Wednesday, January 28, 2015

Can the Vaccine Wars Get Any Weirder? Father of (Unvaccinated) Boy With Leukemia Asks California School Officials to Bar Unvaccinated Students/ NY Times

The son has been treated for leukemia and is still immune-compromised, has not received the live measles vaccine, as it might be dangerous for him.

So the dad wants his child protected by forcing everyone else in the school to be vaccinated, to create a safe cocoon (at least while in school) for his child. Dad acknowledges his child will still be at risk everywhere else.

Except--there is another little boy in the same class who also has a medical condition that precludes vaccination.  Where does that leave dad?

Maybe someone should tell the dad that when kids get live virus vaccinations they sometimes excrete the live virus and pass it on to their schoolmates, "vaccinating" them inadvertently. For a virus like polio, there is often increased virulence when spread this way. This is what caused all US polio infections for years. That is why live polio vaccine is no longer used in the US. But live measles, mumps, rubella, flu, chickenpox, rotavirus and some other vaccines are still used, and a crash vaccine program at the school might expose his child to live vaccine viruses.

Maybe someone should tell dad that no one has died from measles in the US for at least ten years.

The county health officer brought sanity to the issue.  He pointed out that there has not been a single case of measles in Marin county, so in fact, there is no issue. From the NYTimes. And below is an abstract of an expert group opinion paper on this subject.

 2014 Apr;133(4):961-6. doi: 10.1016/j.jaci.2013.11.043. Epub 2014 Feb 28.

Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts.


The present uncertainty of which live viral or bacterial vaccines can be given to immunodeficient patients and the growing neglect of societal adherence to routine immunizations has prompted the Medical Advisory Committee of the Immune Deficiency Foundation to issue recommendations based on published literature and the collective experience of the committee members. These recommendations address the concern for immunodeficient patients acquiring infections from healthy subjects who have not been immunized or who are shedding live vaccine-derived viral or bacterial organisms. Such transmission of infectious agents can occur within the hospital, clinic, or home or at any public gathering. Collectively, we define this type of transmission as close-contact spread of infectious disease that is particularly relevant in patients with impaired immunity who might have an infection when exposed to subjects carrying vaccine-preventable infectious diseases or who have recently received a live vaccine. Immunodeficient patients who have received therapeutic hematopoietic stem transplantation are also at risk during the time when immune reconstitution is incomplete or while they are receiving immunosuppressive agents to prevent or treat graft-versus-host disease. This review recommends the general education of what is known about vaccine-preventable or vaccine-derived diseases being spread to immunodeficient patients at risk for close-contact spread of infection and describes the relative risks for a child with severe immunodeficiency. The review also recommends a balance between the need to protect vulnerable subjects and their social needs to integrate into society, attend school, and benefit from peer education.

Sunday, January 25, 2015

WHO mulls reforms to repair reputation after bungling Ebola; must guard against donor fatigue/ AP, BBC, Businessweek

From the AP:
GENEVA — The World Health Organization is debating how to reform itself after botching the response to the Ebola outbreak, a sluggish performance that experts say cost thousands of lives.
On Sunday, WHO's executive board planned to discuss proposals that could radically transform the United Nations health agency in response to sharp criticism over its handling of the West Africa epidemic. 
"The Ebola outbreak points to the need for urgent change," said Dr. Margaret Chan, WHO's director-general. She acknowledged that WHO was too slow to grasp the significance of the Ebola outbreak, which is estimated to have killed more than 8,600 people, mainly in Guinea, Liberia and Sierra Leone.
Critics say the kinds of reform being debated are long overdue.    
"The groundswell of dissatisfaction and lack of trust in WHO over Ebola has reached such a crescendo that unless there is fundamental reform, I think we might lose confidence in WHO for a generation," said Lawrence Gostin, director of the WHO Collaborating Center on Public Health Law and Human Rights at Georgetown University...
But fear not.  WHO already has the solution: send money. From Bloomberg Businessweek:
The World Health Organization proposed creating a special fund to respond to outbreaks such as Ebola and the establishment of a global health emergency workforce after the organization acknowledged mis-steps in its response to the epidemic.    
The WHO’s executive board agreed “in principle” to establish a contingency fund in a draft resolution at a meeting in Geneva Sunday. Director General Margaret Chan should take “immediate steps” to establish a public-health reserve workforce that can be promptly deployed in response to health emergencies, the board said.    
The WHO was too slow to respond to the Ebola outbreak, which it says has killed 8,675 people in Liberia, Sierra Leone and Guinea. The epidemic highlights the need for “urgent change” at the United Nations agency, Chan said in opening remarks to the board meeting.     
The WHO “did not have the systems and capacities in place to respond to a health emergency that was both severe and sustained,” Chan said...
But why did WHO deny Ebola was a major problem for 3 months after it had been notified of the outbreak? Isn't that the biggest problem for WHO to understand and fix, wrt future outbreaks, both at WHO offices in Africa and Geneva? 

Ebola appears to be halting, and the West doesn't even know why. This is something WHO ought to be on top of, since it signifies major gaps in understanding of Ebola spreads, and appears now to be controlled by nature!  (Are the bulk of exposed but unaffected Africans immune from inapparent infections?  Are they genetically protected?)

But instead of focusing on why the epidemic rapidly flared and as rapidly is extinguishing, WHO has other concerns, like the dreaded donor fatigue. From BBC:
...Liberia announced on Friday that it was down to just five confirmed (Ebola) cases - there were 500 a week in September. Guinea and Sierra Leone have both also experienced falls in infection rates.
Dr Chan said the worst-case scenario had been avoided, but warned: "We must maintain the momentum and guard against complacency and donor fatigue."

Saturday, January 24, 2015

Why do so few European countries recommend flu shots for children?/

The data below come from:  Eurosurveillance, Volume 19, Issue 16, 24 April 2014
Few European countries recommend flu shots for children, and  only 3 suggest them for all children above 6 months old, as does the US. Most countries recommend them only for elders, the group most likely to die from flu.  However, elders are the least likely age group to develop meaningful immunity from the shots.

A 2012 Cochrane review of flu vaccination in children had this to say:
Extensive evidence of reporting bias of safety outcomes from trials of live attenuated influenza vaccines (LAIVs) impeded meaningful analysis... 
It was surprising to find only one study of inactivated vaccine in children under two years, given current recommendations to vaccinate healthy children from six months of age in the USA, Canada, parts of Europe and Australia. If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes, and directly comparing vaccine types are urgently required... 
The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in the light of this finding.”
Here is the table of how European countries recommend flu vaccines:

Remember that most of the countries listed have better mortality rates and better health indices, in general, than the US. Most have national health programs.  Most of these health departments probably know that the benefit of flu vaccine is marginal in healthy children, and the risk is unknown (due to poor quality data). This year, CDC estimated flu vaccine efficacy to be 23%, based on the following:  of a group that did not get flu, 56% were vaccinated, while in a group that got flu, 49% were vaccinated.

But CDC acknowledges the data are not terribly reliable:
The findings in this report are subject to at least four limitations. First, these early VE estimates are imprecise for persons aged ≥18 years, limiting ability to detect statistically significant protection against influenza illness resulting in visits to health care providers; larger numbers of enrollees are required to detect significant protection when VE is low. Second, the VE estimates in this report are limited to the prevention of outpatient medical visits, rather than more severe illness outcomes, such as hospitalization or death; studies are being conducted during the 2014–15 season to estimate VE against more severe illness outcomes. Third, vaccination status included self-report at four of five sites, and dates of vaccination and vaccine formulation were available only for persons with documented vaccination obtained from medical records or immunization registries; complete vaccination data are needed to verify vaccination status and estimate VE for different vaccine formulations. Finally, future interim estimates and end-of-season VE estimates could differ from current estimates as additional patient data become available or if there is a change in circulating viruses late in the season.
So just in case, CDC recommends you get a flu shot and a dose of Tamiflu as soon as you get sick.