The recent outbreaks of measles in Canada and the United States came as a shock to many public health experts but they wouldn't have to Dr. Gregory Poland, one of the world's most admired, most advanced thinkers in the field of vaccinology.
The measles vaccine has failed, he explained two years ago in a prescient paper, "The re-emergence of measles in developed countries." In that paper, he warned that due to factors that most haven't noticed, measles has come back to be a serious public health threat. Thankfully, in that paper and elsewhere he also spelled out in no-nonsense fashion what now needs to be done.
Dr. Poland is no vaccine denier. Not only is he among the harshest and most outspoken critics of the "irrationality of the antivaccinationists," he is also one of the strongest proponents for vaccines and the good that they can do. As Professor of Medicine and founder and leader of Mayo Clinic's Vaccine Research Group, one of the world's largest vaccine research organizations; as editor-in-chief of the peer-reviewed scientific journal, Vaccine; as recipient of numerous awards; as chair of vaccine data monitoring committees for pharmaceutical giant Merck; as patent holder in various vaccines processes; as someone who enjoys special employee status with the Centers for Disease Control and the U.S. Department of Defense and as someone who has sat on every federal committee that has dealt with vaccines, no one can accuse him of seeing vaccines from a narrow perspective.
And he sees the need for a major rethink, after concluding that the current measles vaccine is unlikely to ever live up to the job expected of it: "outbreaks are occurring even in highly developed countries where vaccine access, public health infrastructure, and health literacy are not significant issues. This is unexpected and a worrisome harbinger -- measles outbreaks are occurring where they are least expected," he wrote in his 2012 paper, listing the "surprising numbers of cases occurring in persons who previously received one or even two documented doses of measles-containing vaccine." During the 1989-1991 U.S. outbreaks, 20 per cent to 40 per cent of those affected had received one to two doses. In a 2011 outbreak in Canada, "over 50 per cent of the 98 individuals had received two doses of measles vaccine."
Dr. Poland noted 15 U.S. outbreaks between 2005 and 2011 and 33 in Europe in 2011 alone, involving more than 30,000 known cases. Meanwhile, the "UK has declared measles once again endemic.... such outbreaks result from both failure to vaccinate, and vaccine failure."
People's failure to get vaccinated is deplorable, Dr. Poland often stresses. But the more fundamental problem stems from the vaccine being less effective in real life than predicted, with a too-high failure rate -- between 2 per cent and 10 per cent don't develop expected antibodies after receiving the recommended two shots. Because different people have different genetic makeups, the vaccine is simply a dud in many, failing to provide the protection they think they've acquired.
To make matters worse, even when the vaccine takes, the protection quickly wanes, making it unrealistic to achieve the 95 per cent-plus level of immunity in the general population thought necessary to protect public health. For example, 9 per cent of children having two doses of the vaccine, as public health authorities now recommend, will have lost their immunity after just seven and a half years. As more time passes, more lose their immunity. "This leads to a paradoxical situation whereby measles in highly immunized societies occurs primarily among those previously immunized," Dr. Poland stated.
The measles vaccine's inadequacy doesn't end there, however. It "cannot be administered to those who are immunocompromised, who have allergies to vaccine components, or who are pregnant [among other limitations, leaving] a large enough segment of the population susceptible and unprotected from measles such that cases will continue to occur."
The answer, according to Dr. Poland, lies in our genes. Because of their genetic predisposition, some people will not respond to the current measles vaccine, even with additional boosters. By the same token, the genetic predisposition of others makes them susceptible to harm from the measles vaccine, leading to public wariness, including among the well educated. What is needed, suggests Dr. Poland, is for the public health establishment to accept that the current measles vaccine has so many drawbacks as to make it unworkable, and get on with the job of developing next-generation vaccines.
This next generation vaccine technology, which his Mayo Clinic group is helping pioneer, marries vaccinology with genomics to create personalized, rather than one-size-fits-all, vaccines. Through this new medical discipline of "vaccinomics," a term he dubbed, medical science will not only have the wherewithal to finally achieve the decades-long dream of eradicating measles and other diseases, he believes, but will also do so at lower cost while addressing the concerns of the educated public.
As I will discuss in part two of this series, vaccinomics is no pie-in-the-sky fantasy but possibly the next big coming thing, well worth pursuing, and well worth the investment in its development that will be required.
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Your newborn should get this shot even before leaving the hospital, and receive another dose at one to two months and a third at six to 18 months. The vaccine protects against an incurable, liver-infecting virus, hepatitis B, which can be passed to a baby during childbirth if the mother is infected. This virus spreads through contact with blood or other body fluids (sharing toothbrushes and utensils can put you at risk). Soreness at the site of the shot, or a slight fever, is the most common side effect, according to Gabrielle Gold-von Simson, M.D., assistant professor of pediatrics at NYU Langone Medical Center in New York.
The DTaP vaccine protects against diphtheria (a germ that can form a gray or black film in the throat), tetanus (an infection that can cause muscle spasms so strong they can break bones), and pertussis (a highly contagious disease that causes a severe, uncontrollable cough, known as whooping cough). Five vaccine doses are given to children at two months, four months, six months, 15 to 18 months and four to six years. (And boosters at age 11 or 12 and then every 10 years.) DTaP may be combined with other vaccinations to reduce the number of shots needed. "Now, it's DTaP with hepatitis B and the polio vaccine. So, it's five in one," Dr. Gold-von Simson says.
This combo shot protects against three viruses: measles (which causes high fever and a body-wide rash); mumps (which causes face pain, swelling of the salivary glands, and sometimes scrotal swelling in boys); and rubella or German measles (which can cause birth defects if the infection occurs during pregnancy). The first shot is given at 12 to 15 months of age and once again between the ages of four and six. MMR is sometimes combined with the chickenpox vaccine into one shot (brand name ProQuad). "All these different preparations are designed to reduce the amount of shots the pediatrician has to give," says Dr. Gold-von Simson.
Chickenpox, a highly contagious rash that many people remember from childhood, is caused by the varicella virus. A varicella vaccine was first licensed in 1995 and now spares future generations this itchy misery. Chickenpox infections can be especially dangerous in adults who don't have immunity from the vaccine or haven't had it in childhood, and can also lead to shingles, an extremely painful blistering rash. The shot is given to children at 12 to 15 months and again between four and six years. The vaccine can cause soreness at the site of the shot, fever, and, in some cases, a mild rash.
"Haemophilus influenza type b is the bacterium that causes meningitis," says Dr. Gold-von Simson. Meningitis, an inflammation of the membranes surrounding the brain and spinal cord, is particularly dangerous for kids under the age of five. Hib vaccines are generally given at two, four, six, and 12 to 15 months of age. Depending on the vaccine used, the six-month shot may not be needed. Fever, swelling, and redness at the site of the shot are potential side effects.
Polio vaccine is "such a success," says Dr. Gold-von Simson. "Because of the vaccine, there are no more cases (of polio)." There are no more in the United States that is. The virus hasn't been eradicated worldwide, so kids still get the IPV, or inactivated polio vaccine, which is a shot containing killed virus. Polio is bad news, and can cause paralysis and even death. Children are given the IPV at two months, four months, between six to 18 months, and then again between the ages of four and six years.
This vaccine, known as PCV13 (brand name Prevnar), protects against 13 types of Streptococcus pneumoniae, which are bacteria that can cause all sorts of mayhem, including meningitis, pneumonia, ear infections, blood infections, and even death. A total of four shots are given to kids (at two, four, six, and 12 to 15 months of age) to protect them against the germs, known collectively as pneumococcal bacteria. The most common side effects of the vaccine include drowsiness, swelling at the site of the shot, mild fever, and irritability.
Flu vaccinations are given each year starting in the fall. The Centers for Disease Control and Prevention recommends them for kids ages six months or older, although they aren't required for school attendance. (Connecticut and New Jersey require the vaccine for attending child-care centers and preschool.) Common side effects from the vaccine include soreness, redness, or swelling at the site of the shot. Fever and aches may occur too. "If you have an egg allergy, you shouldn't have the influenza vaccine," says Dr. Gold-von Simson.
The rotavirus vaccine (RV) (brand names RotaTeq, Rotarix) is given to children at two and four months of age. (RotaTeq is also given at six months.) The vaccine protects against a virus that is the most common cause of severe diarrhea and vomiting in young kids worldwide. About 55,000 children in the U.S. were hospitalized each year due to rotavirus before the vaccine was licensed in 2006. It is not required for school attendance. The vaccine is in liquid form and given by mouth to babies. It may make them a bit more irritable and can also cause mild diarrhea or vomiting.
Kids can catch hepatitis A from sharing food or drinks or by putting contaminated food or objects in their mouths. It's a viral infection that affects the liver, and can cause a number of symptoms, including fever, tiredness, jaundice, and loss of appetite. Children ages 12 through 23 months generally get two doses of the Hep A vaccine, with a minimum interval of six months between shots. Some states require the vaccine for school attendance. Soreness where the shot was given, headache, and loss of appetite are the most common side effects of the vaccine.
This vaccine, known as MCV4 (brand name Menactra), protects against meningococcal bacteria, which can infect the membranes surrounding the brain and spinal cord. MCV4 is recommended for kids at 11 or 12 years of age, and anyone between ages two and 55 who is at increased risk of infection (people with certain health conditions, military recruits). Teens starting college should be vaccinated with MCV4 before going to school if they didn't previously get the shot. (Freshman living in dorms are at increased risk of infection.) A little pain at the site of the shot is the most common side effect.
Human papillomavirus (HPV) vaccine (brand names Gardasil, Cervarix) is given in three doses over a six-month period, and is approved for girls between ages nine and 26. While there are over a hundred types of HPV, this vaccine protects against two sexually transmitted types that are the most common causes of cervical cancer. Gardasil also protects against two types that cause genital warts and is approved for boys between nine and 26 as well. The vaccine works only if given before an infection, so doctors recommend it for kids well before they could become sexually active. Although most states don't require HPV vaccination, many are considering mandating it for preteen girls.
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