The decision by advisory groups regarding addition of a vaccine to the immunization schedule is a
complex process, involving many considerations as
well as numerous experts with different areas of expertise. First, a novel vaccine (including combination
vaccines) must be rigorously studied to demonstrate
safety and efficacy. Often, more than 10,000 subjects
are included in randomized, controlled clinical trials
before a request can be submitted to the Food and
Drug Administration for vaccine licensure.
Other issues considered by advisory groups include burden of disease, age when disease is most
likely to occur, the effect of age on the immune response and the duration of the immune response
to a particular vaccine. Compatibility with other
vaccines, the need for booster doses and indirect
immunity (herd immunity) are considered as well.
A vaccine is administered for two reasons: to
protect the vaccinee from disease and to minimize
circulation of an infectious agent to protect others
in the community who may have lost immunity or
who cannot be vaccinated. The number of vaccinat-
ed people needed to reach a threshold for indirect
immunity in a closed population varies by virus. For
example, more than 90% of members of a communi-
ty need to be seropositive to reliably prevent measles
virus circulation after it is introduced.
A survey of a nationally representative sample of
pediatricians and family practitioners conducted in
2012 found that 16% of respondents did not administer vaccines to children younger than 2 years
of age. In a typical month, 93% of responding physicians reported being asked by a family to spread
out vaccines, and 74% of physicians consented to
the request often or sometimes (Kempe A, et al.
Only one vaccine schedule has been shown to
be safe and effective. Any deviation from the recommended schedule may jeopardize benefit and
increase the risk of harm. It is unlikely that a parent
or guardian who wishes to alter the schedule has considered the complex interaction of these numerous
factors. Families who wish to deviate from the recommended vaccine schedule should understand that
the remarkable benefit of vaccines can be assured
only if the established schedule is followed precisely.
A study by Andrew Wakefield, et al. published in
1998 in The Lancet suggested an association between
measles-mumps-rubella vaccination and autism. The
article was later retracted after it became clear there
were serious scientific and methodological flaws in
the report as well as undisclosed conflicts of interest.
Nevertheless, damage was done to measles vaccination programs.
A contemporary example of residual harm from
this erroneous report is the measles outbreak in
Somali-Minnesotans who were convinced by an-ti-vaccine groups not to receive the measles vaccine.
Seventy-eight cases of measles were confirmed in
Minnesota as of June 16, including 74 cases in
children younger than 17 years. Sixty-five of the
cases were Somali-Minnesotans, and 71 were unvaccinated.
The statement regarding a decline in autism in
Denmark after removal of thimerosal from vaccines
is incorrect. Thimerosal has never been a component
of a live measles vaccine.
Although many vaccine-preventable diseases
have become uncommon, the infectious agents that
cause many of these diseases continue to circulate
not only around the globe but also in the United
States. The measles outbreak in Minnesota is just
one unfortunate example of the risk from incomplete vaccination.
Vaccines induce an immune response similar to
that produced by infection, but they do not put a
person at risk of complications from the infection.
The risks from not being vaccinated include deafness
and mental retardation from Haemophilus influenzae
type b meningitis, birth defects from rubella, cirrhosis and liver cancer from hepatitis B and death
Dr. Meissner is professor of pediatrics
at Floating Hospital for Children, Tufts
Medical Center. He also is an ex officio
member of the AAP Committee on Infectious Diseases and associate editor of
the AAP Visual Red Book.
Michael A. Weiss, D.O., FAAP
Coto de Caza, Calif.
Timely access to efficient, evidence-based care is the cornerstone of what we, as pediatricians, stand for. The role of
the AAP in helping to assure this occurs for our vulnerable
rural and underserved patients lies in addressing each of
the italicized descriptors.
The AAP can support timeliness by diligently working
to ensure payers recognize technological solutions to access like telehealth platforms and e-consults. We are well beyond the time where
these are considered “alternative approaches to care,” and we should be working
diligently to secure appropriate and consistent payment for these effective tactics.
Care efficiency for both primary and subspecialty pediatricians is a gating item
for success in caring for the rural and underserved. The AAP can enhance its focus
on helping our colleagues improve operational approaches that will provide more
time for access to care. Focused education and training on team-based care, lean
process redesign methodologies and the use of technology solutions at the point
of care offer a tremendous opportunity to address this issue.
Lastly, because pediatricians and pediatric subspecialists may not be available in
some of these geographies, we, as the AAP, should be outreaching to help educate
our non-pediatric colleagues in evidence-based pediatric care. If we can “raise the
bar,” we will help to avoid the urgent and emergent situations that develop as a
result of delayed or improper care.
Kyle Yasuda, M.D., FAAP
The health of children in rural and medically under-
served areas is dependent on Medicaid. Forty-three percent
of children in rural areas have Medicaid as their health
insurance, and even more in medically underserved areas.
Bottom line: We should accept no cuts to Medicaid.
Access to pediatric primary and specialty care, payment
for services and workforce issues also impact the health care
delivery system for these communities. We must remain vigilant in improving access
to care and appropriate payment for services, and support the diverse, dedicated
pediatricians providing care.
We are at a critical point with workforce issues. Many international medical
graduates help fill the need. Many rural pediatricians are nearing retirement. The
AAP must be involved with this workforce issue. We must advocate for these
communities and pediatricians nationally and at the state level.
Many pediatricians in rural and medically underserved areas are not members
of our Academy. We are missing the opportunity to better understand their needs
and partner with them to help serve children and families. They are committed to
serving these populations, share our mission, but are often in survival mode. We
must understand their needs and develop appropriate support systems.
Telehealth is improving subspecialty consultation in rural and medically underserved areas and can help improve access to subspecialists. Adequate payment
systems need to be established for both ends of this type of delivery system. The
AAP will be in the forefront of this transformation.
Remember: #DontCapMyCare and #KeepKidsCovered
ID Snapshot continued from front page
2017 immunization schedules, http://bit.ly/2rDgIYO
The AAP National Nominating Committee has named Michael A. Weiss, D.O.,
FAAP, and Kyle Yasuda, M.D., FAAP, as candidates for AAP president-elect. The
winner will serve as the 2019 AAP president. The election will be held from Sept.
The candidates responded to the following: The health of children in rural and
medically underserved areas remains a significant challenge. What role can the
Academy play to address this issue?
Answers: All statements are incorrect.