient adherence include public education and reminder/recall strategies, financial incentives, and providing alternative venues for vaccination (Ventola, 2016).
The National Immunization Survey
The National Immunization Survey (NIS) provides one such mechanism by systematically collecting data about the structure, process, and outcomes of the U.S. childhood immunization program. This supplement to the American Journal of Preventive Medicine showcases the NIS and highlights several articles that address important topics regarding quality of the immunization program. Thus, the NIS is an important yardstick with which we can measure key aspects of the quality of our national immunization program.
Vaccines for Children
The Vaccines for Children (VFC) program is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay. CDC buys vaccines at a discount and distributes them to grantees—i.e., state health departments and certain local and territorial public health agencies—which in turn distribute them at no charge to those private physicians’ offices and public health clinics registered as VFC providers. VFC program has markedly reduced the cost of vaccinations for patients and providers).
The Vaccine Adverse Event Reporting System (VAERS) is a national vaccine safety surveillance program run by CDC and the Food and Drug Administration (FDA). VAERS serves as an early warning system to detect possible safety issues with U.S. vaccines by collecting information about adverse events (possible side effects or health problems) that occur after vaccination. VAERS is detecting unusual or unexpected patterns of adverse event reporting that might indicate a possible safety problem with a vaccine (VAERS, 2017).
Immunization Systems in Malaysia
In Malaysia, mass vaccination is practiced in public schools. The vaccines may be administered by a school nurse or a team of other medical staff from outside the school. All the children in a given school year are vaccinated as a cohort. For example, children may receive the oral polio vaccine in Year One of primary school (about six or seven years of age), the BCG in Year Six, and the MMR in Form Three of secondary school. Therefore, most people have received their core vaccines by the time they finish secondary school.
Children who did not receive complete primary immunization at the age of 12 months were more likely to be girls, from urban areas, belonging to mothers who do not trust that vaccines can prevent spread of diseases, and received care at private facilities (Ahmad, Jahis, Kuay, Jamaluddin, & Aris, 2017). Immunization coverage for each of the recommended vaccine was high. However, more attention should be given to immunization timeliness to ensure that the benefits of the available vaccines are fully utilized. Immunization timeliness of children of low educated parents, born in large family should be closely monitored (Awadh, A. I., Hassali, M. A., Al-lela, O. Q., & Bux, S. H. (2015).
The School Health Program
The school health program in Malaysia has remained well established since its inception in 1967, with a strong track record. It was initiated as a pilot program and after experience had been gained, it was extended nationwide. Strong school health teams have been created through adequate capacity-building (training and periodic re-training, supportive supervision, etc.), and work is being guided by written standard operating procedures, used nationwide and with infrequent operational changes, thus ensuring universal awareness of procedures. Adequate resources are being provided, including person power, transportation and free vaccines. Incorporating school-based immunization as part of a comprehensive school health program seems to facilitate the acceptance of vaccination as multiple and non-threatening interactions take place between the members of the school health team and the pupils before immunizations are being given. General parent consent obtained upon establishing the individual school health records supports administration of all subsequent vaccinations. AEFI management appears well established.
Optional Vaccines in Malaysia
Most paediatricians will recommend additional or optional vaccinations in addition to the ones mandated by the Ministry of Health. You can choose to administer them to your children, based on your doctor’s advice.
· > 6 weeks : Rotavirus
· > 2 months : Pneumococcal
· > 6 months : Influenza
· > 10 months : Hepatitis A
· > 12 months :Chicken pox
Conducted study was undertaken in a cross-sectional survey at three hospitals in Kuala Lumpur and Selangor, Malaysia, to ascertain the rate of influenza vaccination uptake, the knowledge and attitude of HCWs regarding the influenza vaccine as well as the employers’ policy on encouraging their workers’ influenza vaccination uptake. This study has demonstrated more workers were vaccinated, with a significant proportion of the healthcare workers believed they were vaccinated to protect themselves, while most of those that were not vaccinated claimed they are worried about the safety of the vaccine. Most employers did not have a flu vaccination policy in place. Hence, the need for government to enforce such policy and make annual flu vaccination free and compulsory for all healthcare workers.
Workplace Vaccination Against Influenza
Samad et al. (2006) sonducted a study to evaluate the health and economic benefits of a workplace vaccination program against influenza funded by the employer. Workplace vaccination of healthy adults against influenza had a clear impact on ILI rates, absenteeism and reduced productivity in this Malaysian company. The health benefits translated into financial benefits for the employer, with cost savings significantly outweighing the costs of the vaccination programm.
· School-based vaccine program. The two key informants working in a low income countries said poor timetable planning and documentation were concerns as these could result in missed dosages, decreasing vaccine coverage and overall program success
· Low Level of Awareness. Pathmanathan and Lakshmanan (2014) stated that the rate of Hepatitis B infection is becoming a growing concern where approximately 1.1 million people are chronically infected with this virus. However, Overall, the level of awareness and knowledge of hepatitis B is low. Each of the three demographic characteristics such as age group, ethnic group and educational qualification are a predictive factor. This low level of awareness and knowledge should be improved through health education and frequent vaccination programs on Hepatitis B among the public; especially in Puchong, Malaysia (Pathmanathan, & Lakshmanan, 2014).
· Vaccination Refusal. The increase in Muslim parents’ refusal and hesitancy to accept childhood vaccination was identified as one of the contributing factors in the increase of vaccine-preventable diseases cases in countries such as Afghanistan, Malaysia and Pakistan. The spread of inaccurate and irresponsible information by the anti-vaccination movement may inflict more harm than good on Muslim communities. To curb this issue, health authorities in Pakistan and Malaysia have resorted to imposing strict punishments on parents who refuse to allow their children to be vaccinated. Information addressing religious concerns such as the halal issue must be made priority and communicated well to the general public, encouraging not only the acceptance of vaccinations but motivating communities to play an active role in promoting vaccination. Local government of the affected region need to work towards creating awareness among Muslim parents that vaccinations are a preventative public health strategy that has been practiced and acknowledged by many doctors of all faiths (Ahmed et el., 2017).
· Parents’ Knowledge. The educational intervention used in this study focused on improving parents’ knowledge about childhood immunization in Malaysia and has brought about a significant positive change in their knowledge about childhood immunization, compared with the baseline results.
· Other Factors. Multivariable logistic regression analyses model revealed that factors significantly associated with complete immunization coverage were ethnicity, occupation of the mother, head of household’s education level, and head of household’s occupation. While sex, citizenship, household income, mother’s age, and marital status were not significantly associated with complete immunization coverage (Lim et el., 2017).
Global Immunization Vision and Strategy
In response to challenges in global immunization, WHO and UNICEF developed the Global Immunization Vision and Strategy (GIVS). Launched in 2006, GIVS is the first ever ten-year Framework aimed at controlling morbidity and mortality from vaccine-preventable diseases and helping countries to immunize more people, from infants to seniors, with a greater range of vaccines (WHO, 2011).
According to WHO (2011), GIVS has four main aims:
· to immunize more people against more diseases;
· to introduce a range of newly available vaccines and technologies;
· to integrate other critical health interventions with immunization; and
· to manage vaccination programs within the context of global interdependence.
CDC’s Strategic Framework for Global Immunization 2016-2020, is built around five interconnected goals: an overarching goal to improve global health impacts; three goals to increase the amount of people reached by strengthening country-owned immunization programs; and CDC’s foundational goal of providing evidence for effective policy and program implementation (CDC, 2016).
Global Policy Recommendation
In developing and formulating policy recommendations, WHO considers factors in addition to the benefit – risk assessment performed by regulators, e.g. important contextual elements such as the feasibility of implementation, epidemiological factors that influence performance of the vaccine, the value of the vaccine in the context of other control measures, and the likely cost – effectiveness of the intervention in different settings (WHO, 2017).
CDC (2016) https://www.cdc.gov/globalhealth/immunization/framework.html
WHO (2017) http://www.who.int/immunization/policy/WHO_vaccine_development_policy.pdf?ua=1
WHO (2011). http://www.who.int/immunization/givs/en/
UNICEF (2015) https://www.unicef.org/immunization/files/unicef-who-immunization-coverage-2015.pdf
VAERS (2017). https://vaers.hhs.gov/
Ventola, C. L. (2016). Immunization in the United States: Recommendations, Barriers, and Measures to Improve Compliance: Part 1: Childhood Vaccinations. Pharmacy and Therapeutics, 41(7), 426–436.
Ahmad, N. A., Jahis, R., Kuay, L. K., Jamaluddin, R., & Aris, T. (2017). Primary Immunization among Children in Malaysia: Reasons for Incomplete Vaccination. Journal of Vaccines & Vaccination, 8(3), 1-8.
Awadh, A. I., Hassali, M. A., Al-lela, O. Q., & Bux, S. H. (2015). Factors Affecting Parents’ Knowledge And Practice About Childhood Immunization: Experience From Malaysia. Value in Health, 18(3), A104-A105.
Pathmanathan, H., & Lakshmanan, P. (2014). Assessment of awareness and knowledge of hepatitis B among the residents of Puchong, Malaysia. Tropical Journal of Pharmaceutical Research, 13(10), 1719-1724.
Ahmed, A., Lee, K. S., Bukhsh, A., Al-Worafi, Y. M., Sarker, M. M. R., Ming, L. C., & Khan, T. M. (2017). Outbreak of vaccine-preventable diseases in Muslim majority countries. Journal of infection and public health.
Lim, K. K., Chan, Y. Y., Ani, A. N., Rohani, J., Norfadhilah, Z. S., & Santhi, M. R. (2017). Complete immunization coverage and its determinants among children in Malaysia: findings from the National Health and Morbidity Survey (NHMS) 2016. Public health, 153, 52-57.
Samad, A. H., Usul, M. H., Zakaria, D., Ismail, R., Tasset-Tisseau, A., Baron-Papillon, F., & Follet, A. (2006). Workplace vaccination against influenza in Malaysia: does the employer benefit?. Journal of occupational health, 48(1), 1-10.
Hendrix, K. S., Sturm, L. A., Zimet, G. D., & Meslin, E. M. (2016). Ethics and Childhood Vaccination Policy in the United States. American Journal of Public Health, 106(2), 273–278. http://doi.org/10.2105/AJPH.2015.302952
The post Vaccination has greatly reduced the burden of infectious diseases. Only clean water, also considered to be a basic human right, performs better. appeared first on Infinite Essays.