Q&A: NFID director discusses vaccine research, ways to address hesitancy

William Schaffner

WHO estimates that vaccines avert 2 to 3 million deaths from diphtheria, tetanus, pertussis and measles worldwide each year. According to the CDC, however, only 72% of children between the ages of 19 and 35 months in the United States have completed the recommended immunization schedule for these diseases, as well as polio, mumps, rubella, hepatitis B and chickenpox. Influenza vaccination rates in the U.S. are even lower, ranging from 31.8% to 67.2% among children and adults.

In addition, research previously published in PLoS Medicine showed that nonmedical vaccine exemptions are becoming more common in the U.S. Since 2009, exemption rates have increased in 12 of the 18 states that allow exemptions for philosophical beliefs, including Arkansas, Arizona, Idaho, Maine, Minnesota, Missouri, North Dakota, Ohio, Oklahoma, Oregon, Texas and Utah. Although exemption rates have slowed in some of these states, data showed that they continue to increase in others like Arkansas, North Dakota, Ohio, Oklahoma, Texas and Utah.

To raise awareness of the importance of immunization, the CDC and National Public Health Information Coalition designated August as National Immunization Awareness Month. To mark the occasion, Infectious Disease News Editorial Board member William Schaffner, MD, professor of preventive medicine at Vanderbilt University and medical director for the National Foundation for Infectious Diseases, discusses the harms associated with nonmedical vaccine exemptions, ways to address vaccine hesitancy and important advances in vaccine research.

Should states allow nonmedical vaccine exemptions for schoolchildren? Why or why not?

Yes and no. I think states should not provide those exemptions because the impact of vaccines is not only to protect the individual but also to protect the entire community. It is unsettling that these so-called “nonmedical vaccine exemptions” have become more common in the U.S. and tend to be localized in certain geographic areas. When that happens, you get a very large accumulation of children susceptible to an array of what used to be bygone infectious diseases but could return as a consequence of importations from abroad. So, my wish would be to have solidly protected communities. On the other hand, it simply may not be politically feasible in every part of the country at the present time to implement that. So, absent that, I hope nonmedical exemptions will be reviewed carefully and not be given out frivolously because the goal is to have the highest possible vaccination rates to keep our children and communities protected.

What is the most effective way to address vaccine hesitancy?

Vaccine hesitancy can best be addressed in every pediatrician and family doctor’s office one patient at a time through good information, as well as powerful reassurance and comfort. You must respect the hesitant parent and their questions, and respond to them, reassure them, and provide the vaccines. I think this is something that we are going to have to live with henceforth. We know, of course, that one of the main reasons why we have so much vaccine hesitancy is because the vaccination programs have been so successful. The average parent has had no personal experience with any of these diseases that we are talking about. If they don’t know about the diseases and respect or fear them, they will not value the vaccine.

We in medicine would be well-advised to look at the information that is being presented to our children in middle school and high school health curriculums. Several of us have very casually done so. Our conclusion is that issues related to vaccine-preventable diseases and vaccines are not at all presented comprehensively. If students receive inadequate information, we should not be surprised that when they grow up and become parents, they have more questions than answers. If we can enhance that curriculum in middle schools and high schools, we would be in better shape 10 years from now.

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What are some important advances recently made in vaccine research?

There are a number of advances that are being made in vaccine research. One of them is a very substantially improved shingles vaccine, which is now recommended for everyone who is immunocompetent and aged 50 years or older. That has been a terrific advance over the first shingles vaccine.

Another big advance, of course, is the first explicitly anticancer vaccine — the HPV vaccine — which originally protected against four different HPV types but now protects against nine. We need to implement that vaccine much more comprehensively in the U.S. – it’s an anticancer vaccine!

A variety of advances have also been made to enhance the effectiveness of influenza vaccination through the use of adjuvants, high-dose vaccine, cell-based vaccine and recombinant vaccine.

I would also commend everyone to the terrific success of the pneumococcal conjugate vaccine, having profoundly reduced invasive pneumococcal disease in children and because of its indirect effect in adults. We started with PCV7 and now have PCV13, but additional vaccines with other serotypes are currently in the research pipeline.

All of these examples are evidence of new and improved vaccines and our testimony to a very brisk research program that is ongoing in academia, in the laboratories of vaccine manufacturers and in the NIH, CDC and FDA laboratories.

If you could develop an effective vaccine for an infectious disease that does not currently have one, which disease would you develop a vaccine for and why?

I would love to see a vaccine against HIV, tuberculosis, malaria and, of course, a universal influenza vaccine that would virtually cover all influenza strains. As I like to say, the lights are on in the research laboratories at night. There are people all over the globe who are trying to create vaccines against those diseases. Together, they are the Holy Grail of vaccinology.

What is the take-home message for clinicians during National Immunization Awareness Month?

When in doubt – vaccinate!

References:

CDC. National Center for Health Statistics – Influenza. https://www.cdc.gov/nchs/fastats/flu.htm. Accessed July 30, 2018.

CDC. National Center for Health Statistics – Immunization. https://www.cdc.gov/nchs/fastats/immunize.htm. Accessed July 30, 2018.

Olive JK, et al. PLoS Med. 2018;doi:10.1371/journal.pmed.1002578.

WHO. 10 Facts on Immunization. http://www.who.int/features/factfiles/immunization/en/. Accessed July 30, 2018.

Disclosures: Schaffner reports serving on Data Safety Monitoring Boards for Merck and Pfizer, and is an occasional consult to Dynavax, GlaxoSmithKline, Novavax, Sanofi-Pasteur and Seqirus.