It’s Pharmacy Awareness Week. You’re probably not aware of this, neatly illustrating the challenge pharmacists have in raising their professional profile with the public. Despite what you may read here in this blog (written by me), pharmacists do a lot more than sell unproven supplements. Beyond their important role in ensuring safe and effective prescription drug therapy, pharmacists are gaining expanded professional responsibilities. Some jurisdictions are allowing pharmacists limited prescribing privileges, and the right to modify prescription therapy without the need to consult a physician. But it’s the right to administer vaccines that is among the most interesting new acts being given to to pharmacists. And it makes sense. Pharmacists are the most accessible health professionals, and are well positioned to support vaccination programs. And vaccination programs need support.
Immunization has prevented more Canadian deaths in the past 50 years than any other health intervention. Our parents and grandparents accepted illness and death from diseases like smallpox, diptheria, and polio as a fact of life. Mass vaccination completely eradicated smallpox, which had been killing one in seven children. Public health campaigns have also eliminated diptheria, and reduced the incidence of pertussis, tetanus, measles, rubella and mumps to near zero.
The sickest and most vulnerable in society rely on the immunization of others to protect them from vaccine-preventable disease. When immunization rates are high, it’s much less likely a pathogen will be carried and transmitted from person to person. But let vaccination rates drop, and diseases can emerge in the population again. Measles is now endemic in the United Kingdom, after vaccination rates dropped below 80%. In Nigeria in 2001, unfounded fears of the polio vaccine led to a drop in vaccinations, an re-emergence of infection, and the spread of polio to ten other countries. (The World Health Organization has just launched a 400,000 person campaign to bring polio back under control, you can track the live progress with the cool Google tool.)
Vaccination rates drop when people questions their safety and efficacy. Some argue that vaccines are dangerous, and even harmful. Many pharmacists might doubt this last statement. I did, until H1n1 hit, and I documented the misleading information that anti-vaccination groups were propagating to fuel public anxiety. As a public advocate for making health care decisions based on reason and science, I learned quickly that some see pharmacists as drug-pushing cogs in the Industrial Medical Complex™. We don’t see these people in the pharmacy, because they don’t trust us, or our opinions.
Anti-vaccination sentiment has been around a long time, under different guises. The picture at the top of this post shows an antivaccination protest in 1920 in Toronto. Over time, the reasons for objections have changed. Some have religious objections, and other allude to “health freedom”. Some question anything that comes from a pharmaceutical company, citing the industry’s repeated bad behaviour as all the evidence needed to reject vaccines. Some object to the mandatory nature of many of the shots, and the fact that access to public services (like education) can be dependent on being immunized. In addition, many of the illnesses we continue to vaccinate against are never seen anymore. When polio was paralyzing children, few questioned the benefit of a vaccine. Now that the disease is eradicated in North America, some wonder why the vaccine is necessary. And when the MMR vaccine was falsely linked to autism, the modern antivaccination movement was born. Andrew Wakefield and his (now retracted) 1998 Lancet paper attempted to link autism-like symptoms to the administration of the MMR vaccine, an argument that was shown to be specious.
Keeping vaccination rates high is an important public health task, and one that pharmacists need to support. The latest iteration of anti-vaccine sentiment may be the “pure parenting” movement, which seeks to eliminate any perceived risk to their child, regardless of the consequences. Nicely skewered by Siri Agrell writing in Toronto Life, Totally Freaked Out documents how an ignorance of history, and a lack of risk perspective among parents, can put children, and public health, at risk. But just how pervasive is anti-vaccination sentiment overall? Is it restricted to the organic-quinoa-feeding, tree-hugging, chemical-fearing, natural-loving, whole-child-raising obsessive parents in metropolitan areas, like Toronto?
A paper just published in the journal Pediatrics gives cause for concern:
Freed and associates sought to understand the nature and prevalence of vaccine safety concerns. An online survey tool was used, which identified a population sample of 1552 parents: mainly female (58%), white (67%) and fairly well-educated (some college or more, 62%). Geographically, participants came from across the United States. Questions were posed about vaccine safety, vaccine refusal, and perceptions about specific vaccines; measles, mumps, rubella (MMR), varicella (chicken pox), meningococcal conjugate, and human papillomavirus (HPV).
First, the positive. 90% agreed with the statement “Getting vaccines is a good way to protect my child(ren) from disease”. 88% do what their doctor recommends. So the overwhelming majority accept the broad principles of immunization and tend to trust physicians.
But now the concern. One in four (25%) agreed with the comment “Some vaccines cause autism in healthy children”. More than one in ten (11%) agreed that “My child(ren) does(do) not need vaccines for diseases that are not common anymore”. Almost one parent in eight (11.5%) had refused at least one vaccine that had been recommended by a physician. HPV was the most common vaccine refused (56%), followed by varicella (chicken pox) at 32.3%. The reasons for refusal varied, as illustrated in the following table:
The authors noted newer vaccines are more likely to be refused, suggesting that reservations may arise from a lack of understanding of the vaccine testing and approval process.
What does this paper tell us? Overall parents seems to accept that vaccines are beneficial, but a substantial number harbour concerns. In particular, women are more likely than men to associate vaccines with autism, to be concerned about adverse effects of vaccines, and to have refused a vaccine for their child. Clearly there exists a subset of parents that need better information about vaccines, and particularly the non-link between vaccines and autism. It would be nice to think the retraction of the Wakefield paper will reduce this sentiment in the population (the survey was done in 2009, prior to the retraction), but judging by the reaction of antivaccination groups, reality doesn’t seem to matter.
In order to maintain herd immunity and prevent the re-emergence of preventable infectious diseases, vaccination rates need to be maintained. Anti-vaccination sentiment shows no sign of abating despite the overwhelming benefit/risk proposition they offer. Pharmacists, as accessible health-care providers, are well positioned to support public health initiatives by reinforcing key messages, anticipating and addressing concerns, and now, even administering vaccines. In order to effectively address anti-vaccination sentiment, it is incumbent on pharmacists to understand these concerns and to proactively try to address them.
Selected Credible Resources
Public Health Agency of Canada: Canadian Immunization Guide (2006)
Canadian Pharmacists Association: Practical Management of Vaccines (PDF)
Centers for Disease Prevention and Control: Vaccines and Immunizations
Science-Based Medicine: Vaccines Reference Library
Freed, G., Clark, S., Butchart, A., Singer, D., & Davis, M. (2010). Parental Vaccine Safety Concerns in 2009 PEDIATRICS DOI: 10.1542/peds.2009-1962