tag:theconversation.com,2011:/us/topics/whooping-cough-625/articlesWhooping cough – The Conversation2023-12-11T12:37:21Ztag:theconversation.com,2011:article/2195182023-12-11T12:37:21Z2023-12-11T12:37:21ZWhooping cough cases increasing in the UK – what you need to know<figure><img src="https://images.theconversation.com/files/564677/original/file-20231210-29-ny65no.jpg?ixlib=rb-1.1.0&rect=35%2C0%2C7904%2C5297&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-got-sick-virus-little-boy-1693664527">Zdan Ivan/Shutterstock</a></span></figcaption></figure><p>You may have read recent alarming reports of a cough that “<a href="https://www.thesun.co.uk/health/24974770/highly-contagious-cough-fractured-ribs-whooping-cough/">lasts 100 days</a>” is “<a href="https://www.mirror.co.uk/news/health/100-day-cough-quickly-spreading-31622932">quickly spreading across the UK</a>” and can “<a href="https://nypost.com/2023/12/07/lifestyle/100-day-cough-highly-contagious-infection-that-could-fracture-ribs-soars-250-in-uk/">fracture ribs</a>”. If you didn’t look beyond the headlines, you might have missed the fact that the reports are about <a href="https://www.nhs.uk/conditions/whooping-cough/">whooping cough</a>.</p>
<p>So, what is going on?</p>
<p>Whooping cough (or pertussis) is what is known in the UK as a “notifiable infectious disease”, which means any doctor who diagnoses a case has a legal duty to report the infection to the local authority. Notifications of whooping cough are indeed much higher this year, particularly in the five months since July than at any time during the previous three years. </p>
<p>In the 21 weeks to November 27, <a href="https://www.gov.uk/government/publications/notifiable-diseases-weekly-reports-for-2023">there were 716 notifications</a> compared with just 217 in the same period in 2022, 213 in 2021 and just 72 in 2020. That is more than a threefold rise this year compared with the previous year. </p>
<p>Like most respiratory infections, whooping cough was suppressed during the COVID years. Notifications for whooping cough this year are still <a href="https://www.gov.uk/government/publications/notifiable-diseases-weekly-reports-for-2023">markedly down on 2019</a> where there were 1,842 notifications over the same 21-week period. </p>
<p>What we are seeing now is a partial return to the pre-COVID situation and not an unprecedented surge in infections. (Although the reported cases represent only a <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-147">fraction of all cases</a> in the community.)</p>
<p>The fact that whooping cough notifications are still relatively low should not distract from the fact that infections in the 2010s were still much <a href="https://www.gov.uk/government/publications/notifiable-diseases-historic-annual-totals">higher than in the previous decade</a>. Since the mid-1950s and the introduction of a vaccine, whooping cough was <a href="https://www.gov.uk/government/publications/pertussis-the-green-book-chapter-24">generally in decline</a> until this most recent decade. </p>
<h2>What is whooping cough?</h2>
<p>Whooping cough is a chest infection caused by the bacterium <em>Bordetella pertussis</em> – although another bacterium <em>Bordetella parapertussis</em> can also cause it. </p>
<p>The illness lasts for about six weeks or more and <a href="https://emedicine.medscape.com/article/967268-overview">progresses through three stages</a>. The first stage is very similar to a bad cold with a runny nose, sneezing and sore eyes. </p>
<p>The second phase, which starts after about two weeks, is characterised by bouts of intense coughing. Each bout can last several minutes and is occasionally followed by the loud whoop that gives the disease its name. Afterwards, a chronic cough can remain for several weeks.</p>
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<figcaption><span class="caption">What whooping cough sounds like.</span></figcaption>
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<p>Most people eventually make a full recovery, but in babies under three months old <a href="https://emedicine.medscape.com/article/967268-overview#a6">1% to 3% may die</a>. And most children under six months will require hospitalisation. </p>
<p>About one in 50 babies under one year will <a href="https://www.cdc.gov/pertussis/about/complications.html">suffer convulsions</a> and one in 150 (0.6%) will have encephalopathy (swelling of the brain). </p>
<p>Other even more serious neurological problems, such as paralysis and blindness, have been reported but are rare. In older children and adults, fainting, rib fractures, <a href="https://www.cdc.gov/pertussis/about/complications.html">pneumonia and urinary incontinence</a> can occur. </p>
<p>Antibiotics have limited value in <a href="https://onlinelibrary.wiley.com/doi/10.1002/ebch.1845">treating whooping cough</a>. They can reduce the time that the patient is infectious to others, but they have limited effect on preventing symptoms. </p>
<h2>How to avoid getting it</h2>
<p>There is an effective vaccine for whooping cough that in the UK is given in <a href="https://www.gov.uk/government/publications/routine-childhood-immunisation-schedule/routine-childhood-immunisations-from-february-2022-born-on-or-after-1-january-2020">combination with other vaccines</a> at eight, 12 and 16 weeks old. Then there is a booster shot given when the child is three years and four months. </p>
<p>The vaccine is also now recommended for pregnant women. This is not to protect the mother but to protect their baby during the first weeks of the child’s life before the first course of vaccine – when the infant would be at the highest risk of death.</p>
<p>Concerns about the safety of the vaccine, particularly during the 1970s, led to a significant fall in vaccine coverage and a re-emergence of whooping cough. </p>
<p>A committee of the US Institute of Medicine concluded that the evidence was “<a href="https://www.ncbi.nlm.nih.gov/books/NBK234367/">consistent with a causal relationship</a>” between the vaccine and acute encephalopathy, with a risk estimated at between zero and ten cases per million jabs administered. </p>
<p>However, subsequent studies suggested that many of the cases in the biggest study had a particular <a href="https://pubmed.ncbi.nlm.nih.gov/20447868/">genetic abnormality known as Dravet syndrome</a> and the whooping cough vaccine was merely bringing forward the date of onset of problems that would have happened anyway. </p>
<p>In any event, the studies reported above were of a time when whole-cell vaccines were being used (made from killed whole bacteria). Since 2004, whooping cough vaccines made with just parts of the bacterium (so-called acellular vaccine) have been used in the UK and these are associated with a <a href="https://pubmed.ncbi.nlm.nih.gov/12706690/">lower risk of side-effects</a>.</p>
<h2>Far from clear</h2>
<p>The recent increase in notifications of whooping cough, as mentioned above, is due to COVID suppression measures – lockdowns, mask-wearing and hand hygiene – coming to an end. But why there were more whooping cough cases during the years 2010 to 2019 compared with the previous decade is far from clear. </p>
<p>Vaccine coverage in the years before COVID up to 2019 was <a href="https://www.gov.uk/government/publications/pertussis-the-green-book-chapter-24">no lower than ten years previously</a>. <a href="https://karger.com/mpp/article/31/4/313/825084/Whole-Cell-and-Acellular-Pertussis-Vaccine">Possible explanations</a> include waning immunity, greater awareness of whooping cough among doctors (so more diagnoses), and improved laboratory diagnosis. </p>
<p>My take on the evidence is that the increasing infections in the years before COVID was down to the shift from whole-cell to acellular vaccine. Although the acellular vaccines cause fewer side-effects, they also generate <a href="https://karger.com/mpp/article/31/4/313/825084/Whole-Cell-and-Acellular-Pertussis-Vaccine">less powerful immunity</a>.</p>
<p>While both vaccines are highly effective at preventing severe disease, the acellular vaccine does not prevent mild infections that can be <a href="https://karger.com/mpp/article/31/4/313/825084/Whole-Cell-and-Acellular-Pertussis-Vaccine">infectious for others for as long</a>, so allowing the infection to continue to spread in the community. </p>
<p>The whole-cell pertussis vaccines were able to achieve herd immunity, which the acellular ones probably cannot. So the chance that young babies come into contact with an infectious older child or adult is now greater. </p>
<p>With the falling vaccination coverage in <a href="https://www.gov.uk/government/publications/pertussis-immunisation-in-pregnancy-vaccine-coverage-estimates-in-england-october-2013-to-march-2014/pertussis-vaccination-coverage-for-pregnant-women-in-england-january-to-march-and-annual-coverage-2021-to-2022">pregnant women</a> this puts babies at risk in their most vulnerable first weeks of life.</p><img src="https://counter.theconversation.com/content/219518/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Hunter consults for the World Health Organization. He receives funding from National Institute for Health Research and has received funding from the World Health Organization and the European Regional Development Fund.</span></em></p>Antibiotics aren’t very effective against it, but we do have a vaccine.Paul Hunter, Professor of Medicine, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2055152023-06-15T06:09:04Z2023-06-15T06:09:04ZMeasles and whooping cough outbreaks in South Africa: a sign of low vaccination coverage, experts warn<figure><img src="https://images.theconversation.com/files/530906/original/file-20230608-12385-a4sqhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Caregivers are conflicted about vaccinating their children. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>The concentrated global effort to use vaccination as a public health intervention began in <a href="https://www.who.int/news-room/fact-sheets/detail/immunization-coverage">1974</a>. Since then, vaccination has changed our lives. Worldwide, in the decades 2000-2020, childhood vaccination led to the reduction of deaths in children under 5 by 50% to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31891-9/fulltext">5.4 million deaths</a> per year. Vaccination currently averts more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32657-X/fulltext">5 million deaths</a> each year <a href="https://www.youtube.com/watch?app=desktop&v=vfAcG_ur27g">worldwide</a>. These are deaths that would have been caused by measles, whooping cough, tetanus, polio, diphtheria, pneumonia, rotavirus diarrhoea, and other <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32657-X/fulltext">vaccine-preventable diseases</a>. But in recent months there have been numerous outbreaks of these diseases. Scientists from the South African Medical Research Council explain why these diseases continue to threaten children’s health in the country.</em></p>
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<h2>The country currently has outbreaks of several diseases. What are they?</h2>
<p>There is an increased spread of <a href="https://www.nicd.ac.za/south-african-measles-outbreak-update-2023-9-june-2023/">measles</a> in South Africa now.</p>
<p>Measles is a highly infectious disease that spreads through droplets. It is the second most frequently reported disease outbreak in Africa after cholera. It accounts for 11.5% of all reported disease <a href="https://www.cambridge.org/core/journals/epidemiology-and-infection/article/infectious-disease-outbreaks-in-the-african-region-overview-of-events-reported-to-the-world-health-organization-in-2018/A504999B25CBA5E179B951FABB8CFE53">epidemics on the continent</a>.</p>
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Read more:
<a href="https://theconversation.com/explainer-a-history-of-the-measles-virus-and-why-its-so-tenacious-130262">Explainer: a history of the measles virus and why it's so tenacious</a>
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<p>Children who have not been vaccinated against measles are at high risk of the disease and its complications. These include pneumonia, brain damage, and death. Measles is one of the most dangerous but preventable childhood diseases. Up to <a href="http://www.samj.org.za/index.php/samj/article/view/6196/4933">10% of children</a> under five years of age who develop measles die from complications of the disease. </p>
<p>An effective vaccine against measles has been available for decades. A child requires two doses of the measles vaccine to develop protective immunity against the disease. The two doses of the measles vaccine are given at 6 and 12 months of age in South Africa. At least 95% coverage of 2 doses of the measles vaccine is required for herd immunity against <a href="https://www.who.int/news-room/fact-sheets/detail/measles">measles</a> and protect those who aren’t able to get vaccinated.</p>
<p>Another highly infectious disease that has recently seen an increase in cases in South Africa is pertussis, also referred to as <a href="https://www.nicd.ac.za/an-increase-in-pertussis-cases-13-dec-2022/">whooping cough</a>. Pertussis spreads easily from person to person through droplets produced by coughing or sneezing. Complications of whooping cough include pneumonia, seizures, brain damage, and death. The best way to prevent pertussis is through <a href="https://www.who.int/health-topics/pertussis#tab=tab_2">vaccination</a>. </p>
<h2>These diseases are preventable. What’s behind the spread?</h2>
<p>The resurgence of vaccine-preventable diseases in South Africa is due to immunity gaps caused by low vaccination coverage. A <a href="https://www.health.gov.za/wp-content/uploads/2022/03/National-EPI-Coverage-Survey_Final-full-report-Dec-2020.pdf">national survey</a> conducted from July to December 2019 found that only 81% of children had received all their vaccine doses scheduled up to 12 months of age in South Africa. This percentage has increased only slightly to <a href="https://www.who.int/data/gho/data/themes/topics/immunization-coverage">82%</a> since then, according to estimates from the World Health Organization (WHO) and the United Nations Children Fund (UNICEF).</p>
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Read more:
<a href="https://theconversation.com/south-africas-immunisation-record-risks-being-dented-by-anti-vaccination-views-153549">South Africa's immunisation record risks being dented by anti-vaccination views</a>
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<h2>What’s the cause of the gaps in immunisation?</h2>
<p>Over the last two years, routine immunisation services and coverage of essential childhood vaccines have been disrupted. And many <a href="https://www.who.int/news/item/24-04-2023-global-partners-announce-a-new-effort-the-big-catch-up-to-vaccinate-millions-of-children-and-restore-immunization-progress-lost-during-the-pandemic">catch-up vaccination efforts</a> have been postponed due to the COVID-19 pandemic. This has led to an increase in the number of children who are unvaccinated or under-vaccinated. </p>
<p>The country’s low vaccination coverage is due to both <a href="https://doi.org/10.1002/14651858.CD013265.pub2">supply and demand issues</a>. These relate to the provision of vaccines and the population’s decision to vaccinate. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378923/pdf/CD013265.pdf">Structural barriers</a> such as vaccine availability and access to health facilities are well known to reduce vaccination coverage. </p>
<p>Research also <a href="https://www.tandfonline.com/doi/pdf/10.1080/21645515.2018.1460987?needAccess=true&role=button">suggests</a> that social and psychological factors, such as concerns about the safety and efficacy of vaccines, influence decisions around vaccination. Some caregivers are conflicted about vaccinating their children. </p>
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Read more:
<a href="https://theconversation.com/unpacking-parents-reasons-for-not-vaccinating-their-children-why-it-matters-171527">Unpacking parents' reasons for not vaccinating their children: why it matters</a>
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<p><a href="https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-05/mhst1-1201.pdf">Vaccine hesitancy</a> represents a motivational state of being conflicted about or opposed to vaccination. Evidence from several studies conducted in South Africa has shown a significant <a href="https://www.tandfonline.com/doi/pdf/10.1080/14760584.2021.1949291">increase in vaccine hesitancy</a>. This has had a dramatic impact on routine immunisation services and ultimately reduced vaccine coverage over the years.</p>
<h2>What steps can be taken to close these gaps?</h2>
<p>Globally, many initiatives exist to improve childhood immunization, especially in low- and middle-income countries. Within the context of the Immunization Agenda 2030 (IA2030) programme, WHO, UNICEF and Gavi, are launching the <a href="https://www.who.int/news/item/24-04-2023-global-partners-announce-a-new-effort-the-big-catch-up-to-vaccinate-millions-of-children-and-restore-immunization-progress-lost-during-the-pandemic">“Big Catch-Up”</a> initiative. This initiative aims to support countries like South Africa to plan and implement intensified efforts to bolster immunisation. It has three main objectives: </p>
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<li><p>to reach children who missed vaccination during 2020-2022 for catch-up vaccination</p></li>
<li><p>to restore vaccination coverage to the last best coverage in 2019 </p></li>
<li><p>to strengthen immunisation programmes to reach the under-vaccinated and unvaccinated children. </p></li>
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<p><a href="https://bmjopen.bmj.com/content/bmjopen/12/11/e058258.full.pdf">Interventions</a> that are focused on improving the healthcare system include cold-chain infrastructure improvements to ensure availability and access to vaccines. Some other <a href="https://www.tandfonline.com/doi/epdf/10.1080/21645515.2016.1221553?needAccess=true&role=button">interventions</a> that can improve uptake of vaccines include using motivational posters or flyers, sending reminders (messages or letters), and material or monetary incentives to caregivers or pay-for-performance schemes for healthcare workers providing vaccinations to children. </p>
<p>Informing and providing education to caregivers and healthcare workers has also been <a href="https://bmjopen.bmj.com/content/bmjopen/12/11/e058258.full.pdf">effective</a> increasing vaccination in children in cases where parents were hesitant. However, not enough research is done on interventions to dispel misinformation and misconception regarding immunisation, which is one of the leading causes of vaccine hesitancy.</p><img src="https://counter.theconversation.com/content/205515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Duduzile Ndwandwe receives funding from the South African Medical Research Council. She is affiliated with Eh! Woza, a non-profit Organization for public engagement. </span></em></p><p class="fine-print"><em><span>Charles Shey Wiysonge and Lindi Mathebula do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Over the last two years, routine immunisation services and coverage of essential childhood vaccines have been disrupted.Charles Shey Wiysonge, Director, Cochrane South Africa, South African Medical Research CouncilDuduzile Ndwandwe, Deputy Director and Specialist Scientist , South African Medical Research CouncilLindi Mathebula, Project Manager, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2024992023-03-28T18:25:23Z2023-03-28T18:25:23ZLow vaccination and immunity rates mean NZ faces a harsh whooping cough winter – what needs to happen<figure><img src="https://images.theconversation.com/files/517522/original/file-20230326-26-35bjxm.jpg?ixlib=rb-1.1.0&rect=0%2C13%2C1167%2C639&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Bastiaan Beentjes/Getty Images</span></span></figcaption></figure><p>Following the <a href="https://www.rnz.co.nz/news/national/486457/baby-whooping-cough-victims-tragic-start-to-epidemic-paediatrician">deaths of two infants</a>, doctors and scientists worry New Zealand’s whooping cough epidemic could be the worst in years. </p>
<p>Known as pertussis or the 100-day cough, whooping cough is a bacterial respiratory infection caused by <em>Bordetella pertussis</em>. It is extremely infectious and endemic in New Zealand.</p>
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<p>Usually, pertussis epidemics occur in three-to-five-year cycles. Community (herd) immunity is thought to account for such cycles, with the end of an epidemic indicating <a href="https://www.sciencedirect.com/science/article/pii/B9781455700905000306">herd immunity has been reached</a>. </p>
<p>Then, over the subsequent three to five years, the pool of susceptible individuals grows until a threshold of susceptibility triggers another epidemic. </p>
<p>But the COVID pandemic, years of <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/immunisation-coverage/national-and-regional-immunisation-data">declining immunisation coverage</a> and some nasty microbes have conspired to create a perfect storm of infectious diseases – including whooping cough, measles, respiratory syncytial virus (<a href="https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/respiratory-syncytial-virus-rsv">RSV</a>) and influenza – for the coming winter. </p>
<p>Infants and young children, particularly Māori, will face the brunt.</p>
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Read more:
<a href="https://theconversation.com/respiratory-infections-like-whooping-cough-and-flu-have-plummeted-amid-covid-but-bounce-back-is-a-worry-176692">Respiratory infections like whooping cough and flu have plummeted amid COVID. But 'bounce back' is a worry</a>
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<h2>Symptoms of whooping cough</h2>
<p>Whooping cough symptoms vary depending on many factors, including age, vaccination history and pre-existing conditions. </p>
<p>Initially, symptoms are non-specific, reading from the common cold’s playbook – runny nose, sneezing, occasional cough and maybe a mild temperature. This is the most infectious stage and also when antibiotics are most effective. </p>
<p>Features such as violent coughing, sometimes ending in vomiting or turning blue, and the “whoop” sound on breathing occur one to two weeks after these initial symptoms. At this stage, antibiotics are not expected to help symptoms, and for severe cases, care is only supportive, rendering clinicians and loved ones feeling helpless.</p>
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<img alt="A women helping a young child with an inhaler" src="https://images.theconversation.com/files/517550/original/file-20230327-20-22hg7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517550/original/file-20230327-20-22hg7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517550/original/file-20230327-20-22hg7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517550/original/file-20230327-20-22hg7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517550/original/file-20230327-20-22hg7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517550/original/file-20230327-20-22hg7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517550/original/file-20230327-20-22hg7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Antiobiotics are most effective during the early stages of infection.</span>
<span class="attribution"><span class="source">Shutterstock/Alexander_Safonov</span></span>
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<h2>Social distancing slowed spread of pertussis</h2>
<p>The youngest infants are <a href="https://www.cdc.gov/pertussis/pregnant/mom/deadly-disease-for-baby.html#:%7E:text=Babies%20are%20at%20risk%20for%20getting%20whooping%20cough&text=Most%20of%20the%20deaths%20each,younger%20than%203%20months%20old">most vulnerable to pertussis</a>. Complications usually arise from violent coughing, and range from facial swelling, broken ribs and lack of oxygen to brain bleeds and swelling. There is also <a href="https://pubmed.ncbi.nlm.nih.gov/21533103/">evidence</a> <em>B. pertussis</em> has immune-suppressing qualities, increasing the risk for co-infections or secondary infections. </p>
<p>Over the past 21 years, <a href="https://surv.esr.cri.nz/surveillance/PertussisRpt.php">at least ten deaths in babies</a> have been caused by pertussis in New Zealand. There have likely been more, with some potentially incorrectly attributed to sudden unexpected death in infancy.</p>
<p>Under normal circumstances, whooping cough epidemics happen in cycles, but the arrival of COVID sparked rigorous and unprecedented social distancing and other infection control measures. This was essentially a global war against infectious diseases.</p>
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Read more:
<a href="https://theconversation.com/future-infectious-diseases-recent-history-shows-we-can-never-again-be-complacent-about-pathogens-177746">Future infectious diseases: Recent history shows we can never again be complacent about pathogens</a>
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<p>As its only host, <em>B. pertussis</em> relies on humans in order to spread. It is possible its spread was disrupted by the measures we took to protect ourselves from COVID, particularly in regions with more severe and prolonged social distancing measures such as Auckland. </p>
<p>The effect of social distancing on transmission patterns and epidemics has not yet been investigated specifically for pertussis. But work on <a href="https://www.pnas.org/doi/full/10.1073/pnas.2013182117">other endemic airborne respiratory diseases</a>, including influenza and RSV, warns large future outbreaks could happen following periods of extended social distancing. These findings are plausible for pertussis. </p>
<h2>A third of infants lack protection</h2>
<p>Social distancing measures may have reduced circulation of <em>B. pertussis</em> and a corresponding reduction in immunity may have increased susceptibility to pertussis infection. A disruption to the cyclic pattern of an epidemic disease may alter the timing and severity of the following epidemic. It may delay onset but increase severity.</p>
<p>While our pandemic actions may have an influence, we can be certain the <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/immunisation-coverage/national-and-regional-immunisation-data">alarmingly low immunisation coverage rates</a> will result in some very severe cases among our most vulnerable infants. Around a third of our youngest infants are not appropriately immunised against pertussis. For Māori infants, more than half are at risk. </p>
<p>Prior to the COVID pandemic, New Zealand immunisation coverage had been diving, following a short but glorious period of high and relatively equitable vaccine coverage. This downward trend continued over the past three years, made worse through the diversion of resources that were already strained. The greatest declines in coverage have been among Māori. </p>
<p>This all means that since the last pertussis epidemic, New Zealand has been accruing susceptible individuals, accentuated by the pandemic and the declining immunisation coverage. It is like an all-you-can-eat smorgasbord of hosts for the pertussis bacterium to infect and travel through.</p>
<h2>How to curb the immediate risk</h2>
<p>The first most important action to prevent infant deaths is by vaccinating pregnant women. This provides transient protection to the newborn until old enough to receive their own vaccinations. </p>
<p>Less than half of pregnant women in New Zealand receive a pertussis booster, and for Māori women this is halved again. We need urgent action to raise awareness and improve access to services because this pregnancy boost is around 90% effective in preventing pertussis in infants.</p>
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<p>The second most important task is to ensure infants receive their vaccines on time, every time. Getting these services to where they are most needed is vital and it requires urgent action to improve awareness and support for services to be delivered. This vaccine is about 85-94% effective in preventing pertussis in infants and young children in New Zealand.</p>
<p>While COVID remains an ongoing challenge, the pandemic has left us more vulnerable than we were to many other respiratory infections. There are many other factors that contribute to infectious diseases like pertussis, including poverty. Interventions that reduce risk through social and environmental policies, such as improving housing conditions, are central to infectious disease control. </p>
<p>However, with a burned-out and under-resourced workforce, and a revised health system that has yet to demonstrate its worth, some of the best tools in our kit for this winter are our underutilised vaccines.</p><img src="https://counter.theconversation.com/content/202499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Petousis-Harris receives research funding for investigator-led research from GSK. She has severed on Advisory Boards for industry. She does not receive industry honoraria. She has received funding from research councils for studies related to vaccine coverage. She also has grants from the US CDC for vaccine safety studies and vaccine confidence workstreams.</span></em></p><p class="fine-print"><em><span>Hannah Chisholm does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>One in three infants is not immunised against pertussis. For Māori babies, more than half are at risk from the potentially deadly infection. But there are relatively simple things we can do.Helen Petousis-Harris, Associate Professor Primary Health, University of Auckland, Waipapa Taumata RauHannah Chisholm, Epidemiologist, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1983722023-02-10T13:52:08Z2023-02-10T13:52:08ZA nagging cough can hang on for weeks or months following a respiratory illness – and there is precious little you can do about it<figure><img src="https://images.theconversation.com/files/508687/original/file-20230207-744-b34d8v.jpg?ixlib=rb-1.1.0&rect=70%2C15%2C5122%2C3440&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Relentless coughing after a viral infection can be frustrating and worrisome, but in most cases, coughs resolve over time.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-coughing-into-elbow-while-sitting-in-bed-royalty-free-image/1286871310?phrase=coughing&adppopup=true">The Good Brigade/DigitalVision via Getty Images</a></span></figcaption></figure><p>When was the last time you walked into a public space and didn’t hear someone coughing? After three years of flinching at the sound, it can be disarming to hear so many people coughing – and embarrassing if it’s you. </p>
<p>But take heart in knowing that you’re not alone. A long-lasting cough following illness from an <a href="https://www.health.harvard.edu/staying-healthy/that-nagging-cough#">upper respiratory infection is surprisingly common</a>. And unfortunately, with the rise in <a href="https://theconversation.com/covid-19-rsv-and-the-flu-are-straining-health-care-systems-two-epidemiologists-explain-what-the-triple-threat-means-for-children-194242">seasonal flu, COVID-19 and respiratory syncytial virus, or RVS</a>, there’s been a lot of coughing lately.</p>
<p>A cough is a common symptom of these sorts of respiratory infections, and coughing is a complaint that leads to an estimated <a href="https://www.ncbi.nlm.nih.gov/books/NBK493221/#article-20073.s5">30 million office visits every year</a>. Some 40% of those end up in a <a href="https://scholar.google.cl/citations?hl=en&user=q-s2b08AAAAJ">pulmonologist’s office like mine</a>. </p>
<p>Given how ubiquitous persistent coughing is, you might presume that the medical profession has a long list of treatments that we know work. That, unfortunately, depends on why you are coughing. But a cough following an upper respiratory infection does usually go away, in time.</p>
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<figcaption><span class="caption">Allergies, sinus problems, medications, asthma and bronchitis are among the things that can lead to chronic cough.</span></figcaption>
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<h2>How a cough works</h2>
<p>Doctors have long wondered why the duration of cough varies so much following an upper respiratory viral or bacterial infection. The answer likely lies in differences in people, such as the presence of a condition like asthma or chronic bronchitis. I see this same variability in my office: Some patients develop a long-term cough, while others seem to kick the cough much sooner, with no clear explanation.</p>
<p>Coughing occurs <a href="https://www.ncbi.nlm.nih.gov/books/NBK493221/#article-20073.s5">due to a complex process</a> that begins with an electrical impulse between the nerves within the airways, including the nose and throat. There are two types of nerves that can trigger a cough in response to external stimuli: chemical receptors and mechanical ones called mechanoreceptors. Chemical receptors respond to smells and fumes; they’re the reason people sometimes cough after breathing in spicy peppers sizzling on a hot skillet. Mechanoreceptors respond to sensations from irritants such as dust.</p>
<p>When these nerves are activated, the throat closes and pressure in the chest increases. This buildup of pressure leads to a burst of air and mucous out of the lungs at around 500 mph – a speed <a href="https://www.automoblog.net/top-10-fastest-cars-in-the-world/">nearly twice as fast</a> as the world’s fastest cars. </p>
<p>Studies show that a viral infection <a href="https://doi.org/10.1007%2Fs00408-015-9832-5">alters how sensitive these same nerves are</a>. When you have a viral infection, the resulting <a href="https://theconversation.com/what-is-inflammation-two-immunologists-explain-how-the-body-responds-to-everything-from-stings-to-vaccination-and-why-it-sometimes-goes-wrong-193503">inflammatory process</a> produces a molecule called bradykinin that <a href="https://doi.org/10.1186/s12931-019-1060-8">drives the urge to cough</a>. And it’s known that the virus itself can <a href="https://doi.org/10.1007%2Fs00408-015-9832-5">activate genetic changes</a> that increase the sensitivity of these nerve pathways, which leads to more coughing. </p>
<p>But when the acute stage of infection is over and you start to feel better, the body repairs the damages caused by inflammation in your airways and lungs. Through this process, the cough reflex also abates. And the molecular processes that were making you cough and sneeze more frequently settle down and return to a normal state – at least in most cases. Unfortunately, in some people, this process takes longer than in others.</p>
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<figcaption><span class="caption">She coughed and coughed and coughed. Then a doctor discovered what was wrong.</span></figcaption>
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<h2>Knowing how long is too long to cough</h2>
<p>Doctors find it useful to break respiratory symptoms like cough into specific categories. </p>
<p>There are <a href="https://doi.org/10.1016/j.chest.2017.10.016">three main types of coughs</a>: <a href="http://www.antimicrobe.org/e40.asp">acute, sub-acute and chronic</a>. An acute cough is what most people experience when they’re sick with an active viral infection. A sub-acute cough lingers for <a href="https://doi.org/10.1183/09031936.04.00027804">three or more weeks following an upper respiratory illness</a>. And a chronic cough is one that <a href="https://my.clevelandclinic.org/health/diseases/15048-chronic-cough-overview">persists longer than 12 weeks</a>. Chronic cough is most commonly caused by asthma, <a href="https://www.webmd.com/allergies/postnasal-drip">postnasal drip</a> and, perhaps surprisingly to some, <a href="https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940#">reflux</a>. </p>
<p><a href="https://doi.org/10.1378/chest.129.1_suppl.138s">Postinfectious cough</a> is one variety of sub-acute cough and is the lingering cough that many people have after they get over their respiratory infection. It can last for weeks or months and can progress into chronic cough.</p>
<p>Because postinfectious cough is so common, doctors have long worked to determine how many people have a cough that persists after their other symptoms go away. Those <a href="https://doi.org/10.1378/chest.129.1_suppl.138s">estimates vary among studies</a>. One small study in Japan found that of people who have a sub-acute and chronic cough, <a href="https://doi.org/10.2147%2Fijgm.s8167">12% resulted from a respiratory tract infection</a>. </p>
<p>When it comes to COVID-19, the best evidence to date shows that only 2.5% of the people who have gotten it have also <a href="https://doi.org/10.1007/s00408-021-00450-w">developed a chronic cough</a> after infection. That number may seem small, but it translates to a lot of people coughing, given that the U.S. has <a href="https://covid.cdc.gov/covid-data-tracker/#datatracker-home">more than 280,000 new cases</a> of COVID-19 per week, as of early February 2023. The actual number, though, is unclear because the studies that look at postinfectious cough are often small and only account for the people who got COVID-19 and showed up in their doctor’s office or in a telehealth visit for evaluation.</p>
<h2>No simple fix</h2>
<p>The <a href="https://doi.org/10.1378/chest.129.1_suppl.138S">American College of Chest Physicians</a> and the <a href="https://doi.org/10.1183/13993003.01136-2019">European Respiratory Society</a> have published guidelines to help clinicians navigate these uncertainties and the dearth of data available on the diagnosis and treatment of coughing. Although the U.S. guidelines were published in 2006, they still represent the best evidence available for clinicians and their patients.</p>
<p>About half of patients recover from their cough <a href="https://doi.org/10.1016/j.chest.2017.10.016">without any treatment</a>. For those who don’t, the limited data available <a href="https://doi.org/10.1378/chest.129.1_suppl.95S">suggests that inhalers, steroids, narcotics</a> and certain <a href="https://doi.org/10.1002/14651858.CD001831.pub5">over-the-counter medications may provide relief</a> for some people.</p>
<p>In adults, the evidence for the efficacy of various treatments is mixed and limited. In my practice, I often prescribe a non-narcotic cough suppressant called benzonatate, sold under the <a href="https://www.webmd.com/drugs/2/drug-10992/tessalon-perles-oral/details">brand name Tessalon Perles</a>. It works by numbing the nerves in the lungs and airways, calming the cough reflex. Data for treatments in children is equally lacking, and studies have shown that over-the-counter cough suppressants and antihistamines were <a href="https://doi.org/10.1002/14651858.CD001831.pub5">no more effective than the placebo</a>.</p>
<p>Home remedies can also play an important role for some patients. Many people swear by honey, and there is some limited supporting evidence behind its benefits. One trial showed that honey was more effective at <a href="https://doi.org/10.1002/14651858.CD007094.pub5">soothing a cough than the placebo</a> over a three-day period. </p>
<h2>When in doubt, ask a doctor</h2>
<p>Being worried about a persistent cough is understandable – a quick Google search can present plenty of reasons to worry. Though not a very satisfying answer, most coughs really will eventually resolve on their own. However, if you lose weight rapidly, cough up blood, have night sweats or produce lots of sputum, you should talk to your primary care provider. In rare cases, sub-acute and chronic cough can be <a href="https://www.webmd.com/lung-cancer/lung-cancer-cough">a sign of lung cancer</a> or various forms of chronic pulmonary disease.</p>
<p>If you are simply nervous about it and want more information and advice, that is reason enough to check in with your doctor. After all, a cough is the reason behind millions of office visits every year.</p><img src="https://counter.theconversation.com/content/198372/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kyle B. Enfield receives funding from the National Heart and Lung Institute, Society of Critical Care Medicine - CureID, and the USDA. He is a member of the Society of Critical Care Medicine, the American Thoracic Society, the Society for Health Care Epidemiology of America, and the Wilderness Medicine Society. He is a volunteer with the Boy Scouts of America.</span></em></p>Some coughs can last for weeks or even months following an upper respiratory infection. The good news – albeit not very satisfying – is that most eventually go away on their own.Kyle B. Enfield, Associate Professor of Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1766922022-02-28T19:14:19Z2022-02-28T19:14:19ZRespiratory infections like whooping cough and flu have plummeted amid COVID. But ‘bounce back’ is a worry<figure><img src="https://images.theconversation.com/files/448795/original/file-20220228-25-s4wnot.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5760%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Public health measures to control COVID, including social distancing, masks, border closures and reduced international travel, have worked to reduce the impact of COVID.</p>
<p>But they’ve also led to a reduction, or changed the pattern, of other respiratory infections such as influenza, whooping cough and respiratory syncytial virus (RSV).</p>
<p>A <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2022/health/primary-and-community-health">Productivity Commission report</a> released last month showed whooping cough rates in 2020–21 were the lowest they’d been in years.</p>
<p>Australia also didn’t experience much of a flu season <a href="https://www.abc.net.au/news/2021-09-16/queensland-what-happened-to-the-flu-in-2021/100456616">in 2020 or 2021</a>. This is good news as we didn’t want to have both flu and COVID circulating in high numbers.</p>
<p>One concern, though, is these low rates may have lulled us into complacency. It might mean many people haven’t been in any rush to get their flu vaccine.</p>
<p>What’s more, because <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-ozflu-flucurr.htm?Open=&utm_source=health.gov.au&utm_medium=redirect&utm_campaign=digital_transformation&utm_content=flureport#current">very few of us</a> have had these infections over the past two years, we have probably experienced less of a boost in any “natural” immunity.</p>
<p>We need to be <a href="https://www.mja.com.au/journal/2022/216/1/preparing-out-season-influenza-epidemics-when-international-travel-resumes">wary of these infections bouncing back</a>, especially as we head into winter and our borders open to international travellers.</p>
<p>The Australian Technical Advisory Group on Immunisation (ATAGI) last week released advice <a href="https://www.health.gov.au/sites/default/files/documents/2022/02/atagi-advice-on-seasonal-influenza-vaccines-in-2022.pdf">urging all Australians to get a flu vaccine</a> once available, which is likely to be in March.</p>
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<h2>Flu rates are way down</h2>
<p>Influenza activity is <a href="https://www.who.int/teams/global-influenza-programme/surveillance-and-monitoring/influenza-updates/current-influenza-update">tracked at a global level</a> by the World Health Organisation and used to decide on which flu strains are covered in the vaccine each year.</p>
<p>In Australia it is a “notifiable disease”. This means laboratory-confirmed cases are reported to our National Notifiable Diseases Surveillance System. </p>
<p>In 2020, there were 21,266 notifications of laboratory-confirmed influenza to this system — almost <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/ozflu-surveil-season-summary-2020.htm">eight times lower</a> than the five-year average, which is 163,015.</p>
<p>In 2021, there were only <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/ozflu-surveil-no16-21.htm">598 notifications</a> up to early November.</p>
<p>It’s important to note some of the reduction in flu cases being notified could be due to fewer people presenting to health-care centres and being tested. This means we may undercount flu cases, especially mild ones.</p>
<p>However, we have also seen a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/ozflu-surveil-no16-21.htm">reduction in more severe cases</a> leading to hospitalisations and deaths due to flu, suggesting it’s a real decrease.</p>
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<h2>Whooping cough is down too</h2>
<p>Whooping cough (also called pertussis) is at historically low levels.</p>
<p>We usually experience an upsurge in whooping cough cases every three to five years. This is probably because we get a natural immune boost after exposure, which then tends to limit the spread and so the epidemic ends, however when our natural immune boost wanes we may then get an increase in cases.</p>
<p>It’s also a “notifiable disease”.</p>
<p>Our last big year was 2015–16, and if we followed the normal pattern we should have seen an increase in 2020–21.</p>
<p>In previous years, notifications of whooping cough have been over 100 per 100,000 children, with the <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2022/health/primary-and-community-health">highest rates</a> of 287 per 100,000 in 2015–16 and 357 per 100,000 in 2011–12.</p>
<p>But in 2020–21 there were only <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2022/health/primary-and-community-health">116 cases</a> notified in children under 14 years old. That’s a rate of 2.4 per 100,000 children, substantially lower than 2011–12 and 2015–16.</p>
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<h2>RSV has changed</h2>
<p>Respiratory syncytial virus (RSV) is a common viral infection that usually leads to an increase in hospitalisations every year, often before the arrival of flu. It can be particularly severe in infants under one year old.</p>
<p>The COVID pandemic and associated public health measures may be behind a shift in the timing of RSV infections.</p>
<p>In NSW from 2015 to 2019, the peak of infections was in autumn and winter. But in 2020, the peak of infections <a href="https://publications.aap.org/pediatrics/article/149/2/e2021053537/184564/RSV-Epidemiology-in-Australia-Before-and-During">shifted</a> to early summer.</p>
<p>In 2020, RSV hospitalisations were <a href="https://publications.aap.org/pediatrics/article/149/2/e2021053537/184564/RSV-Epidemiology-in-Australia-Before-and-During">lower in infants</a> under 12 months and higher in two to four year olds, compared to previous years (2014–19).</p>
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<h2>Vaccines are important for other diseases, too</h2>
<p>The reduction in flu, RSV and whooping cough is likely due to COVID public health measures.</p>
<p>However, for whooping cough, the protection of our youngest infants is probably also due to the impact of maternal whooping cough vaccines during pregnancy.</p>
<p>We don’t have much data on this yet, but one paper from Victoria showed an <a href="https://onlinelibrary.wiley.com/doi/10.5694/mja2.50125">increase in whooping cough vaccine uptake</a> among pregnant women. It climbed from about 38% to over 80% between 2015 and 2017. Another <a href="https://onlinelibrary.wiley.com/doi/10.1111/1753-6405.13133">paper</a> from southeast Queensland showed whooping cough vaccine coverage in pregnant women was approximately 70%.</p>
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<p>Real world effectiveness studies have shown a whooping cough vaccine during pregnancy is <a href="https://www.cdc.gov/pertussis/pregnant/hcp/vaccine-effectiveness.html">more than 90% effective</a> in preventing young infant hospitalisations from the disease. </p>
<p>For this reason, health authorities in Australia, the US and UK <a href="https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/pertussis-whooping-cough">recommend</a> a whooping cough vaccine be given during every pregnancy.</p>
<p>Australian health authorities <a href="https://immunisationhandbook.health.gov.au/vaccination-for-special-risk-groups/vaccination-for-women-who-are-planning-pregnancy-pregnant-or">also recommend</a> pregnant women get flu and COVID vaccines.</p>
<h2>We can’t be complacent</h2>
<p>Concerns about visiting health-care providers during COVID may have meant a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01337-4/fulltext">fall in vaccine coverage for other diseases</a>. This has occurred in some countries and has prompted <a href="https://www.who.int/news/item/15-07-2021-covid-19-pandemic-leads-to-major-backsliding-on-childhood-vaccinations-new-who-unicef-data-shows">an alert</a> from the World Health Organization.</p>
<p>Also, it’s clear fewer people have been naturally exposed to flu in the last two years. It’s possible having a flu infection in one year may give you <a href="https://www.jimmunol.org/content/202/2/335.long">some</a> <a href="https://www.mja.com.au/system/files/issues/194_01_030111/boo10600_fm.pdf">protection</a> in subsequent years (though you really don’t want to get the flu).</p>
<p>Both of these factors may mean we have lower protection when we finally get a flu season. </p>
<p>With winter approaching and borders opening up, it’s possible we may see the emergence of flu again this year.</p>
<p>In the meantime talk to your GP about any vaccines – including flu when it’s available – that you and your children may need to catch up on.</p><img src="https://counter.theconversation.com/content/176692/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas Wood received funding from the NHMRC for a Career Development Fellowship 2018 to 2021. He holds a Churchill fellowship awarded in 2019</span></em></p>Whooping cough rates are the lowest they’ve been for years. But what comes next?Nicholas Wood, Associate Professor, Discipline of Childhood and Adolescent Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1221912019-10-06T18:52:10Z2019-10-06T18:52:10ZPharmacists can vaccinate adults against whooping cough, measles and the flu, but it might cost you more<figure><img src="https://images.theconversation.com/files/293703/original/file-20190924-54782-1fazeoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pharmacist immunisers are gradually being allowed to give more types of vaccines.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1385453168?src=jkf9PEdb4d2ziEPJcyShBw-1-85&size=huge_jpg">FotoDuets/Shutterstock</a></span></figcaption></figure><p>Vaccines have long been available from GPs and nurses. But in recent years, laws have changed to add pharmacists to the list of health professionals who can give select vaccines without a prescription. </p>
<p>This may improve vaccination coverage against the flu, whooping cough and measles. But there’s a chance it could cost you more than if your saw your GP for the same shot.</p>
<h2>Overcoming resistance</h2>
<p>Before 2014, pharmacists couldn’t give vaccinations in Australia. Then <a href="https://eprints.qut.edu.au/91903/1/QPIP%20Final%20Report%202015%20.pdf">a pilot study</a> allowed a select group of Queensland pharmacies to offer the flu vaccine. </p>
<p>By this time, pharmacists had been giving certain vaccines in <a href="https://www.opatoday.com/professional/advocacy/scope-of-practice">Canada</a>, <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/immunisation-programme-decisions/pharmacist-vaccinators">New Zealand</a>, the <a href="https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/pharmacists-role-immunization.ashx">United States</a> and the <a href="https://psnc.org.uk/services-commissioning/advanced-services/flu-vaccination-service/flu-vaccination-training/">United Kingdom</a> for some years. </p>
<p>But in Australia, pharmacists didn’t have the skills and the law didn’t allow it. Another barrier was <a href="https://theconversation.com/how-rivalries-between-doctors-and-pharmacists-turned-into-the-turf-war-we-see-today-122534">the attitudes of other health professionals</a>, such as doctors, that pharmacists couldn’t or shouldn’t give vaccinations. </p>
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Read more:
<a href="https://theconversation.com/how-rivalries-between-doctors-and-pharmacists-turned-into-the-turf-war-we-see-today-122534">How rivalries between doctors and pharmacists turned into the 'turf war' we see today</a>
</strong>
</em>
</p>
<hr>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/28894312">Queensland pilot study</a> concluded pharmacists could safely and effectively administer certain vaccines to adults, once they were trained. This training included how to administer injections and what to do if something went wrong, such as managing <a href="https://immunisationhandbook.health.gov.au/resources/publications/managing-anaphylaxis">anaphylaxis</a> and performing CPR. </p>
<p>State and territory regulations have changed since 2014 and <a href="http://www.ncirs.org.au/new-resource-getting-vaccines-your-local-pharmacy">pharmacist vaccination services</a> have quickly grown. <a href="http://www.healthconsult.com.au/wp-content/uploads/pharmacist-administered-vaccination-program-evaluation.pdf">In Victoria</a>, for example, the number of pharmacies registered to give vaccines grew, from 36 in 2017 to 489 in July 2019. </p>
<h2>What vaccines can you get at the pharmacy?</h2>
<p>The rules <a href="http://ncirs.org.au/sites/default/files/2019-08/NCIRS%20Information%20Sheet-%20Vaccines%20from%20community%20pharmacy_August%202019_Final_0.pdf">vary in each state and territory</a>. Generally, if you’re 16 and over, pharmacist immunisers can give you the following three vaccines:</p>
<ul>
<li>influenza (flu)</li>
<li>diphtheria, tetanus and pertussis (whooping cough) – except Tasmania</li>
<li>measles, mumps and rubella (MMR) – except Tasmania and the ACT.</li>
</ul>
<p>These are important vaccines that are sometimes needed if adults missed doses earlier in life or have waning immunity. The influenza vaccine needs to be given every year in a short time frame.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-are-you-up-to-date-with-your-vaccinations-116510">Health Check: are you up to date with your vaccinations?</a>
</strong>
</em>
</p>
<hr>
<p>There are some further exceptions. </p>
<p>In the <a href="https://www.health.act.gov.au/sites/default/files/2019-04/Pharmacist%20vaccinations.pdf">Australian Capital Territory</a>, pregnant women can’t be vaccinated by a pharmacist. </p>
<p>In <a href="https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/340860/Tasmanian_Vaccination_Program_Guidelines_-_September_2019_.pdf">Tasmania</a> and <a href="http://www.healthywa.wa.gov.au/%7E/media/Files/Corporate/general%20documents/medicines%20and%20poisons/Word/Pharmacist_vaccination_code.ashx">Western Australia</a>, the flu vaccine can be given by a pharmacist to those aged ten and over. </p>
<p>Pharmacist immunisers are gradually being allowed to give more types of vaccines. In Western Australia, for example, pharmacists can now deliver the <a href="https://www.mediastatements.wa.gov.au/Pages/McGowan/2019/08/WA-pharmacists-able-to-administer-greater-range-of-vaccines.aspx">meningococcal ACWY</a> vaccine to those aged 16 and over. This vaccine protects against <a href="https://theconversation.com/what-is-meningococcal-disease-and-what-are-the-options-for-vaccination-88769">around half of the strains that cause meningococcal disease</a> in Australia. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-meningococcal-disease-and-what-are-the-options-for-vaccination-88769">What is meningococcal disease and what are the options for vaccination?</a>
</strong>
</em>
</p>
<hr>
<h2>It might cost you more</h2>
<p>Some vaccines that would be free from your GP, practice nurse or immunisation clinic will need to be paid for if given at a community pharmacy. That’s because pharmacist immunisers <a href="https://www.psa.org.au/pharmacist_administered_vaccinations/">aren’t able to access</a> the government-funded vaccines that your clinic can. </p>
<p>Victoria is an <a href="http://www.ncirs.org.au/new-resource-getting-vaccines-your-local-pharmacy">exception</a> – pharmacists can give select government-funded vaccines. And in the ACT and WA, the over-65s can access government-funded flu vaccines at pharmacies. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/295127/original/file-20191001-173358-1gnevx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pharmacists can’t usually access government-funded vaccines, aside from in Victoria.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1385081492?size=huge_jpg">Dragana Gordic/Shutterstock</a></span>
</figcaption>
</figure>
<p>The cost of vaccines at pharmacies varies. In <a href="http://www.healthconsult.com.au/wp-content/uploads/pharmacist-administered-vaccination-program-evaluation.pdf">Victoria</a>, for example, the total fee charged for people not eligible for a government-funded vaccination is around A$20 for influenza and A$43 for pertussis (whooping cough). </p>
<p>Even if the vaccine is free, the pharmacy may still charge <a href="https://ajp.com.au/news/flu-vax-charges-under-scrutiny/">a consultation fee</a>. </p>
<p>If you see your GP, they may either bulk bill you for the appointment or charge a consultation fee. </p>
<p>The best thing is to check ahead about any out-of-pocket expenses for vaccination when you make your booking.</p>
<h2>Do you need to see a GP?</h2>
<p>Pharmacy vaccination <a href="https://bmjopen.bmj.com/content/6/9/e011948">increases access</a> to preventative health care, especially for those living in rural and remote areas, where it’s <a href="https://grattan.edu.au/wp-content/uploads/2014/04/196-Access-All-Areas.pdf">difficult to visit a doctor or clinics are infrequent</a>.</p>
<p>Having pharmacists as immunisers also increases the immunisation workforce capacity for public health responses. To help address an outbreak of meningococcal disease last year in Tasmania, <a href="http://www.premier.tas.gov.au/releases/supporting_pharmacies_to_deliver_meningococcal_vaccines">pharmacist immunisers administered the meningococcal ACWY vaccine</a> to people aged 10 to 21. </p>
<p>Going to the pharmacist for some vaccines may take some <a href="https://grattan.edu.au/wp-content/uploads/2014/04/196-Access-All-Areas.pdf">pressure off family doctors</a> and free GPs to <a href="https://grattan.edu.au/wp-content/uploads/2017/03/886-Cutting-a-better-drug-deal.pdf">deliver more complex care</a> that only they can perform. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-role-of-pharmacists-should-be-overhauled-taking-the-heat-off-gps-73905">The role of pharmacists should be overhauled, taking the heat off GPs</a>
</strong>
</em>
</p>
<hr>
<p>But there may be instances when it’s better to go to your GP for a vaccination, for example, if you’re pregnant, have a chronic health condition or need some blood tests related to vaccination. Or you might have other things to discuss with your doctor other than vaccines.</p><img src="https://counter.theconversation.com/content/122191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Tran is an employee at the National Centre for Immunisation Research and Surveillance (NCIRS). NCIRS receives service contract funding from the Australian Government Departments of Health, NSW and other state government Departments of Health. Catherine Tran has not personally received any relevant external funding, including from any governments, foundations, or research council grants.</span></em></p><p class="fine-print"><em><span>Clayton Chiu is a public health physician and employee at the National Centre for Immunisation Research and Surveillance (NCIRS). NCIRS receives service contract funding from the Australian Government Departments of Health, NSW and other state government Departments of Health. Clayton Chiu has not personally received any relevant external funding, including from any governments, foundations, or research council grants.</span></em></p><p class="fine-print"><em><span>Kristine Macartney is the Director of the National Centre for Immunisation Research and Surveillance (NCIRS). NCIRS receives funding from the Australian Government, NSW and other state government Departments of Health. She also receives funding from the National Health and Medical Research Council (NHMRC).</span></em></p>You no longer have to go to your GP to get your flu shot or catch up on vaccinations you missed earlier in life or have waning immunity to. But they’re unlikely to be free.Catherine Tran, Senior Research Officer and Pharmacist, National Centre for Immunisation Research and Surveillance, University of SydneyClayton Chiu, Public Health PhysicianKristine Macartney, Professor, Discipline of Paediatrics and Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1111292019-02-22T14:28:40Z2019-02-22T14:28:40ZI had whooping cough as a GP trainee – the experience informed my academic work and clinical practice<figure><img src="https://images.theconversation.com/files/258297/original/file-20190211-174887-50c7l4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1295474197?src=hlnCEnESYS3O-KiZ5WYmjg-2-79&size=medium_jpg">Aaron Amat/Shutterstock</a></span></figcaption></figure><p>During my first year of training to be a GP, I developed a dry cough. I coughed in fits and at the end of a fit, I felt sick. It interrupted my sleep and taking over-the-counter painkillers and natural remedies, such as turmeric, honey and lemon, did little to ease my symptoms.</p>
<p>As doctors make the worst patients, I gave up and succumbed to my family’s nagging and went to see my GP. He took a history and examined me. He gave me antibiotics for a suspected bacterial chest infection and an inhaler for the wheeze he heard in my chest. The inhaler was odd since I was not asthmatic. </p>
<p>The cough was interrupting my sleep and I had to take time off work. After four days, the inhaler and antibiotics were doing very little, so I saw another GP who asked: “What would you do as a trainee GP if someone came to you after just four days of using the antibiotics you prescribed?” The suggestion being that I should have waited longer for the drugs to take effect rather than bother him with another appointment. </p>
<p>It was humiliating to be treated like a student, especially by a fellow doctor. But I could see why the GP was annoyed. He assumed that I had a bacterial infection of the upper airways, and sometimes coughs can last for several weeks after a full course of antibiotics (it’s what’s known as a “post-infectious cough”). But my cough was related to a different kind of bacteria to the one I was being treated for.</p>
<p>I was offered a different inhaler. Later that day I received a call from the GP who suggested I might have whooping cough. This was presumably after the lunchtime meeting where GPs discuss cases from the morning. It must have been puzzling how a GP trainee who rarely visits his GP would suddenly request to be seen twice in one week. The GP suggested a blood test, but wasn’t sure what else he could do. My blood test was positive for whooping cough. I received antibiotics but not before passing on this bacterial infection to two family members. </p>
<p>A couple of months later, coincidentally, we had a GP-led teaching session on whooping cough and several GP trainees thought they had cases that matched the symptom profile. But the sources online (from <a href="https://cks.nice.org.uk/whooping-cough#!diagnosis">NICE</a> and <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/762766/Guidelines_for_the_Public_Health_management_of_Pertussis_in_England.pdf">Public Health England</a>) were difficult to grasp, so I decided to write <a href="https://www.bmj.com/content/364/bmj.l401.full">an article</a> for the BMJ with up-to-date, accessible guidance for healthcare professionals.</p>
<p>As a clinical academic, I often find that my academic work is inspired by questions that arise from my clinical work, but I never thought I would be the patient from whom I would draw inspiration to change clinical practice.</p>
<h2>A guide for readers</h2>
<p>Whooping cough or pertussis is an infection caused by the bacteria <em>Bordetella pertussis</em>. The cough gets its name from the whooping gasps a person makes as they try and catch their breath between bouts of coughing. </p>
<p>People can get whooping cough at any age, but children under the age of six months have a higher risk of complications (including death), which may be due to their immature immune systems and the fact that they haven’t finished the course of immunisation against the disease at this point. </p>
<p>It can affect adults, too, especially those who have existing respiratory problems. The risk of getting whooping cough is also higher in adults who are overweight or obese, or those who have a weak immune system.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/31tnXPlhA7w?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Here’s what it sounds like.</span></figcaption>
</figure>
<p>Being vaccinated against the disease is no guarantee of protection, especially up to a decade after your last vaccine, which is why some countries suggest having boosters. </p>
<p>Although the vaccines are only short-lasting, pregnant women can protect their newborns by being immunised. A recent <a href="https://jmm.microbiologyresearch.org/content/journal/jmm/10.1099/jmm.0.000829#tab2">review article</a> concluded that the vaccine is both safe for mothers and effective for babies.</p>
<p>Symptoms of whooping cough include coughing several times in a row (paroxysms or fits), gasping (“whooping”) between coughing paroxysms and vomiting after coughing. In babies, it can also include intermittently stopping breathing. Treating whooping cough promptly with antibiotics won’t stop the prolonged symptom course of coughing – often called the “100 day cough” – but it can stop the disease spreading, especially to vulnerable groups, such as young babies.</p><img src="https://counter.theconversation.com/content/111129/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dipesh Gopal does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Whooping cough is making a comeback. Here’s how to identify it, and why vaccination is a way to protect babies.Dipesh Gopal, Academic Clinical Fellow, General Practice, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/943382018-04-09T14:54:20Z2018-04-09T14:54:20ZFlu vaccines for pregnant moms protect them against whooping cough<figure><img src="https://images.theconversation.com/files/213136/original/file-20180404-189801-e035jb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Shutterstock</span> </figcaption></figure><p>The influenza virus circulates every year and has the potential to turn into global epidemics. Flu virus infections affect people from all age groups and causes mild to severe illness. But newborns and babies younger than six months are at particular risk for serious disease.</p>
<p>Pregnant women are also increasingly susceptible to catching severe flu in their second and third trimesters and in the first six months after giving birth. Because of this, pregnant women have been identified as a priority group to receive the flu vaccine. </p>
<p>In addition to pregnant women, elderly people, people with chronic diseases or those who have HIV are also prioritised to get it. People with HIV have a high risk of getting severe flu because their immune systems are compromised by the virus. The flu vaccine is normally administered in South Africa from February until the end of the winter season in August. </p>
<p>But the challenge is that babies younger than six months old are unable to get the flu vaccine. This leaves them vulnerable. <a href="http://apps.who.int/iris/bitstream/handle/10665/43640/9280640489_eng.pdf;jsessionid=3BBC31872FCEB004DB436737F138D046?sequence=1">Global studies</a> on childhood deaths show that almost 1 million children younger than five die every year from pneumonia and that 45% of all deaths in children under the age of five occur in <a href="http://www.who.int/gho/child_health/mortality/en/">the first month of life</a>. In South Africa, the neonatal death rate sits at 14.6/ 1000 live births. </p>
<p>We set out to establish whether giving mothers the flu vaccine while they were pregnant could protect them from getting the flu and protect their babies in this first six month period. </p>
<p>We had two important findings. <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1401480">Our study primarily found</a> that giving pregnant mothers the flu vaccine protected their babies from getting the flu in the first six months of life – before they were eligible to get the vaccine themselves. The mothers themselves were also protected from getting sick from flu. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810468/">secondary analysis of the findings</a> has shown that when the flu vaccine was administered to pregnant women they were also protected from developing whooping cough.</p>
<h2>A double hit</h2>
<p>Research shows that children under the age of six months have the highest burden of respiratory diseases such as influenza and whooping cough, known as <a href="http://www.nicd.ac.za/assets/files/Pertussis%20FAQ_final_20170111_%20corrected%20date%20on%20bottom_30Jan2017.pdf">pertussis</a>. </p>
<p>Pertussis is a highly contagious respiratory disease caused by the bacterium <em>Bordetella pertussis</em>. Anyone can get pertussis, which is spread from person to person when an infected person coughs or sneezes. But some people face a higher risk of infection and severe disease. Those with weakened immune systems and chronic lung disease are at higher risk. For babies younger than six months, the disease poses the greatest risk because they are more likely to develop complications and die. </p>
<p>The pertussis vaccine is part of the routine vaccination schedule for all babies in the country. The vaccine, which is administered globally, has significantly reduced the case load of whooping cough. </p>
<p>The challenge is that although babies start their pertussis vaccinations when they are six weeks old, they are only protected against the disease after their third dose of the vaccine when they are three months old. This means that they are particularly vulnerable. Protecting them is a priority in many developing countries, including South Africa.</p>
<p>In our randomised clinical trial we administered the flu vaccine and a placebo to two groups of women. When they received the vaccine they were in their late second or third pregnancy trimester. </p>
<p>Our study proved that the women who received the influenza vaccine had less pertussis infections. But the protection they got from the vaccine was indirect. It stopped them from getting influenza which in turn protected them from getting a co-infection of pertussis. </p>
<h2>An alternative</h2>
<p><a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1401480">Our study</a> shows that there are significant benefits to pregnant women being given the influenza vaccine. But there is still a huge gap in the number of people being vaccinated in the country. </p>
<p>Although the government has increased the number of vaccines made available through the public health system over the past few years, the number being administered is still wholly inadequate. </p>
<p>Influenza vaccination should nonetheless be a priority for all high risk groups.</p><img src="https://counter.theconversation.com/content/94338/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marta C. Nunes receives funding from Bill & Melinda Gates Foundation, Foundation for Influenza Epidemiology, MedImmune</span></em></p><p class="fine-print"><em><span>Clare Cutland receives funding from The Bill & Melinda Gates Foundation. </span></em></p>Giving pregnant mothers the flu vaccine protected their babies from getting the flu in the first six months of life.Marta C. Nunes, Reader and Senior Scientist at the Meningeal Pathogens Research Unit, University of the WitwatersrandClare Cutland, Deputy Director at the Respiratory and Meningeal Pathogens Research Unit, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/814002017-08-28T20:10:18Z2017-08-28T20:10:18ZHealth Check: which vaccinations should I get as an adult?<figure><img src="https://images.theconversation.com/files/181632/original/file-20170810-4244-1cw5cph.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vaccines are one of the greatest public health achievements in history.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Before vaccines were developed, infectious diseases such as diphtheria, tetanus and meningitis were the <a href="https://www.quora.com/What-is-the-most-common-cause-of-human-death-in-history">leading cause of death</a> and illness in the world. Vaccines are one of the <a href="http://www.who.int/bulletin/volumes/86/2/07-040089/en/">greatest public health achievements in history</a>, having drastically reduced deaths and illness from infectious causes.</p>
<p>There is a large <a href="https://newsroom.unsw.edu.au/news/health/millions-australian-adults-missing-out-free-vaccines">gap between vaccination rates</a> for funded <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/adult-vaccination-fact-sheet.pdf">vaccines for adults in Australia</a> and those for infants. More than 93% of infants are vaccinated in Australia, while in adults the rates are between 53-75%. Much more needs to be done to prevent infections in adults, particularly those at risk. </p>
<p>If you are an adult in Australia, the kinds of vaccines you need to get will depend on several factors, including whether you missed out on childhood vaccines, if you are Aboriginal or Torres Strait Islander, your occupation, how old you are and whether you intend to go travelling.</p>
<h2>For those born in Australia</h2>
<p>Children up to four years and aged 10-15 receive vaccines under the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule">National Immunisation Schedule</a>. These are for hepatitis B, whooping cough, diphtheria, tetanus, measles, mumps, rubella, polio, haemophilus influenzae B, rotavirus, pneumococcal and meningococcal disease, chickenpox and the human papillomavirus (HPV).</p>
<p>Immunity following vaccination varies depending on the vaccine. For example, the measles vaccine protects for a long duration, possibly a lifetime, whereas immunity wanes for pertussis (whooping cough). Boosters are given for many vaccines to improve immunity. </p>
<p><strong>Measles, mumps, rubella, chickenpox, diphtheria and tetanus</strong></p>
<p>People born in Australia before 1966 likely have <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-9">natural immunity to measles</a> as the viruses were circulating widely prior to the vaccination program. People born after 1965 should have received two doses of a measles vaccine. Those who haven’t, or aren’t sure, can safely receive a vaccine to avoid infection and prevent transmission to babies too young to be vaccinated. </p>
<p>Measles vaccine can be given as MMR (measles-mumps-rubella) or MMRV, which includes varicella (chickenpox). The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-22">varicella vaccine</a> on its own (not combined in MMRV) is advised for people aged 14 and over who have not had chickenpox, especially women of childbearing age.</p>
<p>Booster doses of diphtheria, tetanus and whooping cough vaccines, are available free at age 10-15, and recommended at 50 years old and also at 65 years and over if not received in the previous ten years. Anyone unsure of their tetanus vaccination status who sustains a tetanus-prone wound (generally a deep puncture or wound) should get vaccinated. While tetanus is rare in Australia, most cases we see are in older adults.</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=838&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=838&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=838&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1053&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1053&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1053&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In July 2017, the government announced free catch-up vaccinations for all newly arrived refugees. This covers any childhood vaccine on the National Immunisation Schedule which has been missed.</span>
<span class="attribution"><span class="source">Information sourced from betterhealth.vic.gov.au and healthdirect.gov.au/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<hr>
<p><strong>Whooping cough</strong></p>
<p>Pregnant women are recommended to get the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/pregnant-women">diphtheria-tetanus-acellular pertussis</a> vaccine in the third trimester to protect the vulnerable infant after it is born, and influenza vaccine at any stage of the pregnancy (see below under influenza). </p>
<p>Pertussis (whooping cough) is a contagious respiratory infection dangerous for babies. One in <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/whooping-cough">every 200 babies</a> who contract whooping cough will die. </p>
<p>It is particularly important for women from 28 weeks gestation to ensure they are vaccinated, as well as the partners of these women and anyone else who is taking care of a child younger than six months old. Deaths from pertussis are also documented in elderly Australians.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-vax-no-visit-if-mum-was-vaccinated-baby-is-already-protected-against-whooping-cough-59374">'No Vax, No Visit'? If mum was vaccinated baby is already protected against whooping cough</a>
</strong>
</em>
</p>
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<p><strong>Pneumococcal disease and influenza</strong></p>
<p>The pneumococcal vaccine is funded for everyone aged 65 and over, and <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-13">recommended for anyone</a> under 65 with risk factors such as chronic lung disease.</p>
<p>Anyone from the age of six months can get the flu (influenza) vaccine. The vaccine can be given to any adult who requests it, but is only funded if they fall into defined risk groups such as pregnant women, Indigenous Australians, peopled aged 65 and over, or those with a medical condition such as chronic lung, cardiac or kidney disease. </p>
<p>Flu vaccine is matched every year to the anticipated circulating flu viruses and is quite effective. The vaccine covers four strains of influenza. Pregnant women are at increased risk of the flu and recommended for influenza vaccine any time during pregnancy. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/millions-of-australian-adults-are-unvaccinated-and-its-increasing-disease-risk-for-all-of-us-74991">Millions of Australian adults are unvaccinated and it's increasing disease risk for all of us</a>
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</em>
</p>
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<p>Health workers, childcare workers and aged-care workers are a priority for vaccination because they care for sick or vulnerable people in institutions at risk of outbreaks. Influenza is the most important vaccine for these occupational groups, and some organisations provide free staff vaccinations. Otherwise, you can ask your doctor for a vaccination.</p>
<p>Any person whose immune system is <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part3%7Ehandbook10-3-3#3-3-3">weakened through medication</a> or illness (such as HIV) is at increased risk of infections. However, live viral or bacterial vaccines must not be given to immunosuppressed people. They must seek medical advice on which vaccines can be safely given.</p>
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<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1780&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1780&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1780&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In July 2017, the government announced free catch-up vaccinations for all newly arrived refugees. This covers any childhood vaccine on the National Immunisation Schedule which has been missed.</span>
<span class="attribution"><span class="source">Information sourced from betterhealth.vic.gov.au and healthdirect.gov.au/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
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<p><strong>Hepatitis</strong> </p>
<p>Australian-born children receive four shots of the hepatitis B vaccine, but some adults are advised to get vaccinations for hepatitis A or B. Those recommended to receive the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-4">hepatitis A vaccine</a> are: travellers to hepatitis A endemic areas; people whose jobs put them at risk of acquiring hepatitis A including childcare workers and plumbers; men who have sex with men; injecting drug users; people with developmental disabilities; those with chronic liver disease, liver organ transplant recipients or those chronically infected with hepatitis B or hepatitis C.</p>
<p>Those recommended to get the hepatitis B vaccine are: people who live in a household with someone infected with hepatitis B; those having sexual contact with someone infected with hepatitis B; sex workers; men who have sex with men; injecting drug users; migrants from hepatitis B endemic countries; healthcare workers; Aboriginal and Torres Strait Islanders; and some others at high risk at their workplace or due to a medical condition.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
</strong>
</em>
</p>
<hr>
<p><strong>Human papillomavirus</strong></p>
<p>The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hpv">human papillomavirus (HPV) vaccine</a> protects against cervical, anal, head and neck cancers, as well as some others. It is available for <a href="https://theconversation.com/boys-should-also-get-the-hpv-vaccine-to-protect-themselves-from-oral-and-genital-cancers-58772">boys</a> and girls and delivered in high school, usually in year seven. There is benefit for older girls and women to be vaccinated, at least up to their mid-to-late 20s. </p>
<h2>The elderly</h2>
<p>With ageing comes a progressive decline in the immune system and a <a href="https://theconversation.com/vaccination-isnt-just-for-kids-a-guide-for-over-65s-27869">corresponding increase</a> in risk of infections. Vaccination is the <a href="http://www.scirp.org/journal/PaperInformation.aspx?paperID=41210">low-hanging fruit</a> for healthy ageing. The elderly are advised to receive the influenza, pneumococcal and shingles vaccines.</p>
<p>Influenza and pneumonia are <a href="http://www.sciencedirect.com/science/article/pii/S0264410X16308520?via%3Dihub">major preventable causes</a> of illness and death in older people. The flu causes deaths in children and the elderly during severe seasons. </p>
<p>The most common cause of pneumonia is streptococcus pneumonia, which can be prevented with the <a href="https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html">pneumococcal vaccine</a>. There are two <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-13">types of pneumococcal vaccines</a>: pneumococcal conjugate vaccine (PCV) and pneumococcal polysaccharide vaccine (PPV). Both protect against invasive pneumococcal disease (such as meningitis and the blood infection referred to as septicemia), and the conjugate vaccine is proven to reduce the risk of pneumonia.</p>
<p>The <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/adult-vaccination-fact-sheet.pdf">government funds</a> influenza (annually) and pneumococcal vaccines for people aged 65 and over.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Vaccination is the low-hanging fruit for healthy ageing.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<p>Shingles is a reactivation of the chickenpox virus. It causes a high burden of disease in older people (who have had chickenpox before) and can lead to debilitating and chronic pain. The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-24">shingles vaccine</a> is recommended for people aged 60 and over. The government funds it for people aged 70 to 79. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-how-do-you-get-shingles-and-who-should-be-vaccinated-against-it-64436">Explainer: how do you get shingles and who should be vaccinated against it?</a>
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</em>
</p>
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<h2>Australian travellers</h2>
<p>Travel is a major vector for transmission of infections around the world, and travellers are at high risk of preventable infections. Most <a href="http://www.sciencedirect.com/science/article/pii/S0264410X16306065">epidemics of measles</a>, for example, are imported through travel. People may be under-vaccinated for measles if they missed a dose in childhood. </p>
<p>Anyone travelling should discuss vaccines with their doctor. If unsure of measles vaccination status, vaccination is recommended. This will depend on where people are travelling, and may include vaccination for yellow fever, Japanese encephalitis, cholera, typhoid, hepatitis A or influenza. </p>
<p>Travellers who are visiting friends and relatives overseas often <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5111124/">fail to take precautions</a> such as vaccination and do not perceive themselves as being at risk. In fact, they are at higher risk of preventable infections because they may be staying in traditional communities rather than hotels, and can be exposed to risks such as contaminated water, food or mosquitoes.</p>
<h2>Aboriginal Australians and Torres Strait Islanders</h2>
<p>Indigenous Australians are at <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part3%7Ehandbook10-3-1">increased risk of infections</a> and have access to funded vaccines against influenza (anyone over six months old) and pneumococcal disease (for infants, everyone over 50 years and those aged 15-49 with chronic diseases). </p>
<p>They are also advised to get hepatitis B vaccine if they haven’t already received it. Unfortunately, overall <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi32suppl.htm">vaccine coverage for these groups</a> is low – between 13% and 50%, representing a real lost opportunity.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dr-g-yunupingus-legacy-its-time-to-get-rid-of-chronic-hepatitis-b-in-indigenous-australia-81672">Dr G. Yunupingu's legacy: it's time to get rid of chronic hepatitis B in Indigenous Australia</a>
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</em>
</p>
<hr>
<h2>Migrants and refugees</h2>
<p>Migrants and refugees are at risk of vaccine-preventable infections because they <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12602/full">may be under-vaccinated</a> and come from countries with a high incidence of infection. There is no systematic means for GPs to identify people at risk of under-vaccination, but the new <a href="https://www.humanservices.gov.au/customer/services/medicare/australian-immunisation-register">Australian Immunisation Register</a> will help if GPs can check the immunisation status of their patients.</p>
<p>The funding of catch-up vaccination has also been a major obstacle until now. In July 2017 the government announced <a href="http://www.sbs.com.au/news/article/2017/07/12/refugees-all-ages-now-eligible-governments-national-vaccination-program">free catch-up vaccinations</a> for children aged 10-19 and for all newly arrived refugees. This covers any childhood vaccine on the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule">National Immunisation Schedule</a> that has been missed. </p>
<p>While this does not cover all under-vaccinated refugees, it is a welcome development. If you are not newly arrived but a migrant or refugee, check with your doctor about catch-up vaccination.</p><img src="https://counter.theconversation.com/content/81400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC and ARC. In the past she has received funding for investigator driven research or educational grants from Merck, GSK, Seqirus and Pfizer. </span></em></p><p class="fine-print"><em><span>Rob Menzies has been engaged as a consultant by Seqirus.</span></em></p>The kinds of vaccines adults need depend on several factors, including whether you were born here, how old you are and whether you intend to travel overseas.C Raina MacIntyre, Professor of Infectious Diseases Epidemiology, Head of the School of Public Health and Community Medicine, UNSW SydneyRob Menzies, Senior Lecturer, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/612892016-08-22T03:46:29Z2016-08-22T03:46:29ZHealth Check: should kids be given antibiotics in their first year?<figure><img src="https://images.theconversation.com/files/128956/original/image-20160701-30632-1p10etd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Two-thirds of children have already received antibiotics by the time they are one year old.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Two-thirds of children have already received antibiotics by the time they are one year old. Antibiotic use is <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(14)70780-7/abstract">increasing in Australia</a>, which directly affects the development of antibiotic resistance. This is now at crisis levels, meaning <a href="http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/antimicrobial-stewardship/antibiotic-awareness-week/">some infections are becoming untreatable</a>.</p>
<p>So if you have a ten-month-old baby, what do you need to know? What do you need to ask your GP about the benefits and risks of antibiotics? </p>
<p>Many doctors think parents come to them seeking a prescription, but parents increasingly want to have the pros and cons explained so they can share in the decision-making about whether or not their child needs antibiotics. </p>
<h2>The pros</h2>
<p>Antibiotics can be life-saving. Before antibiotics were developed and first used in the 1940s, the infant death rate in the developed world was about one in ten and the most common cause was infection. This has dramatically reduced over the past 70 years. While not all of this is because of antibiotics (sanitation and immunisation have also been important), the ability to treat infections effectively has saved millions of lives.</p>
<p>Some infections need antibiotics because they are caused by bacteria and the infection will only get worse if not treated. Examples of serious infections that need antibiotics under one year of age are meningitis, pneumonia, bloodstream infection and urinary infection. </p>
<p>The problem is, it is often difficult to differentiate bacterial from viral infection in young babies, especially those under three months of age, and to identify those at risk of serious bacterial infection. In those situations antibiotics are often started empirically to be safe, then stopped if no bacterial infection is found.</p>
<p>Antibiotics are also used in children to prevent the spread of some bacterial infections, such as whooping cough. However, most serious bacterial infections are not transmitted from one person having the infection to another person in close contact. This includes meningitis, urinary infection and even pneumonia.</p>
<p>Other infections are caused by viruses, so antibiotics are ineffective for treatment or to prevent spread. Under the age of one year, common viral infections include most respiratory infections – for example, ear, throat and chest infections. Treating viral infections with antibiotics results in none of the benefits and only the disadvantages.</p>
<h2>The cons</h2>
<p>In addition to minor disadvantages such as inconvenience and cost, the major disadvantages lie in the risks of antibiotic use. These can be divided into short, medium and long-term risks.</p>
<p>The short-term risks are immediate side-effects such as diarrhoea, vomiting, rash and, more seriously, anaphylaxis (severe allergy). Most of these will resolve themselves without treatment, but some can be life-threatening.</p>
<p>The medium-term risks are the development or acquiring of resistant organisms. Antibiotic overuse has been associated with increases in MRSA, a resistant bacteria that commonly causes skin infections and occasionally more serious infections such as bone or bloodstream infections in children.</p>
<p>The recent concern has been resistant gastrointestinal bacteria because these can cause rapid and severe infections and there is no reliable way of removing them from the gut. We are running out of antibiotics to treat these types of infections.</p>
<p>Many of the major drug companies are focusing their research and development on medicines other than antibiotics, so there are few on the horizon. To try to treat very resistant bacteria, a few old antibiotics are being used again, some of which have significant side-effects such as damage to the kidneys.</p>
<p>Resistant organisms are also a long-term risk because they can be carried by children for a very long time and be spread within the family. However, other potential long-term risks for child health are only just being realised. </p>
<p>Over the last couple of years there has been great interest in the entirety of bacteria living in the gut known as the microbiome.</p>
<p>Antibiotics <a href="http://www.nature.com/ncomms/2016/160126/ncomms10410/full/ncomms10410.html">have been shown</a> to affect the childhood microbiome. Similar changes have been found in the microbiome of children with allergy and obesity – two of the biggest childhood issues in developed countries. While this link is still being researched, this is another reason to limit our antibiotic use.</p>
<p>There are several ways to cut down on antibiotics in children under the age of one: <a href="http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/antimicrobial-stewardship/antibiotic-awareness-week/">not using antibiotics for viral infections</a>, <a href="http://www.nice.org.uk/guidance/CG69">delaying starting antibiotics</a> for some infections such as ear infections to see if they get better on their own, and using a <a href="http://www.asid.net.au/groups/anzpid">short course of antibiotics</a> where it has been shown to be safe instead of traditional longer courses.</p>
<p>So how do you tell the difference between a bacterial and a viral infection in your ten-month-old child? </p>
<p>While some symptoms such as a runny nose make a virus more likely, parents should not feel they are being asked to tell the difference. They should seek advice from their local doctor, but, importantly, have a conversation about whether their <a href="http://www.choosingwisely.org.au">child needs antibiotics</a>. </p>
<p>Antibiotics are a precious resource. To ensure we preserve them for when they are really needed, both now and for future generations, all of us are responsible for asking the question: “Does my child really need antibiotics?”</p><img src="https://counter.theconversation.com/content/61289/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Penelope Bryant does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you have a ten-month-old baby, what do you need to know? What do you need to ask your GP about the benefits and risks of antibiotics?Penelope Bryant, Consultant in Paediatric Infectious Diseases and General Paediatrics, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/593742016-05-29T20:58:33Z2016-05-29T20:58:33Z‘No Vax, No Visit’? If mum was vaccinated baby is already protected against whooping cough<figure><img src="https://images.theconversation.com/files/123728/original/image-20160524-20557-1uuxu9f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's no evidence to show your baby is at risk if visitors don't get a whooping cough vaccine. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/howardignatius/10952969694/">Lily/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><blockquote>
<p>NO VAX, NO VISIT! Our baby girl is due in four weeks. We can’t wait to meet her! If you would like to meet her, we ask that you ask your doctor for a whooping cough booster this week. Our daughter can’t receive her first vaccination until she’s six weeks old, so relies on us to keep her safe from germs. #NoVaxNoVisit</p>
</blockquote>
<p>Have you seen these requests in your social media feeds recently? </p>
<p>No Vax, No Visit is a movement being propagated through social media and social pressure. Expectant parents are demanding that all visitors who wish to visit their newborn are recently vaccinated against whooping cough. If visitors can’t prove they’re vaccinated, they’re refused permission to visit the baby in hospital or at home until after the newborn’s <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule">two-month vaccination</a> (which can be given at six weeks).</p>
<p>It is understandable that prospective parents, aware of how devastating whooping cough can be, want to leave no stone unturned to protect their baby. But is it supported by the best evidence?</p>
<p>No Vax, No Visit is an unofficial extension of the “cocooning” strategy, recommended by the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-12">Australian Immunisation Handbook</a> since 2003. </p>
<p>The official cocooning recommendation is to vaccinate regular household contacts if they haven’t had a whooping cough booster within the last ten years. This strategy targets parents, siblings, grandparents and anyone who is in regular contact with babies, as they are <a href="http://www.ncbi.nlm.nih.gov/pubmed/23200883">the most common sources of infection</a> in newborns.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/123731/original/image-20160524-11032-a6isu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/123731/original/image-20160524-11032-a6isu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/123731/original/image-20160524-11032-a6isu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/123731/original/image-20160524-11032-a6isu1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/123731/original/image-20160524-11032-a6isu1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/123731/original/image-20160524-11032-a6isu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/123731/original/image-20160524-11032-a6isu1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/123731/original/image-20160524-11032-a6isu1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">‘Cocooning’ doesn’t mean a baby can’t come into contact with anyone who hasn’t been vaccinated.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/vstrash/5609832806/">Tom Leuntjens/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The cocooning recommendation doesn’t mean that anyone who comes through the front door to visit and say a quick hello must be vaccinated. It doesn’t mean regular household contacts need to be vaccinated for every child born within those ten years. </p>
<p>Although the idea of creating a “cocoon” of protection around babies is attractive, this approach has <a href="http://www.ncbi.nlm.nih.gov/pubmed/26320420">limitations</a>. And eliminating all possible sources of whooping cough this way just isn’t possible.</p>
<h2>So, what should parents do?</h2>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0140673614606863">Evidence</a> became available in 2014 that showed if mums are vaccinated during pregnancy, the vaccine is 91% effective in preventing severe whooping cough in very young infants. </p>
<p>When a mum is vaccinated during pregnancy, the protective antibodies travel across the placenta and into the baby. It’s essentially a [baby’s first vaccine](http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(1460977-6/fulltext), so the baby is born with an army of antibodies ready for defence. </p>
<p>Contrary to the American vaccine insert, many studies, such as this <a href="http://www.bmj.com/content/349/bmj.g4219">one</a>, have actually tested the vaccine on tens of thousands of pregnant women. The studies demonstrate how effective and safe this is for pregnant mums and their unborn child. Subsequently, in March 2015, the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10-updates%7Ehandbook10-updates-27-03-2015">Australian Immunisation Handbook</a> began recommending that women who are between 28 and 32 weeks pregnant receive a whooping cough booster for each pregnancy.</p>
<p>If mums follow this pregnancy recommendation, the vaccination of all visitors (in addition to regular household contacts) could theoretically offer a small amount of additional protection for the baby. However, there’s no evidence to say this is the case. The person more likely to benefit is the one receiving the vaccination, particularly if they are <a href="http://www.ncbi.nlm.nih.gov/pubmed/22806592">elderly</a>.</p>
<h2>Social consequences</h2>
<p>Important things to consider with No Vax, No Visit are the unintended social consequences. </p>
<p>While some parents will find their family and friends are happy to be vaccinated, we are also hearing stories of isolation of new parents, division in social groups, and guilt of friends feeling irresponsible. Some new parents are even too scared to take their baby to the “disease-riddled” shopping centre, school or playground. </p>
<p>What seems to be forgotten is the high level of protection the baby already has if mum was vaccinated while pregnant. </p>
<p>While there’s no evidence that No Vax, No Visit will offer any additional protection for the newborn, there is <a href="http://www.ncbi.nlm.nih.gov/pubmed/7597543">evidence</a> that social isolation can lead to postnatal depression. This is particularly important when we consider <a href="https://www.beyondblue.org.au/who-does-it-affect/pregnancy-and-early-parenthood/mental-health-conditions/depression">one in seven new mothers</a> in Australia experiences postnatal depression. </p>
<p>Support for new parents is most needed during the newborn’s first few weeks of life. If new parents don’t have any visitors and are too scared to go out into the world with their newborn, what effect will this have on the family’s wellbeing?</p>
<p>So, what else can parents do to protect their newborn before the six-week vaccination if mum was vaccinated during pregnancy, and dad, siblings and grandparents are all up to date with their vaccines? Ask visitors to postpone their visit if they are sick, and hand-washing before cuddles is essential. </p>
<p>With all this in place, there’s little or no extra benefit from No Vax, No Visit.</p><img src="https://counter.theconversation.com/content/59374/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kerrie Wiley receives funding from the Marie Bashir Institute. </span></em></p><p class="fine-print"><em><span>National Centre for Immunisation Research & Surveillance (NCIRS) is funded by Australian Department of Health and NSW Ministry of Health. NCIRS Provides technical secretariat for the Australian Technical Advisory Group on Immunisation. Peter McIntyre previously chaired the ATAGI Pertussis Working Party and also sits on the WHO IVIR Advisory Committee. NHMRC Grant 2010-2014 for neonatal pertussis trial. GSK in kind and Financial support for follow-on studies.</span></em></p><p class="fine-print"><em><span>Samantha Carlson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prospective parents, aware of how devastating whooping cough can be, want to leave no stone unturned to protect their baby. But is No Vax, No Visit supported by the best evidence?Samantha Carlson, Social Science Research Officer for the National Centre for Immunisation Research and Surveillance, University of SydneyKerrie Wiley, Research Fellow, National Centre for Immunisation Research & Surveillance, and School of Public Health, University of SydneyPeter Bruce McIntyre, Professor and Director for the National Centre for Immunisation Research and Surveillance of Vaccine, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/417642015-05-14T20:01:35Z2015-05-14T20:01:35ZNew register shows importance of vaccination beyond childhood<figure><img src="https://images.theconversation.com/files/81666/original/image-20150514-28586-1tf2v9h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Given the increasing number of vaccines recommended for adolescents and adults in Australia, the newly announced initiatives are a very good idea.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/wellcomeimages/16580160449/">Wellcome Images/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>Health was not one of the winners of <a href="http://www.budget.gov.au/">Tuesday night’s big-spending federal budget</a>, but one initiative tucked away in the budget papers is worthy of applause – the establishment of an adult immunisation register and the expansion of the childhood register to include adolescents. </p>
<p>The <a href="http://www.budget.gov.au/2015-16/content/bp2/html/bp2_expense-14.htm">budget papers</a> say immunisation data collection will be expanded to include school-based adolescent vaccinations and that an adult register will be established from September 1, 2016. </p>
<p>The move means that we will soon record all vaccinations delivered to adolescents and adults through the government-funded National Immunisation Program (NIP). The program covers the cost of vaccines, but not all the recommended shots are on the NIP.</p>
<h2>Existing register</h2>
<p>Australia already has an immunisation register for children. The <a href="http://www.humanservices.gov.au/customer/services/medicare/australian-childhood-immunisation-registe">Australian Childhood Immunisation Register (ACIR)</a> is the envy of many countries around the world. It was established in 1996 and, after a shaky start, now provides accurate data on the immunisation status of all registered children under seven years old. </p>
<p>The register also provides data for the regular reporting of immunisation coverage, with data available by state, regions within the states, Indigenous status and age group. This allows gaps in vaccine coverage to be highlighted and, in turn, for targeted interventions to improve uptake. The adult register could perform a similar role.</p>
<p>Recognising how well the ACIR has allowed monitoring of vaccine coverage for children, many clinicians and public health workers have long advocated having the same information available for adolescents and adults. </p>
<p>Adult vaccinations will be recorded, potentially for every Australian adult, and this information could well become part of the new opt-out e-health record.</p>
<h2>Getting the adult register going</h2>
<p>Before the ACIR was established, the call for its establishment was a recurring theme at the immunisation conferences sponsored by the <a href="http://www.phaa.net.au/">Public Health Association of Australia</a>. It’s been exactly the same with the adult immunisation register. </p>
<p>For at least ten years now, one of the resolutions at every immunisation conference has been the establishment of an adult immunisation register. But most of us supporting these resolutions did not think the idea had much traction in Canberra. So, the announcement has been something of a welcome surprise. </p>
<p>Still, it’s probably an idea whose time has come, given the increasing number of vaccines recommended for adolescents and adults in Australia. </p>
<p>The influenza and <a href="http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-pneumococcal">pneumococcal vaccinations</a> have been recommended for adults for a long time. Originally targeted at older people, <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-influenza">influenza vaccines are now recommended much more widely</a> and are funded for people of any age with an existing illness, such as heart or lung disease, that may increase the risk of serious illness. </p>
<p>But data on uptake are sparse and there are unresolved questions about the impact of these vaccines. Knowing precise coverage may help resolve these problems.</p>
<p>A new vaccine against shingles (<em>Herpes zoster</em>) has recently been recommended for older people, as recognition of the burden this virus poses. It has been funded in the budget for adults between 71 to 79 years old, with an opportunity for a catch-up after November 2016.</p>
<h2>Vaccines for adolescents</h2>
<p>Adolescents and young adults are encouraged to receive the <a href="http://hpv.health.gov.au/">human papilloma virus (HPV) vaccine</a> to prevent specific strains of genital warts and reduce the risk of cervical cancer in women. <a href="https://theconversation.com/the-case-for-vaccinating-boys-as-well-as-girls-against-hpv-6">Australia has led the world</a> with the roll-out of this vaccine. Collecting data on the initiative will be critical to understand population coverage and identify coverage gaps.</p>
<p>Measles has been eliminated for Australia, which means there’s no strain of this virus circulating for more than a year. But because the virus is circulating elsewhere in the world, <a href="https://theconversation.com/measles-outbreaks-show-the-illness-is-down-but-not-yet-out-19149">it can be imported into the country</a>, often via young adult returning travellers. </p>
<p>The initiatives announced in the budget would allow monitoring of measles vaccine status in young adults, as the current childhood vaccination register allows monitoring in children. Along with other strategies related to measles control, this may well turn out to be important in maintaining Australia’s measles elimination status.</p>
<p>If unexpected disease outbreaks occur, as there have been for whooping cough (pertusis), immunisation registers will help us determine whether it’s due to low vaccine coverage. <a href="http://www.ncirs.edu.au/immunisation/fact-sheets/pertussis-fact-sheet.pdf">Given new recommendations for adult vaccination against whooping cough</a>, it will be just as important to know the proportion of adults who are vaccinated as it is to know how many children are.</p>
<p>It is hard to see a downside for these initiatives. But whether it will be enough of a sweetener to compensate for the cuts that have been flagged for the overall health budget remains to be seen.</p><img src="https://counter.theconversation.com/content/41764/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heath Kelly does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Tucked away in the budget papers is an intitiative worthy of applause – the establishment of an adult immunisation register and the expansion of the childhood register to include adolescents.Heath Kelly, Professor (Adjunct) in Infectious Diseases Epidemiology, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/400942015-04-14T20:19:18Z2015-04-14T20:19:18ZWant to boost vaccination? Don’t punish parents, build their trust<figure><img src="https://images.theconversation.com/files/77873/original/image-20150414-24627-18i0zu0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">From January, conscientious objectors to vaccine will lose up to $15,000 of childcare and family tax rebates. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-200485304/stock-photo-two-girls-and-boy-with-toys-on-floor-at-home.html?src=VfVGrT7M_vBy3IrtwOblJQ-6-7">Daria Filimonova/Shutterstock</a></span></figcaption></figure><p>Vaccination is one of the greatest public health success stories in history, shifting infectious diseases from the leading cause of childhood death and disease to a relatively rare cause of death in developed countries. Even globally, heart disease <a href="http://www.who.int/mediacentre/factsheets/fs310/en/">overtook infectious diseases</a> as the leading cause of death in 2008. </p>
<p>But unless an infectious disease can be eradicated, high vaccination rates need to be maintained to control the disease. There are many <a href="http://wwwnc.cdc.gov/eid/article/4/4/98-0404_article">historical examples</a> of epidemics of previously rare diseases that have occurred when immunisation programs wane.</p>
<p>Australia, the United States and United Kingdom have different approaches to boost vaccination rates, with much overlap and similar success. But Australia is unique in using parental financial incentives for immunisation. From January, vaccine “conscientious objectors” will <a href="http://www.liberal.org.au/latest-news/2015/04/12/no-jab-no-play-and-no-pay-child-care">lose their</a> childcare and family tax benefits, worth up to A$15,000 a year. </p>
<p>So, how do parents decide whether or not to vaccinate their children – and what works to increase vaccination rates?</p>
<h2>How do parents decide?</h2>
<p>Mass immunisation programs have developed in different ways around the world, and a range of factors are important to maintaining high levels of immunisation:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/77868/original/image-20150414-24656-179mviv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/77868/original/image-20150414-24656-179mviv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/77868/original/image-20150414-24656-179mviv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/77868/original/image-20150414-24656-179mviv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/77868/original/image-20150414-24656-179mviv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/77868/original/image-20150414-24656-179mviv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/77868/original/image-20150414-24656-179mviv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/77868/original/image-20150414-24656-179mviv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>No vaccine is 100% safe nor 100% effective, so public health decisions about which vaccines to recommend and fund are made by <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(08)70258-5/abstract">weighing</a> disease burden and cost against vaccine effectiveness, cost and safety. </p>
<p>Where consumers perceive a risk of infection to be high, the acceptance and demand tends to be high. Conversely, for rare diseases (often because of effective vaccine programs) or diseases perceived as less serious, consumers tend to focus more on risks of vaccination. </p>
<p>Delivery of vaccine programs, therefore, is a delicate partnership between immunisation providers and parents. Trust is critical to maintaining such programs. </p>
<p>The <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140673606681440/abstract">anti-vaccination lobby</a> is a small but vocal group that has been around as long as vaccines have. They believe vaccines are unsafe and tend to associate compulsory vaccination with totalitarianism. </p>
<p>There is, however, a <a href="http://www.biomedcentral.com/1471-2431/12/154">larger group of parents</a> who delay or are hesitant about vaccination. This group is somewhat like <a href="http://content.healthaffairs.org/content/24/3/729.full">swing voters</a> – they are likely to be receptive to health promotion messages about immunisation, particularly from their doctor, but can equally be influenced by misinformation on the internet or false equivalence in the media. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/9481013">Parental vaccine concerns</a> are also influenced by vaccine side-effects or medical problems that coincidentally occur around the time of vaccines, and a host of factors that influence perceptions about the risks and benefits of vaccines. </p>
<p>A <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140673606681440/abstract">loss of confidence</a> and trust by consumers can result in falling vaccination rates and epidemics. This was illustrated in the UK with measles outbreaks following the falsely attributed risk of autism following the measles, mumps, and rubella (MMR) vaccine.</p>
<h2>How do you boost vaccination rates?</h2>
<p>First, vaccines must be readily accessible to the public. This requires reducing or eliminating cost as a barrier and making the vaccine conveniently available. Strong support from health-care providers is central to gaining parental acceptance of vaccines. </p>
<p>Other <a href="http://www.health.gov.au/internet/immunise/publishing.nsf/Content/history-of-ia-prog">strategies</a> include financial incentives to physicians for achieving high vaccination rates among their patients (historically in Australia and the United Kingdom) and requiring vaccination to attend school (US and Australia) or to receive social benefits (Australia).</p>
<p>Australia has school entry <a href="http://www.health.gov.au/internet/immunise/publishing.nsf/Content/history-of-ia-prog">legislation</a> in most states except Western Australia and Queensland, which has “guidelines” for managing student immunisation data. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/77889/original/image-20150414-24618-de95b8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/77889/original/image-20150414-24618-de95b8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/77889/original/image-20150414-24618-de95b8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/77889/original/image-20150414-24618-de95b8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/77889/original/image-20150414-24618-de95b8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/77889/original/image-20150414-24618-de95b8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/77889/original/image-20150414-24618-de95b8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">School-entry legislation raises vaccination rates.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-227904523/stock-photo-little-boy-looking-at-his-arm-while-receiving-vaccine.html?src=1xPhs_aALHl-aDTpyRnDvw-1-0">JPC-PROD/Shutterstock</a></span>
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<p>In the US, all states have school entry requirements that mandate immunisation prior to school entry. All states allow medical exemptions and 48 allow non-medical exemptions. West Virginia and Mississippi allow only medical exemptions. </p>
<p>Amid tremendous national attention surrounding a measles outbreak that originated in Disneyland, California, several states have proposed legislation to ban all non-medical exemptions. </p>
<p>There is certainly <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140673606681440/abstract">evidence</a> that school-entry legislation raises vaccination rates. These are often accompanied by school exclusion policies for unvaccinated children during outbreaks. However, removal of vaccine legislation does not necessarily reduce vaccination rates, as <a href="http://www.ncbi.nlm.nih.gov/pubmed/24783899">seen in</a> a region of Italy.</p>
<p>It has also been shown that ease of applying for conscientious objection to vaccination predicts lower vaccination rates, particularly if it is easier to gain an objection than to get immunised. The greater the administrative hurdles to applying for objection, the higher the vaccination rates.</p>
<p>Following major outbreaks of pertussis, four US states (California, Oregon, Vermont and Washington) that had comparatively high rates of exemptions recently made their exemptions more difficult to obtain. </p>
<h2>Addressing parental concerns</h2>
<p>Recent suggestions to eliminate non-medical exemptions in the US and Australia are rooted in an understandable desire to reduce the risks of diseases and to equitably distribute the benefits and burdens of vaccination. But doing so may backfire. </p>
<p>Parents who feel they are being unduly coerced or punished to vaccinate their children are likely to become anti-vaccination. This coercion may push the hesitant parent in the exact opposite direction to what it is intended to achieve. Other members of the public may also feel sympathy for these parents. </p>
<p>Rarely, vaccination programs do go wrong, such as the first rotavirus vaccine rolled out in the US, which had to be withdrawn due to serious side effects. In a coercive environment, such incidents can derail vaccination programs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/77890/original/image-20150414-24627-tty4ei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/77890/original/image-20150414-24627-tty4ei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=498&fit=crop&dpr=1 600w, https://images.theconversation.com/files/77890/original/image-20150414-24627-tty4ei.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=498&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/77890/original/image-20150414-24627-tty4ei.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=498&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/77890/original/image-20150414-24627-tty4ei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=626&fit=crop&dpr=1 754w, https://images.theconversation.com/files/77890/original/image-20150414-24627-tty4ei.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=626&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/77890/original/image-20150414-24627-tty4ei.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=626&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If vaccination rates are falling, we need to understand why.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-35390059/stock-photo-little-boy-hugging-hugging-father-around-shoulders.html?src=_e17DH8qFBvkrEVp0qfP_Q-1-27">Konstantin Sutyagin/Shutterstock</a></span>
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<p>But while a <a href="https://theconversation.com/forget-no-jab-no-pay-schemes-there-are-better-ways-to-boost-vaccination-37921">small proportion of Australians</a> (less than 2%) are ideologically opposed to vaccines and are unlikely to change their minds, a larger proportion of vaccine-hesitant parents (about 4-5%) may be responsive to efforts to boost vaccination.</p>
<p>If vaccination rates are falling, we need to understand why. We need to listen to and evaluate the concerns of parents and inform policy decisions with what we learn. </p>
<p>Health-care providers need tools and resources to talk with vaccine-hesitant parents. This ensures the credibility of the science as well as how it is communicated to and received by parents. Many such tools have been rigorously evaluated for effectiveness and have been used successfully. </p>
<p>Health-care providers also need to be adequately reimbursed for the time it takes to communicate with vaccine-hesitant parents.</p>
<p>Government systems that monitor the safety and effectiveness of vaccines and communicate the risks and benefits of vaccines can also be helpful. The US and some European countries (but not Australia) have no-fault vaccine compensation schemes to support their mandatory vaccination policies. </p>
<p>It may also be prudent to fund vaccine safety research if many parents are concerned about a particular issue, even if that level of concern is not shared by the scientific community. </p>
<p>There is evidence to support the effectiveness of mandatory vaccination strategies, but penalising parents who object on philosophical grounds may erode public confidence. Australia’s unique policy of linking financial benefits to vaccination poses an additional risk of backlash if these benefits are withdrawn from tax-paying vaccine refusers. </p>
<p>A more effective approach to boost vaccination rates is to increase the administrative hurdles to objection, but still allow it without penalty. </p>
<hr>
<p><em>Do you have a question about vaccination? Contact The Conversation on <a href="https://twitter.com/ConversationEDU">Twitter</a>, our <a href="https://www.facebook.com/ConversationEDU">Facebook page</a> or leave a comment below and we will try to answer it with an article we’ve already published or by getting one of our expert authors to write an article about it.</em></p><img src="https://counter.theconversation.com/content/40094/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC, ARC, and vaccine manufacturers for investigator driven research. She also sits on expert committees on vaccines for government and industry. She leads a NHMRC Centre for Excellence in Immunisation.</span></em></p><p class="fine-print"><em><span>Daniel Salmon receives funding from the National Institutes of Health and the Robert Wood Johnson Foundation. He has received consulting fees from Parents of Kids with Infectious Diseases (PKIDS).</span></em></p>Australia is unique in using parental financial incentives for immunisation.C Raina MacIntyre, Professor of Infectious Diseases Epidemiology, Head of the School of Public Health and Community Medicine, UNSW SydneyDaniel Salmon, Associate Professor, School of Public Health, Global Disease Epidemiology and Control, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/379212015-02-26T19:30:41Z2015-02-26T19:30:41ZForget ‘no jab, no pay’ schemes, there are better ways to boost vaccination<figure><img src="https://images.theconversation.com/files/72999/original/image-20150225-25659-1fgsk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Removing the childcare rebate for parents who do not fully immunise their children is unnecessarily punitive and could have repercussions.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-129678701/stock-photo-baby-in-sling-looking-outdoor-mother-is-carrying-her-child.html?src=CuSRdHRn8aV2GNSR4yW0eQ-1-77&ws=1">Oksana Shufrych/Shutterstock</a></span></figcaption></figure><p>Immunisation in Australia isn’t compulsory – and doesn’t need to be controversial. Most Australians recognise the incredible benefits that vaccination provides to prevent serious disease; we have high and stable <a href="http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Report_Imm_Rates_March_2014.pdf">coverage rates</a> of around 93%. </p>
<p>Getting childhood immunisation to the 95% target rate would be even better, providing more individual protection and “<a href="https://theconversation.com/braving-the-jab-for-community-immunity-330">community immunity</a>”. </p>
<p>However, the <a href="https://www.dss.gov.au/our-responsibilities/review-of-australias-welfare-system">McClure Review</a> recommendation that child and youth welfare payments be conditional on having up-to-date immunisation is not the answer to maintaining or improving vaccine uptake. </p>
<p>Nor is the Productivity Commission’s <a href="http://www.pc.gov.au/inquiries/completed/childcare/report">recent suggestion</a> that parents who have not had their child fully vaccinated should not receive the childcare benefit tax rebate the right way forward.</p>
<p>Most parents whose children are un- or under-vaccinated need more support to help protect their child: a carrot rather than stick approach. </p>
<h2>Why aren’t all children vaccinated?</h2>
<p><a href="http://www.health.gov.au/internet/immunise/publishing.nsf/Content/related-payments">Financial incentives</a> are in place to encourage parents get their child to the clinic multiple times early in life to get their shots on time. We all know this can be challenging. </p>
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<a href="https://images.theconversation.com/files/73030/original/image-20150225-1754-sebzfa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/73030/original/image-20150225-1754-sebzfa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/73030/original/image-20150225-1754-sebzfa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=883&fit=crop&dpr=1 600w, https://images.theconversation.com/files/73030/original/image-20150225-1754-sebzfa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=883&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/73030/original/image-20150225-1754-sebzfa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=883&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/73030/original/image-20150225-1754-sebzfa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1110&fit=crop&dpr=1 754w, https://images.theconversation.com/files/73030/original/image-20150225-1754-sebzfa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1110&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/73030/original/image-20150225-1754-sebzfa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1110&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p><a href="https://theconversation.com/why-do-people-not-vaccinate-24882">Research</a> tells us that parents of the 7% of incompletely vaccinated children fall into two distinct groups. </p>
<p>The first group, more than half of the 7%, face practical, economic, social or geographic impediments to full and timely vaccination. They are more likely to experience poverty or social exclusion. </p>
<p>A smaller proportion, estimated at 2-3% of the population, have beliefs, attitudes and concerns that cause them to reject or delay some or all vaccines. </p>
<p>In addition, some parents who are up-to-date with their child’s routine immunisation can be hesitant or uncertain about vaccines. Who can blame anyone for having questions about vaccines when misinformation abounds, promulgated by small fringe groups. </p>
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<a href="https://images.theconversation.com/files/73031/original/image-20150225-1761-5npbry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/73031/original/image-20150225-1761-5npbry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/73031/original/image-20150225-1761-5npbry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=849&fit=crop&dpr=1 600w, https://images.theconversation.com/files/73031/original/image-20150225-1761-5npbry.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=849&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/73031/original/image-20150225-1761-5npbry.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=849&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/73031/original/image-20150225-1761-5npbry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1067&fit=crop&dpr=1 754w, https://images.theconversation.com/files/73031/original/image-20150225-1761-5npbry.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1067&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/73031/original/image-20150225-1761-5npbry.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1067&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<h2>Reminding and supporting parents</h2>
<p>Recent changes to <a href="http://www.health.nsw.gov.au/immunisation/pages/vaccination_enrolment.aspx">childcare legislation in New South Wales</a> require parents to provide documentation about their child’s immunisation when they enrol into childcare. Other states are examining the legislation and Victoria plans to follow suit in 2015. </p>
<p>This is a great initiative for a number of reasons. First, it provides another “reminder point” to check on a child’s immunisation status and gives an opportunity to enrol the child in a “catch up” program. </p>
<p>Second, it requires that parents who actively decline vaccination have visited an immunisation professional or GP to discuss their decision. If those parents continue to choose not to vaccinate, they need to produce a signed objection form. </p>
<p>Parents who follow any of these options are currently eligible for the childcare rebate.</p>
<p>Unfortunately, these system improvements have been characterised by the media as “no jab, no play”: that unimmunised children don’t have the right to attend childcare. This is blatantly untrue; “no form, no play” is more accurate but not as sensational. </p>
<p>To protect both themselves and others, unimmunised children are required to stay at home from childcare for weeks in the case of a vaccine-preventable disease outbreak, such as measles or whooping cough. This is a financial and practical disincentive for parents who don’t vaccinate their children. </p>
<h2>Punishment can backfire</h2>
<p>Removing welfare payments or childcare rebates for parents who do not fully immunise their children is unnecessarily punitive and could have a number of negative repercussions. </p>
<p>On the one hand, these measures are unlikely to influence the completely committed vaccine objectors. But not all parents who haven’t vaccinated are completely committed to that position. </p>
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<img alt="" src="https://images.theconversation.com/files/72997/original/image-20150225-25670-z4hiw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/72997/original/image-20150225-25670-z4hiw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72997/original/image-20150225-25670-z4hiw6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72997/original/image-20150225-25670-z4hiw6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72997/original/image-20150225-25670-z4hiw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72997/original/image-20150225-25670-z4hiw6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72997/original/image-20150225-25670-z4hiw6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Unimmunised children in NSW must be kept home when outbreaks occur.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/methyl_lives/2276369296">Kirsten Jennings/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<p>On the other hand, removing incentives could paradoxically push very hesitant parents who have some willingness to immunise their children further against doing so.</p>
<p>Removing childcare subsidies carries the risk that children of low-income non-vaccinating families may not attend childcare or access much needed financial support to visit the doctor at all – a terrible outcome. </p>
<p>Removing welfare payments would obviously have a devastating effect on these children and their families. </p>
<p>History tells us that coercive policies can galvanise and further radicalise fringe movements. These proposals, together with a steady flow of adversarial public discussions, may actually increase exposure of everyone to anti-vaccination arguments and “normalise” vaccine objection. </p>
<h2>Increasing vaccination rates</h2>
<p>Strategies that increase the opportunity to vaccinate are <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2012.00897.x/abstract">most effective</a>. Improving access, awareness and affordability could potentially boost coverage rates by as much as 3-4%.</p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2012.00897.x/abstract">Research shows</a> that maintaining openness and trust is key to guiding parents to feel comfortable to immunise. This is also my experience as an immunisation professional who sees parents with low-vaccine acceptance.</p>
<p>Parents can change their position over time. A proportion of registered vaccine objectors have at least one vaccine recorded for their child: some have started the vaccine schedule but then ceased vaccinating or continue to selectively vaccinate.</p>
<p>Some registered objectors <a href="http://ncirs.edu.au/news/newsletter/AUGUST%202014%20NCIRS%20NEWSLETTER.pdf">go on to fully vaccinate</a> their children. The example of the mum who said “I never realised whooping cough could be so bad” and who went on to fully immunise her daughter after a prolonged hospitalisation for that preventable disease, springs to mind. </p>
<p>Having vaccine-hesitant parents engage with well-qualified health professionals who can take the time to address immunisation concerns is pivotal to helping them wade through the challenges that misinformation can create. </p>
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<img alt="" src="https://images.theconversation.com/files/72998/original/image-20150225-25698-f7wbgr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/72998/original/image-20150225-25698-f7wbgr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72998/original/image-20150225-25698-f7wbgr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72998/original/image-20150225-25698-f7wbgr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72998/original/image-20150225-25698-f7wbgr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72998/original/image-20150225-25698-f7wbgr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72998/original/image-20150225-25698-f7wbgr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some vaccine-objectors go on to fully vaccinate their children.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-206999599/stock-photo-auckland-july-newborn-baby-naomi-ben-ari-age-vaccination-as-of-uk-immunization.html?src=UC_7sUH0aDqQ7JcvZbj62g-2-29&ws=1">ChameleonsEye/Flickr</a></span>
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<p>Another strategy that can work is grassroots campaigning for immunisation. </p>
<p>In the Northern Rivers district of New South Wales, which is notorious for low immunisation rates, a community movement called the <a href="http://nrvs.info/">Northern Rivers Vaccination Supporter Group</a> is seeking not to demonise neighbours who don’t vaccinate, but to promote immunisation as part of a healthy lifestyle. </p>
<p>Their message of “love, protect, vaccinate” might not persuade the most ardent sceptics in their region, but it is going a long way to <a href="http://www.northernstar.com.au/news/good-reasonthe-northern-rivers-vaccination-support/2480051/">promote positive messages</a> in their community and tell the real story of serious preventable illnesses. </p>
<p>A similar group in Western Australia, <a href="http://www.immunisationalliance.org.au/">Immunisation Alliance WA</a>, is supporting parents to get the best information about vaccines.</p>
<p>Finally, it’s important to remember the child in this debate. Good policy and practice should afford young children every opportunity to be both healthy through immunisation, educated through childcare, and supported in their family environment. </p>
<p>Let’s focus on improving opportunities for our kids, not punishing parents.</p><img src="https://counter.theconversation.com/content/37921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kristine Macartney receives funding as an employee of the National Centre for Immunisation Research and Surveillance (NCIRS). She has also conducts research on vaccines, vaccine preventable diseases and vaccine safety funded by the National Health and Medical Research Council (NHMRC). </span></em></p>Immunisation in Australia isn’t compulsory – and doesn’t need to be controversial. Most Australians recognise the incredible benefits that vaccination provides to prevent serious disease.Kristine Macartney, Associate Professor, Discipline of Paediatrics and Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/370752015-02-05T06:20:02Z2015-02-05T06:20:02ZWhy Mississippi hasn’t had measles in over two decades<figure><img src="https://images.theconversation.com/files/70867/original/image-20150202-15894-ycjvc4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Do more non-medical vaccine exemptions mean a higher incidence of disease?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-167557547/stock-photo-group-of-kids-going-to-school-together.html?src=bMVRJU5fM6d6ZcG49fPZ9A-1-2&ws=0">luminaimages/Shutterstock</a></span></figcaption></figure><p>As of January 30, <a href="http://www.cdc.gov/measles/cases-outbreaks.html">102 people in 14 states</a> were reported to have measles, and most of these cases are tied to the outbreak that began at Disneyland in December. Public health officials are citing an increase in non-medical exemptions to vaccination as a key factor in these outbreaks. </p>
<p>Last year saw a record number of measles cases – <a href="http://www.cdc.gov/measles/about/faqs.html">644 cases</a> and 23 outbreaks – the highest since the measles was considered eliminated in the US in 2000.</p>
<p>Although US vaccination rates are generally high, <a href="http://www.ncbi.nlm.nih.gov/pubmed/24025754">ranging from 85% to 93%</a>, the Centers for Disease Control and Prevention (CDC) and state health officials across the country have expressed concern about increases in sporadic outbreaks of communicable diseases such as measles and pertussis (whooping cough).</p>
<p>To enroll in school in all 50 states, a child needs to be properly vaccinated, with the exception of students who cannot be vaccinated for medical reasons. Where do exemptions for non-medical reasons fit in?“</p>
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<img alt="" src="https://images.theconversation.com/files/70865/original/image-20150202-13708-hxjh5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/70865/original/image-20150202-13708-hxjh5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/70865/original/image-20150202-13708-hxjh5l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/70865/original/image-20150202-13708-hxjh5l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/70865/original/image-20150202-13708-hxjh5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=458&fit=crop&dpr=1 754w, https://images.theconversation.com/files/70865/original/image-20150202-13708-hxjh5l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=458&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/70865/original/image-20150202-13708-hxjh5l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=458&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-155042309/stock-photo-school-buses-in-a-parking-lot.html?src=aCL9WIVtFvr33HGccGRYow-1-31&ws=0">School buses via Ellen McKnight/Shutterstock</a></span>
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<h2>Types of vaccine exemptions</h2>
<p>In <a href="http://biotech.law.lsu.edu/cases/vaccines/Jacobson_v_Massachusetts_brief.htm">Jacobson v Massachusetts</a> in 1905 the Supreme Court ruled that states can require children document that they’ve received mandatory vaccines before they enter childcare and elementary school. While this is a requirement, all states allow medical exemptions for those with compromised immune systems, prior adverse reactions following vaccination, allergies to vaccine components and certain types of moderate or severe illness. </p>
<p>Most states, with the exception of <a href="http://www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx">Mississippi and West Virginia</a>, offer religious exemptions as well. These are for people whose religious beliefs are inconsistent with vaccination. For example, the Dutch Reformed Church has a tradition of refusing vaccines going as far back as the early vaccinations for smallpox in the early 1800s.</p>
<p><a href="http://www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx">Twenty states</a> provide a broader exemptions when vaccination is incompatible with an individual’s philosophy, personal beliefs or conscience. These are called personal belief exemptions, and appear to be increasingly popular among parents concerned about vaccine safety. There were more than <a href="http://www.ncbi.nlm.nih.gov/pubmed/25321068">17,000 children</a> in California enrolled in kindergarten with exemption from vaccination in 2013-2014 school year for non-medical reasons.</p>
<p>The process for obtaining either type of non-medical exemption varies from state to state. In some parts of the country these exemptions are increasing, and some schools in some districts have a particularly high number of students with exemptions. How much does the increased use of non-medical exemptions contribute to the rising rate of vaccine-preventable illness such as measles and pertussis? The connection between more non-medical exemptions and more cases of vaccine-preventable illness might seem obvious, but given the current controversy over vaccines, data showing this connection is real is vitally important.</p>
<h2>Exemptions could lead to more illness</h2>
<p>Studies over the past two decades have found that allowing non-medical, personal belief exemptions increases the number of exemptions overall, and that more exemptions generally means a higher incidence of vaccine-preventable diseases.</p>
<p>For instance, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/17032989">2006 study</a> looked at both state level rates of non-medical exemption use for school-age kids from 1991-2004, and the incidence of pertussis from 1986-2004 in people 18 or younger. From 2001 to 2004 the study found that states permitting personal belief exemptions had higher non-medical exemption rates than states offering only religious exemptions. The states where personal belief exemptions were available and relatively easy to obtain had a higher incidence (more cases) of pertussis.</p>
<p>Exemptors are also more likely to acquire vaccine preventable illnesses. A <a href="http://www.ncbi.nlm.nih.gov/pubmed/11135778">2000 study </a> looked at the relationship between measles and pertussis incidence and exemption status among children in Colorado between 1987 and 1998. Exemptors were 22.2 times more likely to acquire measles and 5.9 times more likely to acquire pertussis compared to vaccinated children. </p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/10404911">1999 study</a> analyzed data on children collected from the CDC’s Measles Surveillance System between 1985 and 1992. The study evaluated differences in the relative risk of contracting measles among vaccinators and exemptors. Compared to people who were vaccinated, exemptors were were 35 times more likely on average to contract measles. Their data also showed that if the proportion of exemptors increased, so would the number of measles cases among the whole population. </p>
<p>And with my colleague, I <a href="http://dx.doi.org/10.2105/AJPH.2013.301538">studied </a>vaccine-preventable illness incidence data from the National Notifiable Disease Surveillance System from 2001-2008. We found state non-medical exemption laws and DTap vaccine (diphtheria, tetanus and pertussis vaccine) uptake rates are associated with an increase in pertussis cases. The study suggested that increasing non-medical exemption restrictiveness could decrease the incidence of pertussis nationally and an increase in national DTaP vaccine would result in fewer pertussis cases. </p>
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<img alt="" src="https://images.theconversation.com/files/70864/original/image-20150202-13054-64dn59.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/70864/original/image-20150202-13054-64dn59.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/70864/original/image-20150202-13054-64dn59.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/70864/original/image-20150202-13054-64dn59.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/70864/original/image-20150202-13054-64dn59.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/70864/original/image-20150202-13054-64dn59.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/70864/original/image-20150202-13054-64dn59.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some schools have higher numbers of students with non-medical vaccine exemptions.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-78859288/stock-photo-happy-school-girls-running-outdoor-at-sunny-autumn-day.html?src=aCL9WIVtFvr33HGccGRYow-4-60&ws=0">Kids via dotshock/Shutterstock</a></span>
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<h2>Will changing laws about exemptions help?</h2>
<p>These studies, along with recent outbreaks of vaccine-preventable diseases, have compelled legislators and public health officials in various states to strengthen vaccination protections. Herd immunity depends on enough people being immune to a disease, so that it can’t be transmitted from person to person. When vaccination levels drop below a certain threshold, the whole population is put at risk. This is why making sure that people are properly vaccinated is important. </p>
<p>There are a host of policy alterations that can be made to strengthen vaccine rules, from requiring annual re-filing of exemption forms, to requiring parents to complete an education requirement, to extending vaccination requirements to private as well as public schools. Many of these legislative fixes fall well short of removing exemptions based on religion or personal philosophy.</p>
<p>For instance <a href="http://www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization/Exemptions/ExemptionFAQ">Washington in 2011</a> and <a href="http://www.cdph.ca.gov/Pages/NR13-051.aspx">California</a> and <a href="http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/RulesLaws/Documents/Law333-050sb0132.pdf">Oregon</a> in 2014 required that parents obtain a doctor’s signature or take an online course before opting out of vaccination requirements. In Washington, exemption rates <a href="http://www.nytimes.com/2012/09/20/health/washington-state-makes-it-harder-to-forgo-immunizations.html">dropped significantly</a> after the law was passed. It’s still too soon to tell the laws’ effects in California and Oregon.</p>
<p>Colorado has made changes too. Starting in 2014, the state <a href="https://www.colorado.gov/pacific/cdphe/school-immunizations">required</a> parents opposed to vaccinations based on personal beliefs submit to their child’s school either a disclosure statement signed by a health care professional or a certificate saying they had completed an "online education module … that discloses the benefits and risks of immunization to the student and to the community.” That same year, <a href="http://articles.baltimoresun.com/2014-08-14/health/bs-hs-new-vaccinations-maryland-20140813_1_pertussis-tdap-school-health">Maryland required</a> that incoming kindergarten and seventh-grade students in the state obtain immunizations before the <a href="http://www.washingtonpost.com/local/maryland-offers-45-day-extension-for-student-immunizations/2014/09/15/4dc6d00a-3d11-11e4-b0ea-8141703bbf6f_story.html">20th day of school</a>. Failure to do so means that the student in question may not attend school until they present a record of vaccination. </p>
<p>So could eliminating religious or personal belief exemptions curb outbreaks? We can look to the two states – Mississippi and West Virginia – that only allow medical exemptions. Neither state permits children to enroll in kindergarten without getting their full roster of vaccines – no matter their parents’ personal or spiritual beliefs. Mississippi hasn’t seen a case of measles <a href="http://msdh.ms.gov/msdhsite/_static/23,6891,341,517.html">since 1992</a> and West Virginia hasn’t seen one <a href="http://www.newsweek.com/2014/06/27/anti-vaccination-crazies-strike-out-bible-belt-states-255483.html">since 1994</a>.</p><img src="https://counter.theconversation.com/content/37075/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tony Yang receives funding from Robert Wood Johnson Foundation.</span></em></p>As of January 30, 102 people in 14 states were reported to have measles, and most of these cases are tied to the outbreak that began at Disneyland in December. Public health officials are citing an increase…Tony Yang, Associate Professor, Department of Health Administration and Policy, George Mason UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/329812014-10-30T09:49:38Z2014-10-30T09:49:38ZWhy you should worry less about Ebola and more about measles<p>News that a doctor in New York City tested positive for Ebola sparked mandatory quarantine orders for heath workers returning from West Africa in New York and New Jersey last week. The outbreak has killed nearly 5,000 people in West Africa, but only a handful of cases have been reported in the United States. Still, the virus has sparked widespread fear in the US. Views that Ebola is an exotic disease spreading out of control within Africa, with horrific symptoms, inevitable death, and limited means to prevent transmission are contributing to this fear. However, these fears are fueled by a misunderstanding of risk.</p>
<p>The outbreak is a tragic, public health emergency in urgent need of a massive and coordinated global health response. Fear of contagion is justified in communities where incidence is increasing and where protective measures are limited and health care is stretched beyond capacity. </p>
<p>However, this is not the case in the United States. The perceived risk to Americans is exaggerated. The risk of contracting Ebola in the US or the virus reaching epidemic proportions is very, very low. </p>
<p>The fact is, in the United States the risk of infection with measles virus or death from influenza virus is far greater. </p>
<h2>Measles is more infectious than Ebola</h2>
<p>Although the outbreak in West Africa is increasing exponentially, Ebola is not as contagious as many other infectious diseases. Transmission requires direct contact with infected body fluids. Measles, influenza and pertussis (whooping cough) on the other hand, are spread by respiratory secretions. They are much more explosive because transmission does not require direct contact with an infected person. </p>
<p>The speed with which an outbreak grows depends on how many additional people are infected by each infectious case and the time interval between infections. To put the current Ebola numbers in context, one person with Ebola will on average infect only <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1411100#t=articleResults">1.5 to 2.2 additional people</a>. The relatively low number of people infected by a single case should make it easier to interrupt transmission. Further facilitating control is the fact that a person with Ebola is most infectious after the onset of signs and symptoms.</p>
<p>By contrast, a person with measles is infectious for several days <em>before</em> they become sick. And a person with measles will on average <a href="http://practice.sph.umich.edu/micphp/epicentral/basic_reproduc_rate.php">infect 12 to 18 additional people</a>. This year <a href="http://www.cdc.gov/measles/cases-outbreaks.html">594 measles cases</a> have been reported in the United States through September 29th, the most in two decades. These cases represent 18 measles outbreaks in 22 states. </p>
<p>An estimated 122,000 people - mostly children - worldwide <a href="http://www.who.int/mediacentre/factsheets/fs286/en/">died of measles in 2012</a>, about 330 measles deaths every day. In the US the increasing number of measles cases is mostly due to <a href="http://www.cdc.gov/measles/travelers.html">people visiting countries with measles outbreaks</a> and carrying the virus back home and into communities in which large numbers of people are not vaccinated.</p>
<p>Measles is also becoming a public health problem in <a href="http://www.washingtonpost.com/news/morning-mix/wp/2014/09/30/hit-by-ebola-liberia-is-descending-into-economic-hell/">countries affected by Ebola</a>. Immunization services have ceased in many affected areas as health care workers are redeployed to fight Ebola and the public loses confidence in the health care system. Cases of measles have been reported in <a href="http://www.npr.org/blogs/goatsandsoda/2014/10/23/358117900/ebola-is-keeping-kids-from-getting-vaccinated-in-liberia?ft=3&f=1001">Liberia</a> and may spread to neighboring countries and beyond.</p>
<h2>Vaccines and risk perception</h2>
<p>As panic over Ebola grows, it’s worth asking why Americans are becoming more complacent to the threat of vaccine-preventable diseases. </p>
<p>Some Americans <a href="http://www.npr.org/blogs/health/2014/03/19/291405689/half-of-americans-believe-in-medical-conspiracy-theories">distrust vaccines</a> and misunderstand the risks and benefits. Most Americans with measles this year were unvaccinated and declined vaccination because of religious, philosophical or personal objections. The largest measles outbreak this year spread within communities in <a href="http://www.mansfieldnewsjournal.com/story/news/local/2014/09/10/measles-outbreak-officially/15424885/">Ohio</a> with low vaccination coverage, with smaller outbreaks in <a href="http://www.hollywoodreporter.com/features/los-angeles-vaccination-rates/">California</a> and <a href="http://www.nydailynews.com/life-style/health/measles-outbreak-worries-health-officials-article-1.1769026">New York City</a>. </p>
<p>As with Ebola, early diagnosis, isolation and notification are critical to preventing further spread. Unlike Ebola, we have a highly effective and safe vaccine that can prevent measles. The unvaccinated individuals who developed measles in the United States misjudged the risk to themselves and their communities. </p>
<p>Measles isn’t the only risk. As many as <a href="http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm?s_cid=cs_074">50,000 people die</a> in the US of influenza virus infection in a single season. Influenza vaccine coverage in the United States during the 2013-2014 season was only <a href="http://www.cdc.gov/flu/fluvaxview/coverage-1314estimates.htm">59% among children and 42% among adults</a>, putting those most likely to develop severe disease - young infants and the elderly - at risk. </p>
<p>Again, unvaccinated individuals misjudge the risk and consequences of influenza. The Centers for Disease Control and Prevention tracks deaths due to influenza in children. During the 2012-2013 influenza season, <a href="http://www.immunize.nc.gov/PDFs/2014%20PDF/MAY%2027%202014%20-%20CDC%20Influenza%20Key%20Points%20May%2023%202014.pdf">171 children died of influenza</a> in the United States and <a href="http://www.cdc.gov/flu/weekly/summary.htm">109 children died during 2013-2014 season</a>. Although the influenza season has just started, one child death has already been <a href="http://www.cdc.gov/flu/weekly/">reported</a> in other words the same number of deaths currently due to Ebola in the United States.</p>
<p>Some may fear of exposing themselves or their children to <a href="http://www.npr.org/blogs/health/2014/03/19/291405689/half-of-americans-believe-in-medical-conspiracy-theories">risk from vaccines</a>, even though these fears have been disproved time and again. They may do so without calculating the real risk of actually contracting the infection that these vaccines prevent. The risk might be masked thanks to herd immunity, but outbreaks of measles and whooping cough show the risk is growing. From January 1 to August 16, 17,325 cases of whooping cough were reported in the United States, a <a href="http://www.cdc.gov/pertussis/outbreaks/trends.html">30% increase</a> over the same period in 2013. In California alone, which is experiencing a particularly large outbreak, <a href="http://www.cdph.ca.gov/programs/immunize/Documents/Pertussis_report_10-7-2014.pdf">312 people have been hospitalized</a>, most of whom were young infants.</p>
<p>Ebola vaccines are currently in development and testing. Most experts agree an Ebola vaccine would be a welcome tool, even if supplies limit use to health care workers. But this begs another question – how many Americans would be willing to receive an Ebola vaccine?</p><img src="https://counter.theconversation.com/content/32981/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Moss receives funding from the National Institutes of Health and the Bill & Melinda Gates Foundation. He is affiliated with the World Health Organization as a member of the Strategic Advisory Group of Experts Working Group on Measles and Rubella.</span></em></p>News that a doctor in New York City tested positive for Ebola sparked mandatory quarantine orders for heath workers returning from West Africa in New York and New Jersey last week. The outbreak has killed…William Moss, Professor, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health; Head of Epidemiology, International Vaccine Access Center , Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/232582014-04-07T04:31:55Z2014-04-07T04:31:55ZHealth Check: when do adults need to be immunised?<figure><img src="https://images.theconversation.com/files/45691/original/twh2sgph-1396743335.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many adults missed out on vaccines that are routinely given to children today. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-173815904/stock-photo-vaccinating-an-elderly-person.html?src=8l6abJMpMD9swQnp0XKwfA-1-44">Shutterstock</a></span></figcaption></figure><p>Most of us will receive the majority of our vaccinations in childhood. But Australian adults still die and become disabled from vaccine-preventable diseases. Immunisations are therefore an important preventive health measure at all stages of life. </p>
<p>So, when might adults need to be immunised?</p>
<h2>Making sure you are up-to-date</h2>
<p>Some adults are not up-to-date with today’s <a href="http://www.immunise.health.gov.au/">vaccine recommendations</a>. This can be for a number of reasons, such as having missed vaccine doses that were recommended during childhood or booster doses during adolescence. </p>
<p>In some cases, the immunisation schedule has changed which means adults didn’t have the opportunity to get vaccines as part of a childhood program. <a href="http://www.nps.org.au/medicines/immune-system/vaccines-and-immunisation/for-individuals/vaccines-a-z/measles-mumps-and-rubella-mmr">Measles, mumps and rubella</a> (MMR) vaccination is a good example of this. </p>
<p>Two doses of MMR vaccine are now recommended to get maximum protection. However, many adults born after 1966 (when these viruses have no longer been circulating at high levels) grew up when only one dose of MMR vaccine was recommended. </p>
<p>Even though catch-up vaccination campaigns for the second dose of MMR vaccine were rolled out in the late 1990s and early 2000s, many adolescents and young adults still missed out. It’s among this young adult age group where we now see high number of <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-nndss-2011-annual-report.htm">measles cases</a>, often acquired during overseas travel. </p>
<p>Other vaccinations which are routinely recommended during childhood today, for diseases against which adults may not be adequately protected, include <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-diphtheria">diphtheria</a>, <a href="http://www.nps.org.au/medicines/immune-system/vaccines-and-immunisation/for-individuals/vaccines-a-z/tetanus">tetanus</a>, <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-pertussis">pertussis</a> (whooping cough), <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-varicella">varicella</a> (chicken pox) and <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hepb">hepatitis B</a>.</p>
<p>Adults may not always have documentation of what vaccines they have previously received. For some vaccines, such as measles and hepatitis B, a blood test can be done to check for immunity if this information is not available. But in most instances, the best approach is the give the required vaccines. </p>
<p>With the exception of <a href="http://access.health.qld.gov.au/hid/InfectionsandParasites/BacterialInfections/qFever_fs.asp">Q-fever vaccine</a>, there are no safety concerns with giving vaccines to an adult who is already immune. </p>
<h2>Routine vaccinations</h2>
<p>Based on the best available scientific evidence, government health bodies recommend and fund a number of routine vaccinations for adults via the <a href="http://www.immunise.health.gov.au/">National Immunisation Program</a> (NIP).</p>
<p><a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-influenza#flu">Influenza</a> and <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-pneumococcal">pneumococcal disease</a> pose a high risk to the elderly; vaccines against these two diseases are recommended and funded for Australians 65 years or older under the NIP. Even so, the number of older Australians who are vaccinated against them is <a href="http://www.aihw.gov.au/publication-detail/?id=10737418409">less than optimal</a>.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/45693/original/j7rr2k56-1396743980.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/45693/original/j7rr2k56-1396743980.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=906&fit=crop&dpr=1 600w, https://images.theconversation.com/files/45693/original/j7rr2k56-1396743980.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=906&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/45693/original/j7rr2k56-1396743980.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=906&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/45693/original/j7rr2k56-1396743980.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1139&fit=crop&dpr=1 754w, https://images.theconversation.com/files/45693/original/j7rr2k56-1396743980.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1139&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/45693/original/j7rr2k56-1396743980.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1139&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A number of free vaccinations are available on the NIP.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-140732632/stock-photo-macro-photography-of-a-syringe-ready-to-put-a-vaccine.html?src=XwQal9NM6lZjVYyDQGZVIg-1-30">Shutterstock</a></span>
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<p>Importantly, some adults younger than 65 years are also at greater risk of severe influenza and pneumococcal disease than the general population and are eligible for these free vaccines under the NIP. This includes Aboriginal and Torres Strait Islander adults, who are three- to six-times more likely to be hospitalised with influenza than non-indigenous peers. </p>
<p>Invasive pneumococcal disease is also <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-pneumococcal">more common</a> in Indigenous than non-indigenous adults. </p>
<p>Adults with certain medical conditions, such as chronic heart and lung disease and immune-compromising conditions, among others, are also eligible for NIP-funded influenza and pneumococcal vaccine. </p>
<p>Discussing any current or anticipated medical conditions or treatments with your doctor is the best way to make sure you get these important, free vaccines. It may also help identify a need for other vaccines which are recommended for adults with certain medical conditions that are not fully funded on the NIP.</p>
<p>Some additional vaccines that aren’t funded on the NIP are also recommended for elderly Australians and can be accessed with a prescription. The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-4-24">herpes zoster</a> vaccine, for instance, protects against shingles, which is more common in older age.</p>
<h2>Pregnancy</h2>
<p>Planning pregnancy is an important time for <a href="http://www.nps.org.au/medicines/immune-system/vaccines-and-immunisation/for-individuals/who-should-be-vaccinated/pregnant-women">women and those around her</a> to review their vaccination needs. </p>
<p>A pre-pregnancy check for immunity to <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-rubella">rubella</a> (german measles) and varicella (chicken pox) is essential to allow time for vaccination, if required. Both of these viruses can cause severe disease in the unborn child if infection occurs when a woman is pregnant. </p>
<p>All family members should have their immunity to pertussis reviewed before a new baby arrives to reduce the chance of passing the infection on. The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-4-12">highest rates</a> of hospitalisation and death from pertussis are in infants less than six months of age, who are not yet completely vaccinated. </p>
<p>Expectant or new mothers can <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-pertussis">receive pertussis vaccine</a> either when planning pregnancy, in the third trimester of pregnancy, or as soon as possible after giving birth.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/45692/original/g4tjjjm3-1396743797.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/45692/original/g4tjjjm3-1396743797.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/45692/original/g4tjjjm3-1396743797.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/45692/original/g4tjjjm3-1396743797.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/45692/original/g4tjjjm3-1396743797.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/45692/original/g4tjjjm3-1396743797.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/45692/original/g4tjjjm3-1396743797.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pertussis and influenza vaccines are safe to take during pregnancy.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-145205890/stock-photo-image-of-pregnant-woman-touching-her-belly-with-hands.html?src=MZ30RglJ2je-UFRtTV0JLg-3-39">Shutterstock</a></span>
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<p>Influenza vaccine is <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-influenza#pregnant">strongly recommended</a> for women who are pregnant and freely available under the NIP. Influenza infection during pregnancy poses a risk to the pregnant women and their unborn child. </p>
<p>Many <a href="http://www.ncirs.edu.au/immunisation/fact-sheets/influenza-fact-sheet.pdf">clinical studies</a> have shown that influenza vaccine during pregnancy protects the pregnant women and also her infant up to six months of age through the transfer of the mother’s antibodies across the placenta.</p>
<h2>Reviewing other risk factors</h2>
<p>There are a number of health and lifestyle factors that can increase a person’s risk from vaccine-preventable diseases. Some examples include smoking (pneumococcal disease), drug use (hepatitis A and B) , sexual preferences (hepatitis A and B, and human papillomavirus), certain occupations (hepatitis B and influenza, among others) and, of course, travel. </p>
<p>Summaries of the recommended vaccines for these different risk factors are available on National Centre for Immunisation Research and Surveillance <a href="http://www.ncirs.edu.au/immunisation/index.ph">website</a>.</p>
<p>Unlike children, adults don’t often have regular “health-checks” so it’s important for adults to be aware of any changes in their circumstances which may change their risk of illness and in turn their immunisation needs. </p>
<p>Many immunisation providers, including GPs, hospitals and other specialist health services, Aboriginal Medical Services and travel vaccination clinics can provide specific advice on and administer vaccinations for adults. </p>
<p>A great acronym to keep in mind for adults when thinking of immunisation needs is H-A-L-O (health, age, lifestyle and occupation). Reviewing these factors can be a good trigger for discussions on any vaccine needs that might otherwise be forgotten. After all, an ounce of prevention is better than a pound of cure.</p><img src="https://counter.theconversation.com/content/23258/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kristine Macartney receives funding from her employer, the National Centre for Immunisation Research and Surveillance (NCIRS). She is also an investigator on research grants awarded by the NHMRC.</span></em></p><p class="fine-print"><em><span>Melina Georgousakis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most of us will receive the majority of our vaccinations in childhood. But Australian adults still die and become disabled from vaccine-preventable diseases. Immunisations are therefore an important preventive…Melina Georgousakis, Senior Research Officer, National Centre for Immunisation Research and Surveillance, University of SydneyKristine Macartney, Associate Professor, Discipline of Paediatrics and Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/113682012-12-18T19:46:11Z2012-12-18T19:46:11ZAnti-vaccination network told to change its name or be shut down<figure><img src="https://images.theconversation.com/files/18841/original/4jdwxwt8-1355802316.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Parents need the facts about childhood vaccination.</span> <span class="attribution"><span class="source">Nonanet.</span></span></figcaption></figure><p>The <a href="https://theconversation.com/anti-vax-network-wins-court-case-but-its-claims-are-still-misleading-5568">heated battle</a> between Australia’s anti-vaccine lobby, the Australian Vaccination Network (AVN), and those fighting against its misinformation took a positive turn late last week, with the <a href="http://www.fairtrading.nsw.gov.au/About_us/News_and_events/Media_releases/2012_media_releases/20121215_australian_vaccination_network.html">New South Wales Department of Fair Trading </a> ordering the AVN to change its name or risk being shut down.</p>
<p>The move follows what has been described as “<a href="http://www.heraldsun.com.au/news/victoria/minister-orders-anti-vaccination-group-to-change-its-name/story-e6frf7kx-1226537155195">numerous</a>” complaints from both the public and the <a href="https://ama.com.au/media/misleading-claims-about-vaccination-putting-australian-lives-risk">Australian Medical Association</a> that the AVN name was misleading the public and wasn’t an accurate representation of its activities.</p>
<p>The order was hand delivered to the home of Meryl Dorey, AVN president, spokesperson and public officer, just before midday on Friday.</p>
<h2>What’s in a name?</h2>
<p>Publicly, the AVN claims to be pro-choice and a “vaccine safety watchdog”. And its name gives the impression of a neutral resource for vaccination information, but scratching the surface of its slick-looking website quickly reveals an anti-vaccine agenda.</p>
<p>A 12-month investigation of the site by the <a href="http://www.hccc.nsw.gov.au/">NSW Health Care Complaints Commission</a>, found the AVN website, “provides information that is solely anti-vaccination, contains information that is incorrect and misleading, and quotes selectively from research to suggest that vaccination may be dangerous.” This resulted in the <a href="http://www.stopavn.com/HCCCPublicWarning.jpg">publication of a public warning</a> advising people not to get their medical advice from the AVN.</p>
<p>The AVN later <a href="https://theconversation.com/anti-vax-network-wins-court-case-but-its-claims-are-still-misleading-5568">challenged the public warning and won</a>, however during the case the Judge was not convinced by Dorey’s claims “to educate her subscribers and the general public into making decisions about vaccinations”.</p>
<p>As Justice Adamson put it, “It seems slightly coy that your client is so shy about admitting what it is on about”.</p>
<p>Further evidence for the Judge’s suspicions come in the form of T-shirts sold on the AVN website emblazoned with “<a href="http://shop.avn.org.au/products/Love-them-%28text-only%29-T%252dShirt.html">Love Them, Protect Them, Never Inject Them</a>”. And a children’s book called <a href="http://shop.avn.org.au/melanies-marvellous-measles/">Melanie’s Marvellous Measles</a> which teaches children to embrace infectious diseases!</p>
<p>Not very “pro-choice”.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/18830/original/bxntb9j4-1355797994.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/18830/original/bxntb9j4-1355797994.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/18830/original/bxntb9j4-1355797994.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/18830/original/bxntb9j4-1355797994.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/18830/original/bxntb9j4-1355797994.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/18830/original/bxntb9j4-1355797994.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/18830/original/bxntb9j4-1355797994.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The AVN provides incorrect and misleading information to parents wanting to learn more about vaccination.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The issue of the misleading name has led to confusion for parents and professionals alike, with <a href="http://www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ccms.r">The Australian College of Midwives</a> a recent victim. It mistakenly sent out invitations to all its members (which were later withdrawn) for an AVN seminar, as it was unaware the AVN was an “anti-immunisation lobby”.</p>
<p>Parents commenting on the <a href="https://www.facebook.com/stopavn">Stop the AVN Facebook page</a> share similar stories;</p>
<blockquote>
<p>Dear Meryl, I was attracted to the AVN several years ago because the name suggested that you might be a reputable source of information about vaccination (I was preparing for an overseas trip). I found nothing of the sort on your site…..I was indeed misled and deceived by your name. And I’m not the only one.</p>
</blockquote>
<p>In 2009, the <a href="http://www.skeptics.com.au/">Australian Skeptics</a>, with sponsorship from Dick Smith, took out an <a href="http://depletedcranium.com/Anti_AVN_Advertisement.jpg">ad</a> in the Australian newspaper to warn parents not to look to the AVN for health information. During the flurry of publicity that ensued, Dick Smith said:</p>
<blockquote>
<p>They are actually anti-vaccination, and they should put on every bit of their material that they are anti-vaccination in great big words. They have every right for that belief but they should communicate it clearly so people are not misled.</p>
</blockquote>
<p>Yet, the practice of anti-vaccine groups using misleading names is not new. In the United States there is the National Vaccine Information Centre or NVIC, (which refers to itself as a vaccine watch dog) and in New Zealand there is VINE or Vaccination Information Network.</p>
<p>And it’s pretty obvious why they are so keen to disguise their true agenda – I can’t imagine parents looking to the Anti-Vaccine Network for unbiased advice (although kudos to the Australian media, as the AVN is increasingly being called this).</p>
<p>The AVN now has until February 21, 2013 to submit an application for a name change which also must be approved by the Commissioner. Of course, Dorey and co have a right to appeal this order, but if they decide to ignore it, their registration can be cancelled and their assets seized and split up – making this a rather serious matter indeed.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/18843/original/32kwwjfm-1355802684.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/18843/original/32kwwjfm-1355802684.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/18843/original/32kwwjfm-1355802684.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/18843/original/32kwwjfm-1355802684.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/18843/original/32kwwjfm-1355802684.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/18843/original/32kwwjfm-1355802684.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/18843/original/32kwwjfm-1355802684.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The AVN has until February to change its name.</span>
<span class="attribution"><span class="source">Flickr/tyfn</span></span>
</figcaption>
</figure>
<p>So far, <a href="http://nocompulsoryvaccination.com/2012/12/16/government-puts-boot-into-the-avn-democracy-and-the-truth/">Dorey has responded</a> to the order in the only way she knows, with accusations of “suppression of free speech” and “government bully boys”. And in a bizarre analogy she questioned why she was being targeted when “Greenpeace is not green, nor do they go around looking for peace…”.</p>
<p>Of course, this is not an issue of free speech, but one of a name that accurately describes the activities of the organisation. As NSW Fair Trading Minster Anthony Roberts <a href="http://www.2ue.com.au/blogs/2ue-blog/antivac-group-told-to-change-name/20121217-2bimp.html">put it</a> in no uncertain terms on radio 2UE:</p>
<blockquote>
<p>What we are asking this organisation to do is be upfront and honest with people and stop misleading people … for far too long this organisation has been misleading individuals and getting away with it.</p>
<p>These people aren’t about pro-choice, these people are about pushing an anti-vaccine line.</p>
</blockquote>
<p>So here’s my suggestion for the AVN: change your name to the Anti-Vaccination Network. That way there can be absolutely no confusion about your agenda and you get to keep you domain name. Because you’re not fooling anyone anymore.</p><img src="https://counter.theconversation.com/content/11368/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachael Dunlop receives funding from The Institute for Ethnomedicine, WY. She is a Vice President of Australian Skeptics and an administrator of the Stop The AVN Facebook page. </span></em></p>The heated battle between Australia’s anti-vaccine lobby, the Australian Vaccination Network (AVN), and those fighting against its misinformation took a positive turn late last week, with the New South…Rachael Dunlop, Post-doctoral fellow, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/99692012-11-26T19:13:12Z2012-11-26T19:13:12ZParents’ decisions about vaccination and the art of gentle persuasion<figure><img src="https://images.theconversation.com/files/17931/original/hyx7khgn-1353630704.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Too much urging can backfire and entrench some parents' opposition to vaccination.</span> <span class="attribution"><span class="source">Flickr/skippytpe</span></span></figcaption></figure><p>Dr Seuss’ book <a href="http://books.google.com.au/books/about/Green_Eggs_and_Ham.html?id=VTolm6HG2EgC&redir_esc=y">Green Eggs and Ham</a> is built around the urgings of a weird creature, Sam I Am, who insists the narrator eat the food of its title. When the narrator refuses, Sam issues an ever-widening range of appeals – Would you eat them in a box? Would you eat them with a fox? But Sam’s insistence fails to convince an increasingly vehement narrator.</p>
<p>The story provides a light-hearted analogy to the plight of anyone who has tried to persuade another person to abandon an entrenched position – especially a parent’s decision to not vaccinate their child. In fact, <a href="http://www.skepticalscience.com/docs/Debunking_Handbook.pdf">psychologists have found</a> that too much urging can result in a backfire effect, with the person becoming more committed to their beliefs.</p>
<p>When <a href="https://theconversation.com/braving-the-jab-for-community-immunity-330">herd immunity</a> hangs by a narrow margin, the decisions taken by a small group of parents matter. With too few children vaccinated, a disease such as measles can easily spread. This impacts on the whole community, including those too young to be vaccinated and those who can’t have a vaccine for medical reasons. </p>
<p>While a measles epidemic cannot be solely blamed on people who actively forgo vaccination – waning immunity in adults also contributes – it can be an important factor. We saw this play out in the United Kingdom in the late 2000s, when the now-debunked theory that the measles, mumps and rubella (MMR) vaccine <a href="https://theconversation.com/mondays-medical-myth-the-mmr-vaccine-causes-autism-3739">caused autism</a> drove immunisation rates down to 80%.</p>
<h2>Avoiding a disease tragedy</h2>
<p>The most important strategy to prevent the avoidable spread of infectious diseases lies on the supply side, with governments maintaining well-oiled systems. Free, easily accessible, safe and effective vaccines <a href="http://www.thecommunityguide.org/vaccines/universally/index.html">need to</a> get to those who actually want them. It’s a tragedy when parents who want to vaccinate their children <a href="http://www.abc.net.au/unleashed/40620.html">can’t do so</a> because of external impediments. </p>
<p>The second strategy is to <a href="http://www.nature.com/nature/journal/v473/n7348/abs/473443a.html">target those who are hesitant about vaccination</a>. People in this group usually vaccinate but might delay or decline a stigmatised vaccine such as MMR or <a href="https://theconversation.com/study-should-dispel-hpv-vaccine-myths-9914">human papillomavirus</a> (HPV). </p>
<p>Australia <a href="https://theconversation.com/vaccinations-in-the-news-in-2011-4696">could do more</a> to meet the needs of these active information seekers. Just this week, the Academy of Science released a high-end publication <a href="http://www.science.org.au/policy/immunisation.html">The Science of Immunisation: Questions and Answers</a>. It sets out to explain the current situation in immunisation science, including where there is consensus in the scientific community and where uncertainties exist. </p>
<p>The third approach to preventing a disease outbreak is to minimise the proportion of people who refuse vaccines. Even though they represent about 2% of Australian parents, they cluster in certain regions where up to 35% may be unvaccinated. An outbreak of whooping cough or measles in those communities would result in a much more sustained spread.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/17929/original/mqb5s4p4-1353630194.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/17929/original/mqb5s4p4-1353630194.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/17929/original/mqb5s4p4-1353630194.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/17929/original/mqb5s4p4-1353630194.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/17929/original/mqb5s4p4-1353630194.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/17929/original/mqb5s4p4-1353630194.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/17929/original/mqb5s4p4-1353630194.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Parents often form views about vaccination during pregnancy or in their child’s first year.</span>
<span class="attribution"><span class="source">Flickr/stephanski</span></span>
</figcaption>
</figure>
<h2>Talking with vaccine refusers</h2>
<p>One of the most important times to address this problem is when parents are forming or solidifying their views on vaccination – usually during pregnancy or in the child’s first year. At this time, their family doctor or child health nurse has a crucial role in discussing concerns.</p>
<p>These discussions can be challenging for health professionals. With this in mind, I worked with an international group of clinicians and communication scientists to develop a <a href="http://www.biomedcentral.com/1471-2431/12/154">framework for health professionals</a> in communicating about vaccination. We recognised these health professionals posess a good deal of training, experience and skill in communicating – that they already had a collection of communication tools. The trick is often knowing which tools to use and when.</p>
<p>The framework involves a tailored approach and is informed by evidence in the areas of communication science and motivational interviewing. It <a href="http://www.biomedcentral.com/1471-2431/12/154/table/T2">begins</a> with a spectrum of parental positions: unquestioning acceptance, cautious acceptance, hesitance, delay/selective vaccination, and refusal. The <a href="http://www.biomedcentral.com/1471-2431/12/154/table/T4">goals and strategies</a> will differ across these positions. </p>
<p>The common theme is listening and acknowledgement, and, as even Dr Seuss himself inferred, this approach is far more likely to produce a positive result than talking at cross-purposes.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/17928/original/yzhwzf78-1353629939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/17928/original/yzhwzf78-1353629939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/17928/original/yzhwzf78-1353629939.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/17928/original/yzhwzf78-1353629939.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/17928/original/yzhwzf78-1353629939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/17928/original/yzhwzf78-1353629939.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/17928/original/yzhwzf78-1353629939.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Seuss showed us that a simple acknowledgement and a more respectful plea is part of the art of gentle persuasion.</span>
<span class="attribution"><span class="source">AdolfGalland</span></span>
</figcaption>
</figure>
<p>When mum “Kate”, for example, declares her intention to her doctor to give her baby homoeopathic preparations instead of vaccination, he may immediately try to put her right, knowing <a href="http://www.ncirs.edu.au/immunisation/fact-sheets/homeopathy-vaccination-fact-sheet.pdf">homeopathy won’t protect the baby</a> at all. This “righting reflex” is the natural response of health professionals to instinctively leap in and “put right” health-care problems.</p>
<p>With parents such as Kate who are often fixed in their views, the discussion can <a href="http://www.publish.csiro.au/view/journals/dsp_journal_fulltext.cfm?nid=226&f=NB08064">descend</a> into a game of scientific ping-pong, arguing back and forth about the evidence. These discussions are usually time consuming and are likely to further entrench Kate who, feeling cornered, will defensively rehearse and <a href="http://www.skepticalscience.com/Debunking-Handbook-Part-4-Worldview-Backfire-Effect.html">reinforce her arguments</a>. </p>
<p>In this situation, a better goal would be to <a href="http://www.biomedcentral.com/1471-2431/12/154/table/T7">build a rapport</a> that may have gains further down the track, including further discussion, partial vaccination and, perhaps eventually, full vaccination. This would be done by acknowledging her concerns, asking permission to discuss, encouraging her to explore the pros and cons of her decision, and eliciting her own possible motivations to protect her baby from diseases such as whooping cough, particularly since her decision to use homeopathy has already demonstrated some desire for active protection. </p>
<p>This approach draws from <a href="http://www.motivationalinterview.org/quick_links/about_mi.html">motivational interviewing</a> that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change. The method has shown to be effective for a range of health behaviours. </p>
<p>Our framework also sets out strategies for parents who want to delay or select-out some vaccines, are hesitant, or generally accepting of vaccination. Across all such scenarios, it is <a href="http://www.biomedcentral.com/1471-2431/12/154/table/T3">more effective</a> if professionals build rapport, accept questions and concerns, and facilitate valid consent by discussing both benefits and risks of vaccination. </p>
<p>In Green Eggs and Ham, it’s not until Sam I Am finally acknowledges, “You do not like them, so you say. Try them try them and you may” that the winds of refusal change. The narrator tries the strange dish and, by book’s end, happily declares his love for it, and his gratitude to Sam.</p>
<p>Seuss showed us that a simple acknowledgement and a more respectful plea is part of the art of gentle persuasion. </p><img src="https://counter.theconversation.com/content/9969/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julie Leask participated in an ARC Linkage grant that received partial funding from Sanofi Pasteur. She contributed to the Science of Immunisation booklet.</span></em></p>Dr Seuss’ book Green Eggs and Ham is built around the urgings of a weird creature, Sam I Am, who insists the narrator eat the food of its title. When the narrator refuses, Sam issues an ever-widening range…Julie Leask, Associate Professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/69802012-05-14T20:44:12Z2012-05-14T20:44:12ZDoes whooping cough vaccine for parents protect newborns (and who should pay for it)?<figure><img src="https://images.theconversation.com/files/10590/original/qh2fpfm8-1336957681.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infants too young to receive the whooping cough vaccine are at greatest risk.</span> <span class="attribution"><span class="source">flickr/rifqy</span></span></figcaption></figure><p>Recent <a href="http://www.theage.com.au/victoria/vaccQ@ine-cutback-worries-doctors-20120508-1yb9q.html">news reports</a> say the free whooping cough vaccine for parents to protect newborns will be discontinued because it is not effective. Parents who’ve been told this is an important step to protect their baby are <a href="http://www.bendigoadvertiser.com.au/news/local/news/health/free-whooping-cough-vaccines-axed/2549326.aspx">dismayed and confused</a>.</p>
<p>The key message is that whooping cough vaccine given to parents, especially mothers, should provide protection to their newborn. But how much protection is uncertain and depends on vaccine factors and logistics.</p>
<h2>Historical background</h2>
<p>The initial driver of the decision by most states and territories to make whooping cough vaccine (at various times since 2009) available free of charge to parents of newborns was the urgency of an epidemic coupled with <a href="http://danamccaffery.com/openletter.html">tragic</a> and <a href="http://www.adelaidenow.com.au/news/south-australia/baby-dies-of-whooping-cough-in-adelaide/story-e6frea83-1225924755686">widely reported</a> infant <a href="http://www.abc.net.au/news/2011-02-17/whooping-cough-kills-baby-in-melbourne/1946760">deaths</a>. </p>
<p>The rationale for vaccinating parents is twofold. First, infants too young to themselves receive at least two doses of whooping cough vaccine are at greatest risk from severe disease – almost all deaths from whooping cough occurring in those <a href="http://www.ncbi.nlm.nih.gov/pubmed/15014301">under eight weeks old</a>.</p>
<p>Second, <a href="http://www.ncbi.nlm.nih.gov/pubmed/15014301">studies of how infants acquire whooping cough</a> consistently <a href="http://www.ncbi.nlm.nih.gov/pubmed/15545851">identify parents</a>, and in the youngest babies especially mothers, as the most common source of infection. As whooping cough vaccine <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa050824">protects adults</a>, it should also reduce transmission to infants. </p>
<p>So far, so good. </p>
<p>It wasn’t long before state and territory governments looked to the Commonwealth to take over funding of pertussis vaccine for parents under the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/nips2">National Immunisation Program (NIP)</a> in lieu of their emergency funding.</p>
<h2>Limited options</h2>
<p>But the Federal Government has a legislated process for funding vaccines under the National Immunisation Program (NIP) – the <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/health-pbs-general-listing-committee3.htm">Pharmaceutical Benefits Advisory Committee (PBAC)</a> must <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(08)70258-5/abstract">recommend it as cost-effective</a>. Without the PBAC’s recommendation, the government’s hands are tied. </p>
<p>In the case of whooping cough vaccine for parents of newborns, the PBAC concluded that the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/pbac-psd-pertussis-nov11">costs were high and the benefits uncertain</a>. </p>
<p>In considering costs and benefits, the PBAC is most interested in evidence of benefit from large clinical trials that directly compare active vaccine with no vaccine or a different vaccine. This is then used to estimate how many dollars it takes to save one quality-adjusted life year (QALY), which roughly translates to “how many doses of vaccine would need to be given at the quoted vaccine cost to gain one extra year of full quality life?” </p>
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<p>This is a problem for assessing the potential impact of whooping cough vaccine doses for adults to protect infants (known as “cocooning”). First, although any death from pertussis is tragic, there are, on average, less than three identified each year and even factoring in hospitalisations from pertussis would not add up to many QALYs to gain (compared to, say, drugs to prevent heart attacks in adults). </p>
<p>Second, randomized trials of pertussis vaccine for parents are impractical and even lesser-quality evidence, such as before-after studies evaluating this strategy in the field, were not available at the time of the PBAC review.</p>
<h2>Inaccurate reporting</h2>
<p>That said, the way statements to a Victorian Parliamentary Committee were <a href="http://news.ninemsn.com.au/health/8464832/states-reconsider-adult-whooping-cough-jab">widely reported</a> was incorrect. The PBAC did not “determine vaccinating parents was not effective in protecting newborns”. Rather, it found that, under its criteria, this was unlikely to be cost-effective. </p>
<p>Similarly, the PBAC didn’t “determine there is no clinical effectiveness”, it said clinical effectiveness was uncertain. In any case, the role of making clinical recommendations falls to the <a href="http://www.health.gov.au/internet/immunise/publishing.nsf/content/advisory-bodies#atagi">Australian Technical Advisory Group on Immunisation (ATAGI)</a>, a group of vaccine experts responsible for writing the <a href="http://www.health.gov.au/internet/immunise/publishing.nsf/content/handbook-home">Australian Immunisation Handbook</a>. </p>
<p>Based on the available evidence of the source of infection for infants, ATAGI has recommended vaccinating parents against whooping cough since it was included in its 2003 Handbook. The same recommendation was made by the comparable group in the United States. </p>
<h2>To cocoon or not to cocoon</h2>
<p>There are currently several on-going studies investigating the impact of the cocooning strategy on severe disease in infants (including <a href="http://www.cherel.org.au/media/21197/cherel_newsletter__april_2012_-_web_version.pdf">one by my centre</a> in collaboration with the <a href="http://www.health.nsw.gov.au/">NSW Ministry of Health</a>). These studies may show that vaccinating parents fails to protect their newborns – but, if so, this is unlikely to be due to lack of effectiveness of the vaccine. </p>
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<p>A baby who gets whooping cough despite her parent(s) being vaccinated is likely to have acquired the infection from other people, or because her parents were vaccinated too late (as is likely if they wait for a routine visit to a doctor when the baby is six weeks old rather than being vaccinated in the maternity hospital). </p>
<p>This highlights the problem that vaccinating parents doesn’t (and, short of immunizing the whole community, can’t) create a complete “cocoon”. In contrast, direct protection of the newborn can potentially be achieved by only one dose of vaccine to either mother or baby. </p>
<p>Giving the vaccine to the mother in the last months of pregnancy results in high levels of antibodies against whooping cough being transferred to the baby and should protect against the illness from birth. This measure was <a href="http://www.cdc.gov/mmwr/pdf/wk/mm6041.pdf">recommended in the United States</a> in 2011 as preferred to – but not as a replacement of – cocooning.</p>
<p>Giving the whooping cough vaccine to newborns immediately after birth results in earlier acquisition of <a href="http://www.ncbi.nlm.nih.gov/pubmed/20009964">antibodies against whooping cough</a> and Australia is leading the way in further investigating this in a trial funded by the NHMRC. </p>
<p>We already give hepatitis B vaccine at birth in Australia, and coupling it with whooping cough vaccine at birth, if confirmed to significantly hasten protection, could also be valuable. We know that not all women will be vaccinated during pregnancy, even if this is recommended. </p>
<p>Like cocooning, there is currently no concrete evidence that either a dose of whooping cough vaccine to pregnant mothers or to the baby immediately after birth prevents death or severe disease, which (in the context of the issues discussed above) may make it challenging even for these one-dose, more direct approaches to get below the PBAC limbo stick. </p>
<p>What’s certain is that <a href="https://theconversation.com/clear-and-present-danger-how-best-to-fight-the-latest-whooping-cough-outbreak-3134">whooping cough will not go away</a> and, tragically, deaths in very young babies will still occur without better ways to protect them before they themselves can be protected by immunization. </p><img src="https://counter.theconversation.com/content/6980/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Bruce McIntyre has a current NHMRC grant for the study of pertussis vaccine in newborns with ~450 babies enrolled in Sydney, Melbourne, Adelaide and Perth. This study uses vaccine manufactured by GSK and GSK are performing blood tests as an in-kind contribution. GSK have also supplied pertussis toxin for a lab that works with us to set up relevant assay.
Neither Professor McIntyre nor NCIRS receive any direct funding from GSK and he does not participate in any advisory boards for them or any other vaccine manufacturer. Other manufacturers have also supplied vaccine and/or performed specialist laboratory assays not otherwise available for studies initiated by NCIRS.
All interactions between NCIRS and vaccine manufacturers are governed by a policy document approved by our Advisory Board.
Professor McIntyre has funding agreements with the Australian and NSW governments.</span></em></p>Recent news reports say the free whooping cough vaccine for parents to protect newborns will be discontinued because it is not effective. Parents who’ve been told this is an important step to protect their…Peter Bruce McIntyre, Professor and Director for the National Centre for Immunisation Research and Surveillance of Vaccine, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/31342011-09-05T20:40:44Z2011-09-05T20:40:44ZClear and present danger: how best to fight the latest whooping cough outbreak<figure><img src="https://images.theconversation.com/files/3327/original/5458857332_d404800a08_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children too young for the vaccine or those who haven't been vaccinated are most at risk from whooping cough.</span> <span class="attribution"><span class="source">anjanettew/Flickr</span></span></figcaption></figure><p>Even though we’ve had a whooping cough (pertussis) vaccine since the 1950s, the disease is proving difficult to control and beat. Dealing with its resurgence requires clear communication about the importance of vaccination as well as work to understand why we can’t beat this elusive bug once and for all.</p>
<p>In response to the current outbreak of whooping cough, a <a href="http://www.ncirs.edu.au/news/index.php#National">recent conference in Sydney</a> brought together international and local experts to share the latest information on the impact of vaccinating parents to reduce risks to newborns and progress in developing new pertusis vaccines. </p>
<h2>Changing patterns</h2>
<p>Whooping cough has killed seven infants in Australia since 2008 and left many more needing hospital care. But efforts to understand the illness must recognise the myriad reasons for the current outbreak.</p>
<p>Vaccine refusal is one part of the cause, but more testing as well as better tests for the disease, the short period of protection, and waning adult immunity are all contributing to whooping cough’s resurgence. </p>
<p>The epidemic we’re in now (2009-2011) is part of a recurring pattern typical of whooping cough, with large outbreaks roughly every three to five years. </p>
<p>But it’s also unique. Compared with epidemics in 1997 and 2002, many more infections have been reported even though there are fewer deaths and roughly the same number of hospitalisations. </p>
<p>The number of cases has only started to fall this year so the public is right to ask why there’s so much whooping cough around despite vaccinations. </p>
<p>Much of the blame has been levelled at vaccine refusers. And vaccine refusal, as well as the tendency for refusers to geographically cluster, certainly promotes the spread of infections.</p>
<p>But Australia has maintained high vaccination rates over recent years, with 94% of two-year-olds completely up to date with their vaccines. And it’s not just communities with high rates of vaccine refusal that are affected by whooping cough. </p>
<p>In fact, most people who get this disease have had at least one dose of the pertusis vaccine. </p>
<p>The rise in detection of cases is partly because doctors are getting much better at recognising mild symptoms and we have more sensitive tests to diagnose the infection. This means people who previously may have been thought to have a viral cough or cold are now being diagnosed with whooping cough.</p>
<p>And other countries are also seeing changes in patterns of whooping cough, both in terms of the age of people getting infected and the number of cases. </p>
<h2>Adapting our approach</h2>
<p>Before vaccines, it wasn’t uncommon for people to have several bouts of whooping cough infection over their lifetime. And the whooping cough vaccine still doesn’t guarantee lifelong protection from disease, which is why we give booster doses at four years of age and again in high school. </p>
<p>In this most recent outbreak, we saw an unprecedented number of pre-schoolers being infected. So parents have been encouraged to have their children immunised slightly earlier, at three-and-a-half years of age. </p>
<p>Whooping cough, like many other infectious diseases, usually becomes less severe as we grow older. Very young babies – too young to be vaccinated – are at greatest risk of hospitalisation and death. </p>
<p>To try to reduce this risk, authorities have promoted vaccination of groups who are likely to pass the disease on to babies, including parents, grandparents, childcare workers and health-care professionals.</p>
<p>Local and international efforts are helping understand how better to use vaccines to control this troublesome infection. A current national research project funded by the government, for instance, is testing whether giving newborns whooping cough vaccine is safe and will protect them sooner. </p>
<p>Another project is exploring how well newborns are protected if their mothers are vaccinated against pertussis in the second half of pregnancy, a strategy recently recommended by the <a href="http://www.cdc.gov/vaccines/recs/acip/">US Advisory Committee on Immunisation Practices</a>.</p>
<h2>Importance of vaccination</h2>
<p>Opponents of vaccine programs could argue the ongoing problem with whooping cough despite mass vaccination programs means we shouldn’t bother with the shots. They suggest it’s better to get natural immunity and avoid what they believe is a risky vaccine. </p>
<p>In reality, the whooping cough vaccine is overwhelmingly safe and the unvaccinated are at risk of more severe disease even well beyond infancy. And when they <em>do</em> get whooping cough, they’re likely to have more bugs and spread it more efficiently.</p>
<p>As recently as the 1940s, hundreds of people were dying from whooping cough every year, in a population only a third of the present size. The introduction of whooping cough vaccines in the 1950s changed all that and the vaccine’s contribution to the saved lives must be recognised. </p>
<p>Our vigilance in pursuing this bug stems from the belief that even one death that could have been prevented with a vaccine is too many. </p>
<p>But, we must acknowledge the limitations of vaccine programs and this acknowledgement gives rise to a genuine concern that public confidence in vaccine programs could be undermined or that opponents of vaccinations will amplify such a message or decontextualise it. </p>
<p>This fact shouldn’t discourage clear and rational appraisal of immunisation programs, to further enhance their existing achievements in disease prevention.</p><img src="https://counter.theconversation.com/content/3134/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julie Leask receives funding from the Australian Research Council for a study of influenza vaccination of children. The study includes support from Sanofi Pasteur.</span></em></p><p class="fine-print"><em><span>Jodie McVernon receives funding from the National Health and Medical Research Council (Australia) and the Australian Research Council. She has been an investigator on vaccine trials funded by a range of industry partners and government grants in Australia and the United Kingdom.</span></em></p>Even though we’ve had a whooping cough (pertussis) vaccine since the 1950s, the disease is proving difficult to control and beat. Dealing with its resurgence requires clear communication about the importance…Julie Leask, Associate Professor, University of SydneyJodie McVernon, Associate Professor, Population Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/3302011-06-14T21:01:24Z2011-06-14T21:01:24ZBraving the jab for community immunity<figure><img src="https://images.theconversation.com/files/1064/original/Sanofil_Pasteur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If most people in a community are vaccinated, others are also protected. </span> <span class="attribution"><span class="source">Sanofil Pasteur</span></span></figcaption></figure><p>Let’s be clear: immunisations matter. They matter a lot.</p>
<p>We all have a complex and ever-changing ecology of microorganisms and parasites inside our bodies and in our community.</p>
<p>A <a href="http://www.couriermail.com.au/news/fatal-return-of-diphtheria/story-e6freomx-1226048663339">recent</a> fatal case of diphtheria in Brisbane and an <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr11-nr-nr026.htm">ongoing grumbling epidemic</a> of <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Whooping_cough">pertussis</a> (whooping cough) around Australia are reminders of our interdependence in relation to infectious diseases.</p>
<p>Community immunity, often referred to as herd immunity, is the protection individuals gain from others in their community being protected against an infectious disease. </p>
<p>This immunity can come after exposure to natural infection (“wild” organisms), from exposure to related organisms which provide some level of cross-protection, or from immunisation.</p>
<h2>Vaccine protection</h2>
<p>Vaccines protect against disease by presenting parts of “pathogenic organisms” or “subdued whole organisms” to our immune system. This allows our bodies to develop protective immunity against the disease, without paying the price of the disease the full-blown wild organism can cause. </p>
<p>Some vaccines provide stronger immunity than the wild virus – the human papilloma virus (HPV) <a href="http://theconversation.com/the-case-for-vaccinating-boys-as-well-as-girls-against-hpv-6">vaccine</a> given to girls to prevent cervical cancer, for instance. </p>
<p>Even if we’re susceptible to a disease, our chances of being exposed to a disease-causing pathogen are substantially reduced if the people we’re in close contact with have immunity. </p>
<h2>Diphtheria</h2>
<p>The role of vaccinations and community immunity differs from bug to bug. </p>
<p>For <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Diphtheria?open">diphtheria</a>, the organism causes severe and commonly fatal disease only when a particular toxin is present. </p>
<p>The diphtheria vaccine protects against the toxin, not infection with the organism per se, which can occur in the skin, throat or airways. </p>
<p>It is estimated that in a fully susceptible population, a person with diphtheria is likely to infect six or seven other people. </p>
<p>Based on how readily diphtheria spreads, around 85% of a population need to be immune in order to effectively control the disease. </p>
<p>Experience bears this out. In many countries, coverage rates for diphtheria immunisation of around 90% have reduced the number of cases by more than 99.99%. </p>
<p>But while toxin-producing diphtheria strains are around in some regions and can be imported, the disease can recur if high levels of immunisation aren’t maintained. </p>
<p>Following the break-up of the former Soviet Union, disruption to immunisation led to an epidemic of more than 150,000 cases and spread to other regions. </p>
<p>The <a href="http://www.couriermail.com.au/news/fatal-return-of-diphtheria/story-e6freomx-1226048663339">reportedly</a> unimmunised 22-year-old Brisbane woman who recently died of diphtheria is likely to have been infected by a friend who had recently returned from overseas.</p>
<h2>Whooping cough</h2>
<p>Pertussis, or whooping cough, typically occurs in cyclical epidemics every three to five years, when population immunity wanes enough for an outbreak to be sustained. </p>
<p>The current Australia-wide epidemic began in 2008 and has caused the deaths of four infants so far; it shows little sign of waning. </p>
<p>Pertussis is one of the most highly contagious diseases. </p>
<p>For a susceptible population, each infected person infects around 12 to 17 others. More than 92% of people need to be immune for community immunity to be strong enough to provide protection to the remainder of the population. </p>
<p>But pertussis vaccines are typically 80-90% effective in preventing disease. So pertussis can’t be eradicated through immunising children alone. </p>
<p>Nevertheless, if an immunised person is infected with pertussis, the cough and illness tend to be milder and shorter than in the unimmunised.</p>
<p>Unfortunately, immunity against pertussis (from both natural infection and vaccine) wanes after a decade or so. This is why pertussis occurs in people of all ages. </p>
<p>In adolescents and adults, it is one of the most common causes of cough illnesses lasting more than three weeks. </p>
<p>Infant pertussis immunisation (in a combination vaccine) is scheduled at two, four and six months of age, and it takes two doses before protection becomes substantial. </p>
<p>But most severe pertussis infections and almost all deaths occur in infants under three months, before they can be protected through immunisation.</p>
<p>Parents and other household contacts are the most frequent sources of pertussis infection for infants. That’s why governments recommend boosting parental immunisation: to “cocoon” young infants and provide protection against the disease. </p>
<h2>Hib and pneumococcal bacteria</h2>
<p>There are other diseases for which community immunity powerfully augments individual protection. </p>
<p>The <a href="http://www.who.int/mediacentre/factsheets/fs294/en/index.html">Hib bacterium</a> (Hemophilus influenzae type b) causes severe infections in young children, such as <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Meningitis">meningitis</a>. </p>
<p>Following introduction of Hib vaccine in the Gambia in Africa, Hib disease almost disappeared despite only 60% of children receiving the three vaccine doses that provide full immunity.</p>
<p><a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pneumococcal_disease">Pneumococcal bacteria</a> also causes meningitis and other serious infections. Worldwide, these bacteria are the most common cause of severe and fatal pneumonia at all ages. </p>
<p>Within a few years of the US introducing its infants pneumococcal conjugate vaccination program, the number of severe infections in young children plummeted, as hoped. But by reducing transmission of the bacteria across the community, more than twice as many infections were prevented in older people – who did not receive the vaccine – as in children who did. </p>
<p>Vaccines against Hib, pneumococci and meningococcal bacteria are so effective in building community immunity because they reduce carriage of the organisms in the nose and throat (where they normally live), thereby reducing transmission.</p>
<h2>Hepatitis A</h2>
<p>One of the most powerful examples of the benefits of herd immunity is the story of hepatitis A in Queensland. </p>
<p>The deaths of several indigenous children from hepatitis A in north Queensland prompted the introduction of hepatitis A immunisation for Indigenous toddlers in north Queensland in 1998. </p>
<p>Despite only 15% of children there being Indigenous, cases of hepatitis A rapidly plummeted, not only among the whole population of north Queensland (Indigenous and non-Indigenous) but across the state.</p>
<h2>Personal responsibility</h2>
<p>By contrast, one disease where community immunity plays no role is tetanus. </p>
<p>Tetanus spores are widespread in soil and the gut of animals, such as horses. Disease occurs when the causative bacterium grows in contaminated wounds and produces a potent toxin. </p>
<p>We can only be protected against tetanus if we are immunised ourselves. Even having tetanus disease doesn’t protect against subsequent attacks.</p>
<p>But for most diseases targeted by vaccines, immunisation substantially reduces not only our individual vulnerability but also our shared exposure. </p>
<p>Keeping our immunisations up to date, at home and when we travel, not only protects ourselves but helps protect our children, partners, friends, patients, work colleagues and wider community.</p><img src="https://counter.theconversation.com/content/330/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tilman Ruff does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Let’s be clear: immunisations matter. They matter a lot. We all have a complex and ever-changing ecology of microorganisms and parasites inside our bodies and in our community. A recent fatal case of diphtheria…Tilman Ruff, Associate Professor, Disease Prevention & Health Promotion Unit, Nossal Institute for Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.