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Johns Hopkins Bloomberg School of Public Health


Date: Jul 2012

Graduate students in JHSPH’s Vaccine Policy Issues class examine current national and international policy issues across the spectrum of vaccine work. As a part of the course, students selected topics for analysis. Selected entries will appear in a series on the IVAC blog. This is the final of the series.

Guest post by Shreya Patel, MPH

More often than not, these are dreaded words for significant others, employees, and teenagers everywhere. I, however, am not your significant other, boss, or parent. For this discussion, you can call me Switzerland and I am going to be metaphorically sitting directly between parents and pediatricians (ironically, that is often also my physical location as the slightly awkward fourth-year medical student). I am here to tell both parties that we need to talk. For one minute, let’s pretend that we are not warring factions. We will not (figuratively) stick our fingers in our ears and say “la la la, I can’t hear you” while the other party speaks. We will not mumble confusing jargon or excuses or insults. We will not storm out of the office. Ground rules clear? Now for the topic: vaccinations.

Vaccines protect a society from diseases through herd immunity. The more vaccinated people, the less likely a disease will spread. In today’s global society, infectious diseases can jump between continents with a boarding pass and unvaccinated children are suffering. Studies have shown that unvaccinated children are 35 times more likely to contract measles, 6 times more likely to have had pertussis, and 23 times more likely to get whooping cough compared to their vaccinated counterparts. Between January and April 2008 in the US, there were five measles outbreaks and 64 cases; all but one of the cases were either unvaccinated or did not have evidence of immunization. US vaccine exemption rates have been on the rise in the last five years with ten states increasing more than 1.5% and Alaska winning the unfortunate prize of the highest exemption rate in 2011 with 9% of its children currently unvaccinated. Vaccines have all but eradicated diseases that plagued our society in the past; but like any medicine, they only work when taken. So let’s start the discussion.

JHSPH Student Blog Shreya Patel

The author, Shreya Patel.

Parents, I sympathize. Aside from the physical and emotional stress of 2 AM feedings, tantrums over dinner, and your child’s first day of preschool, you are in a twenty-first century world bombarded by more information and opinions on how to raise your child than the average parent from the fifties received in a year. You rightfully worry about everything from what your child is watching on television to what they will be when they grow up. However, first and foremost, you value your children’s health. A physician offering to stick a needle into your child’s arm full of inactivated diseases and other components is certainly a scary thought. Many of you agree that vaccinations are helpful, but worry about their safety. Granted, the risks of being unimmunized in a well-immunized community are low (albeit not as low as an immunized child). So this is where it becomes vital to have a conversation with the only other person as invested in your child’s health as you, your pediatrician. The Internet is an extremely valuable resource for anything from news to celebrity gossip, but is also an open arena for anyone’s opinions, sometimes reading like a sequel to the Rocky Horror Picture Show. Making a decision about vaccinations without talking to your pediatrician is akin to determining how big the universe is without talking to your local expert physicist.

Pediatricians, I sympathize about your job, too. A seemingly endless stream of cranky children coughing in your face, all who must be seen, evaluated, and treated almost immediately in order to move on to the next. Comparatively underpaid and overworked, amazingly, you still know exactly what tricks make even the most terrified child smile. Then, in the middle of your busy day, comes a parent staunchly refusing a medical intervention you and every major medical society in the world recommends. It is often too easy to quickly dismiss them as uneducated, ignore their fears completely, or worst, immediately surrender to their medical opinion over your own. However, while it may seem like you are going to battle with the parent, in reality, you are protecting the health of the child. Refusing to address parental concerns in a calm, respectful manner is not in the best interests of your patient, their parents, the medical profession, and even public health in general.

Conflict resolution specialists use a concept called perceived or enlightened self-interest. To maximize one’s own self-interest in a disagreement, it is generally necessary to recognize the self-interest of the other party and understand that there are solutions where both parties will be satisfied. Instead of parents and pediatricians approaching the conflict from opposite ends of a football field, what if instead, they started on the middle ground where the both agree? Both primarily want to ensure children are healthy and safe. They want children to avoid disease, grow and develop properly, and become productive adults. With so many fundamental, common self-interests, why are so many not even willing to start the conversation?

While my personal opinions on the matter have been revealed, I still consider myself in the middle of this argument and too often watch as both parties give up on the health of their children before any discussion. Parents, make a separate appointment to discuss your concerns and choose a new pediatrician if they refuse to talk with you. Your pediatrician has your child’s best interest in mind, years of education and experience, and hopefully, would like to work with you to come to a decision you are both comfortable with. You have a personal expert at your fingertips. Why resort to celebrities for your medical advice? Pediatricians, do your own homework on the evidence behind vaccine safety or rates of vaccine-preventable diseases. Remember that parents may be misinformed or scared and would like a forum to discuss their concerns. In the end, there will always be a minority who will still refuse vaccines. As someone about to enter the field of medicine and public health, my hope is simply that all parents make their decision with a full understanding of the risks and benefits after an informed discussion with their medical provider.

Shreya Patel completed her MPH at Johns Hopkins Bloomberg School of Public Health in May, 2012, focusing on international health, vaccine policy issues, and epidemiology. She is currently a fourth-year medical student at the University of Arizona College of Medicine and plans to enter the field of Internal Medicine for residency in 2013.

Graduate students in JHSPH’s Vaccine Policy Issues class examine current national and international policy issues across the spectrum of vaccine work. As a part of the course, students selected topics for analysis. Selected entries will appear in a series on the IVAC blog. This is the second in the series.

Guest post by Jennifer Lam

Last fall, when the CDC announced that the flu season had officially started, they also reiterated the message we hear every winter: It’s not too late to get the flu shot. As a student getting a graduate degree in Public Health, and as someone who’s had the unpleasant experience of getting the flu, I’m an easy sell. Each year, I dutifully get my flu shot at the beginning of flu season. I also remind my family and friends to do the same. The person I would never think to remind is my doctor, and ironically, this is the person in my life who’s probably the least likely to have gotten a flu shot.

The author, Jennifer Lam

The author, Jennifer Lam.

Getting healthcare workers vaccinated against the flu has been one of the most frustrating challenges in public health in the U.S. Each year, the Centers for Disease Control (CDC) recommends that all healthcare workers get a flu shot. This includes not just doctors and nurses, but also administrative staff, hospital volunteers, emergency responders – basically, anyone who has contact with patients. Yet, during last year’s flu season only 63.5% of healthcare workers were vaccinated, a mere 2.5% improvement from the previous year despite attempts at federal and state levels to increase vaccination coverage.

To me, the benefit of getting healthcare workers vaccinated is a no-brainer. Healthcare workers are in contact with patients every day. The volume and frequency of contact they have with people who are sick, including patients at high risk for suffering severe consequences from the flu, like children with leukemia or transplant patients, makes it the responsible thing to do to get vaccinated. Not only are they protecting themselves, but they are lowering the chance of inadvertently passing the flu to patients. Plus, since they encourage us to get vaccinated, shouldn’t they follow their own advice and get vaccinated too?

The flu is easily transmitted like the common cold – sick people sneeze and cough and pass the virus onto healthy people – and each year, thousands of people get infected. Getting vaccinated is the best protection against the flu because people can be infectious before they start showing symptoms, so they can pass the flu onto you without even knowing it. When vaccination rates in the population are low, flu spreads easily and outbreaks can happen. This has been documented in hospital and nursing homes setting, especially when a majority of the healthcare workers are not appropriately vaccinated.

Some people argue that since we can’t get healthcare worker flu vaccination rates to an acceptable level, we should restrict the type of patients unvaccinated healthcare workers can have contact with. However, keeping unvaccinated workers away from high-risk patients is hard to enforce and can be a logistical nightmare to carry out in a hospital setting.

Some people suggest that healthcare workers should be required to get the flu shot, especially since it’s been shown that when employers require flu shots, 98.1% of healthcare workers get vaccinated. Flu vaccination mandates are not a new idea and have been met with staunch opposition for years. In 2009, the New York Health Department became the first state to require healthcare workers get a flu shot. New Jersey is currently considering a similar mandate. These mandates have generated an outcry from private citizens and organizations alike who feel that vaccination is a choice, and that requiring workers to get vaccinated is unethical and unconstitutional.

When hearing about this vaccine policy tug-of-war between public health officials and healthcare workers, I think it’s important to remember patient choice as well. For this reason, I suggest that States require hospitals and other medical providers to make their flu vaccination coverage rates public. The data are already being collected – all States have flu vaccine coverage surveillance systems and hospital infectionists are responsible for making sure healthcare workers are up-to-date on their shots. Why not make this information publicly available?

A parent should have the right to know whether the staff at the pediatrician’s office have been vaccinated before bringing a young infant for a check-up. Children finding a nursing home for their parents have a right to know which ones enforce flu vaccination for their employees and which ones don’t. Just as healthcare workers have a right to decide whether to get their flu shot, patients should be able to weigh the risks and benefits of seeking care at a hospital where most staff have not been vaccinated.

By posting flu vaccination coverage data publicly, hospitals and other medical providers have an incentive to encourage flu shots for their staff. We may find that resistance to vaccination drops quickly once hospitals and providers realize that not vaccinating can hurt their bottom line; patients can choose to go to a different medical provider.

Vaccination coverage data are often reported as aggregate percentages. I know that nearly 37% of healthcare workers do not get their flu shot. As a patient, this statistic is not helpful to me. What I’d like to know is whether my family doctor is in the ‘vaccinated’ or ‘unvaccinated’ group. Also, if I were running a hospital, low flu coverage percentages are unlikely to make me spring into action. However, if it’s public knowledge that my hospital ranks the lowest in vaccination coverage of all hospitals in my county, I might be more likely to take note and encourage my workers to get vaccinated.

Making flu vaccine coverage information available is beneficial for public health, and also gives both providers and patients a fair choice. The importance of getting healthcare workers vaccinated can no longer be overlooked and underestimated. We need to take action to make sure that the responsibility of getting vaccinated falls on everybody – patients as well as healthcare staff.

Jennifer Lam is a PhD student in the Global Disease Epidemiology and Control Program at the Johns Hopkins Bloomberg School of Public Health.

Graduate students in JHSPH’s Vaccine Policy Issues class examine current national and international policy issues across the spectrum of vaccine work. As a part of the course, students selected topics for analysis. Selected entries will appear in a series on the IVAC blog. This is the first in the series.

Guest post by Sally Ann Iverson, DVM, MPH

By the time you’ve reached your golden years, diseases you experienced in your childhood have likely been reduced to distant memories of unpleasantness. However, chickenpox is one childhood disease that should not be forgotten. Long after the painful pox have cleared, the virus remains dormant in your nerves waiting for an opportunity to wreak havoc on your adult life in the form of shingles. 

Shingles occurs when the Varicella zoster virus reactivates and causes a painful and sometimes debilitating rash. Although it’s unknown exactly what causes the virus to reactivate, it’s thought to be associated with a weakened immune system and older age. The majority of the US population is susceptible to shingles, as 90% of Americans have experienced chickenpox by the age of 15. Almost one out of every three of these people will go on to develop shingles, resulting in about one million cases every year. About half of these cases occur in men and women over 60 years of age.

Electron micrograph of Varicella zoster

Electron micrograph of Varicella zoster virus, responsible for shingles and chicken pox. Photo courtesy of CDC Public Health Image Library.

You may ask, “What’s so terrible about a rash?” Imagine tingling, burning, and stabbing sensations as the virus dances along your nerves and blisters your skin. People who have experienced shingles have described it as “the demon’s hand” and women have declared it more painful than childbirth. About 20% of the people who experience shingles will suffer from permanent damage to the nervous system, a condition known as post-herpetic neuralgia, that can persist for months or even years after the rash has resolved.

Given the nightmare that shingles is capable of producing, you may be relieved to learn that there is a vaccine for adults that can cut your risk of shingles in half. You may also expect that people would be lining up around the corner to receive this vaccine, especially since the US Advisory Committee on Immunization Practices (ACIP) has made formal recommendations that all adults over 60 should receive the shingles vaccine. Yet surprisingly, only 10% of people in the recommended age group have been vaccinated for shingles.

Although there are many reasons for underutilization of the vaccine, multiple studies have found one factor that seems to be a root cause: money. The herpes-zoster vaccine is the most expensive vaccine recommended for older adults. At around $160-$200, it cost four times as much as the pneumococcal vaccine and ten to twenty times as much as the flu vaccine. It’s also the only routinely recommended vaccine for older adults not covered under Medicare part B; instead, shingles vaccine has been relegated to coverage under Medicare part D prescription drug plan.

The distinction between “part B” and “part D” vaccines is substantial, and affects the 93% of the US population over 65 that is currently covered by Medicare. For vaccines covered under Medicare part B, such as the flu and pneumococcal vaccines, a patient can go to his or her doctor to get vaccinated. The doctor will then bill Medicare and will be fully reimbursed for the cost of the vaccine. However, the process is much more complicated for a vaccine covered under part D. Doctors cannot bill Medicare directly for the cost of the vaccine, so they must either require the patient to pay the full price of the vaccine upfront (and later submit for reimbursement to Medicare), or they will ask the patient to go and purchase the vaccine from a pharmacy, and bring it back to the office to be vaccinated. This later scenario is highly discouraged by the CDC, as the vaccine must be kept at specific temperatures that may be violated during transport from the pharmacy.

This complex system is confusing, inefficient, and expensive for both patients and doctors. Patients may be required to pay initial high costs out of pocket, as well as any co-pays that remain after reimbursement. Doctors are less than enthusiastic about regularly stocking and administering the vaccine due to the complicated process associated with current Medicare coverage. Additionally, financial loopholes in the current system may result in physicians covering up to 25% of the cost of the vaccine, which is more than the full cost of any other vaccine they would be administering!

Transferring coverage of the shingles vaccine to Medicare part B would greatly reduce the burden to patients, and would pave the way for the breakdown of other barriers to vaccination. Surveys of physicians have found that a simpler system would encourage more doctors to regularly stock the vaccine, resulting in improved access for patients. We can also expect that more people will be motivated to receive a vaccine that is affordable and easy to obtain.

On the whole, vaccines have proven themselves as one of the most cost-effective preventative health interventions we have available, and the CDC has also endorsed the shingles vaccine as a cost-saving health intervention. By allocating Medicare resources to preventative measures such as shingles vaccine, we have the opportunity to avert higher healthcare costs later on.

Shingles is a disease not soon forgotten by those who experience its wrath, and it should not be forgotten by our healthcare system either. The inclusion of the shingles vaccine under Medicare part D has been the first step in addressing this debilitating disease, but it is not good enough. Our healthcare system can do a better job and reach more than 10% of the target population. It’s time to dig the shingles vaccine out from under all the paperwork, and slate it for coverage under Medicare part B.

Dr. Sally Ann Iverson recently graduated from the Johns Hopkins Bloomberg School of Public Health with a Master of Public Health degree and a certificate in vaccine science and policy. She will begin a fellowship as a veterinarian at the Plum Island Animal Disease Center this July.