A Better Vaccine or Fewer Shots-Who Wants What?
ABSTRACT & COMMENTARY
Synopsis: Health care professionals were significantly more concerned than mothers about the need for additional vaccine injections. Most parents are willing to accept newer vaccines, such as DTaP, that are less likely to be associated with adverse events, even if it means more vaccine injections. Health care professionals were poor predictors of vaccine preferences of mothers.
Source: Halperin BA, Comparison of parental and health care professional preferences for the acellular or whole cell pertussis vaccine. Pediatr Infect Dis J 1998;17:103-109.
A sample of 400 mothers of 1-month-old infants, 100 immunizing physicians, and 100 immunizing nurses were surveyed during mid-1996 in Canada, where single injection DTwP-IPV-Hib vaccines are used for vaccine preferences for DTwP or DTaP. Accurate information was provided about the frequency of common adverse events (e.g., local reactions, fever, irritability) associated with each vaccine, the rarity of severe vaccine-associated adverse events, and the need for additional injections if DTaP was desired over DTwP. The vaccines were stated to be of equal efficacy.
Physicians and nurses did not differ in knowledge, attitudes about immunization, vaccine preferences, or prediction of mothers and their vaccine preferences. Virtually all mothers and health care professionals (99.5%) agreed that immunizations were important and should be provided as recommended. Significantly more mothers than health care professionals were concerned about the common reactions associated with DTwP vaccine (76% vs 52%; P = 0.001), and these mothers were willing to accept momentary pain from additional injections if it meant decreased likelihood of reactions (90% vs 77%; P = 0.001). More health professionals than mothers felt that multiple injections were stressful (89% vs 70%; P = 0.001) and possibly associated with long-term effects (17% vs 9%; P = 0.003), and that the need for multiple injections negatively influenced their decision to accept the acellular vaccine (77% vs 38%; P = 0.001).
COMMENT BY HAL B. JENSON, MD, FAAP
For years, the pediatric community as well as parents have looked forward to the advent of a pertussis vaccine with fewer side effects than the current whole-cell DTwP vaccine. In the 1980s, the lay press in the United States and abroad aggravated the acceptance of DTwP by promoting the unproved association of pertussis vaccination with brain damage. Now that three acellular DTaP vaccines are available, many providers continue to use DTwP vaccines because of lower cost, and some perhaps because the DTwP-Hib vaccine licensed by Wyeth-Lederle (Tetramune) is the only licensed DTP-Hib combination vaccine licensed for use in infants and requires fewer injections than separate DTaP and Hib vaccines.
The rates of local and systemic adverse events associated with DTaP vaccines are similar in frequency and severity to adverse events from DT vaccines with no pertussis component. Thus, we have achieved the availability of a less reactogenic pertussis vaccine. The efficacy of DTaP vaccines, measured in both humoral antibody responses and clinical protection from pertussis, is proven and may even exceed the efficacy of the DTwP vaccine used in the United States.
The American Academy of Pediatrics now recommends DTaP as the preferred vaccine for all doses (including completion of the series in children who have received one or more doses of whole-cell DTP vaccine, and for the fourth and fifth booster doses in the children who received three doses of whole-cell DTP vaccine) and states that "DTwP is an acceptable alternative." Currently, only one DTaP vaccine (Acel-Immune, Wyeth-Lederle) is licensed for all five doses, but the other two DTaP vaccines (Infanrix, SmithKline Beecham; Tripedia, Connaught) are licensed for the first four doses, and studies will be completed before the children in the cohort receiving these two vaccines reach the age of 4-6 years and need the fifth immunization. A DTaP-Hib combination vaccine (TriHIBit, Connaught) is currently licensed only for the fourth dose, but FDA approval for the first three doses is pending.
The only advantage to DTwP is lower cost (~$3 per dose compared to ~$15 per dose for DTaP). After considering the morbidity of the increased frequency and severity of DTwP-associated adverse events and the cost of additional physician visits or calls that often result from real or perceived DTwP adverse events, this advantage, in my opinion, vanishes.
With eager anticipation, we all look forward to combination vaccines and fewer vaccine injections. In the meantime, we should not overlook the progress that has already been made with the new DTaP vaccines. This study tells us that health care providers may be more hesitant to use the DTaP vaccine than parents want us to be.
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