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Victims of their own success: Vaccines for infectious diseases in Australia Frank Bowden Professor, ANU Medical School Infectious Diseases Physician, Canberra Hospital Timeline of vaccine development: 1798 - 1955 Diphtheria Rabies 1798 Smallpox 1885 1896 Cholera Pertussis 1924 1923 Tetanus http://www.nature.com/nrmicro/journal/v9/n12/fig_tab/nrmicro2668_I1.html 1926 Influenza 1927 BCG 1936 1955 Polio Timeline of vaccine development: 1963 - 2016 1963 Measles 1969 Varicella Zoster Hepatitis B Rubella 1974 1981 Meningococcus http://www.nature.com/nrmicro/journal/v9/n12/fig_tab/nrmicro2668_I1.html 1987 HiB 1995 Rotavirus 1996 Acellular pertussis 1999 2006 HPV 1923 in Australia Annual cases Rate /100,000 Diphtheria 23,199 425 Measles 148,040 2,741 Aus pop Communicable Diseases Intelligence Hall,R Vol17/No. 11 5.4M 1930 Aus pop 6.5M Communicable Diseases Intelligence Hall,R Vol17/No. 11 Annual cases Rate /100,000 Pertussis 45,000 700 Tetanus 98 1.5 1938 Poliomyelitis Communicable Diseases Intelligence Hall,R Vol17/No. 11 Annual cases Rate /100,000 2776 39.1 1961 - The Tied Test Annual cases Rate /100,000 12,000 120 Hepatitis A Communicable Diseases Intelligence Hall,R Vol17/No. 11 Aus pop 10.1M Bad diseases Measles ● Diarrhoea ● Otitis media ● Pneumonia ● Encephalitis ● SSPE Mortality 1960 ^ 1 in 1000 Pertussis Mortality 1 in 200 if < 6 months Rubella Epidemics of deafness in Australia 1899, 1916, 1924, 1925, and in 1938-41. Tetanus 2004 Aceh tsunami: 108 deaths Sydney - 1940 ● Rubella epidemic across Australia in 1940 ● Following year Gregg describes 78 infants with unusual cataracts; 68 born to mothers with rubella in pregnancy ● 1943 adds deafness and congenital heart disease ● Mental retardation recognised Norman Gregg 1892-1966 Rubella epidemic of 1962 - 65 ● 12.5 million cases of rubella occurred in the United States ● 2,000 cases of encephalitis ● 11,250 fetal deaths ● 2,100 neonatal deaths ● 20,000 infants born with congenital rubella syndrome Zika virus ● 3358 Zika cases in the US* ● <100 in returning Australians *21 September 2016 Aedes egypti Vaccination Parental Warning: Some viewers may the find the following slides offensive It contains arithmetic Reproductive number : R0 “The number of new cases that an infected individual causes in a totally susceptible population.” R0 < 1 : no epidemic R0= 1 endemic disease R0 > 1 epidemic disease Endemic disease R0 = 1 Epidemic disease R0 = 3 Herd immunity Herd immunity The threshold proportion of people required to be vaccinated to achieve a decline in incidence of infection Herd immunity threshold (HIT) = 1 - 1 / R0 Herd immunity thresholds R0 Herd immunity threshold Ebola 2 50% Influenza 2.5 60% Smallpox 6 83% Measles 15 93% Unconditional surrender The end of Smallpox - 1980 Ali Maow Maalin Frank Fenner The end of Polio - ? 2020 Victory Measles in the UK Source: Public Health England National Notifiable Diseases System ● Globally WHO estimates 17M lives saved between 2000 and 2016 due to measles vaccination ● But still 114,000 deaths annually Rubella National Notifiable Diseases System Haemophilus influenzae Type B (HiB) National Notifiable Diseases System Meningococcal disease Varicella ? Susceptible Infected Recovered The Cancer Vaccines Hepatitis B ● 10-15% chronic infection in Asia (120 million in China) ● 600,000 deaths annually Human papillomavirus 274,00 deaths 274,000* deaths from cervical cancer annually 85% in the developing world *World Health Organisation Modest successes (or worse…) Pneumococcus Influenza Pertussis Complete failures No vaccines for: HIV Hepatitis C Malaria (TB) Dengue RSV Ebola Chlamydia Gonorrhoea Trichomonas HSV 1 and 2 Chikungunya Zika Staph aureus E.coli Victims of their own success Risk versus benefit Rotavirus vaccine 1998 1st vaccine withdrawn after 1 in 12,000 risk of intussusception observed Between 1998 and 2006 WHO estimated 4.2 million deaths from rotavirus 200 cases of intussusception in Australia annually 14 additional cases per year due to vaccine Annual Australian incidence pre-2007 22,000 ED presentation 10,000 admissions 60-70% reduction post-2007 The Cutter Incident ● 200,000 injected with live poliovirus ● 70,000 infected ● 200 paralysed ● 10 died Melbourne suburbs (red) with less than 90% vaccine coverage Timeline of vaccine development: 1963 - 2016 1963 Measles 1969 Varicella Zoster Hepatitis B Rubella 1974 1981 Meningococcus http://www.nature.com/nrmicro/journal/v9/n12/fig_tab/nrmicro2668_I1.html 1987 HiB 1995 Rotavirus 1996 Acellular pertussis 1999 2006 HPV Summary Vaccines are the most effective biomedical interventions in history Eradication of 1 (nearly 2) diseases, elimination of many others As the diseases they protect against disappear, the benefit of vaccines become less clear to the potential recipient Modern parents will not just follow the advice of health authorities A nuanced, respectful conversation is necessary