2 Pharmacovigilance Centre Veneto Region,
3 University of Verona, Diagnostic and Public Health Department, Pharmacology Section
Focus Farmacovigilanza has already covered the phenomenon of vaccination drop and its possible solutions.1 This article aims at discussing the consequences for public health caused by the choice of not-vaccinating. After all, adverse-reaction reports do not regard the health of a single person only, but allow to retrieve precious data to update the safety profile of a drug.
The decrease of vaccinal covers does not represent a risk just for the single child, but affects the whole community because of the possible return of diseases that we considered extinct. For measles, vaccinal cover must reach at least 95% to eliminate the disease and it can vary depending on the contagiousness of the disease. In a complex era like ours, we cannot afford to look at health limiting ourselves to the proximal determinants, but we need to look at the distal determinants. Epigenetics has become patrimony of doctors and has allowed to overcome the sterile antagonism between genetics and environment, proposing an explanation model that finds determinants of child health in pregnancy or even before.
The campaign “Genitoripiù” (Parentsplus) proposes to approach public health on the basis of those determinants of secure effectiveness for child health:2 abstinence from smoke and alcohol during pregnancy are extremely important for child health, such as reading out loud (“Nati per leggere” - Born to read) to nurture the mind. Within this promotional campaign, vaccination promotion is a practice of demonstrated effectiveness in the whole scientific literature. Every child should be granted access to the best available cures and to the best prevention practices, including all the vaccines that are safe (i.e. not causing too many adverse reactions) and effective (i.e. able to cover against the disease), except being specifically contraindicated.
Although none challenges these principles, for many years we have witnessed the diffusion of suspect and diffidence, or more often doubts and confusion, that translate into a dangerous attitude of “vaccine hesitation”, which has caused a drop in the vaccinal covers.3 This mostly regards diseases with seemingly limited lethality, but with high communicability (requiring much wider cover to grant group protection and avoid epidemics). The vaccine that mostly suffers this condition is the one against measles, mumps and rubella (MMR), which has reached an alarming cover level (86%, minus 4 percentage points in respect to the previous year), with the risk of epidemics right now.
In countertrend, on the other side, are vaccines against diseases with high lethality and low or very low communicability, such as those against the various types of meningitis.4 Besides the sociological considerations on what seems to be an exasperate trend aimed at the individual interest that puts aside the collectivity needs, this remains an unjustified reaction, because the MMR vaccination is “convenient” also for the single person, not just for the community. The seeming benignity of diseases like measles, in fact, is due to the group protective effect ensured by (and retained until now) the high percentage of vaccinated subjects; on the other side, we see the rare but dramatic cases of invasive diseases.
If we consider native populations, not vaccinated, we can verify that whilst to avoid one death from meningococcus B we need to vaccinate hundreds of thousands of children, for the same number of children the MMR vaccine avoids hundreds of deaths, mostly “fragile” subjects, but without excluding people considered perfectly healthy until that moment. And here we are again, back to the initial concept of adverse reactions caused by the non-vaccination, that involve the whole community and not just those who refuse the vaccination. At this regard, it is worthy considering the current strategy for the vaccination against papilloma virus (HPV). At the beginning, it was limited only to girls in pre-puberty age, whilst now it is offered also to boys.5 The extension to boys takes into consideration, among other factors (prevention of anus, penis and oropharynx cancer), the HPV transmission modalities, most frequent from man to woman. When we explain the reasons of the choice to the parents, we underline the importance of vaccinating the males too, even though the womb carcinoma is exclusive of women. We believe this is an effective example of paradigm shift from the health of the single to the health of the community.6
In reality, a wide multitude of parents still have their children vaccinates, but listlessly, with diffidence, often pushed by the emotivity of the moment and the news highlighting dramatic cases of meningitis or a lawsuit from parents whom believe their child has been damaged by a vaccine.7 In this context, some imaginative verdicts, based on the opinions of inadequate consultants, create even more distrust toward science.
We must ask ourselves if we hold the right instruments to answer to these new necessities; not every signal is coherent and, on the other side, we think that some are definitely arguable. We believe that it is right to highlight these last ones, because an attentive reflection could lead to a new fruitful alliance, so that a new era of trust towards this extraordinary vehicle of health and prevention could rise:
- offering 22 different vaccine calendars based on the Region creates confusion and disorientation. We need to harmonize at a national level and avoid regional protagonisms. Besides, if we consider that families often move from one Region to another for work, we risk the paradox that in one Region they might not have to vaccinate their children whilst in another they might have to, besides receiving vaccine offers differing both in numbers and economic cover;
- bad mass media communication, that often discuss the vaccination topic putting on the same level scientific observations and personal opinions of the interviewed guests. Within this perspective, the gut approach, based on emotional perception, always prevails on reason. On the other side, it is not desirable that health professionals exploit death fear to assert their reasons and propose vaccination campaigns in the hit areas, riding the emotional wave of the moment;
- the FNOMCEO (Federazione Nazionale degli Ordini dei Medici Chirurghi e Odontoiatri – National Federation of Medical Doctors and Odontologists) has spoken out against those doctors whom declare themselves “against vaccines”. However, to avoid any problem, it is enough they declare, instead of being against vaccines, to be just scrupulous doctors whom, before proceeding, want to make sure the organism can really “bear” the immunization, and the vaccination can be delayed without any reason;
- the need to improve communication and education of health professionals, the update of surveillance services (of diseases and adverse effects), the punctual evaluation of vaccine programs in use and the guarantee of transparent and univocal introduction processes. A change of route that considers all these aspects is perhaps the only way to retrieve the reduced credibility of vaccinations. In particular, we underline the importance of communicating both with the family and the child when he/she grows up (vaccine against papilloma virus) from the viewpoint of institutional communication;
- threatening to exclude the non-vaccinated children from childhood communities, besides being unfair for the little ones, whom can with no doubts benefit from early inclusion within well-equipped community both from an educational and organizational viewpoint, risks only to exacerbate ideological positions without solving anything, if we consider that the most problems are conceivable for measles and pertussis, against which vaccination is not mandatory;
- the concept of obligation and recommendation should be clarified, since non-mandatory vaccines could appear less important to parents. The term “mandatory” depends only from the input date in the vaccine calendar of a specific vaccine. The most recent vaccines are not mandatory because of a shift of mentality in health promotion. The so-called “gentle push” has substituted the obligation, but it should be better clarified to avoid speculations and false quibbles.
- Focus Farmacovigilanza 2015;91(11):2-4.
- Genitori più: materiale informativo per gli operatori. Verona, 2009.
- Quaderni ACP 2014;21:229-236.
- Quaderni ACP 2015; 22:88-89.
- Quaderni ACP 2016;23:135-136.
- Pediatrics 2016;137:1-9. CDI